EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias.

BACKGROUND: New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations. OBJECTIVE: To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. METHODS: We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. RESULTS: The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn . CONCLUSION: An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process. GUIDELINE REGISTRATION NUMBER: PREPARE-2023CN018.

The impact of an enhanced recovery after surgery pathway for video-assisted and robotic-assisted lobectomy on surgical outcomes and costs: a retrospective single-center cohort study.

To determine the impact of enhanced recovery after surgery (ERAS) pathway implementation on outcomes and cost of robotic- and video-assisted thoracoscopic (RATS and VATS) lobectomy. Retrospective review of 116 consecutive VATS and RATS lobectomies in the pre-ERAS (Oct 2018-Sep 2019) and ERAS (Oct 2019-Sep 2020) period. Multivariate analysis was used to determine the impact of ERAS and operative approach alone, and in combination, on length of hospital stay (LOS) and overall cost. Operative approach was 49.1% VATS, 50.9% RATS, with 44.8% pre-ERAS, and 55.2% ERAS (median age 68, 65.5% female). ERAS patients had shorter LOS (2.22 vs 3.45 days) and decreased total cost ($15,022 vs $20,155) compared with non-ERAS patients, while RATS was associated with decreased LOS (2.16 vs 4.19 days) and decreased total cost ($14,729 vs $20,484) compared with VATS. The combination of ERAS + RATS showed the shortest LOS and the lowest total cost (1.35 days and $13,588, P < 0.001 vs other combinations). On multivariate analysis, ERAS significantly decreased LOS (P = 0.001) and total cost (P = 0.003) compared with pre-ERAS patients; RATS significantly decreased LOS (P < 0.001) and total cost (P = 0.004) compared with VATS approach. ERAS implementation and robotic approach were independently associated with LOS reduction and cost savings in patients undergoing minimally invasive lobectomy. A combination of ERAS and RATS approach synergistically decreases LOS and overall cost.

UEG and EAES rapid guideline: Update systematic review, network meta-analysis, CINeMA and GRADE assessment, and evidence-informed European recommendations on surgical management of GERD.

BACKGROUND: There are several options for the surgical management of GERD in adults. Previous guidelines and systematic reviews have compared the effects of total fundoplication versus pooled effects of different techniques of partial fundoplication. OBJECTIVE: To develop evidence-informed, trustworthy, pertinent recommendations on the use of total, posterior partial and anterior partial fundoplications for the management of GERD in adults. METHODS: We performed an update systematic review, network meta-analysis, and evidence appraisal using the GRADE and the Confidence in Network Meta-Analysis methodologies. An international, multidisciplinary panel of surgeons, gastroenterologists, and a patient representative reached unanimous consensus through an evidence-to-decision framework to select among multiple interventions, and a Delphi process to formulate the recommendation. The project was developed in an online authoring and publication platform (MAGICapp), and was overseen by an external auditor. RESULTS: We suggest posterior partial fundoplication over total posterior or anterior 90° fundoplication in adult patients with GERD. We suggest anterior >90° fundoplication as an alternative, although relevant comparative evidence is limited (weak recommendation). The guideline, with recommendations, evidence summaries and decision aids in user friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/j20X4n. CONCLUSION: This rapid guideline was developed in line with highest methodological standards and provides evidence-informed recommendations on the surgical management of GERD. It provides user-friendly decision aids to inform healthcare professionals' and patients' decision making.

Assessment of Health Related Quality of Life and Digestive Symptoms in Long-term, Disease Free Survivors After Esophagectomy.

OBJECTIVE: The aim of this study was to investigate long-term HRQOL and symptom evolution in disease free patients up to 20 years after esophagectomy. BACKGROUND: Esophagectomy has been associated with decreased HRQOL and persistent gastrointestinal symptoms. METHODS: The study cohort was identified from 2 high volume centers for the management of esophageal cancer. Patients completed HRQOL and symptom questionnaires, including: Digestive Symptom Questionnaire, EORTC QLQ-C30, EORTC QLQ-OG25 Euro QoL 5D, and SF36. Patients were assessed in 3 cohorts: <1 year; 1-5 years, and; >5 years after surgery. RESULTS: In total 171 of 222 patients who underwent esophagectomy between 1991 and 2017 who met inclusion criteria and were contactable, responded to the questionnaires, corresponding to a response rate of 77%. Median age was 66.2 years, and median time from operation to survey was 5.6 years (range 0.3-23.1). Early satiety was the most commonly reported symptom in all patients irrespective of timeframe (87.4%; range 82%-92%). Dysphagia was seen to decrease over time (58% at <2 years; 28% at 2-5 years; 20% at >5 years; P = 0.013). Weight loss scores demonstrated nonstatistical improvement over time. All other symptom scores including heartburn, regurgitation, respiratory symptoms, and pain scores remained constant over time. Average HRQOL did not improve from levels 1 year after surgery compared to patients up to 23 years after esophagectomy. CONCLUSION: With the exception of dysphagia, which improved over time, esophagectomy was associated with decreased HRQOL and lasting gastrointestinal symptoms up to 20 years after surgery. Pertinently however long-term survivors after oesophagectomy demonstrated comparable to improved HRQOL compared to the general population. The impact of esophagectomy on gastrointestinal symptoms and long-term HRQOL should be considered when counseling and caring for patients undergoing esophagectomy.

Quality of life and symptom assessment in paraesophageal hernias: a systematic literature review of reporting standards.

BACKGROUND: Paraesophageal hernias (PEH) present with a range of symptoms affecting physical and mental health. This systematic review aims to assess the quality of reporting standards for patients with PEH, identify the most frequently used quality of life (QOL) and symptom severity assessment tools in PEH and to ascertain additional symptoms reported by these patients not captured by these tools. METHODS: A systematic literature review according to PRISMA protocols was carried out following a literature search of MEDLINE, Embase and Cochrane databases for studies published between January 1960 and May 2020. Published abstracts from conference proceedings were included. Data on QOL tools used and reported symptoms were extracted. RESULTS: This review included 220 studies reporting on 28 353 patients. A total of 46 different QOL and symptom severity tools were used across all studies, and 89 different symptoms were reported. The most frequently utilized QOL tool was the Gastro-Esophageal Reflux Disease-Health related quality of life questionnaire symptom severity instrument (47.7%), 57.2% of studies utilized more than 2 QOL tools and 'dysphagia' was the most frequently reported symptom, in 55.0% of studies. Notably, respiratory and cardiovascular symptoms, although less common than GI symptoms, were reported and included 'dyspnea' reported in 35 studies (15.9%). CONCLUSIONS: There lacks a QOL assessment tool that captures the range of symptoms associated with PEH. Reporting standards for this cohort must be improved to compare patient outcomes before and after surgery. Further investigations must seek to develop a PEH specific tool, that encompasses the relative importance of symptoms when considering surgical intervention and assessing symptomatic improvement following surgery.

Comparison of costs and short-term clinical outcomes of per-oral endoscopic myotomy and laparoscopic Heller myotomy.

OBJECTIVE: Per-Oral Endoscopic Myotomy (POEM) has seen increasing application and comparisons to laparoscopic Heller myotomy (LHM). The aim of the present study was to compare perioperative and short-term outcomes, and costs between the two procedures at a single institution. METHODS: Fifty-one consecutive patients documented in a prospective IRB approved database from January 2014 to December 2017 were included. Perioperative data, pre-operative and 3-month postoperative Eckardt Scores, and cost data were compared. RESULTS: Median hospital stay was comparable between POEM and LHM (1 day each). Complications were minor (Clavien-Dindo 1, 2) and rare in both groups. Median Eckardt scores improved significantly after POEM (5 to 0) and LHM (5 to 0). Normalized median costs were comparable: 14 201 USD (POEM) vs. 13 328 USD (LHM) p = 0.45. CONCLUSIONS: POEM demonstrates comparable clinical outcomes and costs to LHM. Long-term issues related to GERD require ongoing assessment in POEM patients. SUMMARY: In patients with achalasia, extended myotomy of the lower esophageal sphincter offers excellent palliation of symptoms. In the last decades, laparoscopic Heller myotomy (LHM) has been the gold standard. Over the past decade, per-oral endoscopic myotomy (POEM) has seen wide application in specialized centers worldwide. In our patient cohort, we demonstrate, that POEM can be introduced with similar outcomes and costs compared to LHM.

Selective Epidurography for the Assessment of Epidural Catheter Placement After Esophagectomy.

BACKGROUND: Adequate pain control immediately after esophagostomy is critical to patient recovery and may be compromised by uncertainty regarding correct epidural catheter placement. The aim of the current study was to determine the role of performing an epidurogram in selective patients to assess epidural placement after esophagectomy. METHODS: Patients undergoing esophagectomy in a high-volume center were retrospectively reviewed to identify those in whom an epidurogram was performed less than 24 hours after surgery. Since 2012 epidurograms have been selectively performed in patients and have demonstrated features concerning for incorrect epidural catheter placement, including difficult/complicated insertion, negative sensory test, nonreassuring intraoperative hemodyamic response, and inadequate postoperative pain control. RESULTS: Fifty-two of 192 patients (27%; 43 men; age 65 ± 11 years) who underwent esophagostomy since 2012 had an epidurogram. Epidurograms were not associated with any adverse events. In 21 patients (40%) epidurogram findings led to a direct change in patient management, prompting either removal/replacement of an incorrectly sited catheter (n = 9), partial withdrawal of a catheter associated with unilateral contrast distribution (n = 2), or by endorsing a clinical decision to modify the analgesic regimen in a patient with a correctly sited epidural catheter (n = 10). Identifying and rescuing incorrect epidural catheter placement was not associated with longer intensive care unit/hospital stay or postoperative morbidity (p > 0.05) CONCLUSIONS: We reviewed selective epidurogram use in esophagectomy patients to determine its role in "rescuing" inadequate pain control through expediting clinical decision-making. Findings confirm that in selected patients epidurography is feasible and has the potential to directly contribute to patient care.

Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis.

BACKGROUND: Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma. METHODS: Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015. RESULTS: Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001). CONCLUSIONS: Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.

Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs.

BACKGROUND: After esophagectomy, some patients exceed targeted discharge goal within enhanced recovery after surgery programs. This study reviews the demographics, outcomes, cost, readmission rates, and patient satisfaction for the accelerated recovery (AR) group. METHODS: Between 2010 and 2013, 137 consecutive esophagectomy patients were compared according to the length of hospital stay: AR 5 to 6 days, targeted recovery (TR) 7 to 8 days, and delayed recovery (DR) 9 days or more. RESULTS: The AR patients increased from 3% to 46% during the study period. The AR patients were younger, but all groups were comparable regarding comorbidities (Charlson, American Society of Anesthesiologists, and Eastern Cooperative Oncology Group score), cancer stage, and treatment approach. The AR patients were more likely to have neoadjuvant therapy, shorter operations, and less blood loss. The DR patients were more likely to have complications (40% AR versus 45% TR versus 90% DR, p < 0.001). Inhospital and 90-day mortality was 1.5%. All AR patients were discharged home (100% AR versus 87% TR versus 63% DR, p < 0.001), and 30-day readmission rates were comparable between groups (14% AR versus 19% TR versus 5% DR, p = 0.122). Overall mean costs ($38,385 AR versus $41,607 TR versus $61,199 DR, p < 0.001) as well as readmission costs ($7,470 AR versus $27,695 TR versus $33,398 DR, p = 0.202) were lower in the AR group. Patient satisfaction scores were comparable between groups. CONCLUSIONS: Accelerated recovery is achievable in a significant proportion of patients undergoing esophagectomy. Accelerated recovery is associated with decreased treatment costs but does not lead to increased readmissions or decreased patient satisfaction. Enhanced recovery after surgery programs should be designed to accommodate patients appropriate for AR.

Outcomes of Surgical Resection of T1bN0 Esophageal Cancer and Assessment of Endoscopic Mucosal Resection for Identifying Low-Risk Cancers Appropriate for Endoscopic Therapy.

BACKGROUND: Invasive esophageal cancers have been managed historically with esophagectomy. Low-risk T1b patients are being proposed for nonsurgical management. The purpose of this study was to evaluate the ability of endoscopic mucosal resections (EMR) to identify low-risk T1b patients and to review surgical treatment outcomes for T1b cancer. METHODS: All esophageal cancer patients, in an institutional review board-approved prospective database, between 2000 and 2013 with clinical stage (cT1bN0), pathological stage (pT1bN0), and no neoadjuvant therapy were retrospectively reviewed. RESULTS: Fifty-one patients, 38 pT1b and 13 cT1b, were assessed. All cT1b had preoperative EMR and five were found to be understaged at esophagectomy. pT1bN0 patients had a mean age of 66 years, mean BMI of 30, and 95 % had adenocarcinoma. Thirty-eight pT1bN0 patients underwent esophagectomy with a median hospital length of stay (LOS) of 9 days. Complications occurred in 14 patients, but 71 % were minor (Accordion score 1-2). In-hospital 30- and 90-day mortality was zero. EMR specimens were re-reviewed to assess low-risk criteria. Degree of differentiation and the presence of lymphovascular invasion could be assessed in all EMR specimens; however, assessment of submucosal invasion limited to the superficial submucosal layer could not be determined in the majority of cases. Kaplan-Meier 5-year overall survival in pT1bN0 patients was 78.7 %. CONCLUSIONS: Clinical staging of superficial esophageal cancer can be inaccurate especially in submucosal tumors. EMR should be routinely used for preoperative staging. Healthy patients with clinical tumor stage greater than cT1a should undergo multidisciplinary review and be considered for surgical resection.

Lung resection outcomes and costs in Washington State: a case for regional quality improvement.

BACKGROUND: A regional quality improvement effort does not exist for thoracic surgery in the United States. To initiate the development of one, we sought to describe temporal trends and hospital-level variability in associated outcomes and costs of pulmonary resection in Washington (WA) State. METHODS: A cohort study (2000-2011) was conducted of operated-on lung cancer patients. The WA State discharge database was used to describe outcomes and costs for operations performed at all nonfederal hospitals within the state. RESULTS: Over 12 years, 8,457 lung cancer patients underwent pulmonary resection across 49 hospitals. Inpatient deaths decreased over time (adjusted p-trend=0.023) but prolonged length of stay did not (adjusted p-trend=0.880). Inflation-adjusted hospital costs increased over time (adjusted p-trend<0.001). Among 24 hospitals performing at least 1 resection per year, 5 hospitals were statistical outliers in rates of death (4 lower and 1 higher than the state average), and 13 were outliers with respect to prolonged length of stay (7 higher and 6 lower than the state average) and costs (5 higher and 8 lower than the state average). When evaluated for rates of death and costs, there were hospitals with fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs. CONCLUSIONS: Variability in outcomes and costs over time and across hospitals suggest opportunities to improve the quality and value of thoracic surgery in WA State. Examples from cardiac surgery suggest that a regional quality improvement collaborative is an effective way to meaningfully and rapidly act upon these opportunities.

Assessment of short-term clinical outcomes following salvage esophagectomy for the treatment of esophageal malignancy: systematic review and pooled analysis.

BACKGROUND: Combined chemoradiotherapy is increasingly being used as definitive treatment for locoregional esophageal malignancy. Patients with residual or recurrent localized cancer are often selectively considered for salvage esophagectomy (SALV). The aim of this pooled analysis was to compare short-term clinical outcomes from SALV following definitive chemoradiotherapy with those from planned esophagectomy following neoadjuvant chemoradiotherapy (NCRS). METHODS: MEDLINE, EMBASE, Cochrane, trial registries, conference proceedings and reference lists were searched for relevant comparative studies. Primary outcome measures were in-hospital mortality, anastomotic leak and pulmonary complications. Secondary outcomes were length of hospital stay, negative (R0) resection margin, and estimated blood loss. RESULTS: Eight studies comprising 954 patients; 242 (SALV) and 712 (NCRS) were included. SALV was associated with a significantly increased incidence of post-operative mortality (9.50 vs. 4.07 %; pooled odds ratio [POR] = 3.02; p < 0.001), anastomotic leak (23.97 vs. 14.47 %; POR = 1.99; p = 0.005), pulmonary complications (29.75 vs. 16.99 %; POR = 2.12; p < 0.001), and an increased length of hospital stay (weighted mean difference = 8.29 days; 95 % CI 7.08-9.5; p < 0.001). There were no significant differences between the groups in the incidence of negative resection margins or estimated blood loss. CONCLUSIONS: SALV has poorer short-term outcomes when compared with planned esophagectomy following neoadjuvant chemoradiotherapy. Patients and multidisciplinary tumor boards should be made aware of these differences in outcomes and SALV should be reserved for practice in high-volume institutions.

Update on clinical impact, documentation, and management of complications associated with esophagectomy.

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.

Pneumococcal vaccination programs and the burden of invasive pneumococcal disease in Ontario, Canada, 1995-2011.

BACKGROUND: In 1995, a publicly funded pneumococcal vaccination program for 23-valent polysaccharide vaccine (PPV23) was introduced in Ontario. Conjugate vaccines were authorized in 2001 (PCV7), 2009 (PCV10) and 2010 (PCV13). METHODS: From 1995-2011, active, population-based surveillance for invasive pneumococcal disease (IPD) was conducted in Metropolitan Toronto and Peel Region, Canada. RESULTS: 6404 IPD cases were included. After PPV23 program implementation in 1995, IPD due to PPV23 strains decreased 49% in older adults prior to PCV7 introduction. Estimated PPV23 efficacy in vaccine eligible adults was 42.2% (95% CI; 28.6-53.2%). IPD incidence due to PCV7 serotypes in children <5 years decreased significantly after PCV7 authorization and before introduction of a publicly funded PCV7 program. Seven years after PCV7 program implementation, the incidence of IPD due to PCV7 serotypes decreased to zero in children and by 88% in adults, however, overall IPD incidence remained unchanged in adults. In 2011, the incidence of IPD was 4.5 per 100,000 in adults aged 15-64 and 19.9 per 100,000 in adults aged over 65 years, with 45 serotypes causing disease. Between 1995 and 2011, the case fatality rate of IPD in adults decreased 2% per year (95% CI, -0.9% to -3.2%). In multivariable analysis, predictors of mortality included older age, chronic conditions, nursing home residence, current smoking, bacteraemia, and illness due to serotypes 3,11A, 19A, and 19F. CONCLUSIONS: While vaccination programs resulted in substantial public health benefits, herd immunity benefits of PCV7 were seen at low pediatric vaccination rates, and the case fatality rate of IPD has decreased, IPD will continue to be a cause of considerable morbidity and mortality in adults.

The clinical and economic costs of delirium after surgical resection for esophageal malignancy.

OBJECTIVE: The aim of this study was to identify preoperative risk factors and postoperative consequences that are associated with the occurrence of delirium after esophagectomy for malignancy. BACKGROUND: Delirium is an underdiagnosed, serious complication after major surgery, particularly in the elderly population. METHODS: All patients undergoing esophagectomy for cancer (1991-2011) were included. Patients with and without delirium were compared with respect to medical comorbidities, use of neoadjuvant therapy, operative outcomes, postoperative complications, overall cost, and survival. RESULTS: Of the 500 patients included in this analysis, 46 (9.2%) patients developed postoperative delirium. Patients with delirium had higher ASA and Charlson comorbidity index scores. Delirium was associated with a longer hospital (14 ± 7.5 vs 10.9 ± 5.7; P < 0.05) and intensive care unit stay (3.6 ± 3.8 vs 2.7 ± 16.9; P < 0.05) and an increased incidence of pulmonary complications and increased hospital costs. Delirium was preceded by another complication in 32.6% of cases but by a septic complication in only 19.6% of cases. Age was the only preoperative predictor of postoperative delirium in multivariate modeling (P < 0.05). No differences were noted in the use of neoadjuvant chemoradiotherapy or survival. CONCLUSIONS: This study demonstrates that postoperative delirium is associated with a more complicated and costly recovery after esophagectomy and that age is independently predictive of its development. Delirium has often been thought to be the sequela of other complications; however, this study demonstrates that it presents in isolation or precedes other complications in 67.4% of cases. Focused screening will likely allow targeted preventative strategies to be used in the perioperative period to reduce complications and costs associated with delirium.

Outcomes assessment of the surgical management of esophageal cancer in younger and older patients.

BACKGROUND: The aim of this study was to assess the influence of age on disease presentation, clinical and pathologic staging, postoperative outcomes, costs, and long-term survival after esophagectomy for esophageal malignancy. METHODS: All patients undergoing esophagectomy for cancer between 1991 and 2011 were prospectively enrolled in an Institutional Review Board approved database. RESULTS: A total of 493 patients underwent surgical resection during the study period; 58 (11.76%) of these patients were 50 years or less (44 ± 4.7) and 435 patients were greater than 50 years (67 ± 8.44). There was no difference in clinical stage; however, patients 50 years or less were more likely to have adenocarcinoma and reduced Charlson comorbidity index and younger patients tended to have a more delayed presentation as manifested by an increased period of dysphagia and a greater degree of weight loss. In the 50 or less age group there was a significantly greater use of neoadjuvant therapy in stage II patients and the use of neoadjuvant chemotherapy significantly decreased with increasing age. Surgery in the 50 or less age group was associated with significantly reduced intensive care unit stay, incidence of postoperative complications, and overall costs. Multivariate analysis also confirmed associations between increasing age and increased incidence of postoperative complications and cost. There were no significant differences in pathologic stage, positive resection margins, incidence of complete response to neoadjuvant therapy, or in overall survival. CONCLUSIONS: This study demonstrates younger patients have fewer complications and lower overall treatment costs after esophagectomy. In spite of having a more delayed presentation, younger patients presented with a similar stage and demonstrated similar overall survival.

Accordion severity grading system: assessment of relationship between costs, length of hospital stay, and survival in patients with complications after esophagectomy for cancer.

BACKGROUND: The ability to assess and compare the impact of postoperative complications in major cancer surgery is currently limited. The Accordion Severity Grading System provides the opportunity to categorize complications according to treatment responses and resource use. STUDY DESIGN: A retrospective review of patient demographics, perioperative outcomes, and costs was performed using a prospective IRB-approved database of patients undergoing esophagectomy from 2000 to 2008. RESULTS: This study included 285 consecutive patients, 83% were male, and mean age was 63.7 years. Histology was predominantly adenocarcinoma (80%). For patients with invasive cancer, overall survival at 5 years was 50%. Mean overall cost and length of stay were $23,419 and 10.4 days, respectively. Neoadjuvant therapy was used in 156 patients (54.7%) and operative mortality rate was 0.7%. Complications were documented in 144 patients (50.5%), with Accordion grades assigned as 1 (29%), 2 (59%), 3 (3%), 4 (6%), 5 (2%), and 6 (0.7%). Accordion grade was significantly related to costs and length of stay in univariate (p < 0.005) and multivariate analyses (p < 0.005). There was a statistically significant difference in survival between those patients who did and did not experience complications; however, no significant differences were noted among individual Accordion grades. Cox regression multivariate analysis demonstrated a significant relationship between overall survival and occurrence of postoperative complications. CONCLUSIONS: The Accordion Severity Grading System provides a meaningful approach to classifying complications according to resource use, which also directly correlates with treatment costs and length of stay. Survival is affected by overall occurrence of complications, but was not related to individual Accordion grades in this study. The Accordion Severity Grading System should be a component of prospective data collections and can be used in major cancer surgery to study areas appropriate for quality improvement and cost containment.

In an era of health reform: defining cost differences in current esophageal cancer management strategies and assessing the cost of complications.

OBJECTIVE: Outcomes assessing various treatment modalities for esophageal cancer primarily report results in terms of morbidity, mortality, survival, and quality of life. The most appropriate stage-by-stage treatment for esophageal cancer remains controversial. There are limited data outlining the comparative costs of surgical, combined modality and definitive chemoradiation treatments, and added costs associated with complications. METHODS: Between 2000 and 2004, 4 treatment groups were studied: surgery alone, chemotherapy followed by surgery, chemoradiotherapy followed by surgery, and chemoradiotherapy alone. Fifteen consecutive patients from each group receiving their entire treatment at Virginia Mason Medical Center were identified. Patient demographics and outcomes were taken from a prospective institutional review board-approved surgical database, and chart review obtained information for neoadjuvant therapy and definitive chemoradiotherapy groups. Treatment-related costs were extracted from Virginia Mason Medical Center's financial data management system between date of diagnosis to 90 days after completion of primary therapy. RESULTS: Treatment groups were similar in age, gender ratio, American Society of Anesthesiologists status, body mass index, and tumor cell type. Costs increased with the number of treatment modalities: surgery alone, $33,517; chemotherapy followed by surgery, $41,875; chemoradiotherapy followed by surgery, $47,389; and chemoradiotherapy alone, $46,659. Treatment-related complications were surgery alone, 47%; chemotherapy followed by surgery, 64%; chemoradiotherapy followed by surgery, 66%; and chemoradiotherapy alone, 87% (P = .139). Complications increased costs in all groups: surgery alone, 26% (P = .008); chemotherapy followed by surgery, 23% (P = .001); chemoradiotherapy followed by surgery, 9% (P = .702); and chemoradiotherapy alone, 19% (P = .248). CONCLUSIONS: Costs vary significantly among treatment approaches: surgery alone costs 80% of chemotherapy and surgery, 71% of chemoradiotherapy and surgery, and 72% of chemoradiotherapy alone. Costs of tri-modality therapy and definitive chemoradiotherapy are similar. Especially in the absence of definitive evidence-based data, these costs should be a factor in the production of future national treatment guidelines. Decreasing costs requires future quality initiatives in esophageal cancer treatment that focus on minimizing complications related to treatment.

Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy.

OBJECTIVE: Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy. METHODS: A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality. RESULTS: Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100-400 ml) for the TH group and 216 ml (range 80-500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥ 10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p=0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p=0.01. CONCLUSION: This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.