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Objective: The aim of study was to compare overall 5-year survival of esophageal cancer patients undergoing transthoracic esophagectomy with either neck or intrathoracic anastomosis, that is, McKeown and Ivor-Lewis esophagectomy., Background: No national studies comparing long-term survival after McKeown and ivor-Lewis esophagectomies in the West exist., Methods: This population-based nationwide study included all curatively intended transthoracic esophagectomies for esophageal adenocarcinoma or squamous cell carcinoma in Finland in 1987 to 2016, with follow-up until December 31, 2019. Cox proportional hazard models provided hazard ratios (HR) with 95% confidence intervals (ci) of all-cause 5-year mortality. The results were adjusted for age, sex, year of the operation, comorbidities, histology, stage, and neoadjuvant treatment. Adjusted model 2 included also tumor location and lymph node yield., Results: A total of 990 patients underwent McKeown (n = 278) or Ivor-Lewis (n = 712) esophagectomy The observed overall 5-year survival was 43.1% after McKeown, and 45.9% after Ivor-Lewis esophagectomy. McKeown esophagectomy was not associated with the overall 5-year mortality (adjusted HR 1.11, 95% CI: 0.89-1.38), compared to Ivor-Lewis esophagectomy. Additional adjustment for tumor location and lymphadenectomy further attenuated the point estimate (HR 1.06, 95% CI: 0.85-1.33). Surgical approach was not associated with 90-day mortality rate (adjusted HR 1.15, 95% CI: 0.67-1.97)., Conclusions: This population-based nationwide study suggests that overall 5-year survival or 90-day survival with McKeown and Ivor-Lewis esopha-gectomy for esophageal cancer are comparable., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Few population-based studies reporting trends in oesophageal cancer surgery exist. The aim of this study was to assess the incidence of oesophageal cancer, changes in resection rates, patient demographics and short- and long-term outcomes of oesophagectomy at the population level in Finland., Methods: All Finnish patients diagnosed with cancer of the oesophagus or gastrooesophageal junction between 1 January 2004 and 31 December 2014 identified from the nationwide registries were included. The follow-up ended on 31 December 2016. For evaluation of changes in demographics and treatment, data were divided into 2 periods: 2004-2009 and 2010-2014. For comparison of short-and long-term outcomes, adjustments for age, sex, comorbidity, tumour stage and histology were used., Results: The number of diagnosed oesophageal cancers was 4266. Of these, 740 underwent oesophagectomy. Resection rate increased from 15.2% in 2004-2009 to 19.6% in 2010-2014. The median number of oesophagectomies in Finnish hospitals increased from 1.9 to 3.7 per hospital per year. At the same time, minimally invasive surgery became more common (6.3% vs 35.1%, P < 0.0001) and a trend for increase in neoadjuvant treatment was observed (46.8% vs 53.8%, P = 0.0582). The rate of type III anastomosis leaks and conduit necroses was 5.1% without differences in time periods. Three-year [52.4% vs 61.6%, adjusted hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.59-0.95] and 5-year survival (42.1% vs 56.5%, adjusted HR 0.70, 95% CI 0.57-0.87) improved., Conclusions: This nationwide population-based study demonstrates an increase in resection rate, use of neoadjuvant treatment and minimally invasive surgery together with an improvement in long-term outcome after oesophageal cancer surgery., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Studies of long-term survival after minimally invasive and open esophagectomy are needed. The aim of this study was to compare long-term outcomes following minimally invasive and open esophagectomy for esophageal cancer at the population level., Methods: All patients undergoing minimally invasive (n = 159) or open transthoracic (n = 431) esophagectomy for esophageal cancer in Finland between 2004 and 2014 were identified from nationwide registries. Propensity score matching was used to create groups of 150 minimally invasive and open esophagectomies with balanced baseline characteristics (sex, age, comorbidity, center volume, year of surgery, histology, stage (local or locally advanced), and neoadjuvant therapy). The primary outcome was 1-year survival after surgery. Secondary outcomes were the 3-year, 5-year, and 90-day survival., Results: The propensity matched 1-year survival rate was 85.3% after minimally invasive and 74.7% after open esophagectomy (adjusted HR 0.53, 95% CI 0.31-0.89; P = 0.0174). At 3 years, those were 68.7% and 55.6% (adjusted HR 0.62; 95% CI 0.43-0.91; P = 0.0144), respectively; at 5 years, survival rates were 61.8% and 51.9% (adjusted HR 0.68, 95% CI 0.47-0.97; P = 0.0347). The 30- and 90-day survival rates after minimally invasive and open surgery were 99.3% vs. 98.0% and 97.3% vs. 92.0%, respectively, without statistical significance., Conclusions: In this population-based propensity matched study, minimally invasive esophagectomy was associated with improved long-term survival. Due to multiple confounding factors replication studies are needed., (Copyright © 2018 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: Population-based studies comparing minimally invasive esophagectomy (MIE) and open esophagectomy (OE) relative to 90-day postoperative mortality are needed., Objective: The aim of this study was to compare short-term outcomes following these two techniques for esophageal cancer., Methods: Patients undergoing MIE (n = 217) or OE (n = 1397) for esophageal cancer between 2007 and 2014 were identified from nationwide complete registries in Finland and Sweden. The primary outcome was 90-day mortality, and secondary outcomes were 30-day mortality, length of hospital stay, and 30- and 90-day readmission rate. Results were adjusted for age, sex, comorbidity, tumor histology, surgery year, and country., Results: Ninety-day mortality rates were 4.1% (n = 9 of 217) for MIE and 6.8% (n = 95 of 1397) for OE; 90-day mortality was halved after MIE [adjusted hazard ratio (HR) 0.49, 95% confidence interval (CI) 0.24-0.99]. There was no difference in 30-day mortality (adjusted HR 0.87, 95% CI 0.29-2.66). Median hospital stay was 15 days for MIE and 16 days for OE (adjusted β -0.17, standard error 0.08, p = 0.030). The 30-day readmission rates were 8.9% after MIE and 12.0% after OE (adjusted HR 0.57, 95% CI 0.34-0.94), while the 90-day readmission rates were 28.8% and 33.6%, respectively, without a statistically significant difference (adjusted HR 0.82, 95% CI 0.61-1.10)., Conclusions: This population-based study from Finland and Sweden revealed lower 90-day mortality, shorter hospital stay, and lower 30-day readmission rates after MIE compared with OE for esophageal cancer. These findings support the use of minimally invasive approaches.

Objectives: We aimed to assess the potential of near-infrared (NIR) imaging during minimally invasive oesophagectomy in patients with distal oesophageal cancer for detection of nodal metastases inside and outside the standard en bloc surgical field., Methods: We enrolled 6 patients diagnosed with distal oesophageal cancer for intraoperative lymphatic mapping with NIR imaging. Indocyanine green dye was injected endoscopically in 8 corners of the primary tumour at the start of the operation. The minimally invasive oesophagectomy with en bloc lymphadenectomy was performed using 3D optics. A separate endoscopic fluorescence imaging system was used to systematically detect the NIR signal of 23 lymphatic stations. The NIR-positive stations outside the en bloc resection area were also removed for histological analysis., Results: Lymphatic mapping was successful in all patients. The NIR-positive areas were most commonly detected in the lower mediastinum (100% of patients), cardia (83%), region of the left gastric artery (67%), celiac axis (50%) and pericardial-diaphragmatic groove (50%). We detected NIR-positive areas outside the traditional en bloc field above the azygous arch in 50% of the patients. A total of 182 lymph nodes were resected from 6 patients. In 3 patients, a total of 19 lymph node metastases were detected, 4 of which were outside the en bloc field., Conclusions: NIR imaging can be useful for detecting lymphatic stations that most likely present with metastatic disease and to guide the tailored extension of the traditional lymphadenectomy., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Open in new tab Download slide OBJECTIVES The desirable lymph node count was determined to maximize the survival time expectancy according to the lymph node count among patients who have undergone oesophagectomy for oesophageal cancer. METHODS The data of national Finnish population-based cohort including all patients who have undergone oesophagectomy due to oesophageal cancer during 2002–2016 were used. Restricted mean survival time (RMST) estimates were determined by lymph node count, and the desirable count was determined using locally estimated scatterplot smoothing regression. RESULTS A total of 883 patients with the median follow-up time of 3.73 (interquartile range 1.43–7.50) years were included. The lymph node count of 27 (95% confidence interval 25–28) was associated with the highest RMST estimates. Sensitivity analyses indicated that in pN0 patients, the highest RMST estimates was observed at 26 (95% confidence interval 24–28) lymph nodes and in pN+ patients, the RMST estimates peaked at 28 (95% confidence interval 25–33) lymph nodes. CONCLUSIONS According to the findings of this study, at least 24 examined lymph nodes is the recommended target for the lymph node count after oesophagectomy for oesophageal cancer. The beneficial effect of this count on survival may be achieved regardless of nodal metastases. [ABSTRACT FROM AUTHOR]

Objective: To examine the hypothesis that survival in esophageal cancer increases with more removed lymph nodes during esophagectomy up to a plateau, after which it levels out or even decreases with further lymphadenec-tomy. Summary of Background Data: There is uncertainty regarding the ideal extent of lymphadenectomy during esophagectomy to optimize long-term survival in esophageal cancer. Methods: This population-based cohort study included almost every patient who underwent esophagectomy for esophageal cancer in Sweden or Finland in 2000-2016 with follow-up through 2019. Degree of lymphadenectomy, divided into deciles, was analyzed in relation to all-cause 5-year mortality. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI) adjusted for all established prognostic factors. Results: Among 2306 patients, the second (4–8 nodes), seventh (21–24 nodes) and eighth decile (25–30 nodes) of lymphadenectomy showed the lowest all-cause 5-year mortality compared to the first decile [hazard ratio (HR) = 0.77, 95% CI 0.61–0.97, HR = 0.76, 95% CI 0.59–0.99, and HR = 0.73, 95% CI 0.57–0.93, respectively]. In stratified analyses, the survival benefit was greatest in decile 7 for patients with pathological T-stage T3/T4 (HR = 0.56, 95% CI0.40–0.78), although it was statistically improved in all deciles except decile 10. For patients without neoadjuvant chemotherapy, survival was greatest in decile 7 (HR = 0.60, 95% CI 0.41–0.86), although survival was also statistically significantly improved in deciles 2, 6, and 8. Conclusion: Survival in esophageal cancer was not improved by extensive lymphadenectomy, but resection of a moderate number (20–30) of nodes was prognostically beneficial for patients with advanced T-stages (T3/T4) and those not receiving neoadjuvant therapy. [ABSTRACT FROM AUTHOR]

The risk of complications after esophagectomy highlights the need for careful preoperative assessment. Aim was to assess whether stair-climbing test (SCT) could predict outcomes of patients with operable esophageal cancer in minimally invasive era. Patients with esophageal cancer were evaluated for surgical treatment in Central Finland Central Hospital from 2012 to March 2021. Of evaluated 162 patients, 138 were scheduled to eventually undergo surgery. The exercise capacity was evaluated with symptom limited SCT. Patients were divided into four study groups on intent-to-treat basis: surgery and the SCT >14 m (Group 1), surgery and the SCT <11 m (Group 2), non-surgical therapy and the SCT <11 m (Group 3) and non-surgical therapy and the SCT >14 m (Group 4). Results were adjusted for confounders. Major complication rate was 10.1% vs 40.0% between Group 1 and 2 (p = 0.006), and 90-day mortality 0% vs 20.0% (p < 0.001). Overall survival rates in Groups 1–4 at 1-year were 92.3% vs 72.2% vs 46.8% vs 81.8%, at 3-year 68.5% vs 52.7% vs 15.6% vs 27.3% and at 5-year 58.7% vs 39.5% vs 0% vs 0%, respectively (p < 0.001). In adjusted analysis when compared to Group 1, other groups had increased 5-year mortality hazard (Group 2 HR 2.88 (95% CI 1.25–6.63), Group 3 HR 15.6 (95% CI 5.57–43.5) and Group 4 HR 5.35 (95% CI 2.08–13.7)). Exercise capacity measured with SCT in esophageal cancer patients is a strong predictor of complications and survival, and is a potential parameter to be included in any risk or prognostic models. [ABSTRACT FROM AUTHOR]

Population-based studies examining whether preoperative esophageal stenting influences the short-term outcomes after esophagectomy for esophageal cancer are lacking. This nationwide cohort combining data from Finland and Sweden was conducted to cover this gap. Patients with locally advanced esophageal cancer (T ≥ 3 and/or N ≥ 1, M0) who underwent esophagectomy between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. The study exposure was preoperative stenting. The primary outcomes were 30- and 90-day mortality. Secondary outcomes were length of hospital stay and 30- and 90-day readmission rates. Multivariable Cox and linear regression analyses provided hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, comorbidity, tumor histology, year of surgery, and country. Of all 1029 participating patients who underwent surgery for locally advanced esophageal cancer, 127 (12.3%) had an esophageal stent inserted preoperatively. The absolute 30-day mortality rates were higher in stented patients (3.9%) than in those without a stent (1.6%), but the HR was not statistically significantly increased (HR 2.42; 95% CI 0.85–6.92). Similarly, the absolute 90-day mortality rates were increased after preoperative stenting (11.8%) compared to no stenting (7.0%), but again the HR was not statistically significantly increased (HR 1.68; 95% CI 0.95–2.98). Preoperative stenting did not influence length of hospital stay or readmission rates. The possibly increased short-term mortality after preoperative stenting in patients who undergo esophagectomy for esophageal cancer indicated in this study suggests a cautious approach to preoperative stenting until future research or meta-analyses provide a more definite answer. [ABSTRACT FROM AUTHOR]