Validation of the NUn score as a predictor of anastomotic leak and major complications after Esophagectomy.

Predicting major anastomotic leak (AL) and major complications (Clavien-Dindo 3-5) following esophagectomy improves postoperative management of patients. The role of the NUn score in their prediction is controversial. This study aims to evaluate the predictive ability of this simple score. Data were retrospectively collected for consecutive esophagectomies over a 10-year period, and NUn scores were retrospectively calculated for each patient from informatics data. A standardized definition of major AL was used, excluding minor asymptomatic, radiologically detected leaks. The predictive accuracy of the NUn score and its constituent parts, for major AL and major complications, was assessed using area under receiver operating characteristics curves (AUROCs). Of 382 patients, 48 (13%) developed major AL and 123 (32%) developed major complications. The NUn score calculated on postoperative day 4 was significantly predictive of both outcomes, with AUROCs of 0.77 and 0.71, respectively (both P < 0.001). A NUn score cut-off of 10 had a negative predictive value of 95% for major AL. The NUn score was predictive of major complications on multivariable analysis. The NUn score was found to be a significant predictor of major AL, suggesting that this is a useful early warning score for major AL. The score may also be useful in identifying patients that are the most likely to benefit from enhanced recovery protocols.

Prognostic significance of circumferential resection margin involvement in patients receiving potentially curative treatment for oesophageal cancer.

INTRODUCTION: The utility of Circumferential Resection Margin (CRM) status in predicting prognosis in oesophageal cancer is controversial, with different definitions used by the College of American Pathologists and the Royal College of Pathologists. We aimed to determine prognostic significance of CRM involvement and evaluate which system is the best predictor of prognosis. METHODS: A cohort of 390 patients who had potentially curative oesophagectomy (- + neoadjuvant chemotherapy) were analysed. Associations between CRM involvement and patient outcome were assessed for the whole cohort, and for pre-specified subgroups of T3 tumours and those who received neo-adjuvant chemotherapy. RESULTS: CRM-involvement was associated with higher T and N stage, tumour differentiation, increased tumour length and both lymphovascular and perineural invasion. Overall Survival (OS) and Recurrence Free Survival (RFS) significantly worsened with CRM-involvement (p = 0.001, p < 0.001). R1a (<1 mm but no macroscopic involvement) resulted in significantly improved OS (p = 0.037) and RFS (P = 0.026) compared to R1b (macroscopic involvement), but did not differ significantly from R0 (≥1 mm). The association between CRM-involvement and both OS and RFS remained significant regardless of whether neoadjuvant chemotherapy was given. However, CRM-involvement was not a significant prognostic marker in T3 patients (p = 0.148). Multivariable analysis found N stage, lymphovascular invasion, patient age and neoadjuvant chemotherapy to be significantly predictive of patient outcome. CRM-involvement was not a significant independent prognostic marker. CONCLUSIONS: CRM-involvement was not found to be independently predictive of prognosis, after accounting for other prognostic markers. As such, CRM should not be considered a major prognostic factor in patients with oesophageal cancer.

Prognostic significance of tumor length in patients receiving esophagectomy for esophageal cancer.

AIMS: We investigated the prognostic value of tumor length measurements acquired both from pre-operative imaging and post-operative pathology in esophageal cancer. METHODS: Tumor lengths were examined retrospectively for 389 esophagectomy patients with respect to Endoscopy, EUS (Endoscopic Ultrasound), CT and PET-CT, and pathology. Correlations between the measurements on the different approaches were assessed, and associations between tumor length and survival were analyzed. RESULTS: Only the tumor lengths assessed on pathology were found to be significantly associated with overall (P = 0.001) and recurrence free (P < 0.001) survival on univariable analysis. The median overall survival was 47.1 months in those patients with tumor lengths <3.0 cm, falling to 19.6 and 18.0 months in those with 3.0-4.4 and 4.5+ cm tumors, respectively, demonstrating a reduction in patient survival at a tumor length of around 3 cm. Tumor length on pathology was significantly correlated with tumor differentiation and both T- and N-categories. After accounting for these factors, tumor length on pathology was a significant independent predictor of recurrence-free (P = 0.016), but not overall (P = 0.128) survival. CONCLUSIONS: Tumor lengths on pathology were found to be the most predictive of patient outcome. However, after accounting for other tumor-related factors, tumor length only resulted in a marginal improvement in predictive accuracy.

Potential cost savings by minimisation of blood sample delays on care decision making in urgent care services.

BACKGROUND: Timely availability of blood sample results for interpretation affects planning and delivery of patient care from initial assessment in Accident and Emergency (A&E) departments. MATERIALS AND METHODS: Rates of, and reasons for, rejected blood samples submitted from all clinical areas over one month were evaluated. Haemoglobin (Hb) represented haematology and potassium (K+), biochemistry. A prospective observational study evaluated the methodology of sample collection and impact on utility. RESULTS: 16,061 haematology and 16,209 biochemistry samples were evaluated; 1.4% (n = 229, range 0.5-7.3%) and 4.7% (n = 762, range 0.9-14%) respectively were rejected, with 14% (n = 248/1808) K+ rejection rate in A&E. Patients with rejected K+ and Hb had a longer median in-hospital stay of 9 and 76 h respectively and additional stay fixed costs of £26,824.74 excluding treatment. The rejection rate with Vacutainer and butterfly (4.0%) was lower than Vacutainer and cannula (28%). CONCLUSION: Sample rejection rate is high and is associated with increased in-hospital stay and cost. Blood sampling technique impacts on rejection rates. Reduction in sample rejection rates in emergency care areas in acute hospitals has the potential to impact on patient flow and reduce cost.

The incremental benefit of two quadrant lavage for peritoneal cytology at staging laparoscopy for oesophagogastric adenocarcinoma.

BACKGROUND: Patients with positive peritoneal cytology from oesophagogastric cancer have a poor prognosis. The purpose of this study was to compare lavage cytology from the pelvis alone with the pelvis and subphrenic areas at staging laparoscopy in patients with potentially resectable oesophagogastric adenocarcinoma. METHODS: Between November 2006 and November 2010, all patients with operable oesophagogastric adenocarcinoma on spiral CT considered fit for surgical resection underwent staging laparoscopy. Subphrenic and pelvic peritoneal lavage for cytology was performed followed by laparoscopic biopsy of any visible peritoneal disease. Patients were divided into groups: macroscopic peritoneal metastases (P+), no macroscopic peritoneal disease with negative cytology (P-C-), no macroscopic peritoneal disease with positive pelvic cytology (P-PC+), no macroscopic peritoneal disease with positive subphrenic cytology (P-SC+), or both (P-PSC+). RESULTS: A total of 316 staging laparoscopy procedures were performed; 245 patients (78 %) were P-C-, 28 (9 %) were P+, and 43 (14 %) were P-C+, of whom 29 (9 %) were P-PSC+, 10 (3 %) were P-SC+, and 4 (1 %) were P-PC+. Pelvic cytology alone had 76.7 % sensitivity for peritoneal disease, and subphrenic cytology alone had 90.7 % sensitivity. CONCLUSIONS: Peritoneal lavage for cytology at staging laparoscopy has an incremental benefit for staging oesophagogastric adenocarcinoma in the absence of macroscopic metastatic disease. Subphrenic washings have the highest yield of positive results. Performing isolated pelvic washings for cytology will understage 23.3 % of patients with microscopic peritoneal disease. The routine use of subphrenic in combination with pelvic lavage for cytology at staging laparoscopy in patients with oesophagogastric adenocarcinoma has an incremental benefit in detecting cytology-positive disease over either pelvic or subphrenic cytology alone.