Long-term survivors of esophageal cancer: disease-specific quality of life, general health and complications.

INTRODUCTION: The aim of our study was to assess the quality of life as well as secondary cancers/diseases and esophagectomy-related or unrelated interventions in the long-term course of surgery. PATIENTS AND METHODS: Out of 417 patients who underwent esophageal resection for cancer between September 1985 and November 2003, 85 were defined as long-term survivors (≥5 years). Fifty patients still alive in November 2008 complied with our inclusion criteria. The general (QLQ-C 30, version 3.0) as well as the esophagus specific quality of life (QLQ-OES 18) were analyzed with the help of the EORTC QLQ-questionnaires. RESULTS: The median observation interval since the operation was 100.1 (range 60-238) months. A median Global Health Status of quality of life (EORTC QLQ-C 30) of 66.7 was found (range 16.7-100). Among the functioning scores, emotional (83.3 (range 16.7-100)) and cognitive functioning (83.3 (range 0-100)) were highest. The esophagus-specific quality of life (EORTC QLQ-OES 18) revealed a median value (scale 0-100) of 0 each for dysphagia and difficulties with swallowing saliva, whilst reflux was a major problem with a score of 50.0 (range 0-100). CONCLUSION: Our results show that long-term survival with a good quality of life is possible after curative esophagectomy for carcinoma.

Prediction model of lymph node metastasis in superficial esophageal adenocarcinoma and squamous cell cancer including D2-40 immunostaining.

BACKGROUND: It was the aim of our study to establish a model for prediction of lymph node metastases in superficial esophageal cancer. METHODS: We analyzed the clinical and histopathological data of 50 consecutive patients with pT1-esophageal cancer who underwent oncological resection. Submucosal carcinomas (pT1b) were classified according to sm levels 1-3. D2-40 immunostaining was investigated using the ABC technique. In a first step, we performed univariate analysis (One-way ANOVA: Sigma restricted parameterization; test of SS whole vs. SS predicted) to test the predictive value of the following categorical parameters for lymph node status (positive/negative): sex, histologic tumor type, localization, surgical technique (transhiatal/transthoracic), grading, pT1-subclassification (pT1a, pT1b sm 1-3), pL-, pV-status, and D2-40 labeling. Simple regression was applied for the following continuous predictors: age and tumor size. All significant variables of univariate analysis were included in the multivariate analysis. For this purpose, we used the General Liner Models's analysis (forward stepwise). In a third step, the Kruskal-Wallis test with post hoc comparisons was intended to define the cut-off value of parameters tested. RESULTS: Only the following variables gained statistical significance in univariate analysis: sex, histological tumor type, grading, pT1-subclassification, lymphatic infiltration, microvascular infiltration, D2-40 immunostaining, and tumor size (P < 0.05). Variables reaching significance in multivariate analysis were tumor size (P = 0.017) and pV-status (P = 0.037). In the Kruskal-Wallis test with post hoc comparisons, the cut-off value of tumor size was 2 cm (model P = 0.002) and between the categories (P < 0.05). CONCLUSIONS: Lymph node positivity and lymphatic vessel infiltration did not linearly increase with sm tumor infiltration depth. The risk category of lymph node involvement in superficial esophageal cancer exists according to our prediction model on the basis of tumor size of >2 cm and microvascular infiltration. The hitherto common sm levels 1-3 classification of submucosal cancers appears to display a lesser impact than previously assumed with regard to prediction of potential lymph node metastases and consequently the indication for endoscopic or surgical therapy.

[Indications for conventional adrenalectomy]. / Indikationen zur konventionellen Adrenalektomie.

INTRODUCTION: Conventional adrenalectomy still plays an important role, even in the era of minimally invasive endocrine surgery. It was the aim of our study to analyse the indications for conventional adrenalectomy in our own patients since the introduction of the minimally invasive technique in the year 1994 - laparoscopically and retroperitoneoscopically. PATIENTS AND METHODS: Between January 1994 and September 2006, a total of 412 adrenalectomies were performed in 380 patients. Out of these, 106 operations (25.7 %) were carried out conventionally in 98 patients, and 306 operations (74.3 %) endoscopically in 282 patients. RESULTS: Indications for conventional adrenalectomy were - as compared with the minimally invasive procedure - significantly more frequent adrenocortical carcinomas (ACC), especially in the context of multivisceral resections, as well as adrenal metastases (synchronous and metachronous). In contrast, adrenal Cushing's disease (including 19 patients with bilateral tumours), pheochromocytoma, incidentaloma and Conn's syndrome constituted a more frequent indication for minimally invasive adrenalectomy. Conventionally operated adrenal pathologies with on average 6.0 (range: 1.2-19.0) cm diameter were significantly larger than the endoscopically removed tumours with on average 3.3 (range: 0.2-9.2) cm diameter (p < 0.0001). The side localisation and the frequency of bilateral adrenal tumours did not differ significantly in the two groups. CONCLUSION: Since the establishment of the minimally invasive technique in 1994, conventional adrenalectomy has been selected for 26 % of all resected adrenal pathologies at our clinic and, therefore, still plays an important role even in the era of laparoscopic surgery. The benefit of the laparoscopic procedure in the case of malignant pheochromocytoma, adrenocortical carcinoma, and isolated adrenal metastases at a locally confined stage is still unclear and requires prospective, randomised studies.

[Surgical therapy for esophageal carcinoma: a prospective 20-year analysis]. / Chirurgische Therapie des Osophaguskarzinoms: Eine prospektive 20-Jahres-Analyse.

BACKGROUND: The aim of our study was the analysis of long-term developments in the surgical therapy for esophageal carcinoma at our hospital over a period of 20 years with a differentiated view on the two predominant histological tumour types. PATIENTS AND METHODS: Between September 1985 and September 2005, esophageal resections were performed in 470 patients at our clinic on account of a malignant tumour of the esophagus. The abdomino-thoracic resection with abdominal and extended mediastinal lymph node dissection as well as intrathoracic anastomosis was the standard treatment in the case of squamous cell carcinoma, whereas in adenocarcinoma a transhiatal resection with abdominal and dorsal mediastinal lymphadenectomy and cervical esophagogastrostomy was carried out. For analysis of the development, the study period of 20 years was divided into two intervals: interval 1 from 9 / 1985 to 9 / 1995, and interval 2 from 10 / 1995 to 9 / 2005. RESULTS: Both tumour entities displayed in the last interval (10 / 1995 to 9 / 2005) significantly earlier tumour stages. A proportionally identical amount of transhiatal resections for squamous cell carcinoma was found in both intervals, whereas the transhiatal procedures for adenocarcinoma increased in the last decade (3.6 % in the period between 9 / 1985 and 9 / 1995, as compared with 23.6 % between 10 / 1995 and 9 / 2005) (p < 0.05). While the overall prognosis for squamous cell carcinoma did not significantly differ in the two decades (p = 0.2040), patients with adenocarcinoma were found to have a significantly improved long-term survival (log-rank test: p = 0.0365) in the second decade. The prognosis for adenocarcinoma, therefore, could be improved in the course of time with a 3-year survival rate of finally 40 % (as compared with 17.5 % in the first decade), and a 5-year survival rate of 25 % (as compared with 15 %). CONCLUSION: Surgical therapy for esophageal carcinoma has undergone distinct changes over the past 20 years. These are mainly due to epidemiological and diagnostic aspects, an improved selection of patients, whereby the operative procedure is adapted to the tumour stage and the operative risk for the patient. Especially with adenocarcinoma of the esophagus, these changes have led to a significantly more favourable long-term prognosis.

Developments in esophageal surgery for adenocarcinoma: a comparison of two decades.

BACKGROUND: The objective of this study was to examine outcomes in patients undergoing esophageal resection for adenocarcinoma at our institution during a 20-year period and, in particular, to address temporal trends in long-term survival. METHODS: Out of 470 patients who underwent esophagectomy for malignancy between September 1985 and September 2005, a total number of 175 patients presented with esophageal adenocarcinoma. Patients enrolled in this study included AEG (adenocarcinoma of the esophagogastric junction) type I tumors only. Time trends were studied comparing two decades, 9/1985 to 9/1995 (DI) and 10/1995 to 9/2005 (DII). RESULTS: The overall survival was significantly more favourable in patients undergoing esophageal resection for adenocarcinoma in the recent time period (DII, 10/1995 to 9/2005) as compared to the early time period (DI, 9/1985 to 9/1995) (log rank test: p = 0.0329). Significant differences in the recent decade were seen based on lower ASA-classifications, earlier tumor stages, and the operative procedure with a higher frequency of transhiatal resections (p < 0.05). 30-day mortality improved from 8.3% to 3.1% during the 20-year time-interval, thus without statistical significance. CONCLUSION: Based on our experience, overall survival is improving over time for adenocarcinoma of the esophagus. Factors that may play an important role in this trend include early diagnosis and improved patient selection through better preoperative staging, improved surgical technique with a tailored approach carefully evaluated by physiologic patient status, comorbidity and tumor extent.

[Nonerosive and erosive gastroesophageal reflux disease. Long-term results of laparoscopic anterior semifundoplication]. / Nichterosive und erosive gastroösohageale Refluxerkrankung. Langzeitergebnisse der laparoskopischen anterioren Semifundoplikatio.

BACKGROUND: The aim of this study was to evaluate long-term results of laparoscopic anterior semifundoplication in patients with nonerosive (NERD) and erosive (ERD) gastroesophageal reflux disease. PATIENTS AND METHODS: The study includes the period from May 1997 to July 2005. Upper gastrointestinal endoscopy was performed in all 190 patients. The severity of reflux esophagitis was classified according to Savary and Miller (grades I-IV). A standardized questionnaire was used for follow-up, and the modified symptomatic DeMeester score was assessed. RESULTS: 58.5 years of age (range 27-80), patients with nonerosive reflux disease (n=83) were significantly older than those with erosive reflux disease (n=107) (48 years range 15-84) (p=0.0001). Patients with NERD had a lower modified symptomatic DeMeester score postoperatively of 0 (range 0-4) than patients with ERD, of 1 (range 0-5), though without statistical significance (p=0.151). CONCLUSION: Laparoscopic anterior semifundoplication leads to comparable symptomatic long-term results in both NERD and ERD. Anterior semifundoplication is a good therapeutic option for selected patients with persistent reflux-associated symptoms and endoscopically negative esophagitis.