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BACKGROUND: The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery. METHODS: A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups. RESULTS: Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period. CONCLUSIONS: Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.
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The relationship between 'bulky' locoregional lymphadenopathy and survival has not been investigated in the setting of esophageal adenocarcinoma (EAC). This study aimed to explore whether bulky regional lymphadenopathy at diagnosis affected survival outcomes in patients with EAC treated with neoadjuvant chemotherapy and en bloc resection. A single-center retrospective review of a prospectively maintained upper GI cancer surgical database was performed between January 2012 and December 2019. Patients with locally advanced EAC (cT2-3, N+, M0) treated with neoadjuvant docetaxel-based chemotherapy and transthoracic en bloc esophagogastrectomy were identified. Computed tomography scans from before the initiation of treatment were reviewed, and patients were stratified according to whether bulky loco-regional lymph nodes were present. This was defined as lymphadenopathy >2 cm in any axis. Overall survival was compared, and a Cox multivariate regression model was calculated. Two hundred twenty-five of the eight hundred seventy patients identified met the inclusion criteria. Forty-eight (21%) had bulky lymphadenopathy, leaving 177 allocated to the control group. More patients with bulky lymphadenopathy had ypN3 disease (18/48, 38% vs. 39/177, 20%, P = 0.025). Among patients with bulky lymphadenopathy, overall survival was generally worse (32.6 vs. 59.1 months, P = 0.012). However, among the 9/48 (19%) patients with bulky lymphadenopathy who achieved ypN- status survival outcomes were similar to those with non-bulky lymphadenopathy who also achieved lymph node sterilization. Poor differentiation (HR 1.8, 95% CI 1.0-2.9, P = 0.034), ypN+ (HR 1.9, 95% CI 1.1-3.6, P = 0.032), and bulky lymphadenopathy were independently associated with an increased risk of death (HR 1.7, 1.0-2.9, P = 0.048). Bulky regional lymphadenopathy is associated with a poor prognosis. Efforts to identify the ideal treatment regimen for these patients are urgently required.
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PURPOSE: Advanced imaging may augment the diagnostic milieux for presumed acute appendicitis (AA) during pregnancy, however it is not clear when such imaging modalities are indicated. The aim of this study was to assess the sensitivity and specificity of clinical scoring systems with the findings on magnetic resonance imaging (MRI) of AA in pregnant patients. METHODS: A retrospective cohort study between 2019 and 2021 was performed in two tertiary level centers. Pregnant patients presenting with suspected AA and non-diagnostic trans-abdominal ultrasound who underwent MRI as part of their evaluation were identified. Patient demographics, parity, gestation, presenting signs, and symptoms were documented. The Alvarado and Appendicitis Inflammatory Response (AIR) score for each patient were calculated and correlated with clinical and MRI findings. Univariate analysis was used to identify factors associated with AA on MRI. RESULTS: Of the 255 pregnant patients who underwent MRI, 33 (13%) had findings of AA. On univariate analysis, presentation during the second/third trimester, migration of pain, vomiting and RLQ tenderness correlated with MRI findings of AA. Whilst 5/77 (6.5%) of patients with an Alvarado score ≤4 had signs of AA on MRI, a score of ≥5 had a sensitivity, specificity, negative and positive predictive value of 84.8%, 36.6%, 94.0% and 17.2%. For an AIR score ≥ 5, this was 78.8%, 41.5%, 93.0%, and 16.7%, respectively. CONCLUSIONS: Whilst clinical scoring systems may be useful in identifying which pregnant patients require MRI to be performed when AA is suspected, the low sensitivity implies further research is needed to refine the use of this valuable resource.
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Background: The safety and efficacy of enhanced recovery after surgery (ERAS) following elective gastrectomy for gastric cancer in patients >80 years of age are not well described. The aim of this study was to explore whether an ERAS protocol following gastrectomy in this age group can be safely implemented and reduce postoperative length of stay. Methods: A retrospective, single-center analysis was performed. All patients >80 years of age with gastric cancer undergoing elective subtotal and total gastrectomy between January 2010 and December 2021 were identified. With the implementation of an ERAS protocol in January 2016, patients treated beforehand were allocated to Group A (pre-ERAS) and Group B (ERAS). The length of stay, incidence of postoperative complications and representation/readmission to the hospital were compared between the groups. Results: Of the 221 patients identified, 56 met the inclusion criteria with 22 patients (39.3%) allocated to Group A and 34 patients (60.7%) to Group B. There were no differences with regard to the type of resection and surgical approach. Length of stay was shorter in Group B (5 days, range 2-27 versus 10 days, 3-109, P = .040). A trend toward more discharges by postoperative day 3 was noted among patients in Group B (7/34, 20.6% versus 2/22, 9.1%, P = .253). There were no differences in the incidence of postoperative complications or readmission hospital between the groups. Conclusion: Among patients >80 years of age, ERAS following gastrectomy for cancer is associated with a reduced length of stay and can be safely implemented.
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Recuperação Pós-Cirúrgica Melhorada , Gastrectomia , Tempo de Internação , Complicações Pós-Operatórias , Neoplasias Gástricas , Humanos , Gastrectomia/métodos , Gastrectomia/efeitos adversos , Estudos Retrospectivos , Feminino , Masculino , Neoplasias Gástricas/cirurgia , Idoso de 80 Anos ou mais , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos EletivosRESUMO
BACKGROUND: Survival among patients with esophageal cancer with stage IV nonregional lymphadenopathy treated with neoadjuvant therapy and surgical resection is not well described. This study aimed to compare the survival outcomes of patients with nonregional lymphadenopathy with a propensity-matched cohort of patients with locoregional disease. METHODS: This was a retrospective cohort analysis of a prospectively maintained database from a regional upper gastrointestinal cancer network in Quebec, Canada. From January 2010 to December 2022, patients with radiologically suspicious nonregional retroperitoneal or supraclavicular lymphadenopathy were identified. Using 1:1 propensity score matching, a control group without nonregional disease was created. RESULTS: Of the 1235 patients identified, 39 met the inclusion criteria and were allocated to the study group of whom 35 of 39 (89%) had adenocarcinoma. Retroperitoneal and supraclavicular lymphadenopathy occurred in 26 of 39 patients (67%) and 13 of 39 patients (33%). Of the 39 patients, 34 (87%) received neoadjuvant chemotherapy, and 5 (13%) received chemoradiotherapy. After resection, ypN0 of nonregional lymph node stations occurred in 21 of 39 patients (54%). When comparing the study group with a matched non-stage IV control group, the median overall survival was similar in patients with retroperitoneal lymphadenopathy (21.0 months [95% CI, 8.0-21.0] vs 27.0 months [95% CI, 13.0-41.0]; P = .262) but not with supraclavicular disease (13.0 months; 95% CI, 8.0-18.0; P = .039). The median follow-up intervals were 40.1 months (95% CI, 1.0-83.0) for the study group and 70.0 (95% CI, 33.0-106.0) for the control groups. CONCLUSION: Compared with a matched cohort of patients with similar disease burden but not stage IV disease, retroperitoneal lymphadenopathy did not negatively affect survival outcomes. Multimodal curative intent therapy may be appropriate in select cases.
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Adenocarcinoma , Neoplasias Esofágicas , Linfadenopatia , Terapia Neoadjuvante , Estadiamento de Neoplasias , Pontuação de Propensão , Humanos , Neoplasias Esofágicas/terapia , Neoplasias Esofágicas/mortalidade , Neoplasias Esofágicas/patologia , Masculino , Feminino , Pessoa de Meia-Idade , Estudos Retrospectivos , Idoso , Linfadenopatia/terapia , Adenocarcinoma/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Terapia Neoadjuvante/estatística & dados numéricos , Esofagectomia , Taxa de Sobrevida , Quebeque/epidemiologiaAssuntos
Adenocarcinoma , Neoplasias Esofágicas , Imunoterapia , Terapia Neoadjuvante , Humanos , Neoplasias Esofágicas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/tratamento farmacológico , Adenocarcinoma/terapia , Adenocarcinoma/patologia , Adenocarcinoma/tratamento farmacológico , Imunoterapia/métodos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Prognóstico , Esofagectomia , Taxa de SobrevidaRESUMO
BACKGROUND: Changing adherence over time to enhanced recovery after surgery (ERAS) protocols following radical gastrectomy and the impact this has on length of stay (LoS) is not well described. This study aimed to explore the changes in adherence to core ERAS elements over time and the relationship between compliance and LoS. METHODS: A retrospective, single center cohort study was performed between 01/2016-12/2021. An ad hoc analysis revealed the point at which a significant difference in the number of patients being discharge on postoperative day (PoD) 3 was noted allowing allocation of patients to Group A (01/2016-12/2019) or B (01/2020-12/2021). Compliance with core ERAS elements was compared and the relationship between compliance and discharge by (PoD) 3 assessed. Variables significant on univariate analysis were assessed using binary multivariate regression. RESULTS: Of the 268 patients identified, 187 met the inclusion criteria (Group A 112 and Group B 75). More patients in Group B mobilized on PoD 1 (60.0 vs. 31.3%, p = <0.001), tolerated postgastrectomy diet by PoD 3 (84.6 vs. 62.5%, p = 0.049), and were discharged by PoD 3 (34.7 vs. 20.5%, p = 0.002). Protocol compliance of >75% was associated with discharge on PoD 3 (area under the curve, 0.726). Active mobilization on PoD 1 (OR 3.5, p = 0.009), compliance ≥75% (OR 3.3, p = 0.036), and preoperative nutritional consult (OR 0.2, p = 0.002) were independently associated with discharge on PoD 3. Discharge on PoD 3 did not increase readmission or representation to hospital. CONCLUSION: Early mobilization, protocol compliance >75%, and preoperative nutritional consult were associated with discharge on PoD 3 after radical gastrectomy.
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Recuperação Pós-Cirúrgica Melhorada , Gastrectomia , Tempo de Internação , Cooperação do Paciente , Neoplasias Gástricas , Humanos , Gastrectomia/métodos , Masculino , Feminino , Tempo de Internação/estatística & dados numéricos , Estudos Retrospectivos , Pessoa de Meia-Idade , Recuperação Pós-Cirúrgica Melhorada/normas , Idoso , Cooperação do Paciente/estatística & dados numéricos , Neoplasias Gástricas/cirurgia , Fidelidade a Diretrizes/estatística & dados numéricos , Fatores de Tempo , Alta do Paciente/estatística & dados numéricosRESUMO
BACKGROUND: Video-assisted thoracic surgery (VATS) can be performed through 1 or more intercostal or subxiphoid ports. The aim of this study was to evaluate whether number and location of ports had an impact on early perioperative outcomes and postoperative pain after anatomical lung resection (ALR). METHODS: A search of the departmental electronic database identified all patients who underwent VATS ALR between June 2018 and June 2019. We stratified patients according to the surgical approach: 2-port VATS, 3-port VATS, and subxiphoid VATS. We extracted demographic and clinicopathologic data. We used univariate analysis with unpaired t tests and χ2 tests to compare these variables between the subgroups. RESULTS: We included 201 patients in the analysis. When patients were stratified by surgical approach, there was no difference in terms of age, disease load, length of surgery, postoperative complications, duration of pleural drainage, and length of hospital stay. Postoperative pain and morphine equivalent usage were also comparable between the groups. According to these results, number and location of VATS ports seemingly has no clinical impact on early postoperative outcomes. Limitations of the study include its retrospective nature, small sample size, and short follow-up interval. CONCLUSION: Our results suggest that incision location and the number of VATS ports is not associated with differences in the incidence of perioperative complications or postoperative pain. Given the limitations described above, further studies with longer follow-up intervals are required to explore the lasting impact of this surgical approach on quality of life.
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Neoplasias Pulmonares , Cirurgia Torácica Vídeoassistida , Humanos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos , Estudos Retrospectivos , Qualidade de Vida , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/etiologia , Pulmão/patologia , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologiaRESUMO
BACKGROUND: This study evaluated the perioperative outcomes for patients who had locally advanced esophageal adenocarcinoma (EAC) treated with neoadjuvant immunotherapy (IO) and chemotherapy versus a matched cohort of patients who received neoadjuvant chemotherapy (NAC) alone. METHODS: A single-center non-randomized phase 2 trial was undertaken with locally advanced (cT3-4 and/or N+) EAC, and 49 patients completed neoadjuvant avelumab + docetaxel, cisplatin, 5FU (DCF) and esophagectomy between February 2018 and February 2020. These patients were matched with contemporary patients (January 2018 to June 2020) who met the inclusion criteria but received neoadjuvant chemotherapy alone (NAC) with a comparable docetaxel-based therapy. The postoperative outcomes then were compared between the two groups. RESULTS: For this study, 99 patients with locally advanced EAC underwent esophagectomy and met the enrolment criteria. Of these patients, 50 received NAC alone and 49 received IO + NAC. Baseline characteristics such as age, gender, and clinical stage were comparable between the two groups. Operative approach and rate of minimally invasive esophagectomy (~ 60%) were similar in the two groups. For the NAC-alone and IO + NAC groups, the respective overall and major complication rates were similar between the two groups (50% vs. 51% [p = 0.91] and 20% vs. 26% [p = 0.44], respectively), with concordant rates for anastomotic leak (6 [12%] vs. 6 [12%]; p = 0.86) and respiratory complications (13 [26%] vs. 11 [22%]; p = 0.68). The two groups did not differ significantly in terms of hospital length of stay or 30- and 90-day mortality rates. CONCLUSION: The addition of immunotherapy to neoadjuvant chemotherapy for locally advanced esophageal adenocarcinoma does not appear to alter perioperative short-term outcomes significantly after esophagectomy.
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Adenocarcinoma , Protocolos de Quimioterapia Combinada Antineoplásica , Docetaxel , Neoplasias Esofágicas , Esofagectomia , Terapia Neoadjuvante , Humanos , Neoplasias Esofágicas/terapia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/mortalidade , Masculino , Feminino , Terapia Neoadjuvante/mortalidade , Adenocarcinoma/terapia , Adenocarcinoma/patologia , Adenocarcinoma/mortalidade , Pessoa de Meia-Idade , Esofagectomia/mortalidade , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Taxa de Sobrevida , Idoso , Seguimentos , Docetaxel/administração & dosagem , Imunoterapia/métodos , Cisplatino/administração & dosagem , Prognóstico , Fluoruracila/administração & dosagem , Quimioterapia Adjuvante , Complicações Pós-OperatóriasRESUMO
BACKGROUND: The incidence of adverse events (AEs) and length of stay (LOS) varies significantly following paraesophageal hernia surgery. We performed a Canadian multicenter positive deviance (PD) seminar to review individual center and national level data and establish holistic perioperative practice recommendations. METHODS: A national virtual PD seminar was performed in October 2021. Recent best evidence focusing on AEs and LOS was presented. Subsequently, anonymized center-level AE and LOS data collected between 01/2017 and 01/2021 from a prospective, web-based database that tracks postoperative outcomes was presented. The top two performing centers with regards to these metrics were chosen and surgeons from these hospitals discussed elements of their treatment pathways that contributed to these outcomes. Consensus recommendations were then identified with participants independently rating their level of agreement. RESULTS: Twenty-eight surgeons form 8 centers took part in the seminar across 5 Canadian provinces. Of the 680 included patients included, Clavien-Dindo grade I and II/III/IV/V complications occurred in 121/39/12/2 patients (17.8%/5.7%/1.8%/0.3%). Respiratory complications were the most common (effusion 12/680, 1.7% and pneumonia 9/680, 1.3%). Esophageal and gastric perforation occurred in 7 and 4/680, (1.0% and 0.6% respectively). Median LOS varied significantly between institutions (1 day, range 1-3 vs. 7 days, 3-8, p < 0.001). A strong level of agreement was achieved for 10/12 of the consensus statements generated. CONCLUSION: PD seminars provide a supportive forum for centers to review best evidence and experience and generate recommendations based on expert opinion. Further research is ongoing to determine if this approach effectively accomplishes this objective.
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Hérnia Hiatal , Laparoscopia , Humanos , Hérnia Hiatal/cirurgia , Hérnia Hiatal/complicações , Estudos Prospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Canadá , Tempo de Internação , Laparoscopia/efeitos adversosRESUMO
BACKROUND: Real-world, long-term survival outcomes of neoadjuvant, docetaxel-based therapy for esophageal and junctional adenocarcinoma are lacking. This study describes the long-term survival outcomes of patients with esophageal and junctional adenocarcinoma treated with neoadjuvant docetaxel-based chemotherapy and en bloc transthoracic esophagectomy. METHODS: A retrospective cohort analysis of a prospectively maintained database from a regional upper gastrointestinal cancer network in Quebec, Canada, was performed. From January 2007 to December 2021, all patients with locally advanced (cT3 and/or N1) esophageal/Siewert I/II adenocarcinoma treated with neoadjuvant DCFx3 (Docetaxel/Cisplatin/5FU) or FLOTx4 (5FU/Leucovorin/Oxaliplatin/Docetaxel) and transthoracic en bloc esophagectomy were identified. Postoperative, pathological, and survival outcomes were compared. RESULTS: Overall, 236 of 420 patients met the inclusion criteria. Tumor location was esophageal/Siewert I/Siewert II (118/33/85), most were cT3-4 (93.6%) and cN+ (61.0%). DCF and FLOT were used in 127 of 236 (53.8%) and 109 of 236 (46.2%). All neoadjuvant cycles were completed in 87.3% with no difference between the regimens. Operative procedures included Ivor Lewis (81.8%), left thoraco-abdominal esophagectomy (10.6%) and McKeown (7.6%) with an R0 resection in 95.3% and pathological complete response in 9.7% (DCF 12.6%/FLOT 6.4%, p = 0.111). The median lymph node yield was 32 (range 4-79), and 60.6% were ypN+. Median follow-up was longer for the DCF group (74.8 months 95% confidence interval [CI] 4-173 vs. 37.8 months 95% CI 2-119, p <0.001. Overall survival was similar between the groups (FLOT 97.3 months, 78.6-115.8 vs. DCF 92.9, 9.2-106.5, p = 0.420). CONCLUSIONS: Neoadjuvant DCF and FLOT followed by transthoracic en bloc resection are both highly effective regimens for locally advanced esophageal adenocarcinoma with equivalent survival outcomes despite high disease load.
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Adenocarcinoma , Neoplasias Esofágicas , Humanos , Docetaxel , Terapia Neoadjuvante/métodos , Estudos Retrospectivos , Esofagectomia/métodos , Estadiamento de Neoplasias , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/cirurgia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/patologia , Fluoruracila , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , CisplatinoRESUMO
BACKGROUND: Management following endoscopic submucosal dissection (ESD) of pT1b esophageal adenocarcinoma (EAC) remains controversial. This study compared pathological and survival outcomes of patients after endoscopic resection (ER) of pT1b EAC followed by either en bloc esophagectomy or observation. METHODS: From 1/12 to 12/22, all patients with pT1b EAC treated with ER were identified from a prospectively maintained departmental database. ESD was curative (all of: Submucosal invasion < 500 µm; G1/2, LVI/PNI-; deep margin-) or non-curative (one or more of Submucosal invasion ≥ 500 µm; G3; LVI/PNI+; deep margin+). Patients were allocated to observation (OBS) or esophagectomy (SURG) based on patient factors/preference and pathological variables. RESULTS: 56/171 ERs met the inclusion criteria. ER was curative in 8/56 (14%) and non-curative in 48/56 (86%). OBS was undertaken after 8/27 (30%) curative and 19/27 (70%) non-curative resections. All 29 SURG patients had non-curative ERs and were younger, had lower Charlson comorbidity scores and had more deep margin + lesions than OBS patients. Post-esophagectomy, 15/29 (52%) had no residual disease within the surgical specimen while pT+N-/pT-N+/pT+N+ occurred in 5/3/6 (17%/10%/21%) patients. Of those with residual disease in the surgical specimen, 12/14 (86%) had deep margin + ERs; however, only ESD instead of EMR was independently associated with a lower risk of residual disease (OR 0.431, 95% CI - 0.016 to 1.234, p = 0.045). OBS and SURG patients had equivalent overall survival outcomes and recurrence was low in both groups even following non-curative ER. Follow-up was 28 months (0-102) and 30 months (0-97), respectively. CONCLUSION: In select patients, including some of those with a non-curative ESD resection of pT1B EAC, surveillance alone may be appropriate. Alternatives beyond traditional pathological features is needed to direct patient care more accurately.
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Adenocarcinoma , Ressecção Endoscópica de Mucosa , Neoplasias Esofágicas , Humanos , Esofagectomia , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/patologia , Adenocarcinoma/cirurgia , Adenocarcinoma/patologia , Estudos Retrospectivos , Resultado do Tratamento , Recidiva Local de Neoplasia/cirurgiaRESUMO
The treatment paradigm for patients with stage II/III non-small-cell lung cancer (NSCLC) is rapidly evolving. We performed a modified Delphi process culminating at the Early-stage Lung cancer International eXpert Retreat (ELIXR23) meeting held in Montreal, Canada, in June 2023. Participants included medical and radiation oncologists, thoracic surgeons and pathologists from across Quebec. Statements relating to diagnosis and treatment paradigms in the preoperative, operative and postoperative time periods were generated and modified until all held a high level of consensus. These statements are aimed to help guide clinicians involved in the treatment of patients with stage II/III NSCLC.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Neoplasias Pulmonares/cirurgia , Consenso , Canadá , QuebequeRESUMO
BACKGROUND: The perioperative and functional outcomes of patients with epiphrenic diverticula (ED) on a background of achalasia managed via a minimally invasive transabdominal approach are under-reported. We describe our center's experience over 10 years of treating such patients. METHODS: A single-center, retrospective chart of a prospectively maintained hospital database was performed. All patients with a diagnosis of ED and manometrically proven achalasia were identified. Demographic, clinical, and surgical data were extracted from the institution's medical records. Patients were stratified by whether they underwent myotomy only or myotomy plus diverticulectomy and compared in a univariate manner. RESULTS: There were 18 patients who met the inclusion criteria. The median age of the cohort was 67.1 years (range 53.1 to 77.8), the maximal size of the diverticula was 3.5 cm (range 2.0 to 7.0), and the distance of the proximal lip of the diverticulum to the incisors was 33.5 cm (range 28.0 to 38.0). In terms of surgical intervention, 14 patients (77.8%) underwent myotomy plus diverticulectomy, and 4 (22.2%) underwent myotomy alone. The duration of surgery was significantly longer in the former (177.5 vs. 75.0 min, P =0.031). In total, 9/18 (50.0%) of patients were discharged on the day of surgery. There was a trend to more major postoperative complications following diverticulectomy plus myotomy, with 2/13 (15.4%) patients suffering staple line leaks. Excellent long-term functional outcomes were achieved, with 81.3% of patients having sustained resolution of their symptoms. CONCLUSIONS: Laparoscopic transabdominal approach for the treatment of ED offers an acceptable risk profile and favorable functional outcomes in patients with underlying achalasia.
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Divertículo Esofágico , Acalasia Esofágica , Laparoscopia , Idoso , Humanos , Pessoa de Meia-Idade , Divertículo Esofágico/complicações , Divertículo Esofágico/cirurgia , Acalasia Esofágica/complicações , Acalasia Esofágica/cirurgia , Fundoplicatura , Estudos Retrospectivos , Resultado do TratamentoAssuntos
Adenocarcinoma , Neoplasias Esofágicas , Humanos , Terapia Neoadjuvante , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/patologia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/patologia , Quimioterapia Adjuvante , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêuticoRESUMO
Lymph nodes (LNs) are frequently the first sites of metastasis. Currently, the only prognostic LN assessment is determining metastatic status. However, there is evidence suggesting that LN metastasis is facilitated by the formation of a pre-metastatic niche induced by tumour derived extracellular vehicles (EVs). Therefore, it is important to detect and modify the LN environmental changes. Earlier work has demonstrated that neutrophil extracellular traps (NETs) can sequester and promote distant metastasis. Here, we first confirmed that LN NETs are associated with reduced patient survival. Next, we demonstrated that NETs deposition precedes LN metastasis and NETs inhibition diminishes LN metastases in animal models. Furthermore, we discovered that EVs are essential to the formation of LN NETs. Finally, we showed that lymphatic endothelial cells secrete CXCL8/2 in response to EVs inducing NETs formation and the promotion of LN metastasis. Our findings reveal the role of EV-induced NETs in LN metastasis and provide potential immunotherapeutic vulnerabilities that may occur early in the metastatic cascade.
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Armadilhas Extracelulares , Vesículas Extracelulares , Animais , Metástase Linfática/patologia , Células Endoteliais , Linfonodos/patologiaRESUMO
The outcomes of different treatment modalities for patients aged 80 and above with locally advanced and resectable esophageal carcinoma are not well described. The aim of this study was to explore survival and perioperative outcomes among this specific group of patients. A retrospective, cohort analysis was performed on a prospectively maintained esophageal cancer database from the McGill regional upper gastroinestinal cancer network. Between 2010 and 2020, all patients ≥80 years with cT2-4a, Nany, M0 esophageal carcinoma were identified and stratified according to the treatment modality: Neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT); definitive CRT (dCRT); upfront surgery; palliative CT/RT; or best supportive care (BSC). Of the 162 patients identified, 79 were included in this study. The median age was 83 years (80-97), most were cT3 (73%), cN- (56%), and had adenocarcinoma (62%). Treatment included: nCT/nCRT (16/79, 20%); surgery alone (19/79, 24%); dCRT (12/29, 15%); palliative RT/CT (27/79, 34%); and BSC (5/79, 6%). Neoadjuvant treatment was completed in 10/16 (63%). Of the 35/79 who underwent surgery, major complications occurred in 13/35 (37%) and 90-day mortality in 3/35 (9%). Overall survival (OS) for the cohort at 1- and 3-years was 58% and 19%. Among patients treated with nCT/nCRT, this was 94% and 46% respectively. Curative intent treatment (nCT/nCRT/upfront surgery/dCRT) had significantly increased 1- and 3- year OS compared with non-curative treatment (76%/31% vs. 34%/3.3%). Multimodal standard of care treatment is feasible and safe in select octo/nonagenarians, and may be associated with improved OS. Age alone should not bias against treatment with curative intent.