Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center.

Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.

Short- and long-term outcomes in patients operated with total minimally invasive esophagectomy for esophageal cancer.

At our hospital, the main treatment for resectable esophageal cancer (EC) has since 2013 been total minimally invasive esophagectomy (TMIE). The aim of this study was to present the short- and long-term results in patients operated with TMIE. This cross-sectional study includes all patients scheduled for TMIE from June 2013 to January 2016 at Oslo University Hospital. Data on morbidity, mortality, and survival were retrospectively collected from the patient administration system and the Norwegian Cause of Death Registry. Long-term postoperative health-related quality of life (HRQL) and level of dysphagia were assessed by patients completing the following questionaries: EORTC QLQ-OG25, QLQ-C30, and the Ogilvie grading scale. A total of 123 patients were included in this study with a median follow-up time of 58 months (1-88 months). 85% had adenocarcinoma, 15% squamous cell carcinoma. Seventeen patients (14%) had T1N0M0, 68 (55%) T2-T3N0M0, or T1-T2N1M0 and 38 (31%) had either T3N1M0 or T4anyNM0. Ninety-eight patients (80%) received neoadjuvant (radio)chemotherapy and 104 (85%) had R0 resection. Anastomotic leak rate and 90-days mortality were 14% and 2%, respectively. The 5-year overall survival was 53%. Patients with tumor free resection margins of >1 mm (R0) had a 5-year survival of 57%. Median 60 months (range 49-80) postoperatively the main symptoms reducing HRQL were anxiety, chough, insomnia, and reflux. Median Ogilvie score was 0 (0-1). In this study, we report relatively low mortality and good overall survival after TMIE for EC. Moreover, key symptoms reducing long-term HRQL were identified.

Outcome after endoscopic treatment for dysplasia and superficial esophageal cancer - a cohort study.

BACKGROUND: Dysplasia and superficial esophageal cancer should initially be treated endoscopically. Little is known about post-procedural health-related quality of life (HRQL). The aim of this study was to present our results with endoscopic treatment and post-procedural HRQL. MATERIALS AND METHODS: From June 2014 to December 2018, all patients treated with endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA) for low-grade dysplasia (LGD), high-grade dysplasia (HGD), T1a and a minority of patients with T1b at Oslo University Hospital were prospectively included. In June 2019, all patients alive were scored according to the Ogilvie dysphagia score as well as the QLQ-C30 and QLQ-OG25 for assessment of HRQL. RESULTS: Eighty-six patients were treated out of whom 22 (26%) had LGD, 44 (51%) HGD, 13 (15%) T1a, and six patients (7%) T1b. Histology revealed adenocarcinoma in 18 (21%) and squamous cell carcinoma in one (1%), respectively. The mean follow-up was 22.9 months. Tumor regression or downstaging was archived in 78% of the patients with LGD, 66% of patients with HGD and in 89% of patients with T1a/b. Five patients (6%) had esophagectomy. There were few and no serious complications. The 90-days mortality was 1%. Fifty-two patients (88%) experienced no dysphagia (Ogilvie score 0). There was no difference in 11 out of the 15 variables in QLQ-C30 when compared to a non-cancerous reference population. CONCLUSIONS: Endoscopic treatment is safe and efficient for treatment of dysplasia and superficial esophageal cancer. The two-years post-procedural level of HRQL and dysphagia was satisfactory.

Long-term outcome in patients operated with hybrid esophagectomy for esophageal cancer - a cohort study.

Background: Over the past two decades, hybrid and total minimally invasive esophagectomy for esophageal cancer (EC) has increasingly been implemented with the aim to improve morbidity, functional result and ultimately the prognosis in these patients. However, more results are warranted and in this single-center study we report long-time outcome in a cohort of cancer patients treated with hybrid esophagectomy (HE).Material and methods: Hundred and nine patients with EC operated with HE from November 2007 to June 2013 were included. Clinical, pathological and survival data were retrieved from the patient administration system and the Norwegian Cause of Death Registry. Patients alive were asked to fill out the Ogilvie dysphagia score, EORTC QLQ-C30 and EORTC QLQ-OG25. Survival was analyzed by Kaplan-Meier's method and prognostic factors by uni- and multivariable Cox regression analyses.Results: Median overall follow-up time was 55 months (range 2-135) after R0-2 resection (n = 109) and 76 months (5-135) for R0 resection (n = 100). Five-year overall survival rate was 49% and 53%, respectively. Anastomotic leakage rate and 90-days mortality were 5% and 2%, respectively. Six patients (6%) had later surgery for metastases to mediastinum, hepatoduodenal ligament, brain, lung, liver or bladder median 26 months (4-51) after HE. Forty-one out of 51 patients alive (80%) filled out questionnaires after median 65.5 months (63-123) follow-up. All patients could eat normal food without (n = 37) or with (n = 4) problems. Nearly, half of the patients reported problems with reflux, one-third experienced fatigue and anxiety while one out of four had weight loss and episodes of dyspnea.Conclusions: In this patient series, HE offered low postoperative mortality and good overall long-term survival. Most survivors maintained good quality of life more than five years post treatment. There was a low rate of serious postoperative complications.

Outcome after iatrogenic esophageal perforation.

OBJECTIVES: Iatrogenic perforations are the most common cause of esophageal perforation. We present our experience mainly based on a non-operative treatment approach as well as long-term outcome in these patients. MATERIALS AND METHODS: Twenty-one patients were treated for iatrogenic esophageal perforation at Oslo University Hospital, Ullevål from February 2007 to March 2014. The etiology of perforation was dilation of benign stricture in eight patients, either dilation, stenting or stent removal in four with malignant stenosis, during diagnostic endoscopy in four, removal of foreign body in two and by other causes in three patients, respectively. After median 82 months, 10 patients alive (47.6%) were sent questionnaires about dysphagia, HRQoL and fatigue. RESULTS: Median age at time of treatment was 66 years. Median in-hospital stay and mortality were 10.5 days and 4.8%, respectively. Initial treatment in 15 patients (71.4%) was non-surgical of whom one needed delayed debridement for pleural empyema. Initial treatment in six patients (28.6%) was surgical of whom three needed delayed stenting. Altogether 14 patients (66.7%) were stented. Eight (57.1%) had restenting. Median number of stents used was 1 (1-4). The stents were removed after median 36 days. The perforations healed after 2.5 months. After median 82 months, the patients reported reduced HRQoL. There was no significant difference regarding level of dysphagia and fatigue. CONCLUSIONS: We report satisfactorily short-term and long-term results of iatrogenic esophageal perforations. Mortality was low and HRQoL was deteriorated. Dysphagia and fatigue were comparable to a reference population.

Outcome after accidental food bolus-induced esophageal perforation.

OBJECTIVES: Food bolus-induced esophageal perforation is much more seldom than iatrogenic and emetic esophageal rupture. We present results from a non-operative treatment approach as well as long-term functional outcome. MATERIALS AND METHODS: Medical records of 10 consecutive patients with food bolus-induced esophageal perforation from October 2007 to May 2015 were retrospectively registered in a database. Six patients developed perforation related to endoscopic removal of impacted food, and four during esophageal passage of bone, meat or bread. Treatment was sealing the perforation by stenting (n = 7) with (n = 4) or without (n = 3) chest tube drainage, chest tube drainage (n = 1), observation (n = 1) and gastroesophageal resection (n = 1) because of concomitant emesis of gastric effluent. After median 51 months nine patients reported about dysphagia, fatigue and health-related quality of life. RESULTS: Ten patients aged median 62.5 years (range 30-85) stayed in our hospital for 12 days (5-68 days). There was no treatment-related mortality. Nine patients were alive 63 months (18-126) after perforation. Five needed restenting (leakage, migration, impacted stent), two had drainage of a mediastinal abscess, one patient developed a transient esophagobronchial fistula. Dysphagia score was 0 (0-1). One patient developed dysphagia for some solid food. Scores for fatigue and HRQoL was similar to a Norwegian reference population. CONCLUSION: Treatment mainly with a non-operative approach occurred without mortality. Complications were handled by restenting and abscess drainage. Functional result for dysphagia was excellent. Interesting results on fatigue and HRQoL must be interpreted with caution because of a limited patient material.

Outcome after stenting and débridement for spontaneous esophageal rupture.

OBJECTIVES: Surgical repair has been the most common treatment of esophageal effort rupture (Boerhaave syndrome). Stent-induced sealing of the perforation has increasingly been used with promising results. We present our eight years´ experience with stent-based and organ-preserving treatment. MATERIALS AND METHODS: Medical records of 15 consecutive patients with Boerhaave syndrome from February 2007 to May 2015 were retrospectively registered in a database. Treatment was sealing of the perforation by stenting, chest tube drainage and débridement of the contaminated thorax. After median 25 months nine out of 10 patients responded to questions on fatigue and Ogilvie's dysphagia score. RESULTS: Fifteen patients, aged median 67.5 years (range 39-88), had a primary hospital stay of 20 days (range 1-80 days). Overall in-hospital mortality was 13%. Observation time was 44 months (range 0-87) and 10 patients were alive of August 2017. Ten patients (67%) needed surgical chest débridement. Five patients (33%) were restented for leakage, migration and for stent removal. Eleven patients (73%) had complications, which included pleural empyema (n = 4), fatal aortic bleeding, lung arterial bleeding, lung embolism, drain-induced lung laceration and respiratory failure. Dysphagia score was low (median 0.5) meaning that they were able to feed themselves. Total fatigue score (mean 14.6) was slightly increased (p = .05) compared with a reference population. CONCLUSIONS: The mortality rate after initial stenting of effort rupture seems to be comparable to standard surgical repair. Most patients required further intervention, either by restenting and/or surgical débridement. The functional result in these patients was satisfactory.

Surgical treatment of epiphrenic oesophageal diverticulum.

BACKGROUND: Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the department's results for surgical treatment of this rare and distressing condition. MATERIAL AND METHOD: In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery. RESULTS: There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery. INTERPRETATION: Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.

Partial splenectomy after preoperative embolization in a patient with metastatic melanoma - A case report.

INTRODUCTION AND IMPORTANCE: There is lack of evidence regarding the best treatment option for metastatic melanoma. In patients with a single splenic metastasis, preoperative superselective embolization followed by partial splenectomy (PS) could be a feasible treatment strategy to preserve splenic function and hopefully reduce the risk of postoperative bleeding. To our knowledge, this two-step procedure has yet not been published in patients with splenic metastasis. CASE PRESENTATION: We present the case of a 73-year-old man with stage IV melanoma consisting of a single splenic metastasis located at the lower pole. Four days prior to surgery, the patient underwent percutaneous superselective embolization of the segmental arteries going to the lower splenic pole. Subsequent, PS was performed using an upper midline laparotomy were a clearly visible tumor was found at the devascularized lower third of the spleen. The splenic parenchyma was divided using an energy device and hemostasis was secured with diathermia and a hemostatic patch. The patient had an uncomplicated recovery and was discharged home on postoperative day 8. Histology revealed an 8 mm, partly necrotic metastasis from a melanoma. There were no signs of recurrency at his last control four months postoperative. CLINICAL DISCUSSION: There are no guidelines on how splenic metastasis from melanoma are to be removed, nor any literature on postoperative splenic function or survival after PS. CONCLUSION: Superselective embolization followed by PS for metastatic melanoma could be a feasible treatment approach in highly selective patients where there is a strong desire to preserve splenic function.

Targeted genetic and epigenetic profiling of esophageal adenocarcinomas and non-dysplastic Barrett's esophagus.

BACKGROUND: Despite the efforts to describe the molecular landscape of esophageal adenocarcinoma (EAC) and its precursor lesion Barrett's esophagus (BE), discrepant findings are reported. Here, we investigated the prevalence of selected genetic (TP53 mutations and microsatellite instability (MSI) status) and epigenetic (DNA promoter hypermethylation of APC, CDKN2A, MGMT, TIMP3 and MLH1) modifications in a series of 19 non-dysplastic BE and 145 EAC samples. Additional biopsies from adjacent normal tissue were also evaluated. State-of-the-art methodologies and well-defined scoring criteria were applied in all molecular analyses. RESULTS: Overall, we confirmed frequent TP53 mutations among EAC (28%) in contrast to BE, which harbored no mutations. We demonstrated that MSI and MLH1 promoter hypermethylation are rare events, both in EAC and in BE. Our findings further support that APC, CDKN2A, MGMT and TIMP3 promoter hypermethylation is frequently seen in both lesions (21-89%), as well as in a subset of adjacent normal samples (up to 12%). CONCLUSIONS: Our study further enlightens the molecular background of BE and EAC. To the best of our knowledge, this is one of the largest studies addressing a targeted analysis of genetic and epigenetic modifications simultaneously across a combined series of non-dysplastic BE and EAC samples.