The effect of preoperative body mass index on short-term outcome after esophagectomy for cancer: A nationwide propensity score-matched analysis.

BACKGROUND: The true influence of body mass index on the outcome of esophageal cancer surgery is unclear. The aim of this study was to determine the relation between preoperative body mass index and clinical and oncological outcomes of esophagectomy for cancer in a patient cohort from the Dutch nationwide audit. METHODS: All patients who underwent esophagectomy for cancer between January 2011 and 2016 were identified in the Dutch Upper Gastrointestinal Cancer Audit. Patients were divided into 4 body mass index categories (<18.5 kg/m2 underweight, 18.5 to 25 kg/m2 normal weight, 25 to 30 kg/m2 overweight, and >30 kg/m2 obese) and were compared for clinical and oncological outcomes with the use of propensity score-matched analysis. RESULTS: Of the patients, 2,598 were included (underweight = 70, normal weight = 1,097, overweight = 1,007, and obese = 424). Before propensity score-matched analysis, underweight patients had a significantly longer hospital stay, more chyle leakage, underwent more re-operations, and had a higher in-hospital/30-day mortality compared to the other weight groups. After propensity score-matched analysis, 560 patients were included: 62 were underweight, 180 were normal weight, 165 were overweight, and 153 were obese. Length of hospital stay, chyle leakage, necrosis of the reconstruction, re-interventions, re-operations, re-admittance to the intensive care unit/medium care unit, and in-hospital/30-day mortality were seen most in the underweight group. No differences were seen in intraoperative complications and oncological outcomes. CONCLUSION: Underweight patients are more prone for the development of postoperative complications after esophagectomy. Physicians and dieticians should be aware of the impact of underweight on postoperative outcome. Future studies should focus on nutritional status and the effect of preoperative correction of body weight.

Feasibility of extended chemoradiotherapy plus surgery for patients with cT4b esophageal carcinoma.

BACKGROUND: Treatment of cT4b esophageal carcinoma usually consists of definitive chemoradiotherapy (dCRT). However, outcome after dCRT in these patients is poor. Whether surgery should have a place in the treatment of cT4b esophageal cancer is still subject to debate. Goal of this study was to evaluate the feasibility of esophagectomy after extended chemoradiotherapy in patients with cT4b esophageal cancer. METHODS: Patients with cT4b esophageal carcinoma, as determined by endoscopic ultrasound and (PET-)CT, were eligible for this phase-2 study. Patients were treated with weekly carboplatin + paclitaxel with 50.4 Gy radiotherapy in 28 fractions for 5.5 weeks followed by an explorative thoracotomy and esophagectomy if deemed feasible. RESULTS: From July 2011 through March 2013, 16 patients were enrolled. Five patients did not undergo surgery because of detection of distant metastases during/after CRT (n = 3), unwillingness to undergo surgery (n = 1) or death before start of CRT (n = 1). Of the 13 patients who completed CRT, 3 patients experienced major hematologic toxicity (grade 3). A radical (R0) resection was achieved in 9 of 11 patients. Postoperative complications occurred in 9 patients. A reoperation was performed in 2 patients and 2 patients died in hospital after surgery. Three patients developed recurrent disease (1 locoregional and 2 systemic) after a mean interval of 17 months. Median overall survival of all included patients was 14.3 months. CONCLUSIONS: In certain patients with cT4b esophageal carcinoma a radical resection can be accomplished after chemoradiotherapy. However, this treatment is associated with considerable complications and should therefore be reserved for physically fit patients. NETHERLANDS TRIAL REGISTER NUMBER: NTR3060.

Therapeutic approaches to gastroesophageal junction adenocarcinomas.

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the distinction between adenocarcinomas above, below, or within the gastroesophageal junction; combined modality therapy; tumor markers for use in personalized medicine; PET-CT and endoscopic biopsies in the evaluation of response to neoadjuvant chemoradiation therapy; a standardized grading system for tumor regression in squamous cell cancer and adenocarcinoma; the experimental basis for new approaches to medical treatment; the criteria measuring response in esophageal cancer; and the impact of novel imaging on staging and response assessment.

Interobserver reproducibility of diffusion-weighted MRI in monitoring tumor response to neoadjuvant therapy in esophageal cancer.

OBJECTIVE: To investigate the reproducibility of diffusion-weighted magnetic resonance imaging (DW-MRI) in assessing tumor response early in the course of neoadjuvant chemoradiotherapy in patients with operable esophageal cancer. METHODS: Eleven male patients (mean age 54.8 years) with newly diagnosed esophageal cancer underwent DW-MRI before and 10 days after start of chemoradiotherapy. Reproducibility of apparent diffusion coefficient (ADC) measurements by manual (freehand) and semi-automated volumetric methods was assessed. RESULTS: Interobserver reproducibility for the assessment of mean tumor ADC by the manual measurement method was good, with an ICC of 0.69 (95% CI, 0.36 to 0.85; P = 0.001). Interobserver reproducibility for the assessment of mean tumor ADC by the semi-automated volumetric measurement method was very good, with an ICC of 0.96 (95% CI, 0.91 to 0.98; P<0.001). CONCLUSION: Semi-automated volumetric ADC measurements have higher reproducibility than manual ADC measurements in assessing tumor response to chemoradiotherapy in patients with esophageal adenocarcinoma.

Initial experiences of an enhanced recovery protocol in esophageal surgery.

BACKGROUND: A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery (ERAS) programs. Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce. We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease. METHODS: The ERAS program was initiated in 2009. Patients who underwent esophagectomy and were treated according to the ERAS program were included. Items of ERAS included preoperative nutrition, early extubation, early removal of nasogastric tube, and early mobilization. Primary outcome parameters were hospital stay and the incidence of postoperative complications. Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol. A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient. RESULTS: Between 2008 and August 2010, 181 patients in our department underwent esophagectomy. Of these, 103 patients were included in the ERAS program (ERAS+ group) and were compared to 78 patients who had undergone an esophagectomy in 2008 (ERAS- group). Overall hospital stay was 14 days versus 15 days (ERAS+ and ERAS-, respectively; p = 0.013). There were no significant differences in the incidence of postoperative complications in either group. The percentage of achieved items varied between 42 and 93 % per item. CONCLUSIONS: The implementation of an ERAS program in esophageal surgery was feasible and resulted in a small but significant reduction in overall hospital stay, whereas overall morbidity was not affected.

PET/CT-based metabolic tumour volume for response prediction of neoadjuvant chemoradiotherapy in oesophageal carcinoma.

PURPOSE: Neoadjuvant chemoradiotherapy is increasingly used in oesophageal cancer patients. In general, small tumours are associated with a survival benefit compared to large tumours. Little is known, however, about the relationship between initial tumour volume and response to chemoradiotherapy. Therefore, the aim of this study was to determine whether the pretherapy metabolic tumour volume (MTV) on diagnostic PET/CT in oesophageal cancer patients is correlated with response to chemoradiotherapy in the resection specimen. METHODS: A consecutive series of patients underwent diagnostic PET/CT scanning prior to chemoradiotherapy and oesophagectomy. MTVs were determined on PET/CT and an automated tumour contour was generated using specified standard uptake value thresholds. Response to chemoradiotherapy was determined in the resection specimen according to the scoring system developed by Mandard et al. Patients were divided into different groups according to response to chemoradiotherapy. RESULTS: Between January 2008 and May 2011 a total of 115 patients underwent an oesophagectomy. The MTV determined on diagnostic PET/CT scans was available in 79 patients. Of these 79 patients, 30 (38 %) showed no residual tumour cells at the location of the primary tumour. Three of these patients presented with residual tumour cells in the lymph nodes; 27 patients (34 %) had a complete pathological response. There was a trend towards a better response in patients with a smaller MTV (p = 0.084). CONCLUSION: This study demonstrated a trend towards a correlation between response to chemoradiotherapy in oesophageal cancer patients and smaller MTVs as determined on diagnostic PET/CT prior to neoadjuvant chemoradiotherapy. However, tumour volumes overlapped between groups, indicating the need for multifactorial parameters as predictors. In addition, a complete local tumour response may be accompanied by residual disease in the regional lymph nodes.

Feasibility and effectiveness of pre-operative inspiratory muscle training in patients undergoing oesophagectomy: a pilot study.

BACKGROUND: Patients undergoing oesophageal surgery have a high risk for post-operative complications including pulmonary infections. Recently, physical therapy has shifted from the post-operative to the pre-operative phase to diminish post-operative complications and to shorten hospital stay. The purpose of this pilot study was to investigate the feasibility and initial effectiveness of pre-operative inspiratory muscle training (IMT) on the incidence of pneumonia in patients undergoing oesophagectomy. METHODS: A pragmatic non-randomized controlled trial was conducted among all patients who underwent an oesophagectomy between January 2009 and February 2010. Patients in the intervention group received IMT prior to surgery. Feasibility was assessed on the basis of the occurrence of adverse effects during testing or training and patient satisfaction. Initial effectiveness on respiratory function was evaluated by maximal inspiratory pressure (MIP) and endurance, the incidence of post-operative pneumonia and length of hospital stay. RESULTS: Eighty-three patients were included, of which 44 received pre-operative IMT. No adverse effects were observed. IMT was well tolerated and appreciated. In the intervention group, the median MIP and endurance improved significantly after IMT by 32% and 41%, respectively (p < 0.001). The incidence of post-operative pneumonia and the length of hospital stay were comparable for the intervention and the conventional care groups (pneumonia, 25% vs. 23% [p = 0.84]; hospitalization, 13.5 vs. 12 days [p = 0.08]). CONCLUSIONS: Pre-operative IMT is feasible in patients with oesophageal carcinoma and significantly improves respiratory muscle function. This, however, did not result in a reduction of post-operative pneumonia in patients undergoing oesophagectomy.

Results of the introduction of a minimally invasive esophagectomy program in a tertiary referral center.

BACKGROUND: Esophagectomy is accompanied by a high postoperative complication rate. Minimally invasive esophageal surgery appears to be a promising technique that might be associated with a lower pulmonary morbidity rate. The objective of this study was to describe the implementation of minimally invasive esophageal surgery in a tertiary referral center and to compare the results of our first series of minimally invasive esophagectomies (MIE) to conventional open esophagectomies. METHODS: MIE was implemented after several procedures had been proctored by a surgeon with extensive experience with MIE. Preoperative characteristics and the postoperative course of patients who underwent a transthoracic esophagectomy were prospectively registered. Morbidity and overall hospital stay were compared between minimally invasive and open resections performed in the same period. RESULTS: A total of 90 consecutive esophageal cancer patients underwent a transthoracic resection, 41 patients by means of a minimally invasive approach. Preoperative characteristics were comparable for both groups. The duration of surgery was longer in the MIE group (6.0 vs. 5.2 hours, P<0.001) and median blood loss was lower [100 vs. 500 mL (P<0.001)]. There was only a trend towards a shorter hospital stay in the MIE group (11 vs. 13 days, P=0.072), pulmonary complications occurred in 20% of patients in the MIE group vs. 31% in the open group (P=0.229). The overall complication rate was 51% in the MIE group vs. 63% in the open group, P=0.249. CONCLUSIONS: Implementation of MIE in our center was successful and it appears to be a safe technique for patients with potentially curable esophageal carcinoma.

[Outcomes of 16 years of oesophageal surgery: low postoperative mortality and improved long-term survival]. / Uitkomsten van 16 jaar oesofaguschirurgie: lage postoperatieve mortaliteit en verbeterde langetermijnoverleving.

OBJECTIVE: To assess trends in patient characteristics and treatment outcomes in a large cohort of patients who underwent oesophagectomy for oesophageal carcinoma in a tertiary referral centre over a period of 16 years. DESIGN: Retrospective cohort study. METHODS: We carried out a trend analysis on collected data on demographic and clinico-pathological characteristics, complications and survival of patients who underwent oesophagectomy between January 1993 and December 2008 at the Academic Medical Center in Amsterdam (AMC), the Netherlands. Patients were subsequently divided into three comparably-sized groups according to the year of operation: group 1 (1993-1998; n = 332), group 2 (1999-2004; n = 312), and group 3 (2005-2008; n = 296). RESULTS: A total of 940 patients underwent oesophagectomy during the total study period. Transhiatal oesophagectomy was performed more often during the first two time periods (65 and 64%, respectively), while the transthoracic approach was used more often in the third period (53%). The proportion of patients who underwent a microscopically radical resection increased significantly over the three periods of time. In-hospital mortality in all three periods was low, between 3.2%-3.4%. The three-year survival rate improved significantly over the three periods (p = 0.018), from 42% and 48% to 53% in the most recent period. CONCLUSION: Over the past 16 years in-hospital mortality in patients undergoing oesophagectomy for a potentially curable oesophageal carcinoma at the AMC, has been stably low. The total number of complications increased during these periods. Long-term survival improved during this time to a three-year overall survival of more than 50% in the most recent period.