A Role for Tumor Volume Assessment in Resectable Esophageal Cancer.

BACKGROUND: Esophageal cancer has a poor prognosis, and many patients undergoing surgery have a low chance of cure. Imaging studies suggest that tumor volume is prognostic. The study aimed to evaluate pathological tumor volume (PTV) as a prognostic variable in esophageal cancer. METHODS: This single-center cohort study included 283 patients who underwent esophageal cancer resections between 2000 and 2012. PTVs were obtained from pathological measurements using a validated volume formula. The prognostic value of PTV was analyzed using multivariable regression models, adjusting for age, tumor grade, tumor (T) stage, nodal stage, lymphovascular invasion, resection margin, resection type, and chemotherapy response, which provided hazard ratios (HRs) with 95 % confidence intervals (CIs). Primary outcomes were time to death and time to recurrence. Secondary outcomes were margin involvement and lymph node positivity. Correlation analysis was performed between imaging and PTVs. RESULTS: On unadjusted analysis, increasing PTV was associated with worse overall mortality (HR 2.30, 95 % CI 1.41-3.73) and disease recurrence (HR 1.87, 95 % CI 1.14-3.07). Adjusted analysis demonstrated worse overall mortality with increasing PTV but reached significance in only one subgroup (HR 1.70, 95 % CI 1.09-2.38). PTV was an independent predictor of margin involvement (OR 2.28, 95 % CI 1.02-5.13) and lymph node-positive status (OR 2.77, 95 % CI 1.23-6.28). Correlation analyses demonstrated significant positive correlation between computed tomography (CT) software and formula tumor volumes (r = 0.927, p < 0.0001), CT and positron emission tomography tumor volumes (r = 0.547, p < 0.0001), and CT and PTVs (r = 0.310, p < 0.001). CONCLUSIONS: Tumor volume may predict survival, margin status, and lymph node positivity after surgery for esophageal cancer.

Long-term outcome and quality of life after supercharged jejunal interposition for oesophageal replacement.

BACKGROUND: The consequences of major conduit necrosis following oesophagectomy are devastating. Jejunal interposition with vascular supercharging is an alternative reconstructive method if colon is unavailable. Aims of this study were to review the long-term outcome and quality of life of patients undergoing this surgery in our tertiary unit. METHODS: Patients undergoing oesophageal reconstruction with supercharged jejunum were identified and retrospective review of hospital notes performed. Each patient was then interviewed for follow up data and quality of life assessment using the EORTC QLQ-C30 questionnaire. RESULTS: Six patients (5 men) (median age 59 years (range 34-72) underwent supercharged pedicled jejunal (SPJ) interposition from May 2005-August 2010. Indications for surgery were loss of both gastric and colonic conduits following surgery for oesophageal cancer (n = 4), loss of gastric conduit and previous colectomy (n = 1) and lastly, gastric and colonic infarction in a strangulated paraoesophageal hernia (n = 1). Median time to reconstruction was 12 months [6-15 range]. There were no in-hospital deaths. Median postoperative stay was 46 days [13-118]. Three patients required surgical re-intervention for leak, sepsis and reflux, respectively. Median follow up was 6.5 years [range 7-102 months]. One patient died seven months following surgery due to respiratory complications. On follow up, 5 patients have an enteral diet without supplemental nutrition, maintaining weight and good quality of life scores. CONCLUSIONS: Supercharged jejunal interposition is a suitable alternative conduit for delayed oesophageal replacement in patients with otherwise limited reconstructive options. Good functional outcomes can be achieved despite formidable technical challenges in this group.

Factors associated with early recurrence and death after esophagectomy for cancer.

BACKGROUND: Accurate selection of patients for radical treatment of esophageal cancer is essential to avoid early recurrence and death (ERD) after surgery. We sought to evaluate a large series of consecutive resections to assess factors that may be associated with this poor outcome. METHODS: This was a cohort study including 680 patients operated for esophageal cancer between 2000 and 2010. The poor outcome group comprised 100 patients with tumor recurrence and death within 1 year of surgery. The comparison group comprised 267 long-term survivors, defined as those surviving more than 3 years from surgery. Pathological characteristics associated with poor outcome were analyzed using logistic regression to determine odds ratios (OR) and 95% confidence intervals (CI). RESULTS: On the adjusted model T stage and N stage predicted poor survival, with the greatest risk being patients with locally advanced tumors and three or more involved lymph nodes (OR 10.6, 95% CI 2.8-40.0). Poor differentiation (OR 2.8, 95% CI 1.4-5.5), chemotherapy response (OR 3.6, 95% CI 1.2-10.6), and involved resection margins (OR 2.7, 95% CI 1.2-6.0) were all significant independent prognostic markers in the multivariable model. There was a trend toward worse survival with lymphovascular invasion (OR 2.0, 95% CI 0.9-4.2) and low albumin (OR 1.9, 95% CI 0.8-4.4) but not of statistical significance in the adjusted model. CONCLUSIONS: Esophageal cancer patients with poorly differentiated tumors and three or more involved lymph nodes have a particularly high risk of ERD after surgery. Accurate risk stratification of patients may identify a group who would be better served by alternative oncological treatment strategies.

Transhiatal esophagectomy in a high volume institution.

BACKGROUND: The optimal operative approach for carcinoma at the lower esophagus and esophagogastric junction remains controversial. The aim of this study was to assess a single unit experience of transhiatal esophagectomy in an era when the use of systemic oncological therapies has increased dramatically. STUDY DESIGN: Between January 2000 and November 2006, 215 consecutive patients (182 males, 33 females, median age = 65 years) underwent transhiatal esophagectomy; invasive malignancy was detected preoperatively in 188 patients. 90 patients (42%) received neoadjuvant chemotherapy. Prospective data was obtained for these patients and cross-referenced with cancer registry survival data. RESULTS: There were 2 in-hospital deaths (0.9%). Major complications included: respiratory complications in 65 patients (30%), cardiovascular complications in 31 patients (14%) and clinically apparent anastomotic leak in 12 patients (6%). Median length of hospital stay was 14 days. The radicality of resection was inversely related to T stage: an R0 resection was achieved in 98-100% of T0/1 tumors and only 14% of T4 tumors. With a median follow up of 26 months, one and five year survival rates were estimated at 81% and 48% respectively. CONCLUSION: Transhiatal esophagectomy is an effective operative approach for tumors of the infracarinal esophagus and the esophagogastric junction. It is associated with low mortality and morbidity and a five survival rate of nearly 50% when combined with neoadjuvant chemotherapy.

Transabdominal approach for management of Boerhaave's syndrome.

Several transthoracic approaches have been described for the surgical management of Boerhaave's syndrome that carry their own morbidity in patients who can be systemically unwell at presentation, and best practice is not established. We introduce a novel transabdominal approach to manage the perforation and spare these patients the trauma of a thoracotomy. Four patients with spontaneous esophageal rupture were managed using a transabdominal approach. Postoperative complications, length of intensive care unit stay, postoperative hospital stay, time to oral intake, and morbidity and mortality were used as outcome measures. After operation, the median intensive care unit stay was 4 days (range, 0-5) in patients who required a median of 10.5 days (range, 6-17) to establish oral intake. One patient required a transthoracic drainage of an empyema and one patient required percutaneous drainage of a mediastinal collection. The median length of stay was 38 days and there was zero mortality. The transabdominal approach is safe and effective for the management of Boerhaave's syndrome and should be considered in the treatment paradigm for this condition. Intrathoracic complications account for postoperative morbidity.

Breast cancer metastasis to the stomach may mimic primary gastric cancer: report of two cases and review of literature.

BACKGROUND: The stomach is an infrequent site of breast cancer metastasis. It may prove very difficult to distinguish a breast cancer metastasis to the stomach from a primary gastric cancer on the basis of clinical, endoscopic, radiological and histopathological features. It is important to make this distinction as the basis of treatment for breast cancer metastasis to the stomach is usually with systemic therapies rather than surgery. CASE PRESENTATIONS: The first patient, a 51 year old woman, developed an apparently localised signet-ring gastric adenocarcinoma 3 years after treatment for lobular breast cancer with no clinical evidence of recurrence. Initial gastric biopsies were negative for both oestrogen and progesterone receptors. Histopathology after a D2 total gastrectomy was reported as T4 N3 Mx. Immunohistochemistry for Gross Cystic Disease Fluid Protein was positive, suggesting metastatic breast cancer. The second patient, a 61 year old woman, developed a proximal gastric signet-ring adenocarcinoma 14 years after initial treatment for breast cancer which had subsequently recurred with bony and pleural metastases. In this case, initial gastric biopsies were positive for both oestrogen and progesterone receptors; subsequent investigations revealed widespread metastases and surgery was avoided. CONCLUSION: In patients with a history of breast cancer, a high index of suspicion for potential breast cancer metastasis to the stomach should be maintained when new gastrointestinal symptoms develop or an apparent primary gastric cancer is diagnosed. Complete histopathological and immunohistochemical analysis of the gastric biopsies and comparison with the original breast cancer pathology is important.

Tumor stage after neoadjuvant chemotherapy determines survival after surgery for adenocarcinoma of the esophagus and esophagogastric junction.

PURPOSE: Neoadjuvant chemotherapy is established in the management of most resectable esophageal and esophagogastric junction adenocarcinomas. However, assessing the downstaging effects of chemotherapy and predicting response to treatment remain challenging, and the relative importance of tumor stage before and after chemotherapy is debatable. METHODS: We analyzed consecutive resections for esophageal or esophagogastric junction adenocarcinomas performed at two high-volume cancer centers in London between 2000 and 2010. After standard investigations and multidisciplinary team consensus, all patients were allocated a clinical tumor stage before treatment, which was compared with pathologic stage after surgical resection. Survival analysis was conducted using Kaplan-Meier analysis and Cox regression analysis. RESULTS: Among 584 included patients, 400 patients (68%) received neoadjuvant chemotherapy. Patients with downstaged tumors after neoadjuvant chemotherapy experienced improved survival compared with patients without response (P < .001), and such downstaging (hazard ratio, 0.43; 95% CI, 0.31 to 0.59) was the strongest independent predictor of survival after adjusting for patient age, tumor grade, clinical tumor stage, lymphovascular invasion, resection margin status, and surgical resection type. Patients downstaged by chemotherapy, compared with patients with no response, experienced lower rates of local recurrence (6% v. 13%, respectively; P = .030) and systemic recurrence (19% v. 29%, respectively; P = .027) and improved Mandard tumor regression scores (P = .001). Survival was strongly dictated by stage after neoadjuvant chemotherapy, rather than clinical stage at presentation. CONCLUSION: The stage of esophageal or esophagogastric junction adenocarcinoma after neoadjuvant chemotherapy determines prognosis rather than the clinical stage before neoadjuvant chemotherapy, indicating the importance of focusing on postchemotherapy staging to more accurately predict outcome and eligibility for surgery. Patients who are downstaged by neoadjuvant chemotherapy benefit from reduced rates of local and systemic recurrence.

An unusual cause of dysphagia: transabdominal Roux-en-Y cyst-jejunostomy in the surgical management of a symptomatic mediastinal cyst.

We present a 52-year-old gentleman with an unusual cause of progressive dysphagia, namely due to extrinsic lower oesophageal compression from a cystic mass of the posterior mediastinum. Cystic masses in adults are uncommon, and there is a wide differential diagnosis. This includes neoplastic, such as germ cell tumour (cystic teratoma), and non-neoplastic aetiologies. The later include foregut duplication cysts, lymphatic malformations, infective (hydatid), simple mediastinal cysts or pseudocysts. Management is principally surgical with complete excision, or alternatively, in cases of benign cysts, marsupialization or decompression. In our patient, a simple mediastinal cyst was diagnosed and this case is the first description of a totally transabdominal approach to mediastinal cyst decompression by a Roux-en-Y cyst-jejunostomy.

Nocardia spinal epidural abscess: 14-year follow-up.

This article describes an immunocompetent patient with a spinal abscess that developed from Nocardia asteroides. Nocardia is a rare etiology for spinal abscesses, especially in immunocompetent patients. Nocardia usually affects the lungs and brain of immunocompromised individuals. Few reports of Nocardia involving bones or the spine have been published.The patient had a history of chronic back pain and had several procedures to alleviate the pain. In August 1997, the patient had an epidural block and a subsequent infection that was treated with antibiotics. In October 1997, she developed increasing back pain greater than her baseline chronic low back pain. Additional presenting symptoms were fever, chills, and nausea. On admission, magnetic resonance imaging (MRI) revealed an epidural abscess. The patient underwent irrigation and debridement. Postoperatively, the patient was initially placed on broad-spectrum antibiotics. After 38 days, the culture was identified as N asteroides, and the patient was placed on appropriate antibiotics. The patient has been followed with MRI prior to the discovery of the abscess and annually since the abscess due to her baseline chronic low back pain. No residual abscess was discovered.

Multivariate analysis of clinicopathological factors influencing survival following esophagectomy for cancer.

BACKGROUND: A number of clinicopathological characteristics can influence survival following esophagectomy for cancer. The aim of this study was to determine the factors affecting survival in a consecutive series of patients undergoing esophagectomy for cancer at a single tertiary centre over a 7 year period. MATERIALS & METHODS: We analyzed a prospective database of 314 consecutive patients (247 males and 67 females), with a mean age of 62.8 +/- 9.1 years, who underwent esophagectomy for cancer at a single, high-volume centre between January 2000 and June 2007. The impact of 11 variables on survival following esophagectomy was determined by univariate and multivariate analysis. RESULTS: On univariate analysis, gender, ASA grade, blood transfusion, type of cancer, tumor stage, lymph node status, lymphovascular invasion (LVI), longitudinal resection margin (LRM) involvement and circumferential resection margin (CRM) involvement were significant (p<0.05) negative factors for survival. Multivariate analysis using Cox proportional hazard regression demonstrated that the only independent factors negatively impacting on survival were ASA grade (p=0.012), tumor stage (p=0.009), LVI (p=0.009) and LRM involvement (p=0.031). CONCLUSIONS: In the current study we demonstrated that independent variables effecting survival after esophagectomy for cancer were ASA grade, tumor stage, lymphovascular invasion and longitudinal resection margin involvement. Contrary to other studies we did not find CRM involvement to be an independent predictor for survival.

Transhiatal oesophagectomy: treatment of choice for high-grade dysplasia.

OBJECTIVE: To demonstrate that transhiatal oesophagectomy should remain the gold standard treatment for patients with high-grade dysplasia. BACKGROUND: The conventional management of high-grade dysplasia of the oesophagus is surgery. Perceived high incidence of operative morbidity and mortality associated with oesophagectomy has led some to advocate alternative less invasive treatments such as endoscopic mucosal resection (EMR) and photodynamic therapy (PDT). We present our data on the use of transhiatal oesophagectomy for the management of high-grade dysplasia. METHODS: Twenty-three patients underwent transhiatal oesophagectomy for biopsy-proven high-grade dysplasia in a high volume centre, between March 2000 and December 2006. Twenty-two were male and 1 female with a mean age of 63.5 years (+/- 6.5). Staging was ascertained by gastroscopy, EUS and CT. Two patients had PET CT. ASA grade was I (2), II (14), III (6) and IV (1). RESULTS: Clinical anastomotic leak occurred in two patients (9%); this was managed conservatively. Four patients required intensive care admission. Occult adenocarcinoma was found in 35% (8/23) of surgical specimens; there were no involved nodes present. No re-operations were required. Median length of stay was 15 days (10-69). Thirty-day and in-hospital mortality was zero. There was one case of locally recurrent disease, and one death meaning that disease-free survival was 96%, and overall survival was 96% (22/23) at a mean follow-up of 35.4 months. CONCLUSIONS: Transhiatal oesophagectomy for high-grade dysplasia can be performed with acceptable mortality and morbidity when performed at a specialist centre.

Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre.

INTRODUCTION: The aim of this study was to review the management and outcome of patients with Boerhaave's syndrome in a specialist centre between 2000-2007. PATIENTS AND METHODS: Patients were grouped according to time from symptoms to referral (early, < 24 h; late, > 24 h). The effects of referral time and management on outcomes (oesophageal leak, reoperation and mortality) were evaluated. RESULTS: Of 21 patients (early 10; late 11), three were unfit for surgery. Of the remaining 18, immediate surgery was performed in 8/8 referred early and 6/10 referred late. Four patients referred late were treated conservatively. Oesophageal leak (78% versus 12.5%; P < 0.05) and mortality (40% versus 0%; P < 0.05) rates were higher in patients referred late. For patients referred late, mortality was higher in patients managed conservatively (75% versus 17%; not significant). CONCLUSIONS: The best outcomes in Boerhaave's syndrome are associated with early referral and surgical management in a specialist centre. Surgery appears to be superior to conservative treatment for patients referred late.

Surgical management of late complications after colonic interposition for esophageal atresia.

Late complications after colonic interposition for neonatal esophageal atresia may lead to debilitating symptoms, poor quality of life, and malnutrition in young adults with otherwise normal life expectancies. We report our experience with 3 patients who underwent revision surgery more than 20 years after colonic interposition. Revision surgery may relieve symptoms and improve quality of life in selected patients. However, for patients with recurrent symptoms, further reconstructive options may be limited due to the lack of an available conduit, and long-term enteral feeding may be the only option for these patients.

Is cardiopulmonary exercise testing a useful test before esophagectomy?

BACKGROUND: Cardiopulmonary exercise (CPX) testing may identify patients at high risk of postoperative cardiopulmonary morbidity and mortality. This study aims to assess the utility of CPX testing before esophagectomy. METHODS: Between January 2004 and October 2006, 78 consecutive patients (64 men) with a median age of 65 years (range, 40 to 81 years) underwent CPX testing before esophagectomy (50% transhiatal; 50% transthoracic). Measured variables included anaerobic threshold (AT) and maximum oxygen uptake at peak exercise (VO2peak). Outcome measures were postoperative morbidity and mortality, length of hospital stay, and unplanned intensive therapy unit admission. RESULTS: Cardiopulmonary complications occurred in 33 (42%) patients and noncardiopulmonary complications in 19 (24%). One in-hospital death (1.3%) occurred, and 13 patients (17%) required an unplanned intensive therapy unit admission. The level of VO2peak was significantly lower in patients with postoperative cardiopulmonary morbidity (p = 0.04). The area under a receiver operating characteristic curve was 0.63 (95% confidence interval [CI], 0.50 to 0.76) for the VO2peak and 0.62 (95% CI, 0.49 to 0.75) for AT. An AT cutoff of 11 mL/kg/min was a poor predictor of postoperative cardiopulmonary morbidity. CONCLUSIONS: Although the VO2peak was significantly lower in those patients who developed cardiopulmonary complications, CPX testing is of limited value in predicting postoperative cardiopulmonary morbidity in patients undergoing esophagectomy.

Distal thoracic oesophageal perforation secondary to blunt trauma: case report.

BACKGROUND: Traumatic perforation of the distal oesophagus due to blunt trauma is a very rare condition and is still associated with a significant morbidity and mortality. This is further exacerbated by delayed diagnosis and management as symptoms and signs are often masked by or ascribed to more common blunt thoracic injuries. CASE REPORT: We present a case of a distal oesophageal perforation, secondary to a fall from a third storey window, which was masked by concomitant thoracic injuries and missed on both computed tomography imaging and laparotomy. The delay in his diagnosis significantly worsened the patient's recovery by allowing the development of an overwhelming chest sepsis that contributed to his death. CONCLUSION: Early identification of an intrathoracic oesophageal perforation requires deliberate consideration and is essential to ensure a favorable outcome. Treatment should be individualised taking into account the nature of the oesophageal defect, time elapsed from injury and the patient's general condition.

Duodenal volvulus: report of a case.

A duodenal volvulus is a hitherto unreported condition caused by an abnormal mobility of the third and fourth parts of the duodenum. We herein report the first such case, including its presentation, management, and possible etiology.

Recurrent laryngeal nerve palsy due to impacted dental plate in the thoracic oesophagus: case report.

BACKGROUND: Retained oesophageal foreign bodies must be urgently removed to prevent potentially serious complications. Recurrent laryngeal nerve palsy is rare and has not been reported in association with a foreign body in the thoracic oesophagus. CASE PRESENTATION: We present a case of a dental plate in the thoracic oesophagus that caused high dysphagia. Delayed diagnosis led to a recurrent laryngeal nerve palsy, which persisted despite successful surgical removal of the foreign body. CONCLUSION: Oesophagoscopy is essential to fully assess patients with persistent symptoms after foreign body ingestion, irrespective of the level of dysphagia. Recurrent laryngeal nerve palsy may indicate impending perforation and should prompt urgent evaluation and treatment.

Vomiting-induced pneumomediastinum and subcutaneous emphysema does not always indicate Boerhaave's syndrome: report of six cases.

Spontaneous pneumomediastinum is an uncommon, self-limiting condition resulting from alveolar rupture in young adults. Because of the ambiguous presentation and the general lack of awareness of this condition, its diagnosis is often delayed, missed, or confused with spontaneous esophageal perforation. We report our experience of treating six patients who were referred to our unit with vomiting-induced pneumomediastinum, subcutaneous emphysema, and an initial diagnosis of spontaneous esophageal perforation. Ultimately, we diagnosed spontaneous pneumomediastinum in all six patients, who recovered uneventfully without any surgical intervention. We review the literature with particular emphasis on differentiating spontaneous pneumomediastinum from spontaneous esophageal perforation.