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This article discusses the outcomes of different treatment approaches after R0 endoscopic resection (ER) of high-risk T1 esophageal adenocarcinoma (EAC). The study aimed to assess the outcomes following R0 ER for high-risk T1 EAC, specifically looking at the risk of lymph node metastases (N+). The study found that the majority of cases with surgical T1 had ER misclassified as R0, challenging previous studies that reported higher N+ rates. The results suggest that surgery is not a definitive curative approach and did not improve disease-specific mortality. Further research is needed to evaluate outcomes in patients treated endoscopically for high-risk T1 EAC. [Extracted from the article]

Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective. [ABSTRACT FROM AUTHOR]

Background: Little is known about recurrence patterns in patients with a pathologically complete response (pCR) or an incomplete response after neoadjuvant chemoradiotherapy (CRT) followed by resection for oesophageal cancer. This study was performed to determine the pattern of recurrence in patients with a pCR after neoadjuvant CRT followed by surgery. Methods: All patients who received neoadjuvant CRT followed by oesophagectomy between 1993 and 2009 were identified from a database, and categorized according to pathological tumour response. Recurrences were classified as locoregional or distant. Results: One hundred and eighty-eight patients were included. Median potential follow-up was 71·6 months. A pCR was achieved in 62 (33·0 per cent) of 188 patients. Recurrence developed in 24 (39 per cent) of 62 patients with a pCR and 70 (55·6 per cent) of 126 without a pCR ( P = 0·044). Locoregional recurrence with or without synchronous distant metastases occurred in eight patients (13 per cent) in the pCR group and 31 (24·6 per cent) in the non-pCR group ( P = 0·095). Locoregional recurrences without synchronous distant metastases occurred four (6 per cent) and ten (7·9 per cent) patients respectively ( P = 0·945). The overall 5-year survival rate was significantly higher in the pCR group than in the non-pCR group (52 versus 33·9 per cent respectively; P = 0·019). Conclusion: Of patients with a pCR, 13 per cent still developed a locoregional recurrence. Although pCR is more favourable for survival, it is not synonymous with cure or complete locoregional disease control. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure with a long learning curve, which is associated with increased morbidity and mortality. To master MIE, training in essential steps is crucial. Yet, no consensus on essential steps of MIE is available. The aim of this study was to achieve expert consensus on essential steps in Ivor Lewis and McKeown MIE through Delphi methodology. Methods: Based on expert opinion and peer-reviewed literature, essential steps were defined for Ivor Lewis (IL) and McKeown (McK) MIE. In a round table discussion, experts finalized the lists of steps and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments, steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved. Results: Two Delphi rounds were conducted and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 106 essential steps for both the IL and McK approach. Cronbach's alpha in the first round was 0.78 (IL) and 0.78 (McK) and in the second round 0.92 (IL) and 0.88 (McK). Conclusions: Consensus among European experts was achieved on essential surgical steps for both Ivor Lewis and McKeown minimally invasive esophagectomy. [ABSTRACT FROM AUTHOR]

Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P <0.0001 and 17% vs. 12%; P <0.0001, respectively) and postoperative blood transfusion (26.7%–11%; P <0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10–23) in TC compared with 10 days (IQR 8–14) in ERP patients (P <0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P =0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P =0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P =0.0001), anastomotic leak (P =0.047), several infectious complications (P =0.01–0.034), blood transfusion (P =0.001), Comprehensive Complications Index (P =0.01), and length of stay (P =0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates. [ABSTRACT FROM AUTHOR]

Background. Solitary fibrous tumor (SFT) is a rare variant of soft tissue sarcoma (STS). Materials and Methods. We reviewed SFT patients (pts) treated at our institution between 12/1990 and 09/2017. Results. We identified 94 pts with a median follow-up (mFU) of 4.7 years (range: 0.1–21.53). Primary sites were the chest (33%), abdomen (21.3%), brain (12.8%), and extremities (9.6%); 6.4% of pts presented with synchronous metastasis. Median overall survival (mOS) from the first diagnosis was 56.0 months (m) (0.3–258.3). Doege–Potter syndrome was seen in 2.1% of pts. Primary resection was performed in 86 pts (91.5%). Median progression-free survival was 34.1 m (1.0–157.1), and 43% of pts stayed SFT-free during FU. Local recurrence occurred in 26.7% after a mFU of 35.5 m (1.0–153.8), associated with an OS of 45.1 m (4.7–118.2). Metachronous metastasis occurred in 30.2% after a mFU of 36.0 m (0.1–157.1). OS in metastatic pts was 19.0 m (0.3–149.0). Systemic therapy was given to 26 pts (27.7%) with inoperable/metastatic disease. The most common (57.7%) upfront therapy was doxorubicin, achieving responses in 13.3% of pts with a PFS of 4.8 m (0.4–23.8). In second line, pts were treated with ifosfamide or pazopanib, the latter achieving the highest response rates. Third-line treatment was heterogeneous. Conclusion. SFT is an orphan malignancy with a highly variable clinical course and a considerable risk of local failure and metachronous metastasis. Surgery is the only curative option; palliative systemic therapy is used in inoperable/metastatic cases but achieves low response rates. The highest response rates are seen with pazopanib in second/third line. [ABSTRACT FROM AUTHOR]

Background: Up to 40 per cent of patients undergoing oesophagectomy develop pneumonia. The aim of this study was to assess whether preoperative inspiratory muscle training (IMT) reduces the rate of pneumonia after oesophagectomy. Methods: Patients with oesophageal cancer were randomized to a home‐based IMT programme before surgery or usual care. IMT included the use of a flow‐resistive inspiratory loading device, and patients were instructed to train twice a day at high intensity (more than 60 per cent of maximum inspiratory muscle strength) for 2 weeks or longer until surgery. The primary outcome was postoperative pneumonia; secondary outcomes were inspiratory muscle function, lung function, postoperative complications, duration of mechanical ventilation, length of hospital stay and physical functioning. Results: Postoperative pneumonia was diagnosed in 47 (39·2 per cent) of 120 patients in the IMT group and in 43 (35·5 per cent) of 121 patients in the control group (relative risk 1·10, 95 per cent c.i. 0·79 to 1·53; P = 0·561). There was no statistically significant difference in postoperative outcomes between the groups. Mean(s.d.) maximal inspiratory muscle strength increased from 76·2(26·4) to 89·0(29·4) cmH2O (P < 0·001) in the intervention group and from 74·0(30·2) to 80·0(30·1) cmH2O in the control group (P < 0·001). Preoperative inspiratory muscle endurance increased from 4 min 14 s to 7 min 17 s in the intervention group (P < 0·001) and from 4 min 20 s to 5 min 5 s in the control group (P = 0·007). The increases were highest in the intervention group (P < 0·050). Conclusion: Despite an increase in preoperative inspiratory muscle function, home‐based preoperative IMT did not lead to a decreased rate of pneumonia after oesophagectomy. Registration number: NCT01893008 ( https://www.clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Esophageal sarcomas are rare and evidence in literature is scarce making their management difficult. The objective is to report surgical and oncological outcomes of esophageal sarcoma in a large multicenter European cohort. This is a retrospective multicenter study including all patients who underwent en-bloc esophagectomy for esophageal sarcoma in seven European tertiary referral centers between 1987 and 2016. The main outcomes and measures are pathological results, early and long-term outcomes. Among 10,936 esophageal resections for cancer, 21 (0.2%) patients with esophageal sarcoma were identified. The majority of tumors was located in the middle (n=7) and distal (n = 9) third of the esophagus. Neoadjuvant chemoradiotherapy was performed in five patients. All the patients underwent en-bloc transthoracic esophagectomy (19 open, 2 minimally invasive). Postoperative mortality occurred in 1 patient (5%). One patient received adjuvant chemotherapy. Definitive pathological results were carcinosarcoma (n = 7), leiomyosarcoma (n = 5), and other types of sarcoma (n = 9). Microscopic R1 resection was present in one patient (5%) and seven patients (33%) had positive lymph nodes. Median follow-up was 16 (3-79) months in 20 of 21 patients (95%). One-, 3 and 5-year overall survival rates were 74%, 43%, and 35%, respectively. One-, 3 and 5-years disease-free survival rates were 58%, 40%, and 33%, respectively. Median overall survival was 6 months in N+ patients vs. 37 months for N0 patients (p = 0.06). At the end of the follow-up period, nine patients had died from cancer recurrences (43%), three patients died from other reasons (14%), one patient was still alive with recurrence (5%) and the seven remaining patients were free of disease (33%). Recurrence was local (n = 3), metastatic (n = 3), or both (n = 4). In conclusion, carcinosarcoma and leiomyosarcoma were the most common esophageal sarcoma histological subtypes. Lymph node involvement was seen in one third of cases. A transthoracic en-bloc esophagectomy with radical lymphadenectomy should be the best surgical option to achieve complete resection. Long-term survival remained poor with a high local and distant recurrence rate. [ABSTRACT FROM AUTHOR]

The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRM < 1 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and to ≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy. Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis. There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRM < 1 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes. On univariate analysis, no statistically significant difference was found between R0-resection and CRM < 1 mm (P = 0.103) for OS, but DFS showed a significant difference (P = 0.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both P = 0.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRM < 1 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS. After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. HoweverCRM<1mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane. [ABSTRACT FROM AUTHOR]

Recurrent disease after esophagectomy bears an infaust prognosis, especially when multiple recurrences are present. But little is known about survival in patients with limited recurrence (solitary locoregional recurrence or solid organ metastasis). Herein, we report our experience with these subgroups. We analyzed 1754 consecutive patients surgically treated with curative resection for esophageal cancer and cancer of the gastroesophageal junction between 1990 and 2012. Seven subgroups were defined according to the recurrence type (locoregional vs. organ metastasis), the site of recurrence (abdominal, thoracic, cervical for lymph nodes and lung, liver, adrenals and others for organ metastasis) and also the number of lesions (one vs. multiple lymph node stations or organ metastasis) Of these groups; clinical isolated locoregional recurrence (ciLR) was defined as solitary lymph-node recurrence confined to one compartment (cervical, thoracic or abdominal, within or outside surgical dissection-field) at clinical staging. Clinical solitary solid organ metastasis (csSOM) was defined as metastasis in a resectable solid organ, i.e. liver, lung, brain or adrenal. Salvage therapies were grouped in five categories. Kaplan-Meier curves were used to calculate survival. Recurrent disease was observed in 766 patients (43.7%) with overall 5-year survival of 4.5% after diagnosis of recurrence. Fifty-seven patients (7.4%) showed ciLR and 110 (14.4%) csSOM. Median timeto-recurrence was 16.8 months in ciLR and 9.9 months in csSOM (P=0.0074). Survival is significantly improved compared to supportive therapy when local therapy is possible (P<0.0001). In 25 (15%) of ciLR or csSOM patients, surgical therapy with or without systemic therapy, yielded a 5-year survival of 49.9% (median 54.8 months) after diagnosis of recurrence. When surgery was impossible or contraindicated, the combination of chemoradiotherapy appeared to be superior to chemotherapy alone (respectively 27.0% vs. 4.6% 5-year survival) or radiotherapy alone (no 5-year survival). Recurrent disease after esophagectomy is a common problem with poor overall survival. However prolonged survival could be obtained in selected patients if the recurrent disease is limited to ciLR or csSOM, if surgery (+/- systemic therapy) can be performed. If not a combination of chemoradiotherapy seems to offer the second best option. Patients presenting with a ciLR or csSOM should be discussed in a dedicated multidisciplinary team meeting as to evaluate and define the place of salvage treatment which in well selected cases could offer a perspective of prolonged survival. [ABSTRACT FROM AUTHOR]

Extended-criteria donors have been widely used to enlarge the donor pool. However, experience with lung transplantation (LTx) from older donors (≥ 70 years) is limited. This study aims to describe our experience with septuagenarian and octogenarian donors and compare short- and long-term outcome using a propensity-matched cohort of younger donors (< 70 years). All bilateral LTx between 2010 and 2020 were retrospectively analyzed. Matching was performed for donor (type, gender, smoking history, X-ray abnormalities, P/F ratio, time on ventilator) and recipient characteristics (age, gender, LTx indication, perioperative ECMO, CMV mismatch) resulting in a 1:1 matching. Primary graft dysfunction (PGD) grade 3 (within 72 hours), 5-year patient survival and chronic lung allograft dysfunction (CLAD)-free survival were analyzed. We performed 695 LTx, 69 with donors ≥ 70 years. Mean age in the older donor group (47 female/22 male) was 74 years (range 70-84 years) vs. 49 years (range 12-69 years) in the younger group (45 female/24 male). Overall acceptance rate for the lungs was 8.2% in the older group vs. 25.9% in the younger group. No significant differences were observed in length of ventilatory support, ICU or hospital stay. PGD 3 in the older cohort occurred in 26.1% similar to 29.0% for recipients of younger donors (P=0.85). Reoperation rate was comparable (29.0% vs. 15.9%, respectively; P=0.10). Follow-up bronchoscopy revealed no differences in rate of anastomotic complications (P=1.00). Patient 5-year survival was 73.6% vs. 73.1%, respectively (P=0.72). CLAD-free 3- and 5-year survival was 60.8% and 51.5% vs. 68.6% and 59.2%, respectively (P=0.41). LTx from selected donors ≥ 70 years is feasible and safe, yielding comparable short- and long-term outcome in a propensity-matched analysis with younger donors. Given this large potential, it is important to further analyze long-term outcome and processes of aging in this population. [ABSTRACT FROM AUTHOR]

Background Small-sized patients with cystic fibrosis usually face long waiting times for a suitable lung donor. Reduced-size lung transplantation (LTx) was promoted to shorten waiting times. We compared donor and recipient characteristics and outcome in lobar ([L]) versus full-size ([FS]) lung recipients. Methods Between July 1, 1991, and February 28, 2011, 535 isolated LTx were performed, including 74 in cystic fibrosis patients (8 L, 66 FS). Patients were followed up until September 2012. Results [L] recipients were younger, smaller, and lighter. Sex, waiting times, and donor data (age, sex, height, weight, PaO 2 /FiO 2 , and ventilation time) were comparable. Cardiopulmonary bypass was used more often in [L]; cold ischemia was comparable for first lung but longer in [L] for second lung; implantation times were comparable. In-hospital mortality rate was 0% in [L] versus 3% in [FS]. Both intensive care unit and hospital stay were longer in [L]. Grade 3 primary graft dysfunction was more pronounced in [L] at T0 and at T48. FEV 1 increased significantly in both groups from preoperative value. Bronchiolitis obliterans syndrome was absent in [L] and diagnosed in 18 patients in [FS], accounting for 6 of 15 late deaths. All [L] are still alive. No differences in survival were found between the groups. Conclusions Although hindered by a higher incidence of primary graft dysfunction, L-LTx is a viable option with excellent survival and pulmonary function comparable to FS-LTx. [ABSTRACT FROM AUTHOR]

Post-transplant lymphoproliferative disease (PTLD) is a complication often encountered after lung transplantation (LTx). We present a case where necrotic subcarinal lymph nodes (LNs) affected by PTLD caused a large broncho-esophageal fistula, for which all treatment options were exhausted. A 64-year-old LTxrecipient presented with a 1.5-month history of fever and general weakness, 11 years after bilateral LTx for IPF and 4 years after redo LTx for BOS. PET/CT revealed hypermetabolic subcarinal, paratracheal, supraclavicular and infra-diaphragmatic LNs (image A). EBV-associated diffuse large B-cell lymphoma (DLBCL)-PTLD was confirmed on supraclavicular LN biopsy. The patient had to be intubated for respiratory failure due to pneumonia, prior to initiating PTLD-specific treatment. An underlying bilateralbroncho-esophageal fistula was diagnosed by chest computed tomography (CT) (image B) and confirmed with esophagoscopy and bronchoscopy. Treatment of the DLBCL consisted of reduction of tacrolimus, discontinuation of mycophenolate mofetil, steroids, rituximab, and cyclophosphamide. Esophagostomyand gastrostomy were performed to prevent airway aspiration. Despite broad-spectrum antibiotics and antifungals, the patient developed neutropenic sepsis due to respiratory infection as well as probable invasive pulmonary aspergillosis. Twenty days after surgical intervention, chest CT (image C) and bronchoscopy (image D) showed that the posterior side of the airway below the carina was completely eroded. No therapeutic options remained, and the patient passed away. Management of a broncho-esophageal fistula resulting from PTLD following LTx is challenging. Due to erosion of necrotic subcarinal LNs, surgical intervention was performed to prevent ongoing infection precipitated by PTLD-specific treatment. [ABSTRACT FROM AUTHOR]

Oesophageal perforation related to anterior cervical surgery is an uncommon but well recognised and potentially life-threatening complication with an incidence of 0–3.4%. Our experience with this complication and a review of the literature are presented. We retrospectively reviewed our clinical experience over 10 years and found four patients in whom an oesophageal perforation was recognised after anterior surgery for cervical spine trauma. In three patients the perforation was noticed in the early post-operative period and the other had a delayed presentation. In all patients, the hardware was removed, long-term intravenous antibiotics were administered and parenteral nutrition was instituted. In two patients a primary suture of the perforation was performed and in one of these an additional sternocleidomastoid myoplasty was carried out as well. One patient had conservative treatment and one died before closure of the perforation could be performed. The two patients, in whom surgical repair of the perforation was performed, recovered well with residual neurological deficits as expected due to the cervical trauma. In the patient in whom conservative treatment was instituted, healing of the perforation occurred. One patient died due to systemic complications, indirectly related to the perforation. Although not very frequent and sometimes difficult to diagnose, oesophageal perforations after anterior cervical surgery constitute a potentially life-threatening complication. Diagnosis is made by imaging or endoscopic studies, but clinical suspicion is most important. Basic treatment consists of surgery with removal of hardware, drainage of abscesses, primary closure of the perforation if possible, parenteral nutrition and antibiotic therapy. Residual instability should be recognised in time and may be anticipated in patients in whom there has been little time for solid bony fusion. Successful management depends on early diagnosis and immediate institution of treatment. [ABSTRACT FROM AUTHOR]

In countries with a legal framework for physician-assisted death, organ donation after euthanasia (DCD-V) can increase the donor pool. DCD-V grafts are characterized by absence of lung injury related to brain-death, intubation and a long agonal phase. We review our experience with LTx after DCD-V and compare outcome with DBD and DCD-III experience in the same era. Between 01/2007-09/2019, 797 LTx were performed, of which 158 from DCD donors, including 20 DCD-V {8M/12F; mean age (range): 50 (28-66y)} due to neuromuscular (8) / mental (9) disorder or untreatable pain (3). After the request for euthanasia was granted in accordance with legislation, an explicit wish for organ donation was expressed by the patient and approved by the Institutional Review Board. Euthanasia was carried out in-hospital (local: 4; remote: 16) adjacent to the operating room in absence of the retrieval team. Twenty patients {7M/13F; age: 53y (27-64)} underwent bilateral LTx for emphysema (n=10), pulmonary fibrosis (n=5), cystic fibrosis (n=3, liver transplant in 1) and bronchiolitis obliterans (n=2). Waiting time was 326d (34-662). Agonal phase was short: 3min (0-14). Warm ischemia time between circulatory arrest and flush was 12min (7-21). Intensive care unit and hospital stay were 6d (2-10) and 28d (16-44). Three patients died due to cardiac problem (3mo), haematological disorder (3mo) or aspergillosis (10y). Follow-up was 4y (2mo-10.5y), CLAD occurred in 4. Five-year patient survival for DCD-V was 89%, equaling the DBD {80% (p=0.68)} and DCD-III cohort {81% (p=0.78)}. CLAD-free survival was 66.7%, equal to DBD {68.2% (p=0.68)} and DCD-III {69.9% (p=0.91)}. Our series represents the largest LTx experience from DCD-V and demonstrates for the first time that long-term outcome is comparable with DBD and DCD-III. DCD-V can further expand the donor pool in nations with a legal framework for physician-assisted death. [ABSTRACT FROM AUTHOR]

The overall prognosis of patients with carcinoma of the esophagus and gastroesophageal junction (GEJ) remains poor mainly because of the advanced stage of the disease at the time of presentation. As a result, controversy persists over the appropriate extent of surgery. This article reviews the impact of aggressive surgery on staging, disease-free survival, and cure rate.Despite recent advances in staging including positron emission tomography (PET), the findings after aggressive surgery indicate that the overall accuracy, sensitivity, and specificity of clinical staging are still too low. These shortcomings in clinical staging therefore question the value of the indications, results, and interpretation of outcomes in multimodality treatment regimens.Extended surgery increases the R0 resection rate, which seems to have an undeniable beneficial effect on the incidence of locoregional recurrence and which should be considered as a parameter of surgical quality, especially within the context of multimodality trials.As to the effect on cure rate, the only randomized trial with published results did not indicate a significant difference between extended and more limited resections for adenocarcinoma of the esophagus and GEJ, albeit that a subsequent subanalysis did show a significant survival benefit favoring more extended surgery in distal third adenocarcinomas. However, the bulk of current literature suggests that better survival is achieved by more aggressive surgery.For three-field lymphadenectomy the available data suggest a potential survival benefit. It appears that positive cervical lymph nodes in patients with middle or proximal third carcinoma should no longer be considered as M1a/b distant lymph node metastasis but rather as N1 regional disease. [Copyright &y& Elsevier]

Objective: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3–4+cM1lymph). Methods: Induction therapy consisted of 5-fluorouracil days 1–5 and days 21–25, cisplatin day 1+day 21 and concomitant radiotherapy 18–20 fractions of 2 Gy (total dose 36–40 Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90/109=83%): 85 patients underwent resection with curative intent (resectability: 85/109=78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n=86) who underwent primary surgery in the same period. Results: Resection was complete (R0) in 68 patients (68/90=76%). Mean duration of surgery was 428 min (range: 240–690). Peroperative complications were haemorrhage in three patients (3/90=3.3%), tracheobronchial perforation in three patients (3/90=3.3%). Median total hospital stay was 20.5 days (range: 8–355). Mean duration of intubation was 7 days (range: 1–190); 67 patients (67/90=74.4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n=86) overall mortality was 2.3% (P=0.015) and nil after two- and three-field lymphadenectomy (P=0.011). Medical morbidity consisted of pneumonia in 43 patients (43/90=48%), atelectasis in ten patients (10/90=11%), dysrhythmia in 21 patients (21/90=23%), sepsis in 11 patients (11/90=12%) and adult respiratory distress syndrome in ten patients (10/90=11%). Surgical morbidity included pleural effusion in 16 patients (16/90=18%), tracheal fistula in two patients (2/90=2%), chylothorax in two patients (2/90=2%) and acute pancreatitis in one patient (1/90=1%). Ten patients (10/90=11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27/90=30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P=0.023). Conclusions: Chemoradiotherapy followed by resection of cT3–4 +/− cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P=0.015) in the same period in our department. [Copyright &y& Elsevier]

Purpose To investigate if selective compared to elective pleural irradiation of malignant pleural mesothelioma (MPM) can allow dose escalation. Patients and methods Twelve consecutive stage I-IV MPM patients (6 consecutive left-sided and 6 consecutive right-sided) were retrospectively identified from a prospective institutional database and included. In all patients, the staging computed tomography and the staging magnetic resonance imaging (MRI) were used for gross tumor volume (GTV) definition. The patients had not received chemotherapy. An MRI-based pleural GTV was contoured and a planning target volume (PTV) was generated. Two sets of PTVs were generated for each patient: (1) a “selective” PTV (S-PTV), originating from a 5-mm isotropic expansion from the GTV, and (2) an “elective” PTV (E-PTV), originating from a 5-mm isotropic expansion from the whole ipsilateral pleural space. Two sets of volumetric modulated arc therapy (VMAT) treatment plans were generated for each patient: a “selective” pleural irradiation plan (SPI plan) and an “elective” pleural irradiation plan (EPI plan). Results In the SPI plans, the median dose to the S-PTV was 53.6 Gy (SD: 5.4, range: 41–63.6 Gy). In 4/12 patients it was possible to escalate the dose to the S-PTV to > 58 Gy. In the EPI plans, the median dose to the E-PTV was 48.6 Gy (SD: 5.8, range: 38.5–58.7), with a median dose to the S-PTV of 49 Gy (SD: 6, range: 38.6–59.5 Gy). No significant dose escalation was achievable. Conclusion The omission of elective irradiation of the whole ipsilateral pleural space allows dose escalation from 49 Gy to more than 58 Gy in 4/12 chemo-naive MPM patients. This strategy may form the basis for non-surgical radical combined modality treatment of MPM. [ABSTRACT FROM AUTHOR]