Surgical Resection of Hypopharynx and Cervical Esophageal Cancer with a History of Esophagectomy for Thoracic Esophageal Cancer

Background

Cancer of the hypopharynx and cervical esophagus (PhCe cancer) frequently develops synchronously or metachronously with esophageal cancer. The surgical approach is usually difficult, especially in metachronous PhCe cancer after esophagectomy. The purpose of this study was to clarify the treatment outcomes of patients with metachronous PhCe cancer with a history of esophagectomy.

Methods

The subjects evaluated in this study were 14 patients with metachronous PhCe cancer who underwent pharyngo-laryngo-esophagectomy after subtotal esophagectomy and gastric tube pull-up for primary esophageal cancer.

Results

Definitive chemoradiotherapy (CRT; radiation dose >50 Gy) was performed for primary laryngeal (n = 1), pharyngeal (n = 2), esophageal (n = 1), and recurrent esophageal cancer (n = 2). For seven patients with metachronous PhCe cancer, induction CRT (radiation dose <40 Gy) was performed. In all 14 patients, pharyngo-laryngo-esophagectomy was followed by free jejunal graft interposition with reconstruction of the jejunal vessels. Although postoperative complications developed in four patients, no perioperative death or necrosis of the reconstructed free jejunum occurred. The 2- and 5-year overall survival rates were 84 and 50 %, respectively.

Conclusions

Pharyngo-laryngo-esophagectomy with free jejunal transfer is considered to be safe for metachronous PhCe cancer, even in patients with a history of CRT and esophagectomy.     

The Use of Short Segment Free Jejunal Transfer as Salvage Surgery for Cervical Esophageal and Hypopharyngeal Cancer

Background

Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy.

Methods

We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates.

Results

The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %.

Conclusions

Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.     

Feasibility of esophageal reconstruction using a pedicled jejunum with intrathoracic esophagojejunostomy in the upper mediastinum for esophageal cancer

Objective

An alternative conduit is needed when the gastric tube cannot be used as an esophageal substitute for reconstruction after esophagectomy. We adopted pedicle jejunal reconstruction with intrathoracic anastomosis in the upper mediastinum under such circumstances. The aim of this study was to evaluate the feasibility of this technique.

Methods

Two hundred and ten patients with esophageal cancer underwent esophagectomy and reconstruction from 1998 to 2013. Among them, 6 patients underwent colon interposition (colon group) and 13 underwent jejunum reconstruction (jejunum group) including 8 thoracoscopic anastomosis. The operative results of both groups were compared with those of 191 gastric tube reconstructions (stomach group).

Results

The operative times in the colon and jejunum groups were significantly longer than that in the stomach group (P = 0.001 and P = 0.018, respectively). The colon group showed more operative blood loss and more frequent anastomotic leakage and ischemic stenosis of the conduit than did the stomach group (1605 vs. 530 g, P = 0.007; 50 vs. 12.6 %, P = 0.035; 16.7 vs. 0 %, P = 0.03, respectively). There was no anastomotic leakage, conduit necrosis and mortality in the jejunum group. Ischemic stenosis of the conduit occurred more frequently in jejunum group than in the stomach group (23.1 vs. 0 %, P < 0.001). However, the stenosis could be managed safely with endoscopic treatment. Patient survival in the colon and jejunum groups was consistent with that in the stomach group.

Conclusions

Pedicle jejunal reconstruction with intrathoracic anastomosis can be performed safely under thoracotomy or thoracoscopic surgery when stomach cannot be used as an esophageal substitute after esophagectomy.     

Clinical Significance of Incidental Pulmonary Nodules in Esophageal Cancer Patients

Introduction

Incidental pulmonary nodules are frequently identified during staging investigations for esophageal cancer patients. Their clinical significance is unclear and may bias treatment decisions towards palliative options.

Methods

From 2005 to 2011, 423 esophageal cancer patients were treated at a tertiary hospital. Those with incidental pulmonary nodules were identified. Demographics, imaging, pathology and perioperative outcomes were analyzed.

Results

Ninety-two patients (22 %) had lung nodules. Twenty-nine (32 %) were palliative due to poor performance status or extra-pulmonary distant metastasis on imaging. Sixty-three had no evidence of extra-pulmonary metastasis and underwent curative-intent treatment comprising of neoadjuvant therapy [35 (55 %)] followed by esophagectomy [with lung resection, 33 (52 %) or without lung resection, 30 (48 %)]. Of those 33 lung resections, there were 27 benign lesions, 4 stage I lung cancers, and 1 esophageal cancer metastasis. Of 30 patients with lung nodules that underwent curative esophagectomy without lung resection, none showed interval size increase on follow-up imaging [median 9 months (3–40)]. There was no difference in perioperative complications or mortality between patients with combined esophagectomy and lung resection and those with esophagectomy alone.

Conclusion

Incidental pulmonary nodules in the absence of extra-pulmonary metastases in esophageal cancer patients are rarely metastases and should not bias caregivers towards palliative therapy.     

Induction Chemotherapy or Chemoradiotherapy Followed by Radical Esophagectomy for T4 Esophageal Cancer: Results of a Prospective Cohort Study

Background

We hypothesized that the survival rate of patients undergoing R0 esophagectomy after induction chemotherapy or chemoradiotherapy for unresectable T4 esophageal cancer (URT4) would be similar to that of patients undergoing esophagectomy for immediately resectable esophageal cancer with no unfavorable prognostic factors (RNU).

Methods

Between April 2002 and June 2012, 87 of 283 patients with esophageal cancer who presented at the University Hospital of the Ryukyus were enrolled in this prospective cohort study. Tumors were classified as RNU and URT4 in 44 and 43 of the 87 patients, respectively. Outcomes of treatment for URT4 patients were compared with those of RNU patients.

Results

The R0 resection rate (61 %) and in-hospital mortality rate (20 %) of URT4 patients were significantly poorer than those of RNU patients (98 and 2.3 %, respectively), although the morbidity rate was similar in the two groups (63 and 52 %, respectively). The 5-year survival rate (35 %) of URT4 patients was significantly poorer than that of RNU patients (67 %) in the intention-to-treat analysis. However, no significant difference was noted between the two survival curves for cases of R0 resection (5-year survival rate, 60 % vs. 69 %). Multivariate analysis revealed R status as the only significant independent prognostic factor for URT4 patients (P < 0.001; hazard ratio = 8.279).

Conclusions

Satisfactory survival rates can be achieved if R0 resection is performed after induction treatment in patients with T4 esophageal cancer, although secondary radical esophagectomy is associated with a higher risk of in-hospital mortality.     

Influence of resection extent on morbidity in surgery for squamous cell cancer at the pharyngoesophageal junction

Purpose

Squamous cell cancer (SCC) of the pharyngoesophageal junction area has a poor prognosis mainly due to late symptom manifestation and diagnosis. Treatment of choice is still pharyngolaryngoesophagectomy, substantially affecting quality of life. Limited surgical procedures have been adopted as well. The aim of this retrospective study was to evaluate whether the extent of resection influences postoperative safety and mortality.

Methods

From 1984 to 2006, 66 patients were operated at a single tertiary referral center. Nineteen patients (28.8 %) had SCC of the hypopharynx and 47 patients (71.2 %) had SCC of the cervical and cervicothoracic esophagus. Thirty-five patients (53.0 %) underwent cervical esophageal resection (CE) and 31 underwent total esophagectomy (TE). In 39 patients (59.1 %), the larynx was preserved. Thirteen patients (19.7 %) underwent multimodal treatment.

Results

Overall postoperative morbidity was 69.7 % and reoperation rate reached 28.8 %. TE (P?=?0.03) and larynx preservation (P?=?0.02) were followed by a higher rate of non-lung infections compared with CE and pharyngolaryngectomy, respectively. Pulmonary complications have been observed more frequently after larynx preservation (P?=?0.02). Hospital mortality was 9.1 %. Four patients died after TE (12.9 %) and two patients died after CE (5.7 %). In all of them, the larynx had been preserved (15.4 %). Overall, 53 patients (80.3 %) died until follow-up. One-year and 5-year survival in patients with the major tumor burden at the cervicothoracic site was 35.7 and 0 %.

Conclusions

CE can be recommended as long as R0 resection is warranted. The advantage of larynx preservation is gained by higher morbidity and mortality rates and may not be recommended as standard procedure. Surgery may not be appropriate for advanced SCC in the cervicothoracic region.     

The Impact of Neoadjuvant Chemoradiotherapy on Perioperative Outcomes, Tumor Pathology, and Survival in Clinical Stage II and III Esophageal Cancer

Background

The purpose of this study was to evaluate the impact of neoadjuvant chemoradiotherapy (NCR) on perioperative outcomes, tumor pathology, and survival following surgical resection of clinical stage II and III esophageal cancer.

Methods

Patients undergoing esophagectomy for clinical stage II and III cancer were divided into two groups: those who received NCR and those who underwent primary surgery (1991–2011).

Results

A total of 173 (50.9 %) of 340 stage II/III patients received NCR, 108 (31.8 %) patients underwent primary surgery, and 59 (17.4 %) underwent neoadjuvant chemotherapy followed by surgery. Patients who received NCR were younger but had a similar Charlson comorbidity index and incidence of adenocarcinoma. There were no differences between groups in the incidence of complications, in-hospital mortality, and ICU stay, but patients who received NCR demonstrated a reduced length of hospital stay. NCR was associated with a reduced the incidence of positive pathological lymph node status and positive resection margin (3.1 vs. 21.1 %) in stage III esophageal cancer. No overall survival benefit was seen with use of NCR, although a nonsignificant improvement in survival of 22 months (p = 0.06) was noted in patients with adenocarcinoma. Negative resection margin was associated with an improved survival in both stage II and III patients.

Conclusions

This study highlights the importance of planning operations to optimize the opportunity to provide negative surgical resection margins and to identify patients not responding to NCR to allow them to proceed directly to surgery. Additional assessment of the effect of NCR on patients with adenocarcinoma is warranted.     

Efficacy and Predictor of Octreotide Treatment for Postoperative Chylothorax After Thoracic Esophagectomy

Background

Postoperative chylothorax sometimes follows thoracic esophagectomy for esophageal cancer. The effectiveness of octreotide treatment for it and factors that predict its response are unclear. This study aimed to evaluate the efficacy of octreotide for treating postoperative chylothorax following thoracic esophagectomy for esophageal cancer and factors that might predict successful treatment and allow chest drain removal.

Methods

We assessed 521 consecutive patients who underwent thoracic esophagectomy for esophageal cancer to investigate the efficacy of octreotide for postoperative chylothorax. Among those with postoperative chylothorax, one group (group A) underwent conservative management, and the other (group B) was treated conservatively with added octreotide administration. We evaluated the clinical outcomes after octreotide administration and assessed the factors associated with successful treatment.

Results

Among the 521 patients, 20 (3.8 %) developed postoperative chylothorax: five in group A and 15 in group B. Two of the five (20 %) group A patients and 13 of the 15 (86.6 %) group B patients were treated successfully (p = 0.03). Factors significantly associated with treatment failure were (1) chest drain output of >1,000 ml/day before treatment (p = 0.04); (2) no reduction in chest drainage by the second day of treatment (p = 0.016); (3) chest drainage of >1,000 ml/day through the second day of treatment (p = 0.006).

Conclusions

For patients with esophageal cancer who undergo thoracic esophagectomy, octreotide can be an effective treatment for postoperative chylothorax.     

Gender differences in prognosis after esophagectomy for esophageal cancer

Purpose

The purpose of this study was to clarify the gender differences in the prognosis, as well as mortality and morbidity, of patients who have undergone esophagectomy for esophageal cancer.

Methods

The clinical results of esophagectomy were compared between 975 male and 156 female patients with esophageal cancer.

Results

The male to female ratios of cervical and thoracic esophageal cancer were 1.87 and 7.38, respectively (P < 0.01). The incidence of preoperative comorbidities was 32.4 and 17.4 %, respectively, and the rates of both tobacco and alcohol abuse were significantly lower in the females than in the males. The mortality rate was lower in the females (3.8 %) than in the males (5.7 %), although the differences were not significant. The overall survival was significantly better in the female than in the male patients (P = 0.039). The 5- and 10-year overall survival rates were 32.6 and 20.5 % in the males and 39.5 and 32.5 % in the females, respectively. A multivariate analysis revealed gender to be an independent prognostic factor. However, no significant differences were recognized in disease-specific survival.

Conclusions

These results suggest that the prognosis of females with esophageal cancer is better than that of males after esophagectomy, most likely due to multiple clinical factors, such as a more favorable lifestyle and general status.     

Surgery Is an Essential Component of Multimodality Therapy for Patients with Locally Advanced Esophageal Adenocarcinoma

Background

Experience with neoadjuvant chemoradiation (CXRT) has raised questions regarding the additional benefit of surgery after locally advanced esophageal adenocarcinoma patients achieve a clinical response to CXRT. We sought to quantify the value of surgery by comparing the overall (OS) and disease-free survival (DFS) of trimodality-eligible patients treated with definitive CXRT vs. CXRT followed by esophagectomy.

Methods

We identified 143 clinical stage III esophageal adenocarcinoma patients that were eligible for trimodality therapy. All patients successfully completed neoadjuvant CXRT and were considered appropriate candidates for resection. Patients that were medically inoperable were excluded. Cox regression models were used to identify significant predictors of survival.

Results

Among the 143 patients eligible for surgery after completing CXRT, 114 underwent resection and 29 did not. Poorly differentiated tumors (HR?=?2.041, 95% CI?=?1.235–3.373) and surgical resection (HR?=?0.504, 95% CI?=?0.283–0.899) were the only independent predictors of OS. Patients treated with surgery had a 50 and 54 % risk reduction in overall and cancer-specific mortality, respectively. Median OS (41.2 vs. 20.3 months, p?=?0.012) and DFS (21.5 vs. 11.4 months, p?=?0.007) were significantly improved with the addition of surgery compared to definitive CXRT.

Conclusions

Surgery provides a significant survival benefit to trimodality-eligible esophageal adenocarcinoma patients with locally advanced disease.     

Clinical and oncological effects of triplet chemotherapy followed by radical esophagectomy for resectable esophageal cancer associated with unfavorable prognostic factors

Purposes

The purpose of this study was to evaluate the hypothesis that the survival of patients undergoing R0 resection after triplet chemotherapy for resectable esophageal cancer with unfavorable prognostic factors (Category 3) would be similar to that of patients undergoing esophagectomy for esophageal cancer without such factors (Category 1).

Methods

Patients with Category 3 tumors were assigned to receive triplet chemotherapy consisting of 5-fluorouracil, doxorubicin and nedaplatin (FAN) followed by radical esophagectomy. The outcomes of the bimodality treatment for Category 3 patients (n = 25) were compared with those of Category 1 patients (n = 41) in a prospective cohort study.

Results

Grade 3 or higher toxicity developed during chemotherapy in 32 % of the Category 3 patients, with no treatment-related deaths. No significant difference was detected in the surgery-related mortality and morbidity rates between the two groups. The recurrence-free survival was significantly worse in Category 3 than in Category 1 patients (p = 0.002), although the overall survival was not significantly different (p = 0.085) between the two groups in cases of R0 resection (5-year survival rates: 34.4 vs. 66.5 %).

Conclusions

Although FAN chemotherapy followed by radical esophagectomy can be safely performed, this treatment modality may not have sufficient power to cure Category 3 disease.     

Factors Influencing the Long-Term Survival in Patients with Esophageal Cancer Who Underwent Esophagectomy After Chemoradiotherapy

Background

Salvage esophagectomy is potentially the only treatment available that can offer a chance of long-term survival when definitive chemoradiotherapy (CRT) fails to achieve local control for patients with esophageal squamous cell carcinoma (ESCC). However, salvage esophagectomy is a highly invasive procedure with various postoperative complications compared to planned esophagectomy after neoadjuvant chemoradiotherapy (CRT). We hypothesize that severe postoperative complications may affect not only surgical mortality but also tumor recurrence and long-term survival for patients with salvage esophagectomy after definitive CRT.

Methods

For the present study we reviewed the surgical procedures, postoperative complications, and the prognosis of 65 consecutive patients with thoracic ESCC who underwent the esophagectomy after neoadjuvant (neoadjuvant group: n = 40) or definitive (salvage group: n = 25) CRT.

Results

Most patients underwent right-transthoracic extended esophagectomy and reconstruction using gastric conduit by way of subcutaneous route with left cervical anastomosis. The incidence of postoperative pneumonia was found to be higher in the salvage group than in the neoadjuvant group. In both groups, the survival of patients with R0 resection was significantly better than those with R1/R2 resection. Moreover, in the salvage group, the postoperative survival rate of patients with pneumonia or bacteremia/sepsis was significantly lower than that for patients who did not suffer the same complications. In the neoadjuvant group, R0 resection was selected to be the only independent prognostic factor in univariate and multivariate analysis. In contrast, in the salvage group, R0 resection and bacteremia/sepsis remained significant and were independent of the other factors in multivariate analysis.

Conclusions

This study reveals that postoperative morbidity affects not only the perioperative mortality but also the long-term survival of patients with ESCC who undergo salvage esophagectomy after definitive CRT.     

Technical Factors that Affect Anastomotic Integrity Following Esophagectomy: Systematic Review and Meta-analysis

Background

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.

Methods

Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.

Results

No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61–13.9; P = 0.005).

Conclusions

A tailored surgical approach to the patient’s physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.     

Gef??anschluss an die A.?carotis communis

Background

In the treatment of esophageal cancer neoadjuvant radiotherapy often leads to vascular damage of the usual recipient arteries for free jejunal transfer. End-to-side anastomosis to the carotid artery could be a potential alternative.

Patients and methods

A total of 70 patients with locally advanced carcinoma of the esophagus underwent esophagectomy after neoadjuvant radiochemotherapy. In all patients reconstruction was carried out with a free jejunal transfer. Smaller vessels could be used for anastomoses in 54 of these patients and in 16 cases the jejunal flap artery was attached to the carotid artery.

Results

Out of 54 patients 9 (17%) with microvascular anastomoses to the smaller vessels needed surgical intervention for ischemia. In 16 patients with anastomosis to the carotid artery no significant failure of perfusion occurred.

Conclusion

The carotid artery as recipient vessel in free jejunal transfer seems to be a safe therapeutic option for intestinal reconstruction of preradiated esophageal cancer with good functional results.     

Atrial fibrillation after esophageal cancer surgery: an analysis of 207 consecutive patients

Purpose

The aim of this study was to identify perioperative risk factors that are associated with postoperative atrial fibrillation (AF) and the outcomes of different pharmacological interventions in esophageal cancer patients who underwent transthoracic esophagectomy.

Methods

This study included 207 patients who underwent a transthoracic esophagectomy for esophageal cancer resection by a single surgeon from January 1, 2004, through December 31, 2010.

Results

Postoperative AF occurred in 19 patients (9.2 %), all of whom received antiarrhythmic drug therapy at the early stage. Antiarrhythmic treatment was effective in 12 cases (63.2 %). In this study, landiolol hydrochloride, an ultrashort-acting β₁-selective β-blocker, was the first-line therapy for postoperative AF. A multivariate logistic regression analysis showed that postoperative AF was significantly associated with the use of an ileo-colon for reconstruction after esophagectomy (P = 0.0023, odds ratios [OR] = 13.6) and with the presence of tachycardia with a heart rate of >100 bpm on postoperative day (POD) 1 (P = 0.0004, OR = 18.4).

Conclusions

Postoperative AF is associated with the use of a colon conduit for reconstruction after esophagectomy and with tachycardia with a heart rate >100 bpm on POD 1. Identifying patients at high risk for postoperative AF will allow for more direct application of pharmacological methods of prophylaxis.     

Cost-Effectiveness of Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer

Background

A recent randomized trial comparing minimally invasive (MIE) and open esophagectomy for esophageal cancer reported improved short-term outcomes. However, MIE has increased operative costs, and it is unclear whether the short-term benefits of MIE outweigh the increased operative costs. Therefore, the objective of this study was to determine the cost-effectiveness of MIE compared to open esophagectomy for esophageal cancer.

Methods

A decision-analysis model was developed to estimate the expected costs and outcomes after MIE and open esophagectomy from a health care system perspective with a time horizon of 1 year. Costs were represented in 2012 Canadian dollars, and effectiveness was measured in quality-adjusted life-years (QALYs). Probabilistic sensitivity analysis assessed parameter uncertainty.

Results

MIE was estimated to cost $1641 (95 % confidence interval 1565, 1718) less than open esophagectomy, with an incremental gain of 0.022 QALYs (95 % confidence interval 0.021, 0.023). MIE was therefore dominant over open esophagectomy. On deterministic sensitivity analyses, the results were most sensitive to variations in length of stay. Probabilistic sensitivity analysis demonstrated the robustness of the base case result, with 66, 77, and 82 % probabilities of cost-effectiveness at willingness-to-pay thresholds of $0/QALY, $50,000/QALY, and $100,000/QALY, respectively.

Conclusions

MIE is cost-effective compared to open esophagectomy in patients with resectable esophageal cancer.     

Significance of Thoracoscopy-Assisted Surgery with a Minithoracotomy and Hand-Assisted Laparoscopic Surgery for Esophageal Cancer: The Experience of a Single Surgeon

Background

This retrospective study evaluated the surgical learning curve and outcomes of thoracolaparoscopic esophagectomy.

Patients and Methods

The study group comprised a series of 92 patients with preoperatively diagnosed resectable thoracic esophageal cancer. Additionally, the surgical outcomes in 79 esophageal cancer patients receiving open esophagectomies were compared. All patients underwent thoracolaparoscopic esophagectomy in the lateral decubitus position. The short- and long-term outcomes were evaluated, and the surgical learning curve was assessed.

Results

The total operation time was 477.8?±?102.2 min, the thoracoscopic time was 157.9?±?61.3 min, the total blood loss was 554.4?±?280.5 ml, and the number of retrieved lymph nodes was 34.3?±?14.3. Postoperative morbidity was observed in 23 patients. After the surgeon??s first 40 cases, the surgical technique and short-term outcomes were stable. The 5-year disease-specific survival was 66.6% and the 5-year overall survival was 64.6% in patients receiving R0 thoracolaparoscopic esophagectomy. Comparison of 5-year disease-specific survival rate according to tumor?Cnode?Cmetastasis stage between patients receiving R0 thoracolaparoscopic esophagectomy and conventional open esophagectomy showed that there were no significant differences in survival in any stage between the two groups. Loco-regional recurrence was observed in 6 patients, distant recurrence in seven, and combined recurrence in nine after R0 thoracolaparoscopic esophagectomy. There was no significant difference in the pattern of recurrence between the two groups.

Conclusions

Thoracolaparoscopic esophagectomy for esophageal cancer was technically feasible and oncologically satisfactory, according to the surgical learning curve.     

Reduced plasma ghrelin levels on day 1 after esophagectomy: a new predictor of prolonged systemic inflammatory response syndrome

Background and purpose

Ghrelin, a stomach-derived hormone, stimulates growth hormone secretion and appetite, and inhibits excessive inflammatory response. Plasma ghrelin might affect the inflammatory response to stressful surgical interventions. The aim of this study was to investigate the relationship between serial changes in plasma ghrelin concentrations and the postoperative clinical course after esophagectomy.

Methods

The prospective cohort study subjects were 20 patients with esophageal cancer, who underwent esophagectomy with gastric tube reconstruction. Blood samples were taken six times perioperatively during the course of esophagectomy.

Results

The plasma ghrelin level decreased to 33 % (range 15?C90 %) on postoperative day (POD) 1, relative to the preoperative level, then recovered to about 50 % by POD 3?C10. The duration of systemic inflammatory response syndrome (SIRS) was significantly longer in patients with a marked ghrelin reduction to <33 % on POD 1, than in those with less marked reduction of ??33 % (6.1 ± 1.3 vs. 2.1 ± 0.6 days, P = 0.019). On POD 1, the only inflammatory marker that correlated with the duration of SIRS was the % ghrelin, whereas C-reactive protein, leukocyte count, and IL-6 did not.

Conclusion

An early postoperative drop in plasma ghrelin correlated with prolonged SIRS after esophagectomy. Thus, the supplementation of low plasma ghrelin may help minimize excess inflammatory response in these patients.     

Extent of Lymphadenectomy Does Not Predict Survival in Patients Treated with Primary Esophagectomy

Background

The number of lymph nodes resected and its impact on survival for patients with esophageal cancer remains undefined. Current guidelines recommend extended lymphadenectomy in patients not receiving neoadjuvant therapy. We reviewed our single institutional experience with nodal harvest for esophageal cancer in a non-neoadjuvant therapy setting.

Methods

Patients who underwent esophagectomy as primary therapy were indentified from a prospectively maintained database consisting of 704 patients who underwent esophagectomy. Patients were stratified by number of lymph nodes (LN) resected: >5, 10, 12, 15, or 20. Survival, clinical, and pathologic parameters were analyzed with Kaplan–Meier curves, chi-square, or Fisher’s exact tests where appropriate.

Results

We identified 246 patients who underwent esophagectomy as initial treatment. The mean age was 65?±10 years. The majority of patients were male (87 %). Ivor–Lewis esophagectomy was performed for 71 %, minimally invasive esophagectomy for 15 %, transhiatal esophagectomy for 12 %, and three-field esophagectomy for 2 %. At 60 months follow-up, there was no statistically significant difference in overall survival (OS) or disease-free survival (DFS) between patients with < vs. >5 LN resected (p?=?0.74 and p?=?0.67, respectively) or in the < vs. >10 (p?=?0.33, p?=?0.11), 12 (p?=?0.82, p?=?0.90), 15 (p?=?0.45, p?=?0.79), or 20 (p?=?0.72, p?=?0.86) resected LN groups. Patients were then subdivided into node-positive and node-negative cohorts and stratified by nodal harvest. In the subgroups of patients with node-negative and node-positive disease, OS and DFS also did not significantly differ between groups with respect to number of nodes resected (p?>?0.05). A total of 49 (20 %) patients developed recurrent disease; however, recurrence was not statistically associated with number of LN resected (p?>?0.05).

Conclusion

We found no impact of extent of lymphadenectomy on overall or disease-free survival in patients treated with esophagectomy without neoadjuvant therapy. In addition, the number of nodes resected at esophagectomy did not affect recurrence rates. Current recommendations for increased nodal resection during esophagectomy in patients not receiving neoadjuvant therapy may not improve patient outcomes, and this phenomenon warrants further investigation.