Cachexia index for prognostication in surgical patients with locally advanced oesophageal or gastric cancer: multicentre cohort study.

BACKGROUND: Features of cancer cachexia adversely influence patient outcomes, yet few currently inform clinical decision-making. This study assessed the value of the cachexia index (CXI), a novel prognostic marker, in patients for whom neoadjuvant chemotherapy and surgery for oesophagogastric cancer is planned. METHODS: Consecutive patients newly diagnosed with locally advanced (T3-4 or at least N1) oesophagogastric cancer between 1 January 2010 and 31 December 2015 were identified through the West of Scotland and South-East Scotland Cancer Networks. CXI was calculated as (L3 skeletal muscle index) × (serum albumin)/(neutrophil lymphocyte ratio). Sex-stratified cut-off values were determined based on the area under the curve (AUC), and patients were divided into groups with low or normal CXI. Primary outcomes were disease progression during neoadjuvant chemotherapy and overall survival (at least 5 years of follow-up). RESULTS: Overall, 385 patients (72% men, median age 66 years) were treated with neoadjuvant chemotherapy for oesophageal (274) or gastric (111) cancer across the study interval. Although patients with a low CXI (men: CXI below 52 (AUC 0.707); women: CXI below 41 (AUC 0.759)) were older with more co-morbidity, disease characteristics were comparable to those in patients with a normal CXI. Rates of disease progression during neoadjuvant chemotherapy, leading to inoperability, were higher in patients with a low CXI (28 versus 12%; adjusted OR 3.07, 95% c.i. 1.67 to 5.64; P < 0.001). Low CXI was associated with worsened postoperative mortality (P = 0.019) and decreased overall survival (median 14.9 versus 56.9 months; adjusted HR 1.85, 1.42 to 2.42; P < 0.001). CONCLUSION: CXI is associated with disease progression, worse postoperative mortality, and overall survival, and could improve prognostication and decision-making in patients with locally advanced oesophagogastric cancer.

Diagnosis, treatment, and outcome of patients with oesophagogastric cancer during the COVID-19 pandemic: national study.

BACKGROUND: The national response to COVID-19 has had a significant impact on cancer services. This study investigated the effect of national lockdown on diagnosis, management, and outcomes of patients with oesophagogastric cancers in Scotland. METHODS: This retrospective cohort study included consecutive new patients presenting to regional oesophagogastric cancer multidisciplinary teams in National Health Service Scotland between October 2019 and September 2020. The study interval was divided into before and after lockdown, based on the first UK national lockdown. Electronic health records were reviewed and results compared. RESULTS: Some 958 patients with biopsy-proven oesophagogastric cancer in 3 cancer networks were included: 506 (52.8 per cent) before and 452 (47.2 per cent) after lockdown. Median age was 72 (range 25-95) years and 630 patients (65.7 per cent) were men. There were 693 oesophageal (72.3 per cent) and 265 gastric (27.7 per cent) cancers. Median time to gastroscopy was 15 (range 0-337) days before versus 19 (0-261) days after lockdown (P < 0.001). Patients were more likely to present as an emergency after lockdown (8.5 per cent before versus 12.4 per cent after lockdown; P = 0.005), had poorer Eastern Cooperative Oncology group performance status, were more symptomatic, and presented with a higher stage of disease (stage IV: 49.8 per cent before versus 58.8 per cent after lockdown; P = 0.04). There was a shift to treatment with non-curative intent (64.6 per cent before versus 77.4 per cent after lockdown; P < 0.001). Median overall survival was 9.9 (95 per cent c.i. 8.7 to 11.4) months before and 6.9 (5.9 to 8.3) months after lockdown (HR 1.26, 95 per cent c.i. 1.09 to 1.46; P = 0.002). CONCLUSION: This national study has highlighted the adverse impact of COVID-19 on oesophagogastric cancer outcomes in Scotland. Patients presented with more advanced disease and a shift towards treatment with non-curative intent was observed, with a subsequent negative impact on overall survival.

Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data.

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.

Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer.

BACKGROUND AND OBJECTIVES: Gastrectomy for gastric cancer is associated with significant infective postoperative complications. C-reactive protein (CRP) is a useful biomarker in the early detection of infective complications following major abdominal surgery. This single-centre retrospective study aimed to determine the relationship between postoperative CRP levels and development of postoperative infective complications after gastrectomy. METHODS: Daily postoperative CRP levels were analyzed to determine a CRP threshold associated with infective complications. ROC curve analysis was used to determine which postoperative day (POD) gave the optimal cutoff. Multivariate analysis was performed to determine significant factors associated with complications. RESULTS: One hundred and forty-four patients were included. A total of 61 patients (42%) had at least one infective complication. A CRP level of 220 mg/L was associated with the highest AUC (0.765) with a sensitivity of 70% and specificity of 76% (positive predictive value, 67%; negative predictive value, 78%). More patients with a CRP > 220 mg/L on POD 3 developed infective complications (67% vs. 21%, p < 0.001). CONCLUSIONS: A CRP of more than 220 mg/L on POD 3 may be useful to alert clinicians to the increased risk of a postoperative infective complication or enable earlier safe discharge from critical care for those with a lower value.

Impact of anaemia in oesophago-gastric cancer patients undergoing curative treatment by means of neoadjuvant chemotherapy and surgery.

BACKGROUND: The present study investigated factors associated with pre-neoadjuvant chemotherapy (NAC), and pre-operative anaemia, and examined their impact on outcomes in patients with oesophago-gastric cancer treated with curative intent. METHODS: Patients diagnosed with oesophago-gastric cancer (January 2010 to December 2015) and treated with curative intent by NAC then surgery at a tertiary centre were included. Patients were grouped by the presence of anaemia (haemoglobin <130 mg/L in males and <120 mg/L in females) and into microcytic (MCV <80 fL), normocytic (80-100 fL) and macrocytic (>100 fL) subgroups. Categorical data were analysed by chi-squared test and overall survival by univariate and multivariate Cox regression. RESULTS: 99/295 (34%) patients who received NAC were diagnosed with pre-NAC anaemia, and 157/268 (59%) of patients who subsequently underwent surgery were diagnosed with pre-operative anaemia. Normocytic anaemia was the most common, with 76 (26%) in pre-NAC and 107 (40%) in pre-operative groups. Pre-NAC anaemia was associated with increasing clinical N stage (p = 0.022), higher modified Glasgow Prognostic Score (mGPS) (p = 0.006), and a higher rate of intra-operative transfusion (p = 0.030). Pre-operative anaemia was associated with pre-NAC anaemia (p = 0.004), increasing age (p = 0.026), higher pre-operative mGPS (p = 0.021), and a higher rate of intra-operative transfusion (p = 0.021). Anaemia before NAC and surgery was associated with poorer overall survival in patient following R0 resection, independent of stage (HR 1.26, 95% CI 1.02-1.54, p = 0.030). CONCLUSION: Anaemia was associated with poorer overall survival and greater requirement for intra-operative blood transfusion in oesophago-gastric cancer patients undergoing treatment with curative intent.

Single modality radical radiotherapy is an acceptable alternative for the older patient with squamous cell carcinoma of the oesophagus.

BACKGROUND: Oesophageal cancer remains a common cause of cancer mortality worldwide. Increasingly, oncology centres are treating an older population and comorbidities may preclude multimodality treatment with chemoradiotherapy (CRT). We review outcomes of radical radiotherapy (RT) in an older population treating squamous cell carcinoma (SCC) oesophagus. METHODS: Patients over 65 years receiving RT for SCC oesophagus between 2013 and 2016 in the West of Scotland were identified. Kaplan-Meier and Cox-regression analysis were used to compare overall survival (OS) between patients treated with radical RT and radical CRT. RESULTS: There were 83 patients over 65 years treated with either RT (n=21) or CRT (n=62). There was no significant difference in median OS between CRT versus RT (26.8 months vs 28.5 months, p=0.92). All patients receiving RT completed their treatment whereas 11% of CRT patients did not complete treatment. CONCLUSION: Survival in this non-trial older patient group managed with CRT is comparable to that reported in previous trials. RT shows better than expected outcomes which may reflect developments in RT technique. This review supports RT as an alternative in older patients, unfit for concurrent treatment.

Staging the Tumor and Staging the Host: Pretreatment Combined Neutrophil Lymphocyte Ratio and Modified Glasgow Prognostic Score Is Associated with Overall Survival in Patients with Esophagogastric Cancers Undergoing Treatment with Curative Intent.

BACKGROUND: This study examined whether an innate systemic inflammatory response (SIR) measured by combination neutrophil to lymphocyte ratio (NLR) and modified Glasgow Prognostic Score (mGPS) was associated with overall survival (OS) in patients with esophagogastric cancer (EC) undergoing neoadjuvant chemotherapy (NAC) followed by surgery. METHODS: Patients diagnosed with EC, managed with NAC prior to surgery at a regional referral center, between January 2010 and December 2015, were included. The mGPS and NLR were calculated within 12 weeks before NAC. Patients were grouped by combined NLR/mGPS score into three groups of increasing SIR: NLR ≤ 3 (n = 152), NLR > 3 + mGPS = 0 (n = 55), and NLR > 3 + mGPS > 0 (n = 32). Univariable and multivariable Cox regression was used to analyse OS. RESULTS: Overall, 337 NAC patients were included, with 301 (89%) proceeding to surgery and 215 (64%) having R0 resection. There were 203 deaths, with a median follow-up of those alive at censor of 69 months (range 44-114). Higher combined NLR/mGPS score (n = 239) was associated with poorer OS independent of clinical stage and performance status (hazard ratio 1.28, 95% confidence interval 1.02-1.61; p = 0.032), higher rate of progression on NAC (7% vs. 7% vs. 19%; p = 0.003), and lower proportion of eventual resection (80% vs. 84% vs. 53%; p = 0.003). CONCLUSIONS: The combined NLR/mGPS score was associated with OS and initial treatment outcomes in patients undergoing NAC prior to surgery for EC, stratifying survival in addition to clinical staging and performance status. The host SIR may be a useful adjunct to multidisciplinary decision making.

The downstaging approach to irresectable oesophageal and gastric cancer: a single centre experience.

BACKGROUND: There is uncertainty over optimal management of locally advanced non-metastatic oesophageal and gastric (OG) adenocarcinomas which are deemed irresectable at time of diagnosis due to local tumour or nodal burden. Current practice in our regional centre is to administer chemotherapy in a "downstaging" strategy in the hope of achieving tumour shrinkage to allow radical treatment. Patients without sufficient response to downstaging are treated palliatively. The aim of this study was to review our single unit outcomes of this treatment strategy. METHODS: Data was collected retrospectively from electronic patient records on all cases discussed at regional MDT over a 32-month period (January 2015-August 2017). RESULTS: A total of 44 patients [70.5% male, median age 70 years, 13 (29.5%) oesophageal, 12 (27.3%) junctional and 19 (43.2%) gastric] were included in the study. Thirty-six (81.8%) of patients received the full number of planned cycles of chemotherapy; toxicity and disease progression (both 6.8% of cases) were the most common reasons for early cessation of treatment. Seventeen (38.6%) patients underwent resection and an R0 resection was achieved in 13 (76.5%) of these patients. After median follow up of 16.8 months, the median overall survival (OS) in the resection vs. palliative cohorts was 42.6 vs. 16.4 months (P<0.05). CONCLUSIONS: Our data show that a downstaging approach can be successfully implemented (R0 resection achieved) in up to a third of patients with good survival results. Further prospective data identifying patient and pathological characteristics predicting response to treatment are needed to optimise selection into a downstaging programme.

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.

Recurrent respiratory distress and cardiopulmonary arrest caused by megaoesophagus secondary to achalasia.

INTRODUCTION: Respiratory distress and arrest from tracheal compression secondary to megaoesophagus are rare complications of achalasia. We present the case of a man with end-stage achalasia who required oesophagectomy to prevent recurrent life-threatening tracheal compression and respiratory arrest. A literature review is also presented. PRESENTATION OF CASE: A 40-year old man presented with post-prandial stridor which resolved spontaneously, later being diagnosed with achalasia. He underwent pneumatic dilatation year later, intended as definitive treatment. Despite intervention, the patient had developed megaoesophagus. One month later he presented with tracheal compression and cardiorespiratory arrest but was successfully resuscitated. He subsequently underwent elective oesophagectomy. DISCUSSION: Over 40 case reports of achalasia presenting with stridor have been published. However, only three cases (all female, age range, 35-79 years old) of cardiac, respiratory or cardiorespiratory arrest have been published. The definitive treatments received by these patients were botulinum toxin injections, open Heller cardiomyotomy with Dor fundoplication and pneumatic dilatation. None of these patients suffered recurrent respiratory distress following definitive treatment. The patient currently reported was unique as he suffered cardiorespiratory arrest following an intended definitive treatment, pneumatic dilatation. As such oesophagectomy was considered the greatest risk-reduction intervention. CONCLUSION: Oesophagectomy should be considered for patients with end-stage achalasia and mega-oesophagus causing respiratory compromise to avoid potential fatal complications such as tracheal compression and subsequent respiratory arrest.

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.

Persistent elevation of C-reactive protein following esophagogastric cancer resection as a predictor of postoperative surgical site infectious complications.

BACKGROUND: Infectious complications, particularly in the form of anastomotic leaks (ALs) or surgical site infections (SSIs), represent a serious morbidity after esophagogastric cancer resections. Therefore, early detection is of paramount importance. Although markers of the systemic inflammatory response, including C-reactive protein (CRP) and white cell count (WCC), have been used in this regard, their relative predictive value is unclear. The aim of the present study was to examine serial postoperative WCC, albumin, and CRP and their diagnostic accuracy in case of infectious complications. PATIENTS AND METHODS: White cell count, albumin, and CRP were routinely measured postoperatively for 7 days in 136 consecutive patients who had undergone esophagogastric cancer resection. All postoperative complications were recorded. The diagnostic accuracy of the WCC, albumin, and CRP values were analyzed by receiver operating characteristics curve analysis with surgical site and remote infectious complications as outcome measures. RESULTS: Fifty-four (40%) patients developed infectious complications, and 17 of them developed an AL. CRP was significantly higher from postoperative day (POD) 3 onward in those patients who developed an AL. On POD 3, a threshold reading of 180 mg/l was associated with development of an AL, providing a sensitivity of 82% and a specificity of 63%. On POD 4, the same CRP threshold of 180 mg/l provided 71% sensitivity and 83% specificity. CONCLUSIONS: Postoperative CRP measurements on PODs 3 and 4 are clinically useful in predicting surgical site infectious complications, in particular an AL, after resection for esophagogastric cancer.

Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center.

BACKGROUND: Minimally invasive techniques are now increasingly adopted for the treatment of esophageal cancers. Benefits such as earlier functional recovery and less need for transfusion and intensive care stay should be balanced by a determination to avoid compromise to the oncologic integrity of the procedure, especially in the early phase of transition from open to laparoscopic surgery. This study aimed to compare primary outcomes including oncologic clearance, complications, and functional recovery between open and laparoscopic esophagectomy in a single center. METHODS: This prospective study recruited 75 consecutive patients undergoing Ivor-Lewis esophagectomy, all treated by a single surgeon. These patients were divided into three groups. The 24 patients in group A underwent open Ivor-Lewis esophagectomy. The remaining patients underwent laparoscopic Ivor-Lewis esophagectomy in two groups: 25 patients in an early cohort (group B) and 26 patients in a later cohort (group C). All the patients were treated according to the same protocol. RESULTS: The three groups were adequately matched. The findings showed trends toward a reduction in median operative time, with group A requiring 260 min, group B requiring 249 min, and group C requiring 223 min (p = 0.06), and a significant reduction in the requirement for perioperative blood transfusion between groups A (65%) and C (27%) (p = 0.02). The median lymph node yield was significantly less in group B (n = 13) than in group A (n = 24) or group C (n = 22) (p = 0.003). There was no significant difference between the three groups in the length of hospital stay (median stay, 14-16 days) or the requirement for critical care beds (median stay, 3-4 days). The in-hospital mortality rate was zero, and the morbidity rate did not differ between the three groups. CONCLUSIONS: This study shows that laparoscopic Ivor-Lewis esophagectomy is associated with a reduced need for blood transfusion, a shorter operative time, and an adequate lymph node harvest. Oncologic principles are not compromised during the transition phase from open to laparoscopic esophagectomy.

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.

The role of oesophageal diversion and exclusion in the management of oesophageal perforations.

AIM: Persistent sepsis from an oesophageal perforation has a near 100% mortality. We describe our experience with early oesophageal diversion and exclusion for patients in-extremis. METHODS: A retrospective review of oesophageal perforations was performed between 2000 and 2007. There were five cases Boerhaaves and one case of iatrogenic perforation that required oesophageal diversion and exclusion. 4 males, 2 females with a mean age of 67.6 (58-72) years. RESULTS: The primary procedure was performed within 24h in four patients; the other two were after 3 and 10 days. The intensive care unit (ITU) stay was a median of 25 days. Mortality rate was 50%. Median length of stay for the survivors was 60 days. Three patients underwent a successful colonic interposition in our unit after 6 months. CONCLUSION: Exclusion and diversion procedures are required in very rare circumstances. In conditions of persistent leak and continuing sepsis or those patients not fit to undergo a major procedure they could be lifesaving if performed early. As it is a relatively easy and quick procedure it should be considered early as a 2nd line management option.

Outcomes following colectomy for Clostridium difficile colitis.

INTRODUCTION: Clostridium difficile associated diarrhoea has become an important health problem in UK hospitals but surgical intervention is rarely required. There is little evidence regarding best practice for patients requiring surgical intervention. The aim of this multicentre study was to review our experience in patients requiring surgery for C. difficile colitis. METHODS: Patients who underwent surgery for C. difficile colitis in 5 hospitals in Southeast England over a 7-year period (1 teaching hospital and 4 district general hospitals) were identified from histopathology databases. Data were collected regarding the presentation, indication for surgery and post-operative outcomes. RESULTS: 15 patients (9 males; mean age=71 years (range 35-84 years)) underwent surgery. 46% of patients (n=7) contracted C. difficile during their hospital admission for other medical reasons and 73% of patients were initially admitted under other medical specialties. Diagnosis was only made preoperatively in 8 patients (53%). Indications for surgery were peritonitis and systemic toxicity (n=12), failure of medical management (n=2) and unresolving large bowel dilatation (n=1). 12 patients underwent total colectomy and the rest underwent segmental resection. All patients were admitted to the intensive care unit post operatively with a mean stay of 6 days. 2 patients needed a second look laparotomy. Mortality rate was 67% (n=10), with all but 1 patient dying within the 30-day mortality period. The mean length of hospital stay of survivors was 30 days (range 17-72). CONCLUSIONS: Surgical intervention for C. difficile colitis remains uncommon. Total colectomy and end ileostomy is the procedure of choice. The outlook for patients requiring surgery remains poor.

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.

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.