Surgical Treatment Of Esophageal Cancer Research Articles

Comparison of the short-term outcomes of robot-assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy.

BackgroundThe development of minimally invasive surgery has initiated many changes in the surgical treatment of esophageal cancer (EC) patients. The aim of this study was to compare the short-term outcomes of robotic-assisted minimally invasive esophagectomy (RAMIE), video-assisted minimally invasive esophagectomy (VAMIE), and open esophagectomy (OE).MethodsOur study included patients who had undergone McKeown esophagectomy at Tianjin Medical University Cancer Institute and Hospital between January 2016 and December 2018. We analyzed clinical baseline data, as well as perioperative and pathological outcomes.ResultsA total of 312 cases met the inclusion criteria (OE: 77, VAMIE: 144, RAMIE: 91). The OE group had a greater number of late-stage patients as well as those who received the neo-adjuvant therapy, compared with the other two groups (P=0.001). The procedure time in the OE group was also shorter by approximately 20 minutes (P=0.021). Total blood loss was significantly lower in the two MIE groups (P=0.004) than in the OE group. There were no differences in the total number of dissected lymph nodes between the three groups (OE: 24.09±10.77, VAMIE: 23.07±10.18, RAMIE: 22.84±8.37, P=0.680). Both the lymph node number (P=0.155) and achievement rate (P=0.190) in the right recurrent laryngeal nerve (RLN) area were comparable between the three groups. However, in the left RLN area, minimally invasive approaches resulted in a higher number of harvested lymph nodes (P=0.032) and greater achievement rate (P=0.018). Neither MIE procedure increased the incidence of postoperative complications.ConclusionsMinimally invasive surgery could guarantee the quality of bilateral RLN lymphadenectomy without increasing postoperative complications, especially in RAMIE patients. The rational choice of different surgical approaches would improve both safety and oncological outcomes for patients.

T-shaped linear-stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy: a pilot study.

Minimally invasive esophagectomy (MIE) has become a good option in the surgical treatment of esophageal cancer. Cervical esophagogastric anastomoses (CEGA) are widely used during esophagectomy. However, CEGA are related with a higher incidence of anastomotic complications. In the present study, a new procedure of T-shaped linear-stapled cervical esophagogastric anastomosis was used during MIE and the short-term outcomes are presented. From May 2014 to December 2018, 32 consecutive patients with esophageal cancer who underwent total MIE followed by T-shaped linear-stapled cervical esophagogastric anastomosis were included. Postoperative outcomes were analyzed. Fifteen men and 17 women were included this pilot study. The histology of all cases was squamous cell carcinoma. Mean operation time of T-shaped linear-stapled cervical esophagogastric anastomosis was 17.6 minutes. There were no early or late mortalities. A minor cervical anastomotic leakage occurred in 1 patient. No complications of anastomotic stenosis occurred in this study. The T-shaped linear-stapled cervical esophagogastric anastomosis is efficient, reliable, easy to perform, and associated with lower postoperative complication rate.

Brief introduction of surgical development of esophageal cancer in Japan

Esophageal cancer surgery originated in the early 20(th) century. However, the true meaning of trans-thoracic esophagectomy and digestive tract reconstruction began in the 1930s. Almost at the same time, Japan and Western countries began the surgical exploration of esophageal cancer. Based on the pathological type of esophageal cancer in Asia, squamous cell carcinoma is the majority, and its biological characteristics and treatment strategies are different from those of European and American patients. After more than eighty years of development, the surgical treatment of esophageal cancer in Japan has been developed from the initial attempt, deep cultivation practice to the pursuit of excellence, and explored a set of more advanced surgical techniques and diagnostic strategies, which is unique in the world. On the basis of the establishment of the Japanese Society of Esophagus, Japanese scholars have developed and irregularly updated the Japanese Classification of Esophageal Cancer and published the professional academic journal Esophagus. The Japanese Clinical Oncology Group organized a number of phase Ⅲ clinical studies on esophageal cancer, providing strong evidence for the diagnosis and treatment of esophageal squamous carcinoma. Focused on the origin, development, current situation and future of esophageal cancer surgery in Japan, this paper summarized the development of esophageal cancer surgery in Japan through literature review, interviews with senior experts and Hot topics of esophageal cancer surgery-questionnaire survey of Japanese experts.

Perioperative Patient Factors Related to 2-Year Outcome after Esophageal Cancer Surgery: A Retrospective Cohort Study

Background: Surgical treatment for esophageal cancer is major invasive surgery. Recently, opioids have been implicated in the promotion of cancer recurrence and metastasis because of their immunosup-pressive effects. However, it has not been fully evaluated whether the intraoperative use of opioids is directly correlated with postoperative prognosis in the clinical setting. Therefore, this study aimed to identify perioperative factors related to postoperative complications and 2-year survival in patients undergoing esophageal cancer surgery. Methods: We retrospectively reviewed 105 patients who underwent surgery for esophageal cancer at Kagoshima University Hospital from January 2013 to December 2017. Patient parameters were compared between survivors and non-survivors for 2 years after surgery. Results: The 2-year survival rate after esophageal cancer surgery was 76.2% (80 survivors vs. 25 non-survivors). The incidence of postoperative pneumonia within 7 days after surgery was significantly higher in non-survivors compared with survivors (36.0% vs. 16.3%; odds ratio, 2.90; 95% confidence interval, 1.06 - 7.96, P P = 0.029). The intraoperative dosage of opioids calculated as fentanyl equivalents was not correlated with any postoperative complications or 2-year survival. The preoperative albumin level and neutrophil-lymphocyte ratio were associated with the incidence of postoperative pneumonia. Conclusions: Postoperative pneumonia may be a possible predictor of 2-year prognosis in patients after esophageal cancer surgery, and is not correlated with intraoperative use of opioids. Preoperative physical status including immune and nutrient states may be more important for postoperative prognosis after esophageal cancer surgery.

Laparothoracoscopic Ivor Lewis esophagectomy with esophageal-gastric intrapleural anastomosis

To describe the methodology of laparothoracoscopic Ivor Lewis esophagectomy in surgical treatment of esophageal cancer and compare early outcomes of this procedure with conventional Ivor Lewis surgery. There were 30 laparothoracoscopic Ivor Lewis esophagectomies followed by non-hardware esophageal-gastric intrapleural anastomosis for esophageal cancer. All procedures have been performed for the period 2016-2019 at the Moscow Regional Research and Clinical Institute (suturing of anastomosis was based on the method of professor A.S. Allakhverdyan). Laparothoracoscopic esophagectomy is characterized by higher surgery time by 136.57 min (p=0.012), less duration of anesthesia and mechanical ventilation by 77.5 min (p=0.042), postoperative ICU-stay by 2.25 hours (p=0.021), blood loss by 550 ml (p=0,000), duration of postoperative fasting by 2 days (p=0.034), hospital-stay by 8 days (p=0.021) compared to open esophagectomy. There were no significant between-group differences in the number of resected lymph nodes (p=0.142). Incidence of esophageal-gastric anastomosis failure is insignificantly higher in the OE group (χ2=1.89; p=0.075). Incidence of pulmonary complications (pneumonia, chylothorax, paresis of the vocal cords, pleural empyema) is less in the LTSE group (p<0.05). Cardiovascular morbidity is significantly lower in the LTSE group (p<0.05). A 30-day mortality rate was similar in both groups (χ2=2.56; p=0.0253). Early results of laparothoracoscopic Ivor Lewis esophagectomy are superior to the results of conventional Ivor Lewis surgery in surgical treatment of esophageal cancer.

Evaluation of POSSUM scoring systems in predicting postoperative morbidity and mortality in indian patients operated for esophageal cancer

Background: Surgical treatment for esophageal cancer is a high-risk procedure. Prediction of postoperative adverse events could aid in the stratification of patients, thus improving outcomes as well as achieving optimal use of resources. The Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) is a prediction model that utilizes both physiological and surgical parameters to assess risk. This study evaluates the effectiveness of POSSUM, Portsmouth-POSSUM (P-POSSUM), and esophagogastric-POSSUM (O-POSSUM) scoring systems in predicting postoperative morbidity and mortality in Indian patients operated for esophageal cancers. Patients and Methods: It is a retrospective study conducted in a tertiary care teaching hospital with data collected from esophagectomies performed from January 2015 to January 2019. The calibration and discriminative abilities of the scores to predict 30-day morbidity and mortality were analyzed using the Hosmer–Lemeshow test, observed to predicted ratios (observed/expected [O/E]), and the receiver operating characteristic curve tests. Results: A total of sixty patients were included. The 30-day mortality and morbidity were 6.67% (4/60) and 46.66% (28/60), respectively. POSSUM morbidity showed proper calibration and discrimination (O/E: 0.86) with a modest predictive ability (area under the curve [AUC]: 0.701). While analyzing mortality, though all scores displayed good calibration, O-POSSUM displayed superior predictive ability (O/E: 1.02). The POSSUM score overpredicted mortality by nearly twice (O/E: 0.52), whereas P-POSSUM underpredicted it (O/E: 1.71). All scores showed moderate discrimination with P-POSSUM outperforming other tests (AUC: 0.825). Conclusions: The POSSUM scoring system was useful in predicting morbidity risk following esophageal resection for cancer, with O-POSSUM more accurate for mortality prediction in this group of patients.

P221 THE ROLE OF SUBCARINAL LYMPH NODE DISSECTION IN ESOPHAGECTOMY - A 5-YEAR SINGLE CENTER EXPERIENCE

Abstract Aim To evaluate the involvement of subcarinal lymph node dissection (SLND) in the surgical treatment of esophageal cancer, as well as its impact on surgical outcomes following esophagectomy. Background &amp; Methods Data on patients that underwent esophagectomy from 01/03/2014 to 01/03/2019 were prospectively collected and retrospectively reviewed. Based on the medical records, the following parameters were collected and analyzed: patient demographics, histopathological parameters, surgical- oncological outcomes. All patients were staged according to the AJCC 8th edition. Results A total of 79 patients underwent Ivor Lewis or McKeown esophagectomy for either squamous cell carcinoma (n= 7 patients) or adenocarcinoma of the esophagus or gastroesophageal junction (n= 72 patients). In 26 cases, esophagectomy was performed without SLND, while 53 cases underwent SLND. Among the 53 patients, 50 (94.3%) were men, and 3 (5.7 %) were women. Mean age was 61.4 years, (range 34-78). Mean nodal harvest was 34.7 lymph nodes per patient. Lymph node invasion was noted in 33 patients (62.2%), with a mean of 9 positive lymph nodes per patient. Subcarinal lymph nodes were involved in 5 out of 53 patients (9.4%). The ratio of positive subcarinal lymph nodes to resected ones was 1/2 (50%), 3/3 (100%), 1/2 (50%), 1/2 (50%) and 1/1 (100%) for each patient. Final histopathological report showed adenocarcinoma of moderate or poor differentiation (G2 2/5, G3 3/5) in all five patients (100%). Four out of 5 patients had not received neoadjuvant treatment and their pathological staging was T3N3M0. One patient had received neoadjuvant chemotherapy and his final staging was ypT3N2M0. Noteworthy, the seven patients diagnosed with squamous carcinoma, were subjected to SLND and were 100% negative for invasion histologically. Conclusion Subcarinal lymph nodes were infiltrated in 9.4% of patients operated for esophageal cancer. In the squamous cell cancer group, the relative infiltration rate was notably 0%. It seems that omission of subcarinal lymph node dissection during transthoracic esophagectomy cannot be justified.

P183 NEW METHOD OF ESOPHAGO-GASTRO ANASTOMOSIS WITHIN MINIMALLY INVASIVE HYBRID IVOR LEWIS PROCEDURE

Abstract Aim Improve the results of surgical treatment of esophageal cancer by developing and implementing a new method for the formation of invagination mechanical esophagogastoanastomosis. Material and methods Reconstruction after esophagectomy together with the reliability of the esophagus-gastric anastomosis (EGA) constitute some of the most important problems in the surgery of the esophagus, because anastomosis leakage is one of the main reasons of lethal surgery. The research included 60 patients who anderwent the minimally invasive hybrid Ivor Lewis procedure for malignant tumors of esophagus in Shalimov National Institute of Surgery and Transplantation (1 group comprised 30 patients with mechanical EGA end-to-side; 2 group comprised 30 patients with invaginated mechanical EGA). The objects for estimation included post-operative mortality as well as the number of post-operative anastomosis complications: the number of EGA leakages in the early post-operative period and the number of post operative strictures in the EGA area three, six and twelve months after the surgery. All patients underwent a course of neoadjuvant chemo/RT in accordance with NCCN guidelines. Data processing was done by means of Statistic - licensed application programs for Windows. Results and discussion Patients belonging to both groups were comparable according to their age, sex, weight, height and surgery duration. Research group did not register a single case of EGA leakage while 2 patients in control group (р&lt;0,05). had the leakage which was stopped by means of “Endovac” system. There were 2 cases of esophagus post-operative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of EGA (р&lt;0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (р&lt;0,05). There were 5 cases of esophagus post-operative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of EGA (р&lt;0,05). Neither of the groups had any cases of post-operative mortality. Conclusion The study found that invaginated mechanical EGA within minimally invasive hybrid Ivor Lewis procedure reduces EGA leakages as well as EGA benign strictures.

O187 ANASTOMOTIC TECHNIQUES AND ASSOCIATED MORBIDITY IN TOTAL MINIMALLY-INVASIVE TRANSTHORACIC ESOPHAGECTOMY – RESULTS FROM THE ESOBENCHMARK DATABASE

Abstract Background Total minimally-invasive transthoracic esophagectomy (ttMIE) faces increasing application in surgical treatment of esophageal cancer. For esophago-gastric reconstruction, different anastomotic techniques are currently used, but their impact on postoperative anastomotic leakage and morbidity has not been investigated. The aim of this retrospective multicenter analysis was to describe anastomotic techniques used for ttMIE and to analyze the associated morbidity. Patients and Methods Patients were selected from a basic dataset, collected over a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the CD classification and the Comprehensive Complication Index® (CCI). Results Five anastomotic techniques were identified in 966 patients after ttMIE: Intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n=90, purse-string n=337), intrathoracic (n=109) or cervical (n=255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n=175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs. 17.2%, P=0.601), but overall complications (56.7%% vs. 63.7%, P=0.029) and median 90-day CCI (21 (IQR 0-36) vs. 29 (IQR 0-40), P=0.019) favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%) and cervical side-to-side linear-stapled esophago-gastrostomies (11.8%) (P&lt;0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. Conclusion Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

Current state of esophageal cancer surgery in China: a national database analysis

BackgroundThe present standard of surgical treatment for esophageal cancer is country dependent. The aim of the present study was to investigate the basic aspects of surgical procedures performed for esophageal cancer, and provide information about the present state of esophageal cancer surgery in China.MethodsData were obtained from a database administered by the Chinese Ministry for Health. A total of 542 participating hospitals were divided into seven geographic areas, and 10% of hospitals in each area were randomly chosen for inclusion. All patients with esophageal cancer, who underwent esophagectomy in these participating hospitals from January 1 to December 31, 2015, were included in the present study. The clinical characteristics, stage of tumor at diagnosis, operation summary and outcomes, and histological findings of patients were extracted and analyzed.ResultsThe present study included 11,791 patients, and the average number of patients per hospital was 218. Squamous cell carcinoma was the most common pathological type, while the mid-esophagus was the most common location. Open procedures were performed in 63.8% of patients, while minimally invasive esophagectomy was performed in 36.2% of patients. Multiple approaches to transthoracic esophagectomy were utilized. Two-field lymphadenectomy was the most frequently performed (64.8%), followed by three-field lymphadenectomy (21.8%). Gastric tubes, thoracic duct ligation and postoperative enteral nutrition were implemented to minimize complications.ConclusionThe standard operative procedure and detailed technique for esophageal carcinoma surgery is presently being debated in China. This survey provides some basic information about the present state of esophageal cancer surgery countrywide.

Creation of Virtual Three-Dimensional Animation Using Computer Graphic Technology for Videoscopic Transcervical Upper Mediastinal Esophageal Dissection.

Background: Videoscopic transcervical mediastinal lymphadenectomy has been attempted to reduce thoracotomy-related complications of surgical treatment for esophageal cancer. However, many surgeons would hesitate to attempt this procedure because of the difficulty in understanding the anatomical orientation. In this study, we aimed to create a three-dimensional computer graphic (3D CG) animation and compare it with the real-life operation. Materials and Methods: LightWave 3D® version 7 was used as a rendering software to create the 3D CG. The 3D CG images were superimposed to generate an animation using AfterEffects CC®. Results: The 3D CG animation for videoscopic transcervical upper mediastinal esophageal dissection was successfully created; it dynamically shows the scene, especially the separation between the esophagus and trachea, and enables surgeons to easily understand the anatomical orientation when using transcervical approach. This 3D CG animation was of high quality and similar to the real-life operation. Conclusions: We created a virtual 3D CG animation for the transcervical approach, which will contribute to understanding this procedure for esophageal cancer preoperatively.

Complications of the surgical treatment of esophageal cancer and microbiological analysis of the respiratory tract.

The aim of this study was to reduce the severe respiratory complications of esophageal cancer surgery often leading to death. Two groups of patients operated on for esophageal cancer were evaluated in this retrospective analysis. The first group was operated between 2006-2011, prior to the implementation of preoperative microbiological examination while the second group had surgery between 2012-2017 after implementation of this examination. In total, 260 patients, 220 males and 40 females underwent esophagectomy. Between 2006-2011, 113 (87.6%) males and 16 (12.4%) females and between 2012-2017, esophagectomy was performed in 107 (81.7%) males and 24 (18.3%) females. In the first cohort, 10 patients died due to respiratory complications. The 30-day mortality was 6.9% and 90-day was 9.3%. In the second cohort, 4 patients died from respiratory complications. The 30-day mortality was 1.5% and 90-day mortality was 3.1%. With regard to the incidence of respiratory complications (P=0.014), these occurred more frequently in patients with sputum collection, however, severe respiratory complications were more often observed in patients without sputum collection. Significantly fewer patients died (P=0.036) in the group with sputum collection. The incidence of respiratory complications was very significantly higher in the patients who died (P<0.0001). The incidence of severe respiratory complications (causing death) may be reduced by identifying clinically silent respiratory tract infections.

The effectiveness of a nurse-led exercise and health education informatics program on exercise capacity and quality of life among cancer survivors after esophagectomy: A randomized controlled trial

BackgroundEsophagectomy is the primary surgical treatment for esophageal cancer. However, patients often experience a decrease in physical activity, poor nutrition, and a reduction in quality of life following surgery. ObjectivesThe aim of this study was to examine the effects of an exercise and nursing education health informatics program on quality of life, exercise capacity, and nutrition among patients following esophagectomy for esophageal cancer. DesignA randomized controlled trial. Settings and methodsPatients who had undergone an esophagectomy for cancer were recruited by purposive sampling from a medical center in Taiwan. Patients who met inclusion criteria and agreed to participate (N = 88) were randomly assigned to an exercise informatics program (intervention group, n = 44) or usual post-surgery care (control group, n = 44). Quality of life was assessed at baseline and 1, 3, and 6 months after discharge. Secondary outcomes of nutrition (albumin, body mass index), and exercise capacity (maximal oxygen uptake, the six-minute walking test) were conducted at baseline and 3 months following discharge. Differences in quality of life, nutrition and exercise capacity between the two groups were analyzed using generalized estimating equations. ResultsAnalysis demonstrated significant improvements in outcome measures following hospital discharge for the intervention group compared to controls. Measures of quality of life were significantly better for the intervention group and varied with time following discharge. Functional scores for physical (1 and 3 months), role (1, 3, and 6 months), emotional (1 month), social (3 months) and global health (3 months) were significantly higher than controls. Cancer-related subscales improved for insomnia (1 and 3 months) and nausea/vomiting (3 and 6 months). Esophageal cancer-specific symptoms improved for dry mouth (1 month), dysphagia (3 months), and loss of taste (1 and 6 months). Three months following discharge, levels of albumin were significantly higher for the intervention group compared to controls (β=0.32, 95% CI 0.09, 0.54, p < .01); body mass index did not differ between groups. Exercise capacity was also significantly better; the intervention group had higher maximal oxygen consumption (β=2.61, 95% CI 1.54, 3.69, p < .001) and greater distance on the six-minute walking test (β=83.30, 95% CI 52.60, 113.99, p < .001). ConclusionThe intervention group experienced significant improvements in nutrition, exercise capacity, and variables related to quality of life. These findings suggest a nurse-led exercise and health education informatics program should be implemented for survivors of esophagectomy prior to hospital discharge.

Expert recommendation for robot-assisted esophagectomy (2019 edition)

Minimally invasive esophagectomy for the surgical treatment of esophageal cancer has gradually been recognized and applied. With the application of robot-assisted technology in esophageal surgery, robot-assisted esophagectomy has been carried out in large domestic centers, and its feasibility and safety have been recognized by some domestic experts. In view of no advice or guidelines about robot-assisted esophagectomy has been written before, Committee of Esophageal Cancer in China Anticancer Association organized relevant domestic experts to establish this expert recommendation for standardization of robot-assisted esophagectomy, aiming at helping surgeons perform this complex procedure safely.

Open surgical treatment for esophageal cancer: transhiatal vs. transthoracic, does it really matter?

Esophageal cancer has become a global health problem; it is the sixth cause of death related to malignant neoplasms around the world (1). Squamous cell cancer (SCC) and adenocarcinoma (AC) occur as a result different factors for each histology, therefore, they have different biological behavior and affect the esophagus in different anatomical sites. Surgical treatment options are diverse, depending on the anatomical site affected by the tumor, extension and the preference and experience of the surgeon, Ivor Lewis esophagectomy, McKeown esophagectomy, minimally invasive variants of Ivor Lewis or McKeown, transhiatal esophagectomy, or thoracoabdominal approaches are some of the options available. A study that surveyed 618 esophageal surgeons on the United States and around the world (2) determined that the most used approaches are transhiatal esophagectomy in 35–44% of the cases and transthoracic esophagectomy (Ivor-Lewis) in 36–50% of the cases, with some variations depending on the location of the tumor. In 14–18% of the cases surgeons performed en bloc resections and minimally invasive approaches are used only in 3.9–6.5% of the cases. This variability in terms of surgical approaches is a reflection of the lack of consensus that exists in this issue (3). The extent of lymphadenectomy is defined by fields, where the first field refers to the abdominal portion, the second field to the thoracic portion below the azygos vein and the third field refers to the upper thoracic portion and cervical nodes. Most of the surgeons dissect at least the first and the second field, while a minority dissects the third field. Since open approaches continue to be practiced more often than minimal invasive approaches, the objective of this review is to answer the questions on which of the open approaches confers greater morbidity, which one have advantage in terms of doing a more extensive lymphadenectomy and to present the evidence supporting the assertion that an extensive lymphadenectomy confers a better outcome in terms of survival; all this based on the available scientific evidence

Significance of the board-certified surgeon systems and clinical practice guideline adherence to surgical treatment of esophageal cancer in Japan: a questionnaire survey of departments registered in the National Clinical Database

BackgroundIt remains unknown how much institutional medical structure and process of implementation of clinical practice guidelines for esophageal cancers can improve quality of surgical outcome in Japan.MethodsA web-based questionnaire survey was performed for departments registered in the National Clinical Database in Japan from October 2014 to January 2015. Quality indicators (QIs) including structure and process indicators (clinical practice guideline adherence) were evaluated on the risk-adjusted odds ratio for operative mortality (AOR) of the patients using registered cases in the database who underwent esophagectomy and reconstruction in 2013 and 2014.ResultsAmong 916 departments which registered at least one esophagectomy case during the study period, 454 departments (49.6%) responded to the questionnaire. Analyses of 6661 cases revealed that two structure QIs (certification of training hospitals by Japan Esophageal Society and presence of board-certified esophageal surgeons) were associated with significantly lower AOR (p < 0.001 and p = 0.005, respectively). One highly recommended process QI regarding preoperative chemotherapy had strong tendency to associate with lower AOR (p = 0.053). In two process QIs, the answer “performed at the doctor’s discretion” showed a significant negative impact on prognosis, suggesting importance of institutional uniformity.ConclusionsThe medical institutional structure of board-certified training sites for esophageal surgeons and of participation of board-certified esophageal surgeons improves surgical outcome in Japan. Establishment of appropriate QIs and their uniform implementation would be crucial for future quality improvement of medical care in esophagectomy.

Updated German S3 guidelines on esophageal cancer and supplements from a surgical perspective

The updated German S3 guidelines recommend transthoracic subtotal esophagectomy with 2‑field lymphadenectomy for surgical treatment of esophageal cancer in patients with squamous cell carcinoma and adenocarcinoma of the esophagogastric (AEG typeI) junction of the middle and lower third. For AEG typeIII transhiatal extended total gastrectomy with distal esophageal resection is favored. Patients with AEG typeII can be treated by both procedures under the prerequisite that an R0 resection can be achieved. Alimited resection of the distal esophagus and the proximal stomach can only be considered in cT1 N0 M0 possibly cT2 AEG junction without an oncological risk constellation, i.e. gradeG1/G2, intestinal type and no poorly cohesive carcinoma, because the rate of lymph node metastasis at the distal stomach is less than 2%. Minimally invasive procedures provide advantages compared to open esophagectomy due to the lower rate of postoperative total and especially pulmonary complications. This is true for hybrid esophagectomy (laparoscopy and thoracotomy) versus open access in cases of intrathoracic anastomoses and for total minimally invasive esophagectomy including robotic techniques versus open access in cervical esophagogastrostomy.

Prognostic impact of allogenic blood transfusion following surgical treatment of esophageal cancer

Esophageal cancer (EC) surgery is associated with relatively high morbidity and mortality rates and poor overall survival (OS). The impact of allogeneic blood transfusion (aBT) on OS is still a matter of debate. We aimed to investigate the impact of aBT on OS in a homogeneous population of patients undergoing surgical treatment for EC in a single center during a 15-year period. In total, 409 patients who had undergone surgical resection for EC were studied. The clinicopathological parameters and OS were compared between 170 patients (41.6%) who received perioperative aBT and 239 patients (58.4%) who did not. Compared with the non-transfused patients, patients who received aBT had lower preoperative hemoglobin levels, more comorbidities, and a more advanced stage of disease as reflected by tumor diameter, nodal metastases, perineural invasion, and the need for multiorgan resection. Transfused patients suffered more frequently from major postoperative complications (26/170 [21.5%] vs. 13/239 [5.7%], p < 0.001) and had a significantly longer hospital stay (17 vs. 15 days, p < 0.001). Multivariate analysis identified tumor grade (p = 0.02), perineural invasion (p = 0.001), N stage (p < 0.001), major postoperative complications (p = 0.01), and comorbidity (p = 0.04) as independent predictors of OS in patients with EC. Perioperative aBT was not found to be an independent predictor of OS in the entire cohort, neither in the stratified subanalysis. In our study, an advanced stage of disease and comorbidities resulted in the need for blood transfusion and the occurrence of major postoperative complications, which appeared to decrease the OS in patients with EC.

Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review.

Robotic assisted minimal invasive esophagectomy (RAMIE) is increasingly applied as a clinically and oncologically safe technique in the surgical treatment of esophageal cancer. This review focuses on the advantages and potential opportunities of RAMIE to improve the perioperative and oncological outcomes based on the evidence from current literature. In addition, critical notes on aspects such as procedure duration and costs are addressed in this paper.

Robotic-assisted McKeown esophagectomy.

Over the last few decades, minimally invasive approaches have gained in popularity for the surgical treatment of esophageal cancer, with the hopes of reducing the morbidity and mortality of this formidable procedure. The traditional McKeown approach includes thoracic esophageal dissection, abdominal mobilization of the gastric conduit and a cervical anastomosis. It presents several advantages over the Ivor Lewis approach: it is suitable for proximal tumors, allows a 3-field lymph node dissection, and avoids the morbidity associated with an intra-thoracic anastomotic leak. Here, we discuss the technical aspects of robotic-assisted minimally invasive McKeown esophagectomy (McKeown RAMIE).