Chylous leakage after esophagectomy for esophageal cancer: a systematic review.

BACKGROUND: Chylous leakage is a rare complication following esophagectomy; however, it can lead to mortality. We aimed to systematically evaluate the factors that may lead to increased chylous leakage after esophagectomy. METHODS: Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for all studies investigating the occurrence of chylous leakage after esophagectomy. RESULTS: A total of 32 studies were identified, including 26 randomized controlled trials and 3 cohort and case-control studies, each. The overall incidence of chylous leakage was 4.7% (278/5,971 cases). Analysis of preoperative, intraoperative, and postoperative factors showed that most of the qualitative analysis results did not significantly increase the incidence of chylous leakage. In some quantitative analyses, the chylous leakage rate was significantly lower in the thoracic duct mass ligation group than in the conservative treatment group (relative risk [RR] = 0.33; 95% confidence interval [CI], 0.13-0.83; I2 = 0.0%; P = 0.327). Direct oral feeding significantly reduced chylous leakage compared with jejunostomy (RR = 0.06; 95% CI 0.01-0.33; I2 = 0.0%; P = 0.335). However, preoperative inspiratory muscle training (RR = 1.66; 95% CI, 0.21-12.33; I2 = 55.5%; P = 0.134), preoperative chemoradiotherapy (RR = 0.99; 95% CI, 0.55-1.80; I2 = 0.0%; P = 0.943), and robotic assistance (RR = 1.62; 95% CI, 0.92-2.86; I2 = 0.0%; P = 0.814) did not significantly reduce the incidence of chylous leakage. CONCLUSIONS: Ligation of the thoracic duct and direct oral feeding can reduce the incidence of chylous leakage after esophagectomy in patients with esophageal cancer. Other contributing factors remain unclear and require validation in further high-quality studies.

Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes.

Importance: Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes. Objective: To investigate associations between surgical performance and postoperative outcomes after MIE. Design, Setting, and Participants: In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes. Exposure: Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction. Main Outcome and Measure: The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes. Results: In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31). Conclusions and Relevance: These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.

Effect of oesophagectomy on lipid profiles in patients with oesophageal cancer combined with hyperlipidaemia: a retrospective study.

BACKGROUND: Surgery is widely regarded as a pivotal therapeutic approach for treating oesophageal cancer, and clinical observations have revealed that many oesophageal cancer patients also present with concomitant hyperlipidaemia. It is surprising that few studies have been performed to determine how blood lipid levels are affected by oesophageal cancer resection. This research was designed to assess the influence of oesophageal cancer resection on lipid profiles among individuals diagnosed with both oesophageal cancer and hyperlipidaemia. METHODS: A retrospective analysis was carried out on 110 patients with hyperlipidaemia and oesophageal cancer who had undergone oesophagectomy at the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army. Preoperative and postoperative serological data were collected at seven-, thirty-, sixty-day-, and one-year-long intervals. Changes in lipid levels were compared, the remission of various types of hyperlipidaemia was statistically assessed, and Pearson correlation was used to analyse the association between lipid changes and preoperative body weight. The research sought to assess the reduction in body weight and the proportion of body weight lost one year following surgery. RESULTS: Noteworthy decreases were observed in total cholesterol (TC), triglyceride (TG), and low-density lipoprotein (LDL) levels, with TC decreasing from 6.20 mmol/L to 5.20 mmol/L, TG decreasing from 1.40 mmol/L to 1.20 mmol/L, and LDL decreasing from 4.50 mmol/L to 3.30 mmol/L. Conversely, there was a notable increase in high-density lipoprotein (HDL) levels, which increased from 1.20 mmol/L to 1.40 mmol/L (P < 0.05) compared to the preoperative levels. Notably, the remission rates for mixed hyperlipidaemia (60.9%) and high cholesterol (60.0%) were considerably greater than those for high triglycerides (16.2%). Alterations in TC at one year postoperatively correlated with preoperative weight and weight loss (r = 0.315, -0.216); changes in TG correlated with preoperative weight, percentage of total weight loss (TWL%), and weight reduction (r = -0.295, -0.246, 0.320); and changes in LDL correlated with preoperative weight, TWL%, and weight loss (r = 0.251, 0.186, and -0.207). Changes in non-high-density lipoprotein(non-HDL) were linked to preoperative weight (r = 0.300), and changes in TG/HDL were correlated with preoperative weight and TWL% (r = -0.424, -0.251). CONCLUSIONS: Oesophagectomy significantly improved lipid profiles in oesophageal cancer patients, potentially leading to a reduction in overall cardiovascular risk.

A approach of gastric conduit via the anterior of pulmonary hilum route during minimally invasive McKeown esophagectomy.

BACKGROUND: The gastric conduit is the most commonly used replacement organ for reconstruction after minimally invasive McKeown esophagectomy. Although the optimal route of gastric conduit remains controversial, the posterior mediastinal route is physiologically preferable but is not without disadvantages. Here, we report the safety and efficacy of a method of gastric conduit reconstruction via the anterior of the pulmonary hilum route. METHODS: We have used the anterior of the pulmonary hilum route since 2021. This procedure involves pulling the gastric conduit up through a substernal tunnel between the right thoracic cavity and the abdominal cavity and passing it into the neck via the anterior of the pulmonary hilum route. In this retrospective study, we compared the clinical outcomes between 20 patients who underwent this procedure and 20 patients who underwent the posterior mediastinal route from 2021 to 2022. RESULTS: No mortality was reported in either group. No significant differences were observed between the two groups in duration of surgery, blood loss, incidence of postoperative complications, and postoperative hospital stay. As a result of the anterior of the pulmonary hilum route, the primary tumor bed and lymph node drainage area were effectively bypassed, which facilitates postoperative adjuvant radiotherapy or chemoradiotherapy. The distance of the gastric conduit accompanying the airway was significantly shorter in the anterior of the pulmonary hilum route group. CONCLUSIONS: Our method is considered to be a safe and useful technique for the reconstruction of gastric conduit.

Long-term quality of life after hybrid robot-assisted and open Ivor Lewis esophagectomy for esophageal cancer in a single center: a comparative analysis.

PURPOSE: Due to improved survival of esophageal cancer patients, long-term quality of life (QoL) is increasingly gaining importance. The aim of this study is to compare QoL outcomes between open Ivor Lewis esophagectomy (Open-E) and a hybrid approach including laparotomy and a robot-assisted thoracic phase (hRob-E). Additionally, a standard group of healthy individuals serves as reference. METHODS: With a median follow-up of 36 months after hRob-E (n = 28) and 40 months after Open-E (n = 43), patients' QoL was assessed using the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire Core 30 (QLQ-C30) and the EORTC Esophagus specific QoL questionnaire 18 (QLQ-OES18). RESULTS: Patients showed similar clinical-pathological characteristics, but hRob-E patients had significantly higher ASA scores at surgery (p < 0.001). Patients and healthy controls reported similar global health status and emotional and cognitive functions. However, physical functioning of Open-E patients was significantly reduced compared to healthy controls (p = 0.019). Operated patients reported reduced role and social functioning, fatigue, nausea and vomiting, dyspnea, and diarrhea. A trend towards a better pain score after hRob-E compared to Open-E emerged (p = 0.063). Regarding QLQ-OES18, hRob-E- and Open-E-treated patients similarly reported eating problems, reflux, and troubles swallowing saliva. CONCLUSIONS: The global health status is not impaired after esophagectomy. Despite higher ASA scores, QoL of hRob-E patients is similar to that of patients operated with Open-E. Moreover, patients after hRob-E appear to have a better score regarding physical functioning and a better pain profile than patients after Open-E, indicating a benefit of minimally invasive surgery.

[Treatment of primary malignant melanoma of the esophagus]. / Lechenie pervichnoi melanomy pishchevoda.

OBJECTIVE: To present treatment of primary esophageal melanoma in a young patient, as well as review of modern data on this issue. MATERIAL AND METHODS: We describe the results of treatment of a patient with primary melanoma of the esophagus. PubMed, SCOPUS, and elibrary databases were used for the review. RESULTS: We present a rare case of primary esophageal melanoma and variant of radical surgical treatment. The review is devoted to historical information about this nosology, statistical data, options for diagnosis and treatment. CONCLUSION: Such a rare clinical case is of great scientific interest due to the rarity of this disease. In our opinion, a certain register of orphan malignant tumors is necessary for diagnosis and treatment of various rare malignancies.

Protocol of a pilot randomized clinical trial to evaluate nutritional support and rehabilitation on prevention of skeletal muscle mass loss during neoadjuvant chemotherapy in patients with esophageal cancer.

BACKGROUND: Subtotal esophagectomy with lymph node dissection followed by neoadjuvant chemotherapy (NAC) is the standard treatment for stage II-III esophageal cancer. Esophagectomy is still associated with high morbidity rates, and reducing these rates remains challenging. Among several complications, postoperative pneumonia (PP) is sometimes fatal, which has been reportedly caused by sarcopenia. Thus, nutritional support and rehabilitation may be promising for preventing skeletal muscle mass loss and reduce the incidence of PP. METHODS: This single-center, randomized, open-label, pilot trial will randomize a total of 40 patients with esophageal cancer in a 1:1 ratio either to ISOCAL Clear + rehabilitation arm or only rehabilitation arm. Although all patients will be educated about rehabilitation by a specialized physician and will be asked to undergo the prespecified rehabilitation program, patients treated with ISOCAL Clear + rehabilitation arm will be supplemented by 400 mL of ISOCAL Clear (Nestlé Japan Ltd, Tokyo, Japan) per day during two courses of NAC with docetaxel, cisplatin, and fluorouracil. Body composition will be assessed using Inbody (Inbody Co., Ltd., Tokyo, Japan) just before starting NAC and surgery. The primary endpoint is the change of skeletal muscle index (SMI) during NAC. Secondary endpoints include (i) body weight, total skeletal muscle mass, appendicular skeletal muscle mass, and lean body mass index changes; (ii) the percentage of ISOCAL Clear continuation; (iii) appetite evaluation; (iv) the percentage of targeted calorie achievement; (v) adverse events of NAC; (vi) postoperative complication rates; and (vii) postoperative hospital stay. DISCUSSION: This prospective trial assesses the efficacy of nutritional support in addition to rehabilitation during NAC for patients with esophageal cancer. The results will be utilized in assessing whether the effects of nutritional support by ISOCAL Clear are promising or not and in planning future larger clinical trials.

The influence of postoperative outcomes on survival after esophageal cancer surgery: validation of a consensus-based updated textbook outcome parameter.

BACKGROUND: Esophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for esophageal adenocarcinoma. The primary aim of this study was to assess the influence of textbook outcome (TO) as a composite quality performance indicator (QPI) and its perioperative parameters on survival in patients who underwent esophagectomy with curative intent. METHODS: Consecutive patients who underwent an esophagectomy between January 2014 and December 2022 at Christchurch Hospital were identified from a prospectively maintained hospital database. Univariable and multivariable analyses were performed to assess prognostic factors for each composite and individual postoperative outcome. Survival analysis was performed to evaluate the influence of these outcomes on overall survival. RESULTS: A total of 108 patients underwent an esophagectomy during the study period. The overall and Clavien-Dindo (CD) grade ≥ 3 postoperative complication rates were 62% and 26%, respectively. The anastomotic leak rate was 6.5% (n = 7). The TO rate, 30-day readmission rate, and 30-day mortality rate were 20%, 13%, and 1%, respectively. Resection margin and nodal disease were found to be independent prognostic factors for reduced survival. CONCLUSION: TO as originally defined and its postoperative parameters of 30-day postoperative complications and 30-day readmission are validated QPIs of esophageal cancer surgery. Updating the postoperative complication parameter to include CD grade ≥ 3 complications resulted in a positive association between achieving TO and increased survival. Our findings support the call to redefine TO based on an update to this parameter, making it a more precise QPI of esophageal cancer surgery.

Role of indocyanine green fluorescence imaging for evaluating blood supply in the gastric conduit via the substernal route after McKeown minimally invasive esophagectomy.

BACKGROUND: Anastomotic leakage (AL) is a determining factor of morbidity and mortality after esophagectomy. Adequate perfusion of the gastric conduit is crucial for AL prevention. This study aimed to determine whether intraoperative angiography using indocyanine green (ICG) fluorescence improves the incidence of AL after McKeown minimally invasive esophagectomy (MIE) with gastric conduit via the substernal route (SR). METHODS: This retrospective cohort study included 120 patients who underwent MIE with gastric conduit via SR for esophageal cancer between February 2019 and April 2023. Of 120 patients, 88 experienced intraoperative angiography using ICG (ICG group), and 32 patients experienced intraoperative angiography without ICG (no-ICG group). Baseline characteristics and operative outcomes, including AL as the main concern, were compared between the 2 groups. In addition, the outcomes among patients in the ICG group with different levels of fluorescence intensity were compared. RESULTS: The ICG and no-ICG groups were comparable in baseline characteristics and operative outcomes. There was no significant difference between the 2 groups regarding the rate of AL (31.0% vs 37.5%; P = .505), median dates of AL (9 vs 9 days; P = .810), and severity of AL (88.9%, 11.11%, and 0.0% vs 66.7%, 16.7%, and 16.7% for grades I, II, and III, respectively; P = .074). Patients in the ICG group with lower intensity of ICG had higher rates of leakage (24.6%, 39.3%, and 100% in levels I, II, and III of ICG intensity, respectively; P = .04). CONCLUSION: The use of ICG did not seem to reduce the rate of AL. However, abnormal intensity of ICG fluorescence was associated with a higher rate of AL, which implies a predictive potential.

Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy.

INTRODUCTION: Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS: Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS: Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS: This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

Thoracoscopic McKeown esophagectomy in a patient with an azygos lobe.

BACKGROUND: The azygos lobe is a relatively rare anatomical variation, and there have been no reports, until date, of thoracoscopic McKeown esophagectomy for esophageal cancer in a patient with an azygos lobe. The azygos lobe can be diagnosed by chest X-ray or CT, and is usually not associated with any symptoms. However, surgeons should be aware that transthoracic surgical procedures in patients with an azygos lobe could be associated with a high risk of complications. CASE PRESENTATION: An 83-years-old man was brought to our emergency room with fever, severe headache, and difficulty in moving. MRI revealed a brain abscess, which was treated by abscess drainage and systemic antibiotic treatment. Further examinations to determine the cause of the brain abscess revealed esophageal cancer. In addition, CT revealed an azygos lobe in the right thoracic cavity. Although intrathoracic adhesions were anticipated on account of a previous history of bacterial pyothorax, we decided to perform esophagectomy via a thoracoscopic approach. Despite the difficulty in dissecting the intrathoracic adhesions, we were able to obtain the surgical field thoracoscopically. Then, we found the azygos lobe, as diagnosed preoperatively, and the azygos vein was supported by the mesentery draining into the superior vena cava. After dividing the mesentery, we clipped and cut the vessel, and both ends were further ligated. After these procedures, we safely performed esophagectomy with 3-field lymph node dissection. The postoperative course was uneventful, and the patient was discharged on the 21st postoperative day. CONCLUSIONS: Although there was a firm adhesion in the thoracic cavity, preoperative recognition of the azygos lobe could help in preventing intraoperative injury. Especially, esophageal surgeons are required to deal with the azygos lobe safely to avoid serious intraoperative injury.

Comparison of clinical outcomes of robotic-assisted and video-assisted esophagectomy for esophageal cancer.

INTRODUCTION: Robotic-assisted minimally invasive esophagectomy (RAMIE) is a recently developed technique for the treatment of resectable esophageal cancer. The present study compares the outcomes of RAMIE and video-assisted thoracoscopic esophagectomy (VATE). METHOD: Patients undergoing minimally invasive esophageal surgery between December 2020 and September 2022 were included in the study, while those undergoing conventional surgery were excluded. The patients were divided into two groups, as those undergoing RAMIE (Group 1) and those undergoing VATE (Group 2). The demographic and clinical characteristics, intraoperative parameters, pathological data, and postoperative parameters of the groups were compared. RESULTS: A total of 28 patients were included in the study, with 13 patients in Group 1 and 15 patients in Group 2. The gender distribution was similar (P = 0.488), and the mean age was 64.7 and 59.0 years in Groups 1 and 2, respectively (P = 0.068). The majority of the sample was in the ASA2 category (46.2% vs. 66.7%, P = 0.341); Ca19.9 levels were higher in Group 1 than in Group 2 (25.7 vs. 13.7, P = 0.027); preoperative Hb was lower in Group 1 than in Group 2 (10.9 g/dL vs. 12.2 g/dL, P = 0.043); the most commonly performed surgery was the McKeown procedure (69.2% vs. 66.7%, P = 0.492); an intraoperative feeding jejunostomy was placed only in Group 2; the operation time was similar between the groups (338.5 min vs. 340 min, P = 0.916); and the distribution of tumor localizations was similar between the groups (P = 0.407). In terms of tumor histology, squamous cell carcinoma (SCC) was the most common tumor type in the two groups (84.6% vs. 80%, P = 0.636); the tumor diameter was similar between the groups (14.9 vs. 18.1, P = 0.652); the number of removed lymph nodes was similar between the groups (24.9 vs. 22.5, P = 0.419); and the number of metastatic lymph nodes was higher in Group 2 (0.08 vs. 1.07, P = 0.27). One patient in Group 2 underwent repeat surgery due to suspected ischemic anastomosis; the distribution of postoperative complications according to the Clavien-Dindo classification system was similar in the two groups (P = 0.650); there was no early mortality within the first 30 days in either group; one patient in Group 2 was re-admitted within 90 days of discharge with decreased oral intake; the length of hospital stay was shorter in Group 1 (9 days vs. 16.5 days, P = 0.006); and the patients in Group 2 more often received neoadjuvant therapy in proportion to the disease stage (15.4% vs. 60%, P = 0.016). CONCLUSION: Robotic procedures can be safely performed in esophageal cancers with complication rates and oncological radicality similar to those of other minimally invasive techniques.

Online tools to predict individualised survival for primary oesophageal cancer patients with and without pathological complete response after neoadjuvant therapy followed by oesophagectomy: development and external validation of two independent nomograms.

OBJECTIVE: This study aimed to develop and validate robust predictive models for patients with oesophageal cancer who achieved a pathological complete response (pCR) and those who did not (non-pCR) after neoadjuvant therapy and oesophagectomy. DESIGN: Clinicopathological data of 6517 primary oesophageal cancer patients who underwent neoadjuvant therapy and oesophagectomy were obtained from the National Cancer Database for the training cohort. An independent cohort of 444 Chinese patients served as the validation set. Two distinct multivariable Cox models of overall survival (OS) were constructed for pCR and non-pCR patients, respectively, and were presented using web-based dynamic nomograms (graphical representation of predicted OS based on the clinical characteristics that a patient could input into the website). The calibration plot, concordance index and decision curve analysis were employed to assess calibration, discrimination and clinical usefulness of the predictive models. RESULTS: In total, 13 and 15 variables were used to predict OS for pCR and non-pCR patients undergoing neoadjuvant therapy followed by oesophagectomy, respectively. Key predictors included demographic characteristics, pretreatment clinical stage, surgical approach, pathological information and postoperative treatments. The predictive models for pCR and non-pCR patients demonstrated good calibration and clinical utility, with acceptable discrimination that surpassed that of the current tumour, node, metastases staging system. CONCLUSIONS: The web-based dynamic nomograms for pCR (https://predict-survival.shinyapps.io/pCR-eso/) and non-pCR patients (https://predict-survival.shinyapps.io/non-pCR-eso/) developed in this study can facilitate the calculation of OS probability for individual patients undergoing neoadjuvant therapy and radical oesophagectomy, aiding clinicians and patients in making personalised treatment decisions.

Lymph node volume predicts survival in esophageal squamous cell carcinoma treated with neoadjuvant chemoradiotherapy and surgery.

Large primary tumor volume has been identified as a poor prognostic factor of esophageal squamous cell carcinoma (ESCC) treated with definitive concurrent chemoradiotherapy (CCRT). However, when neoadjuvant CCRT and surgery are adopted, the prognostic impact of primary tumor and lymph node (LN) volume on clinical outcomes in ESCC remains to be elucidated. This study included 107 patients who received neoadjuvant CCRT and surgery for ESCC. The volume of the primary tumor and LN was measured using radiotherapy planning computed tomography scans, and was correlated with overall survival (OS), disease-free survival (DFS), and cancer failure pattern. The median OS was 24.2 months (IQR, 11.1-93.9) after a median follow-up of 18.4 months (IQR, 8.1-40.7). The patients with a baseline LN volume > 7.7 ml had a significantly worse median OS compared to those with smaller LN volume (18.8 vs. 46.9 months, p = 0.049), as did those with tumor regression grade (TRG) 3-5 after CCRT (13.9 vs. 86.7 months, p < 0.001). However, there was no association between OS and esophageal tumor volume (p = 0.363). Multivariate analysis indicated that large LN volume (HR 1.753, 95% CI 1.015-3.029, p = 0.044) and high TRG (HR 3.276, 95% CI 1.556-6.898, p = 0.002) were negative prognostic factors for OS. Furthermore, large LN volume was linked to increased locoregional failure (p = 0.033) and decreased DFS (p = 0.041). In conclusion, this study demonstrated that large LN volume is correlated with poor OS, DFS, and locoregional control in ESCC treated with neoadjuvant CCRT and esophagectomy.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

BACKGROUND: Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS: All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS: Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS: AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Preoperative DLco and FEV1 are correlated with postoperative pulmonary complications in patients after esophagectomy.

Limited information is available regarding the association between preoperative lung function and postoperative pulmonary complications (PPCs) in patients with esophageal cancer who undergo esophagectomy. This is a retrospective cohort study. Patients were classified into low and high lung function groups by the cutoff of the lowest fifth quintile of forced expiratory volume in 1 s (FEV1) %predicted (%pred) and diffusing capacity of the carbon monoxide (DLco) %pred. The PPCs compromised of atelectasis requiring bronchoscopic intervention, pneumonia, and acute lung injury/acute respiratory distress syndrome. Modified multivariable-adjusted Poisson regression model using robust error variances and inverse probability treatment weighting (IPTW) were used to assess the relative risk (RR) for the PPCs. A joint effect model considered FEV1%pred and DLco %pred together for the estimation of RR for the PPCs. Of 810 patients with esophageal cancer who underwent esophagectomy, 159 (19.6%) developed PPCs. The adjusted RR for PPCs in the low FEV1 group relative to high FEV1 group was 1.48 (95% confidence interval [CI] = 1.09-2.00) and 1.98 (95% CI = 1.46-2.68) in the low DLco group relative to the high DLco group. A joint effect model showed adjusted RR of PPCs was highest in patients with low DLco and low FEV1 followed by low DLco and high FEV1, high DLco and low FEV1, and high DLco and high FEV1 (Reference). Results were consistent with the IPTW. Reduced preoperative lung function (FEV1 and DLco) is associated with post-esophagectomy PPCs. The risk was further strengthened when both values decreased together.