Facing adenocarcinoma of distal esophagus and esophagogastric junction: a CROSS versus FLOT propensity score-matched analysis of oncological outcomes in a high-volume institution.

Multimodality treatments are the gold standard for advanced resectable gastroesophageal cancer. Neoadjuvant CROSS and perioperative FLOT regimens are adopted for distal esophageal and esophagogastric junction adenocarcinoma (DE/EGJ AC). At present, none of the approaches is clearly superior in the context of a curative-intent multimodal treatment. We analyzed consecutive patients treated with CROSS or FLOT and surgery for DE/EGJ AC between August 2017 and October 2021. Propensity score matching was performed to balance baseline characteristics of patients. The primary endpoint was disease-free survival. Secondary endpoints included overall survival, 90-day morbidity/mortality rates, pathological complete response, margin-negative resection, and pattern of recurrence. Of the 111 patients included, 84 were correctly matched after PSM, 42 in each group. The 2-year DFS rate was 54.2% versus 64.1% in the CROSS and FLOT group, respectively (p = 0.182). Patients in the CROSS group showed a lower number of harvested LN when compared to the FLOT group (29.5 versus 39.0 respectively, p = 0.005). A higher rate of distal nodal recurrence was found in the CROSS group (23.8% versus 4.8%, p = 0.026). Although not significant, the CROSS group showed a trend toward higher rate of isolated distant recurrence (33.3% versus 21.4% respectively, p = 0.328), together with a higher rate of early recurrence (23.8% versus 9.5% respectively, p = 0.062). FLOT and CROSS regimens for DE/EGJ AC offer similar DFS and OS, together with comparable morbidity/mortality rates. CROSS regimen was associated with a higher distant nodal recurrence rate. Results of ongoing randomized clinical trials are awaited.

Oncological outcomes of squamous cell carcinoma of the cervical esophagus treated with definitive (chemo-)radiotherapy: a systematic review and meta-analysis.

PURPOSE: To determine the oncological outcomes of cervical esophageal squamous cell carcinoma (CESCC) treated with definitive chemoradiotherapy (CRT). METHODS: A systematic review and meta-analysis was performed according to the PRISMA guidelines. RESULTS: A total of 1222 patients (median age: 63.0 years, 95% CI 61.0-65.0) were included from 22 studies. The median follow-up time was 34.0 months (n = 1181, 95% CI 26.4-36.0). Estimated pooled OS rates (95% CI) at 1, 3, and 5 years were 77.9% (73.9-82.2), 48.4% (43.2-54.3), and 35.3% (29.7-41.9), respectively. The median OS (95% CI) was 33.4 months (25.8-42.2). Estimated pooled PFS rates (n = 595; 95% CI) at 1, 3, and 5 years were 64.1% (57.9-71.0), 38.0% (33.3-45.5), and 29.8% (23.9-37.1), respectively. The median PFS (95% CI) was 19.8 months (14.9-26.6). CONCLUSIONS: Definitive CRT is a valuable first-line treatment for the management of CESCC. Further studies should focus on survival predictors able to define stage-based clinical guidelines.

Reply to Letter to the Editor regarding "Oncological outcomes of squamous cell carcinoma of the cervical esophagus treated with definitive (chemo-)radiotherapy: a systematic review and meta-analysis".

In a previous study, we performed a meta-analysis of the oncological outcomes of patients suffering from cervical esophageal squamous cell carcinoma treated with definitive chemoradiotherapy. Further analysis was performed, and a random effect modeling showed a pooled local-regional failure rate of 41.4% (95% CI 32.2-50.8), and a pooled distant failure rate of 21.6% (95% CI 17.0-26.5). The included studies used a median radiotherapy (RT) dose of 61.2 Gy (95% CI 60.0-62.0, range 56.0-66.0), but we measured a non-significant impact of the RT dose on the pooled overall survival (OS), suggesting that an increased RT dose might not be related to an improved OS (p = 0.23). Further research should be conducted to define predictors and prognostic categories that may select the best treatment option for each patient.

Oncological outcomes of cervical esophageal cancer treated primarily with surgery: a systematic review and meta-analysis.

PURPOSE: To determine the oncological outcomes of cervical esophageal cancer (CEC) treated primarily with surgery. METHODS: A systematic review and meta-analysis was performed according to the PRISMA guidelines. RESULTS: A total of 868 patients were included from 18 studies. Estimated pooled Overall Survival (OS) rates (95% Confidence Interval, CI) at 1 and 5 years were 74.4% (66.5-83.3), and 26.6% (20.3-34.7), respectively. Larynx non-preserving surgery (n = 229) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 59.3% (51.5-68.2) and 14.6% (8.8-24.3), respectively. On the other hand, larynx preserving surgery (n = 213) showed an estimated pooled OS rates (95% CI) at 1 and 5 years of 83.6% (78.2-89.4) and 35.1% (24.9-49.6), respectively. CONCLUSIONS: Primary larynx-preserving surgery remains a valuable option for the management of CEC, with similar survival outcomes compared to primary chemoradiotherapy (CRT). On the other hand, larynx non-preserving surgery showed a significantly reduced survival, that may reflect the more advanced T classification of these tumors. Further studies are mandatory to directly compare primary surgery and primary CRT, distinguishing larynx preserving and non-preserving surgery.

Critical Competences for the Management of Post-Operative Course in Patients with Digestive Tract Cancer: The Contribution of MADIT Methodology for a Nine-Month Longitudinal Study.

There is a high postoperative morbidity rate after cancer surgery, that impairs patients' self-management, job condition and economic strength. This paper describes the results of a peculiar psychological intervention on patients undergoing surgery for esophageal, gastric and colorectal cancer. The intervention aimed to enhance patients' competences in the management of postoperative daily life. A narrative approach (M.A.D.I.T.­Methodology for the Analysis of Computerised Text Data) was used to create a questionnaire, Health and Employment after Gastro-Intestinal Surgery­Dialogical Questionnaire, HEAGIS-DQ, that assesses four competences. It was administered to 48 participants. Results were used as guidance for specific intervention, structured on patients' competence profiles. The intervention lasted nine months after surgery and was structured in weekly to monthly therapeutic sessions. Quality of Life questionnaires were administered too. At the end of the intervention, 94% of patients maintained their job and only 10% of patients asked for financial support. The mean self-perception of health-related quality of life was 71.2. The distribution of three of four competences increased after nine months (p < 0.05). Despite economic difficulties due to lasting symptoms after surgery, and to the current pandemic scenario, a structured intervention with patients let them to resume their jobs and continue activities after surgery.

Managing the Consequences of Oncological Major Surgery: A Short- and Medium-Term Skills Assessment Proposal for Patient and Caregiver through M.A.D.I.T. Methodology.

The effects of cancer surgery and treatment harm patients' life and working ability: major causes of this can be intensified by the postoperative symptoms. This study, the first part of the HEAGIS project (Health and Employment after Gastrointestinal Surgery), proposes a method to assess patients and caregivers' competences in dealing with postoperative course and the related needs to improve the adequate competences. In this observational study, an ad hoc structured interview was conducted with 47 patients and 15 caregivers between the third and fifteenth postoperative day. Oesophageal (38%), esophagogastric junction (13%), gastric (30%), colon (8%) and rectum (11%) cancer patients were considered. Computerized textual data analysis methodology was used to identify levels of competences. Text analysis highlighted three different levels (low, medium and high) of four specific types of patients and caregivers' competences. In particular, the overall trend of the preview of future scenarios and use of resource competences was low. Less critical were situation evaluation and preview repercussion of own actions' competences. Caregivers' trends were similar. The Kruskal-Wallis test did not distinguish any differences in the level of competences related to the characteristics of the participants. Patients and caregivers are not accurate in planning the future after surgery, using personal beliefs rather than referring to physicians, and not recognizing adequate resources. The medium-low competences' trend leads to unexpected critical situations, and patients could not deal with them in a maximally effective way. Both patients and caregivers should be taken over by healthcare professionals to improve patients' competences and make the curative surgery effective in daily life.

Management of Liver Oligometastatic Esophageal Cancer: Overview and Critical Analysis of the Different Loco-Regional Treatments.

Esophageal cancer (EC) is an aggressive disease that is associated with a poor prognosis. Since metastastic EC is usually considered suitable only for palliative therapy with an estimated 5-year overall survival (OS) less than 5%, the optimal management of patients with liver oligometastatic EC (LOEC) is still undefined. The aim of this review is to provide an overview of the different treatment options for LOEC. A literature search was conducted using PubMed, Embase, and Cochrane to identify articles evaluating different treatment strategies for LOEC. Among 828 records that were identified, 20 articles met the inclusion criteria. These studies included patients who have undergone any type of surgical procedure and/or loco-regional therapy. Liver resection resulted in the best survival for patients with low tumor burden (3 lesions): 5-year OS 30-50% versus 8-12% after only chemotherapy (CHT). The 5-year OS of loco-regional therapies was 23% with a local recurrence risk ranging 0-8% for small lesions (2 to 3 cm). An aggressive multidisciplinary approach for LOEC patients may improve survival. Surgery seems to be the treatment of choice for resectable LOEC. If unfeasible, loco-regional therapies may be considered. In order to better select these patients and offer a chance of cure, prospective trials and a definition of treatment protocols are needed.

Gastric tube cancer after esophagectomy for cancer: a systematic review.

Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

Two-year subjective, objective, quality of life, and endoscopic follow-up after laparoscopic Nissen-Rossetti in patients with columnar-lined esophagus.

INTRODUCTION: Barrett esophagus (BE) is a complication of gastroesophageal reflux disease. We wish to determine the effects of surgery on the histology of the esophageal mucosa and evaluate Quality of Life. MATERIALS AND METHODS: Twenty-seven patients with columnar-lined esophagus (CLE) metaplasia underwent laparoscopic Nissen-Rossetti fundoplication. Patients were submitted to close follow-up. RESULTS: One patient voluntarily left follow-up after surgery. CLE was still present in 18 patients (66.6%); no patient developed dysplasia or esophageal adenocarcinoma. Two patients with gastric metaplasia and 1 patient with intestinal metaplasia had regression at 12 and 24 months after surgery (11.1%). DeMeester and Johnson score decreased from 38.69 (SD ± 51.44) to 11.99 (SD ± 18.08) at 6 months, 12.69 (SD ± 12.91) at 12 months, and it was 11.38 (SD ± 6.43) at 24 months. Preoperative gastroesophageal reflux disease-health related quality of life was 19.90 (SD ± 18.54), 9.80 (SD ± 8.77) at 6 months, 9.57 (SD ± 9.14) at 12 months, and 11.53 (SD ± 6.48) at 24 months. Short form-36 measurement showed significant improvement. CONCLUSIONS: Management of CLE requires multidisciplinary approach. Medical therapy does not prevent biliary reflux into the esophagus. Surgical therapy is effective and long lasting. It should be performed by experienced surgical teams.

An unexpected case of giant hiatal hernia and review of literature. GHH: case report and literature review.

INTRODUCTION: The management of giant hiatal hernia remains one of the most complicated surgical challenge and several operative approaches have been proposed during the years. Currently, the most practiced is the laparoscopic approach, which adds functional outcomes overlapping those of the conventional open surgery to the own advantages of the technique. The main problem of this operation is the high rate of recurrence, occurring independently by the specific technique adopted. PRESENTATION OF CASE: An unexpected case of giant hiatal hernia, incidentally discovered in a patient candidate to cholecystectomy for gallstones, is presented. We describe the surgical procedure performed and our cornerstones for a correct and long-lasting hiatal hernia repair, comparing us with the current standards of care. DISCUSSION: Laparoscopy has facilitated the execution of some surgical steps, such as the hiatal visualization and the intra-thoracic esophagus mobilization, fundamental for the success of the operation. Inheriting the concept of tension free repair, the use of mesh reinforcing the hiatal defect is being encouraged, especially biologic meshes, although some authors warn their employment may introduce potential catastrophic complications for patient. CONCLUSION: Laparoscopy should be the approach of choice, whenever possible, to treat this condition, while the use of supportive prosthetic devices depends on the single patient's hernia characteristics and on the surgeon's personal experience and preferences. Anyways, many factors determine the final outcomes of the surgical intervention, some of which patient dependent, others operator-dependent but, independently from the approach adopted, this operation is often burdened by a high risk of recurrence.

Quality of life after Nissen-Rossetti fundoplication.

BACKGROUND: We investigated Quality of Life (QoL) and Johnsson & DeMeester score of patients after Nissen-Rossetti fundoplication. MATERIALS AND METHODS: From January 2007 to June 2008, 43 patients with chronic gastroesophageal reflux underwent laparoscopic Nissen-Rossetti fundoplication; 7 were lost during the follow-up. Patients underwent endoscopy, 24-hour pH-metry, Gastroesophageal Reflux Disease-Health-Related Quality-of-Life (GERD-HRQL), and Short Form 36 (SF-36) questionnaires preoperatively, 6 months, and 12 months after surgery. RESULTS: Endoscopic findings revealed complete healing of esophagitis in all patients. Barrett esophagus was still present. Six patients reported persistence of symptoms but postoperative pH-metry and endoscopy showed the absence of reflux; 2 patients (5.5%) were still on proton pump inhibitor therapy at 12 months. Seven patients (19.4%) reported dysphagia for solids for at least 3 months. Readmission for dysphagia was required for 2 (5.5%) and 1 patient underwent endoscopic dilatation. At 6 and 12 months, no dysphagia was reported. During the follow-up, no gas-bloat syndrome was reported. The Johnsson & DeMeester score and QoL measurement obtained from GERD-HRQL and SF-36 revealed a significant improvement in the related domain. At 6 months, 23 patients (63.8%) were completely satisfied and after 12 months, 30 patients (83.3%) were satisfied. CONCLUSIONS: Nissen-Rossetti fundoplication is safe and effective for the treatment of GERD, improving QoL.

Laparoscopic Nissen-Rossetti fundoplication for gastroesophageal reflux disease patients after 2-year follow-up.

INTRODUCTION: Gastroesphageal reflux disease (GERD) is a common condition in the general population, affecting patients' quality of life and predisposing to Barrett's esophagus and its most fearsome complication, esophageal adenocarcinoma. The aim of this study is to compare objective and subjective outcomes of laparoscopic Nissen-Rossetti fundoplication after 2 years of follow-up. SUBJECTS AND METHODS: Seventy-six GERD patients underwent laparoscopic Nissen-Rossetti fundoplication. Patients were subjected to close follow-up. RESULTS: The DeMeester and Johnson score average decreased from a mean preoperative value of 35.48 (SD±40.24) to 9.83 (SD±6.40) at 6 months; at 12 months it was 11.44 (SD±10.28), and at 24 months it was 10.25 (SD±5.61). GERD Health-Related Quality of Life decreased from a preoperative value of 23.04 (SD±11.59) to 9.84 (SD±8.98) at 6 months, 8.34 (SD±8.98) at 12 months, and 6.8 (SD±6.46) at 24 months. The Short Form-36 measurement showed significant improvement. CONCLUSIONS: GERD patients need adequate reflux control. Successful antireflux surgery is more effective than medical therapy in preventing both acid and bile reflux. Surgical therapy is effective in terms of reflux control and improvement in quality of life. Strict and rigorous follow-up with both subjective and objective tests is important in order to identify asymptomatic recurrence of reflux after surgery.

Partial or total fundoplication (with or without division of the short gastric vessels): which is the best laparoscopic choice in GERD surgical treatment?

BACKGROUND: Gastroesophageal reflux disease (GERD) has emerged as one of the most common diseases in the modern civilization.The immense success of laparoscopic surgery as an effective treatment of GERD has established the minimally invasive surgery as the gold standard for this condition with lower morbidity and mortality, shorter hospital stay, faster recovery, and reduced postoperative pain. METHODS: Articles were sourced from PubMed and Medline, using the MeSH terms "gastroesophageal reflux disease" and "laparoscopic surgery" and "fundoplication technique." The selection of articles was based on peer review, journal, relevance, and English language. RESULTS AND CONCLUSIONS: There are some controversies with regard to the technique. First, whether total or partial fundoplication is the more appropriate treatment for GERD; second, if a total fundoplication (360 degrees) is performed, what is the effect of fundic mobilization and the division of short gastric vessels. In this review article the authors evaluate the most recent articles to establish the parameters for a "gold standard technique" in antireflux surgery.

Functional evaluation at 1-year follow-up of laparoscopic Nissen-Rossetti fundoplication.

Laparoscopic Nissen fundoplication is currently the gold standard for surgical treatment of gastroesophageal reflux disease. The aim of this study was to present our experience with this procedure at 1 year of follow-up. Forty patients were operated on between January 2006 and July 2007, and 30 underwent a 24-hour postoperative pH-metry study. Ninety-two percent of the patients were asymptomatic at a follow-up of 12 months. All pH-metric parameters improved. DeMeester and Johnson's score was reduced from 44.7 to 7.75; endoscopy with histologic samples revealed the healing of esophagitis in all patients; 4 (13%) patients complained of dysphagia, which resolved within 1 month after surgery. Twenty-seven (90%) patients were completely satisfied by their surgical results. One year after surgery, 24-hour ph-metric results show that laparoscopic Nissen fundoplication can completely control acid reflux with relatively few complications and a high degree of patient satisfaction.

Adenocarcinoma of the proximal esophagus: report of 9 patients and review of the literature.

BACKGROUND: Adenocarcinoma of the proximal esophagus is a rare clinical entity, with only 28 cases described in the literature. We report our experience with 9 patients and a review of the literature on this topic. METHODS: Between 1980 and 2004, 1010 patients with esophageal or gastroesophageal junction adenocarcinoma (from a total of 4655 cancers, 3510 squamous and 1145 adeno) presenting at our department were retrospectively evaluated. RESULTS: Nine patients (0.9%) had adenocarcinoma located in the proximal esophagus. Four patients (Group A) were considered unfit for surgery due to severe comorbidities and/or advanced stage disease. Three of them received endoscopic yttrium-aluminum-garnet (YAG)-laser therapy; 1 patient had feeding gastrostomy. Their median survival was 6 months (range, 3-9 months). The other 5 patients (Group B) were given a first-line cytoreductive treatment: 4 had complete response, and 1 patient did not complete chemotherapy due to toxicity and underwent surgery for residual disease. The median survival for these 5 patients receiving cytoreductive therapy was 36 months (range, 24-132 months). For the 4 patients with complete clinical response to cytoreductive treatment, the median survival was 54 months (range, 24-132 months). CONCLUSION: First-line chemoradiotherapy is an effective treatment for adenocarcinoma of the proximal esophagus. Salvage surgery may be reserved for patients with incomplete response or recurrent disease.

[Treatment of esophagopericardial fistula following esophagogastroplasty for esophageal caustic stenosis]. / Trattamento di fistola gastro-pericardica in pregressa esofagogastroplastica retrosternale per stenosi esofagea da caustici per stenosi esofagea da caustici.

Esophagopericardial fistula is a rare and severe complication, involving several benign, malignant and traumatic pathologies of the esophagus. Only few cases of esophagopericardial fistula have been published so far, as compared to more frequently reported cases of gastropericardial fistula. We report on a 25-year-old female with an esophagopericardial fistula following retrosternal esophagogastroplasty for esophageal caustic stenosis. One month before admission to our hospital, the patient had fever and nonradiating substernal chest pain which was relieved by aspirin, unfortunately without adequate antacid therapy. After 3 weeks, for abdominal pain and worsening chest pain with shock, she was admitted to another hospital and underwent laparotomy: an haemoperitoneum was found, due to a rupture of an ovarian cyst which was removed. For persistent shock, the patient had an echocardiogram which revealed a cardiac tamponade, treated with placement of a pericardic drainage (300 cc of purulent liquid). She was then transferred to our unit: an esophageal swallow with a small amount of methilene blue revealed a fistula between the stomach of the esophagogatroplasty and the pericardium. She eventually underwent surgery. A pericardial window was created, the gastric tube was taken down because of the impossibility to suture the gastric ulcer, and an esophagocoloplasty was used for the reconstruction of the alimentary transit. The postoperative course was unevenqf&l. She is alive and well at 15 months after surgery. Esophagopericardial fistula is a rare complication, with a high mortality rate. A timely decision is mandatory and an aggressive treatment often necessary.