Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study.

BACKGROUND: Minimally invasive oesophagectomy has been shown to reduce the risk of pulmonary complications compared with open oesophagectomy, but the effects on health-related quality of life (HRQoL) and oesophageal cancer survivorship remain unclear. The aim of this study was to assess the longitudinal effects of minimally invasive compared with open oesophagectomy for cancer on HRQoL. METHODS: All patients who had surgery for oesophageal cancer in Sweden from January 2013 to April 2018 were identified. The exposure was total or hybrid minimally invasive oesophagectomy, compared with open surgery. The study outcome was HRQoL, evaluated by means of the European Organisation for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-OG25 at 1 and 2 years after surgery. Mean differences and 95 per cent confidence intervals were adjusted for confounders. RESULTS: Of the 246 patients recruited, 153 underwent minimally invasive oesophagectomy, of which 75 were hybrid minimally invasive and 78 were total minimally invasive procedures. After adjustment for age, sex, Charlson Co-morbidity Index score, pathological tumour stage and neoadjuvant therapy, there were no clinically and statistically significant differences in overall or disease-specific HRQoL after oesophagectomy between hybrid minimally invasive and total minimally invasive surgical technique versus open surgery. CONCLUSION: In this population-based nationwide Swedish study, longitudinal HRQoL after minimally invasive oesophagectomy was similar to that of the open surgical approach.

Reintervention or mortality within 90 days of bariatric surgery: population-based cohort study.

BACKGROUND: Bariatric surgery carries a risk of severe postoperative complications, sometimes leading to reinterventions or even death. The incidence and risk factors for reintervention and death within 90 days after bariatric surgery are unclear, and were examined in this study. METHODS: This population-based cohort study included all patients who underwent bariatric surgery in one of the five Nordic countries between 1980 and 2012. Data on surgical and endoscopic procedures, diagnoses and mortality were retrieved from national high-quality and complete registries. Multivariable Cox regression analysis was used to calculate hazard ratios (HRs), adjusted for country, age, sex, co-morbidity, type of surgery and approach, year and hospital volume of bariatric surgery. RESULTS: Of 49 977 patients, 1111 (2·2 per cent) had a reintervention and 95 (0·2 per cent) died within 90 days of bariatric surgery. Risk factors for the composite outcome reintervention/mortality were older age (HR 1·65, 95 per cent c.i. 1·36 to 2·01, for age at least 50 years versus less than 30 years) and co-morbidity (HR 2·66, 1·53 to 4·62, for Charlson co-morbidity index score 2 or more versus 0). The risk of reintervention/mortality was decreased for vertical banded gastroplasty compared with gastric bypass (HR 0·37, 0·28 to 0·48) and more recent surgery (HR 0·51, 0·39 to 0·67, for procedures undertaken in 2010 or later versus before 2000). Sex, surgical approach (laparoscopic versus open) and hospital volume did not influence risk of reintervention/mortality, but laparoscopic surgery was associated with a lower risk of 90-day mortality (HR 0·29, 0·16 to 0·53). CONCLUSION: Reintervention and death were uncommon events within 90 days of bariatric surgery even in this unselected nationwide cohort from five countries. Older patients with co-morbidities have an increased relative risk of these outcomes.

ANTECEDENTES: La cirugía bariátrica conlleva un riesgo de complicaciones postoperatorias graves, que algunas veces ocasionan reintervenciones o incluso son causa de mortalidad. La incidencia y los factores de riesgo de reinterveniones y mortalidad a los 90 días tras cirugía bariátrica no están claros, y fueron examinados en este estudio. MÉTODOS: Todos los pacientes que fueron sometidos a cirugía bariátrica en uno de los cinco países nórdicos en 1980-2012 fueron incluidos en un estudio de cohortes de base poblacional. Los datos de los procedimientos quirúrgicos y endoscópicos, diagnóstico, y mortalidad se obtuvieron a partir de registros nacionales completos y de alta calidad. Mediante una regresión de Cox multivariable se obtuvieron los cocientes de riesgos instantáneos (hazard ratios, HR) y los intervalos de confianza 95% (i.c. del 95%) ajustados por país, edad, sexo, comorbilidad, y tipo, abordaje, año y volumen de casos de cirugía bariátrica del hospital. RESULTADOS: De un total de 49.977 pacientes, 1.111 (2,2%) precisaron una reintervención y 95 (0,2%) fallecieron durante los primeros 90 días tras la cirugía bariátrica. Los factores de riesgo para el resultado compuesto reintervención/mortalidad fueron la edad avanzada (HR = 1,7 (i.c. del 95% 1,4-2,0) edad ≥ 50 versus < 30 años)) y la comorbilidad (HR = 2,7 (i.c. del 95% 1,5-4,6) puntuación del índice de comorbilidad de Charlson ≥ 2 versus 0)). Se observó una disminución de los HRs tras la gastroplastia vertical con banda en comparación con el bypass gástrico (HR = 0,4, (i.c. del 95% 0,3-0,5)) y el periodo de estudio más reciente (HR = 0,5 (i.c. del 95% 0,4-0,7) ≥ 2010 versus < 2000)). El sexo, el abordaje quirúrgico laparoscópico versus abierto y el volumen del hospital no influyeron sobre el riesgo de reintervención/mortalidad, pero la cirugía laparoscópica se asoció con una mortalidad a los 90 días más baja (HR 0,3, i.c. del 95% 0,2-0,5). CONCLUSIÓN: La reintervención y la mortalidad son eventos infrecuentes durante los primeros 90 días tras la cirugía bariátrica, incluso en esta cohorte nacional y no seleccionada de cinco paises. Los pacientes mayores con comorbilidades tienen un riesgo relativo aumentado de reintervención y mortalidad.

Population-based study of anastomotic stricture rates after minimally invasive and open oesophagectomy for cancer.

Background: The population-based incidence of anastomotic stricture after minimally invasive oesophagectomy (MIO) and open oesophagectomy (OO) is not known. The aim of this study was to compare rates of anastomotic stricture requiring dilatation after the two approaches in an unselected cohort using nationwide data from Finland and Sweden. Methods: All patients who had MIO or OO for oesophageal cancer between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. Outcomes were the overall rate of anastomotic stricture and need for single or repeated (3 or more) dilatations for stricture within the first year after surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95 per cent confidence intervals, adjusted for age, sex, co-morbidity, histology, stage, year, country, hospital volume, length of hospital stay and readmissions. Results: Some 239 patients underwent MIO and 1430 had an open procedure. The incidence of strictures requiring one dilatation was 16·7 per cent, and that for strictures requiring three or more dilatations was 6·6 per cent. The HR for strictures requiring one dilatation was not increased after MIO compared with that after OO (HR 1·19, 95 per cent c.i. 0·66 to 2·12), but was threefold higher for repeated dilatations (HR 3·25, 1·43 to 7·36). Of 18 strictures following MIO, 14 (78 per cent) occurred during the first 2 years after initiating this approach. Conclusion: The need for endoscopic anastomotic dilatation after oesophagectomy was common, and the need for repeated dilatation was higher after MIO than following OO. The increased risk after MIO may reflect a learning curve.

Antecedentes: Se desconoce la incidencia poblacional de estenosis anastomóticas tras esofaguectomía mínimamente invasiva (minimally invasive oesophagectomy, MIO) y esofaguectomía abierta (open oesophagectomy, OO). El objetivo de este estudio fue comparar las tasas de estenosis anastomótica que precisan dilataciones después de los dos abordajes de esofaguectomía en una cohorte no seleccionada utilizando los datos poblacionales de Finlandia y Suecia. Métodos: Todos los pacientes sometidos a MIO (n = 239) o OO (n = 1430) por cáncer de esófago entre 2007 y 2014 fueron identificados a partir de los registros nacionales en Finlandia y Suecia. Las variables de resultados fueron la incidencia global de estenosis anastomótica y la necesidad de una sola dilatación o dilataciones repetidas (≥ 3) para la estenosis durante el primer año de la cirugía. La regresión multivariable de Cox proporcionó los cocientes de riesgos instantáneos (hazard ratios, HRs) con los i.c. del 95% ajustados por edad, sexo, comorbilidad, histología, estadio, año, país, volumen del hospital, duración de la estancia hospitalaria y reingresos. Resultados: La incidencia de estenosis que precisaron una dilatación fue del 16,7%, y del 6,6% para estenosis que precisaron ≥ 3 dilataciones. El HR de estenosis que requirieron una dilatación no se incrementó tras MIO en comparación con OO (HR 1,19, i.c. del 95% 0,66­2,12), pero fue 3 veces más para dilataciones repetidas (≥ 3) (HR 3,25, i.c. del 95% 1,43­7,36). De las 18 estenosis tras MIO, 14 (78%) ocurrieron durante los primeros dos años en los que se inició este abordaje. Conclusión: La necesidad de dilatación endoscópica de la anastomosis tras esofaguectomía fue frecuente y la necesidad de dilataciones repetidas fue más alta tras MIO en comparación con OO. El riesgo aumentado tras MIO puede deberse a la curva de aprendizaje.

Health-related quality of life after open transhiatal and transthoracic oesophagectomy for cancer.

BACKGROUND: Transhiatal and transthoracic oesophagectomy in patients with oesophageal cancer have similar survival rates. Whether these approaches differ in health-related quality of life (HRQoL) is uncertain and was examined in this study. METHODS: Patients undergoing transhiatal or transthoracic surgery for lower-third oesophageal or gastro-oesophageal junctional cancer between 2011 and 2015 were selected from an institutional database. HRQoL outcomes were measured at 6 and 12 months after surgery using validated written questionnaires (European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25). Linear mixed models provided mean score differences (MSDs) with 95 per cent confidence intervals, adjusted for preoperative HRQoL, age, physical status (ASA fitness grade), tumour location, tumour stage, neoadjuvant therapy, adjuvant therapy and postoperative complications. MSD values of 10 or more were regarded as clinically relevant. RESULTS: Some 146 patients underwent transhiatal (86, 58·9 per cent) or transthoracic (60, 41·1 per cent) oesophagectomy. The HRQoL questionnaires were returned by 111 patients at 6 months and 74 at 12 months. At 6 months, transthoracic oesophagectomy was associated with worse role function (MSD -12, 95 per cent c.i. -23 to 0; P = 0·046). At 12 months, patients in the transthoracic group had more nausea and vomiting (MSD 11, 0 to 22; P = 0·045), dyspnoea (MSD 13, 1 to 25; P = 0·029) and constipation (MSD 20, 7 to 33; P = 0·003) than those in the transhiatal group. CONCLUSION: Transhiatal oesophagectomy seems to offer better HRQoL than transthoracic oesophagectomy 6 and 12 months after surgery.

Meta-analysis of health-related quality of life after minimally invasive versus open oesophagectomy for oesophageal cancer.

BACKGROUND: The aim of this systematic review and meta-analysis was to compare health-related quality of life (HRQoL) outcomes between minimally invasive and open oesophagectomy for cancer at different postoperative time points. METHODS: A search of PubMed (MEDLINE), Web of Science, Embase, Scopus, CINAHL and the Cochrane Library was performed for studies that compared open with minimally invasive oesophagectomy. A random-effects meta-analysis was conducted for studies that measured HRQoL scores using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-OES18 questionnaires. Mean differences (MDs) greater than 10 in scores were considered clinically relevant. Pooled effects of MDs with 95 per cent confidence intervals were estimated to assess statistical significance. RESULTS: Nine studies were included in the qualitative analysis, involving 1157 patients who had minimally invasive surgery and 907 patients who underwent open surgery. Minimally invasive surgery resulted in better scores for global quality of life (MD 11·61, 95 per cent c.i. 3·84 to 19·39), physical function (MD 11·88, 3·92 to 19·84), fatigue (MD -13·18, -17·59 to -8·76) and pain (MD -15·85, -20·45 to -11·24) compared with open surgery at 3 months after surgery. At 6 and 12 months, no significant differences remained. CONCLUSION: Patients report better global quality of life, physical function, fatigue and pain 3 months after minimally invasive surgery compared with open surgery. No such differences remain at longer follow-up of 6 and 12 months.

A simple novel prognostic model for early stage oral tongue cancer.

The prognostication of patient outcome is one of the greatest challenges in the management of early stage oral tongue squamous cell carcinoma (OTSCC). This study introduces a simple histopathological model for the prognostication of survival in patients with early OTSCC. A total of 311 cases (from Finland and Brazil) with clinically evaluated early stage OTSCC (cT1-T2cN0cM0) were included in this multicentre retrospective study. Tumour budding (B) and depth of invasion (D) were scored on haematoxylin-eosin-stained cancer slides. The cut-off point for tumour budding was set at 5 buds (low <5; high ≥5) and for depth of invasion at 4mm (low <4mm; high ≥4mm). The scores of B and D were combined into one model: the BD predictive model. On multivariate analysis, a high risk score (BD score 2) correlated significantly with loco-regional recurrence (P=0.033) and death due to OTSCC (P<0.001) in early stage OTSCC. The new BD model is a promising prognostic tool to identify those patients with aggressive cases of early stage OTSCC who might benefit from multimodality treatment.

Toll-like receptor 5 (TLR5) expression is a novel predictive marker for recurrence and survival in squamous cell carcinoma of the tongue.

BACKGROUND: Toll-like receptor 5 (TLR5) is an immune receptor recognising bacterial flagellin. Activation of TLR5 results in cancer invasion and cytokine release. As certain bacteria have been linked to oral cancer, we wanted to study TLR5 expression in oral tongue squamous cell carcinoma (OTSCC). METHODS: Samples from 119 patients with OTSCC were obtained, including 101 samples of adjacent normal lingual mucosa. The TLR5 histoscore (0-300) was assessed semiquantitatively by immunohistochemistry in a blinded manner. RESULTS: Toll-like receptor 5 was expressed in 84 normal epithelia and 118 cancer samples. Expression of TLR5 was increased in cancer when compared with normal lingual epithelium (median histoscore 15 vs 135). In cancer, higher TLR5 was associated with age of >70 years at the time of diagnosis, female gender and disease recurrence. No association between TLR5 expression and tumour grade, stage or treatment was found. In multivariate analysis, TLR5 was an independent predictor of cancer mortality (hazard ratio (HR) 3.587, 95% confidence interval (CI) (1.632-7.882)) and disease recurrence (HR 4.455, 95% CI (2.168-9.158)). CONCLUSION: Toll-like receptor 5 has a previously undescribed role in the pathophysiology of OTSCC and might represent a link between bacteria and cancer. It could be a useful marker for predicting recurrence or survival of OTSCC patients.