Modified gastric pull‐up reconstructions following pharyngolaryngectomy with total esophagectomy

Reconstruction following pharyngolaryngectomy with total esophagectomy is a challenging surgery to perform. Between April 2008 and August 2012, three types of modified gastric pull‐up reconstruction procedures, including a gastric tube creation combined with a free jejunal transfer (n = 7), elongated gastric tube creation with vascular anastomoses (n = 2) and pedunculated gastric tube creation with Roux‐en‐Y anastomosis (n = 5), were performed after pharyngolaryngectomy with total esophagectomy. To clarify feasibility of these reconstructive methods, we retrospectively analyzed the short‐term outcomes. There were no graft failures. Salivary fistulae were observed in two cases after high pharyngoenteral anastomoses due to oropharyngeal extension of hypopharyngeal cancers. Overall morbidity rate was 21.4%, and no deaths occurred. Although the operation time was shortest for pedunculated gastric tube reconstructions, morbidity rates were similar among all methods. All three types of modified gastric pull‐up reconstruction procedures can be performed safely. We can choose one of these methods according to the tumor status and the patient condition, understanding advantages and disadvantages of each procedure.     

Salvage esophagectomy after definitive chemoradiotherapy for esophageal cancer

Salvage esophagectomy is performed for esophageal cancer after definitive chemoradiotherapy. The clinical significance and safety of salvage surgery has not been well established. We reviewed 14 cases of salvage esophagectomy following definitive chemoradiotherapy from 1994 through 2005 and investigated complication rates and outcomes. Seven of 14 cases were completely resected with salvage surgery. Operation time and bleeding were greater in patients who experienced incomplete resection (R1/R2). Anastomosis leakage, pulmonary dysfunction and heart failure were recognized in four, two and one patients, respectively. The postoperative complications were more frequent (71.4%) in patients with incomplete resection (R1/R2) than in patients with complete resection (R0) (28.4%). Two patients with complete resection (R0) showed long-term survival. Salvage esophagectomy may be indicated when the tumor can be resected completely after definitive chemotherapy. However, all cases of T4 cancer cannot be resected completely, resulting in a high risk for complications and poor survival.     

Salvage esophagectomy after exclusive chemoradiotherapy: results at the Brazilian National Cancer Institute (INCA)

Surgical resection is considered the gold standard treatment for esophageal cancer, with global cure rates ranging from 15 to 40%. Exclusive chemoradiotherapy has been used for patients with locally advanced esophageal carcinoma or without clinical conditions for esophagectomy, reaching a 5‐year survival rate of up to 30%. However, locoregional control is poor, with local recurrence of 40–60%, being reported in the literature. Maybe, these patients can benefit from salvage surgery. In this study, 15 patients with esophageal cancer submitted to salvage esophagectomy after exclusive chemoradiotherapy treatment were retrospectively analyzed. Salvage esophagectomy was demonstrated to be technically feasible. However, it presents with high surgical morbidity. Currently, salvage esophagectomy is considered the best available treatment to attempt cure in cases of tumor recurrence or persistence after exclusive chemoradiotherapy. All the other types of treatments are regarded as palliative with discouraging survival results.     

Salvage esophagectomy after definitive chemoradiotherapy for synchronous double cancers of the esophagus and head-and-neck

Head-and-neck cancer is frequently associated with esophageal cancer. Because the operative procedures for these synchronous double cancers are too invasive, definitive chemoradiotherapy tends to be applied as an initial treatment. A salvage esophagectomy for either recurrent or residual disease after definitive chemoradiotherapy in patients with such double cancer has never been reported. We reviewed 21 patients with esophageal cancer who underwent a salvage esophagectomy after definitive chemoradiotherapy. Among them, the treatment course of five patients who underwent a salvage esophagectomy for patients with synchronous double cancers of the esophagus and head-and-neck region was analyzed. Because head-and-neck cancer was well controlled after chemoradiotherapy in all five patients, a salvage esophagectomy was indicated for either recurrent or residual esophageal cancer after definitive chemoradiotherapy. Anastomotic leakage developed in four patients; however, no other complications including pulmonary complications were recognized. All of them were discharged to home and three of them are still alive without any recurrence for 20–43 months. A salvage esophagectomy should be considered as a treatment option for either recurrent or residual esophageal cancer with well-controlled head-and-neck cancer after definitive chemoradiotherapy when complete resection of the esophagus is expected.     

Outcomes from salvage esophagectomy post definitive chemoradiotherapy compared with resection following preoperative neoadjuvant chemoradiotherapy

Chemoradiotherapy (CRT) as a definitive treatment for esophageal cancer, is being used with increasing frequency and as a result, surgeons will be required to assess more patients who have residual or recurrent local malignancy. This article aimed to assess outcomes after esophagectomy following definitive CRT (dCRT) and compare any difference between them and patients who had preoperative neoadjuvant CRT (nCRT) using a similar regimen of chemotherapy. From a prospective database the details of patients who had a resection following nCRT and dCRT were analyzed. The main therapeutic difference between the groups was the dose of radiotherapy (35 vs 60 Gy) and the timing of the resection following completion of the CRT (median 4 vs 28 weeks). Fourteen patients had an esophagectomy following a dCRT and 53 had one following a nCRT. Preoperatively, the dCRT group had worse respiratory function and more ECG abnormalities. Preoperative tumor length, pathological TNM staging and R0 resection rates were the same in both groups. Post resection, the dCRT group had greater morbidity than the nCRT group, spending longer in the intensive care unit (median 48 vs 24 h), more days in hospital (median 31 vs 13) and having more severe respiratory complications (37%vs 6%). The operative mortality was higher in the dCRT group (7%vs 0%). The three-year survival was 24% after dCRT. Patients selected for salvage esophagectomy following dCRT are a major challenge in postoperative care. However, some patients survive for a reasonable period of time, making resection a worthwhile option.     

Salvage surgery after definitive chemoradiotherapy for esophageal cancer

Background Definitive chemoradiotherapy has been performed as a first-line treatment for esophageal cancer, whereas salvage surgery might be the only reliable treatment for patients with recurrence after definitive chemoradiotherapy.Methods We reviewed 38 patients with squamous cell carcinoma who underwent esophagectomy and 6 patients who underwent lymphadenectomy after definitive chemoradiotherapy (≥50 Gy).Results The median survival time and 5-year survival rate after salvage esophagectomy were 16 months and 27%, respectively. Three of the 7 patients who had cervical esophageal cancer underwent cervical esophagectomy with laryngeal preservation. Two patients (5.2%) who underwent salvage esophagectomy with three-field lymphadenectomy before 1997 died of postoperative complications, but no patient died of complications thereafter. Although the overall survival after salvage esophagectomy was correlated with residual tumor (R) (P = 0.0097), the median survival time of 7 patients with residual tumors (R₂) was 7 months. Overall postoperative survival was closely correlated with the response to chemoradiotherapy (P < 0.0001) but was not associated with histologic effects on resected specimens. Survival was significantly correlated with the depth of viable tumor invasion (pT) (P = 0.0013) and with lymph node metastasis (pN) (P < 0.0001). Long-term survival was achieved in 5 of the 6 patients who underwent salvage lymphadenectomy.Conclusions Salvage surgery should be considered for patients with recurrence after definitive chemoradiotherapy. Salvage lymphadenectomy may be useful for recurrence confined to the lymph nodes whereas postoperative complications of salvage esophagectomy should be warranted.     

Salvage chemoradiotherapy for locally advanced esophageal carcinomas

‘Salvage chemoradiotherapy (CRT)’ was introduced in 2005 to treat thoracic esophageal carcinomas deemed unresectable based on the intraoperative findings. The therapeutic concept is as follows: the surgical plan is changed to an operation that aims to achieve curability by the subsequent definitive CRT. For this purpose, the invading tumor is resected as much as possible, and systematic lymph node dissection is performed except for in the area around the bilateral recurrent nerves. The definitive CRT should be started as soon as possible and should be performed as planned. We hypothesized that this treatment would be feasible and provide good clinical effects. We herein verified this hypothesis. Twenty‐seven patients who received salvage CRT were enrolled in the study, and their clinical course, therapeutic response, and prognosis were evaluated. The patients who had poor oral intake because of esophageal stenosis were able to eat solid food soon after the operation. The radiation field could be narrowed after surgery, and this might have contributed to the high rate of finishing the definitive CRT as planned. As a result, the overall response rate was 74.1%, and 48.1% of the patients had a complete response. No patient experienced fistula formation. The 1‐, 3‐, and 5‐year overall survival rates were 66.5%, 35.2%, and 35.2%, respectively. Salvage CRT had clinical benefits, such as the fact that patients became able to have oral intake, that fistula formation could be prevented, that the adverse events associated with the definitive CRT could be reduced, and that prognosis of the patients was satisfactory. Although the rate of recurrent nerve paralysis was relatively high even after the suspension of aggressive bilateral recurrent nerve lymph node dissection, and the rate of the progressive disease after the definitive CRT was high, salvage CRT appears to provide some advantages for the patients who would otherwise not have other treatment options following a non‐curative and residual operation.     

Risk factors for complications after pharyngolaryngectomy with total esophagectomy

Background

Pharyngolaryngectomy with total esophagectomy (PLTE) is an effective surgical treatment for synchronous or metachronous hypopharyngeal or laryngeal cancer and thoracic esophageal cancer, although it is more invasive than esophagectomy and total pharyngolaryngectomy. The aim of this study was to identify risk factors for complications after PLTE.

Methods

From November 2002 to December 2014, a total of 8 patients underwent PLTE at the Shizuoka Cancer Center Hospital, Shizuoka, Japan. We investigated the clinicopathological characteristics, surgical procedures, and postoperative complications of these patients.

Results

Of the 8 patients, 5 underwent one-stage PLTE and 3 underwent staged PLTE. There was no mortality in this study. Two cases of tracheal necrosis, two of anastomotic leakage, and one of ileus were observed as postoperative complications. Two patients who underwent one-stage PLTE with standard mediastinal lymph node dissection developed tracheal necrosis and severe anastomotic leakage.

Conclusion

One-stage PLTE and standard mediastinal lymph node dissection were identified as the risk factors for severe postoperative complications. Staged PLTE or transhiatal esophagectomy should be considered when PLTE is performed and standard mediastinal lymph node dissection should be avoided when one-stage PLTE is performed with transthoracic esophagectomy.

     

Salvage or planned esophagectomy after chemoradiation therapy for locally advanced esophageal cancer – a review

Definitive chemoradiation (without esophagectomy) and neoadjuvant chemoradiation followed by planned esophagectomy are commonly used treatments for locally advanced esophageal cancer. These two treatment strategies have similar survival outcomes, so the value of planned esophagectomy is debated. However, persistence or recurrence of local disease is not uncommon after definitive chemoradiation. Salvage esophagectomy for isolated local failures of definitive chemoradiation is an option for selected patients. In this article we review the debate over definitive chemoradiation versus neoadjuvant chemoradiation and surgery, and then restate the argument in terms of salvage versus planned esophagectomy. Although both forms of esophagectomy are done in the setting of previous chemoradiation, they are different in several ways. Salvage esophagectomy appears to be a more morbid operation than planned esophagectomy. Surgeons supportive of the salvage esophagectomy strategy face the challenge of reducing its postoperative mortality.     

Clinical significance of salvage esophagectomy for remnant or recurrent cancer following definitive chemoradiotherapy

Background

The purpose of this study was to clarify the effect of preoperative chemoradiotherapy (CRT) for esophageal cancer on the postoperative course, and to determine the clinical significance of salvage esophagectomy after definitive CRT.

Methods

Based on their preoperative treatment, 477 patients with esophageal cancer were classified into three groups: 253 patients who received surgery alone (Group I), 197 who received planned CRT (30?C45?Gy, Group II), and 27 who received a salvage esophagectomy (radiation ??60?Gy, Group III).

Results

Postoperative complications developed in 25, 40, and 59% of the patients in Groups I, II, and III, respectively, with pulmonary complications developing in 10, 15, and 30%, and anastomotic leakage developing in 13, 23, and 37%, respectively. Mortality rates were 2.4, 2.0, and 7.4%, respectively. Multivariate analysis revealed preoperative therapy to be an independent factor associated with postoperative risks: the odds ratios (ORs) of Groups II and III compared to Group I were 1.8 and 4.0 for pulmonary complications, while they were 1.9 and 2.8, respectively, for anastomotic leakage. No critical complications developed in the 14 patients who received salvage surgery performed with strict surgical indications after 2005. The survival of Group III was not significantly different from that of Groups I and II. Most patients who received an R1/R2 resection after definitive CRT died within 2?years after salvage surgery.

Conclusions

Preoperative CRT is associated with postoperative complications especially in patients with R2 resection, while long-term survival can be achieved after R0 resections. Salvage surgery should be considered for carefully selected patients in whom R0 resection can be achieved.     

Systematic review and meta‐analysis on the significance of salvage esophagectomy for persistent or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy

The therapeutic strategy to be recommended in case of recurrent or persistent squamous cell esophageal cancer after completed definitive chemoradiotherapy (dCRT) has to be documented. Salvage esophagectomy has traditionally been recognized as a viable option, but many clinicians oppose the use of surgery due to the associated excessive morbidity and mortality. ‘Second‐line’ chemoradiotherapy (CRT) without surgery may offer a treatment alternative in these difficult and demanding clinical situations. Until now, no comprehensive attempt has been carried out to compare the respective therapeutic options. A systematic literature search was performed focusing on studies comparing survival and treatment‐related mortality in patients submitted to salvage esophagectomy or second‐line CRT for recurrent or persistent esophageal squamous cell carcinoma after dCRT. Hazard ratios and risk ratios were calculated to compare the effect of these therapeutic strategies on overall survival and treatment‐related mortality, respectively. Four studies containing 219 patients, with persistent or recurrent esophageal squamous cell carcinoma after dCRT, were included in the meta‐analysis. The analysis revealed an overall survival benefit following salvage esophagectomy with a pooled hazard ratio for death of 0.42 (95% confidence interval 0.21–0.86, P = 0.017) compared with second‐line CRT. A treatment‐related mortality of 10.3% was recorded in the 36 patients who were submitted to salvage esophagectomy, while it was impossible to perform a meta‐analysis comparing treatment‐related mortality between the groups. Salvage esophagectomy offers significant gain in long‐term survival compared with second‐line CRT, although the surgery is potentially at a price of a high treatment‐related mortality.     

Salvage lymphadenectomy without esophagectomy is an option for recurrent or residual lymph nodes after definitive chemoradiotherapy for esophageal cancer

Purposes

The aim of this study was to determine the prognostic factors in salvage surgery following definitive chemoradiotherapy (dCRT) for esophageal cancer.

Methods

We retrospectively reviewed twenty-five patients who underwent salvage surgery from 1986 to 2011 at Kurume University Hospital.

Results

Esophagectomy was adopted for 20 patients, while lymphadenectomy alone without esophagectomy was adopted for the other 5 patients. Univariate analysis found that age, response to initial treatment, presence of residual tumor, pT after salvage surgery, and severe complications were each significantly correlated with overall survival after salvage surgery. The type of surgery (esophagectomy vs lymphadenectomy) and presence of residual tumor (R) were each determined to be an independent prognostic factor by the multivariate analysis. Namely, the prognosis after R0 resection was better than that after R1/2 resection (HR 18.050, p < 0.0001), and the prognosis after salvage lymphadenectomy was better than that after salvage esophagectomy (HR 5.091, p = 0.0086).

Conclusions

Salvage lymphadenectomy without esophagectomy is suggested to be an option for patients having recurrent or residual lymph nodes without any other recurrence or residual tumor after dCRT for esophageal cancer.     

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.     

Exocrine pancreatic insufficiency following esophagectomy

Weight loss following esophagectomy is a management challenge for all patients. It is multifactorial with contributing factors including loss of gastric reservoir, rapid small bowel transit, malabsorption, and adjuvant chemotherapy. The development of a postoperative malabsorption syndrome, as a result of exocrine pancreatic insufficiency (EPI), is recognized in a subgroup of patients following gastrectomy. This has not previously been documented following esophageal resection. EPI can result in symptoms of flatulence, diarrhea, steatorrhea, vitamin deficiencies, and weight loss. It therefore has the potential to pose a significant level of morbidity in postoperative patients. There is some evidence that patients with proven EPI (fecal elastase‐1 < 200 μg/g) may benefit from a trial of pancreatic enzyme replacement therapy (PERT). We observed symptoms compatible with EPI in a subgroup of patients following esophagectomy. We hypothesized that this was contributing to malabsorption and malnutrition in these patients. To investigate this, fecal elastase‐1 was measured in postoperative patients, and in those with proven EPI, a trial of PERT was commenced in combination with specialist dietary education. At routine postoperative follow‐up, which included assessment by a specialist dietitian, those patients with symptoms suggestive of malabsorption were given the opportunity to have their fecal elastase‐1 measured. PERT was then offered to patients with fecal elastase‐1 less than 200 μg/g (EPI) as well as those in the 200–500 μg/g range (mild EPI) with more severe symptoms. Fecal elastase‐1 was measured in 63 patients between June 2009 and January 2011 at a median of 4 months (range 1–42) following surgery. Ten patients had fecal elastase‐1 less than 200 μg/g, and all had failed to maintain preoperative weight. All accepted a trial of PERT. Nine (90%) had symptomatic improvement, and seven (70%) increased their weight. Thirty‐nine patients had a fecal elastase‐1 in the 200–500 μg/g range. Twelve were given a trial of PERT based on level of symptoms, five (42%) reported an improvement in symptoms, but only two (17%) gained weight. Our early results support the observation that EPI is a factor contributing to postoperative morbidity in patients recovering from esophagectomy and that these patients can benefit from a trial of PERT. Our study has limitations, and a formal trial is required to evaluate the impact of EPI and PERT following esophagectomy. Currently, our practice is to measure fecal elastase‐1 in any patient with unexplained weight loss or symptoms of malabsorption. In patients with proven EPI or those who are symptomatic with mild EPI, a trial of PERT should be offered and symptoms reassessed.     

Mediastinoscopic esophagectomy for patients with early esophageal cancer

Objective

The purpose of this study was to detect the feasibility, safety, and effectiveness of mediastinoscopic esophagectomy for early esophageal cancer.

Methods

The clinical data of 194 patients who underwent mediastinoscopic esophagectomy for early esophageal cancer in our center from December 2005 to October 2014 were retrospectively analyzed.

Results

All the surgery was performed successfully. The average duration of thoracic surgery was 48.2±7.8 min and the average intra-operative blood loss was 128.1±34.5 mL. An average of 3.1±1.6 lymph node stations were dissected, with an average number of dissected lymph nodes being 9.38±6.2, among which 4.2±5.4 were mediastinal lymph nodes. No peri-operative mortality was noted, and the rate of peri-operative morbidity was 13.4%. The median duration of follow-up was 39 [3-108] months, and the overall survival was 72.73%. The overall survival rates significantly differed among different T stages; more specifically, the 5-year survival was 95.23% in patients with stage T_1a esophageal cancer, 70.15% for T_1b, and 55.56% for T₂ (P<0.001). The overall survival was significantly better in patients with negative lymph nodes than those with lymph nodes metastasis (P=0.003); more specifically, the 5-year survival rate was 84.9% for N₀, 62.5% for N₁, and 50.0% for N₂ + N₃.

Conclusions

The mediastinoscopic esophagectomy can achieve a similar effectiveness as the conventional thoracoscopic surgery for patients with early stage esophageal cancer.     

Patterns of operative mortality following esophagectomy

Esophagectomy has one of the highest mortality rates among all surgical procedures. We investigated the type and frequency of complications associated with perioperative mortality after esophagectomy. We performed a retrospective review of all perioperative deaths following esophagectomy for esophageal cancer at the Mayo Clinic, Rochester from 1993 through 2009. Of 1522 esophagectomies, perioperative mortality occurred in 45 (3.0%). The majority who died were male (82%); median age was 72 years (range 46–92). The median age‐adjusted Charlson comorbidity score was 6. Twenty‐three (51%) underwent neoadjuvant chemoradiotherapy. The type of esophagectomy was transthoracic in 27 patients (60%), transhiatal in eight (18%), tri‐incisional in seven (16%), left thoracoabdominal in one (2%), and transabdominal in one (2%). A mean of 3.2 major complications occurred prior to death (median 2.5, range 1–8), with the most common being pulmonary complications occurring in 30 patients (67%) and anastomotic complications in 20 (44%). The primary underlying cause of death was pulmonary complications and anastomotic complications in 18 patients (40%) each, respectively, abdominal sepsis in three (7%), fatal hemorrhage in three (7%), and pulmonary embolism, stroke and multisystem organ failure in one each (2%), respectively. Patients died a median of 19 days (range 3–98) following esophagectomy. Most patients who died following esophagectomy experienced multiple serious complications rather than a single causative event. Major pulmonary and anastomotic complications were implicated in the vast majority of perioperative mortality, and should remain the focus of efforts to improve clinical outcomes.     

Surgical repair of redundant intra-thoracic stomach after Ivor Lewis esophagectomy

We present two patients with low esophagogastric anastomosis, redundant intrathoracic stomach, and markedly symptomatic reflux and regurgitation after Ivor Lewis esophagectomy. The diagnosis, technique of surgical revision, and outcome is discussed.     

Comparison of esophagectomy with and without thoracotomy in a low‐resource tertiary care center in a developing country

Esophageal cancer surgery is traditionally performed by a number of open surgical approaches. Open approaches require thoracotomy and laparotomy. Developments in instrumentation and optics have allowed the use of minimally invasive approaches to esophageal cancer, which had been traditionally managed by open operation. Minimally invasive surgery (MIS) avoids thoracotomy and laparotomy and results in quicker return to normal functions and less morbidity. In this prospective study, we compared the immediate surgical and oncologic outcomes of patients who have undergone MIS with those who have had open surgery. From November 1, 2003 to March 30, 2006, 62 cases of carcinoma esophagus were operated in Surgical unit 3 (MIS unit) in the institute. Out of the 62 patients, 34 (54.8%) underwent minimally invasive esophagectomy (MIE), and the remaining 28 patients (45.2%) underwent open surgery. Both operations were done by the same team of surgeons. The groups were compared in terms of perioperative outcomes, morbidity, mortality, and adequacy of oncologic excision. The average duration for MIS was 312.35 min (60–480 min), which was more than that of open group surgery whose average duration was 261.96 min (60–360 min). This difference was found to be not significant (P < 0.110). The average blood loss was 275.74 mL (200–500 mL) in minimally invasive group compared with 312.50 (200–500 mL) in open group (P‐value 0.33). Four patients (11.76%) in MIS group had been converted to open surgery. Average duration of hospitalization was 11.9 (4–24) days in MIS group compared with 12.19 (5–24) days in open group (P‐value 0.282). Nine (26.47%) patients in MIS group had developed major or minor morbidity. Similarly, eight (28.57%) patients in open group had morbidity. One patient each expired in each group. The morbidity and mortality rates were not statistically significant. There were four leaks (11.76%) in MIS group and three leaks (10.71%) in open group (P‐value 0.85). Regarding the extent of nodal clearance, an average number of 9.5 (0–19) nodes were removed in MIS group compared with an average of 7.26 (0–12) nodes in open group (P‐value 0.05). Better visibility and magnification enabled more number of lymph nodes to be removed in MIS group. MIE is oncologically safe compared with open surgery. It has almost similar postoperative course, morbidity pattern, and duration of hospital stay as open surgery. Increased duration of procedure compared with open surgery is a disadvantage of MIS, especially in the early part of learning curve.     

Surgical outcomes of oro-intestinal continuity reconstruction after total esophagectomy in patients with cervicothoracic malignancy: a thoracic surgeon’s perspective

BackgroundOro-intestinal continuity reconstruction following total esophagectomy in patients with head-neck or esophageal cancer is rare and results in high operative morbidity and mortality. This case series aimed to investigate the perioperative surgical outcomes of oro-intestinal continuity reconstruction after total esophagectomy in selected patients with advanced head/neck or esophageal cancer.MethodsFrom 2011 to 2018, 14 patients who underwent oro-intestinal reconstruction after total esophagectomy were assessed. We analyzed perioperative mortality, postoperative complications, oncologic outcomes, and recovery of dietary function.ResultsThe median age of the patients was 61 (range, 42–72) years old and median follow-up time was 18.6 (range, 0–52.9) months. For conduit selection, 11 cases of oro-gastrostomy (78.6%), 2 of oro-colo-gastrostomy (14.3%), and 1 of oro-jejuno-gastrostomy (7.1%) were performed. Complete resection was pathologically confirmed in 10 patients (71.4%). Anastomosis site leakage was observed in three patients (21.4%) and conduit necrosis in two (14.3%). Postoperative mortality within 30 days, 90 days, and 1 year was 7.1%, 28.6%, and 42.8%, respectively.ConclusionsOro-intestinal continuity reconstruction following total esophagectomy showed acceptable morbidity and mortality in selected patients with advanced head/neck cancer or esophageal cancer. Careful selection of surgical candidates and multidisciplinary collaboration of experienced surgical teams are essential to minimize the surgical risk.     

Neoadjuvant chemoradiotherapy followed by esophagectomy does not increase morbidity in patients over 70

Esophagectomy in elderly esophageal carcinoma patients is correlated with a high morbidity and even mortality. Studies on neoadjuvant chemoradiotherapy (NT) in elderly patients are scarce. The aim of this study was to evaluate the effect of advanced age in combination with NT in esophageal carcinoma patients who underwent an esophagectomy. Patients who underwent NT prior to esophagectomy between 1993 and 2010 were divided into three groups: <70, 70–74, and ≥75 years. Toxicity of NT and postoperative morbidity were compared between groups. Primary endpoints were toxicity, complication rate, and survival. Two hundred thirteen patients underwent NT during the study period, 26 were aged 70–74 years, and 17 were ≥70 years. Toxicity of NT was comparable for younger and elderly patients (46% vs. 54% vs. 47%, P = 0.263). Overall complications occurred in 62% of younger patients versus 73% and 71% among patients aged 70–74 years and ≥75 years, respectively (P = 0.836). Cardiac complications occurred in 14% of younger patients versus 27% and 41% of elderly patients (P = 0.021). Three‐year survival rates were 59% versus 44% versus 31% among patients aged <70, 70–74, and ≥75 years, respectively (P = 0.237). Higher age (odds ratio 1.750, P < 0.001) was an independent risk factor for development of cardiac complications. Toxicity of NT and postoperative complications are comparable for patients aged <70, 70–74, and ≥75 years, with the exception of cardiac complications. Therefore, we consider NT followed by esophagectomy in elderly patients a safe treatment modality in our center.