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Background: Extraanatomic retrosternal and presternal esophageal reconstruction performed after esophagectomy poses a significant technical challenge to those patients who require cardiac surgery. This study reviewed a single-center experience with cardiac surgical procedures in patients with extraanatomic esophageal conduits, to examine the relative advantages of median sternotomy and thoracotomy approaches., Methods: This case series identified patients who underwent cardiac surgery after extraanatomic esophageal reconstruction between January 1, 1999 and October 1, 2019 at the Mayo Clinic in Rochester, Minnesota. Electronic medical records were reviewed for patient demographics, surgical indications, characteristics, and outcomes. Continuous variables were reported as the mean or as the median and range, as appropriate., Results: Seven individual patients had 8 cardiac surgical procedures after extraanatomic esophageal reconstruction (5 retrosternal, 2 presternal). All were male, with a median age of 65.5 years (range, 51 to 71 years). Preoperative computed tomography was obtained in all but 1 patient. Median sternotomy was performed in 4 patients, left thoracotomy in 2, right thoracotomy in 1, and right anterior thoracotomy in 1. Median bypass time was 91 minutes (interquartile range, 113.5 minutes). The median cross-clamp time was 57.5 minutes (interquartile range, 27.0 minutes). There was 1 delayed injury to a retrosternal conduit after median sternotomy approach. There were no injuries to the blood supply of any conduit. In-hospital mortality was 0%. The median length of stay was 7.5 days (range, 5 to 34 days)., Conclusions: Different cardiac surgical procedures can be performed safely in patients with extraanatomic esophageal reconstructions through median sternotomy or thoracotomy. Preoperative planning with computed tomography with intravenous contrast enhancement of the chest, abdomen, and pelvis is essential for individualization of the surgical approach., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux., Methods: A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty)., Results: Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox., Conclusions: The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this retrospective cohort study was to evaluate resource consumption of clinically significant esophageal anastomotic leaks., Methods: Between September 1, 2008, to December 31, 2014, a prospectively maintained database was queried to identify patients with grade III to IV anastomotic leaks after esophagectomy for esophageal cancer. Inflation-adjusted standardized costs were applied to billed services related to leak diagnosis and treatment, from time of leak detection to resumption of oral diet. A matched analysis was used to compare average expenditures in patients without vs. those with an anastomotic leak., Results: Of 448 patients undergoing esophagectomy after neoadjuvant treatment, 399 patients met inclusion criteria. Twenty-four grade III to IV anastomotic leaks were identified (6% leak rate). Five transhiatal esophagectomies accounted for 20.8% of cases, whereas 9 Ivor Lewis and 10 McKeown esophagectomies accounted for 37.5% and 41.7%, respectively. The median time required to treat an anastomotic leak was 73 days (range 14-701). The additional median standardized cost per leak was $68,296 (mean $119,822). Matched analysis demonstrated that mean treatment costs were 2.6 times greater for patients with an anastomotic leak. This was primarily attributed to prolonged hospitalization, with post-leak detection length of stay ranging from 7 to 73 days. The largest contributors to cost for all patients were intensive care stay (30%), hospital room (17%), pharmacy (16%), and surgical intervention (13%)., Conclusions: Grade III to IV esophageal anastomotic leaks more than double the cost of an esophagectomy and have a significant cost burden. Focus should be placed on preventative measures to avoid leaks at the time of the index operation., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Endoscopic mucosal resection (EMR) and esophagectomy are treatment options for cT1 esophageal adenocarcinoma. Our aim was to study outcomes for patients undergoing EMR then esophagectomy., Methods: We identified patients undergoing EMR and esophagectomy for cT1 esophageal adenocarcinoma over 10 years. EMR histology was used to predict nodal involvement with a risk-scoring tool. Patient demographics, surgical techniques, pathology, postoperative outcomes, and survival were recorded., Results: Of 1,092 that esophagectomies were performed, 51 patients underwent EMR and esophagectomy for cT1 esophageal adenocarcinoma. The mean time between EMR and esophagectomy was 4 (SD,8.0) months. According to the risk-scoring tool based on EMR histology, 1 patient was low risk, 13 (25%) were at moderate risk, and 37 (73%) were at high risk for lymph node metastasis. The time between EMR and the surgical intervention was longer and more patients had multiple EMRs in the moderate-risk group (9 vs 1.4 months, p = 0.03) compared with the high-risk group (38% vs 11% patients, p = 0.04). Operative mortality was 4% and morbidity was 43%. Pneumonia occurred in 3 of 51 patients (6%), atrial fibrillation in 4 (8%), and clinical anastomotic leak in 6 (12%). Of the 51 patients, 14 (27%) were upstaged after esophagectomy. Nodal involvement was present in 3 of 13 moderate-risk patients (23%) and in 7 of 37 high-risk patients (19%). The 5-year survival was reduced in moderate-risk compared with high-risk patients (54% vs 84%, p = 0.04)., Conclusions: Studying outcomes for cT1 esophageal adenocarcinoma is important. These patients can be divided into those undergoing EMR for staging before esophagectomy and those in whom esophagectomy is a salvage procedure after therapeutic EMRs. Care should be taken to avoid upstaging of patients in the latter group, and we recommend frequent restaging and surveillance to prevent undetected progression of disease. A low threshold for esophagectomy when EMR fails to control disease should be considered., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Five-year survival of stage IV esophageal cancer is rare. The treatment of advanced esophageal cancer is typically palliative and the role of surgery remains controversial. We sought to understand the impact of curative surgery on survival and identify any favorable tumor or patient characteristics that might make surgical resection appropriate when treating stage IV esophageal cancer., Methods: A retrospective review of 3,500 esophagectomies performed at our institution from 1985 to 2013 identified 52 (1.5%) patients with stage IV esophageal cancer who underwent surgical resection with intent for cure. In 46 (88.5%) patients, M1 disease was discovered at the time of surgery and 6 (11.5%) patients had known M1 disease prior to surgery., Results: Median age at the time of surgery was 60 years (range, 31 to 81 years). The majority of patients were men (82.7%) with adenocarcinoma (88.5%). Neoadjuvant therapy was used in 18 (34.6%) patients; all patients operated on after 1999 received neoadjuvant therapy. An Ivor Lewis esophagectomy was performed in 39 (75%) patients. Follow-up was complete in all patients for a median of 324 days (range, 4 days to 8.5 years). Overall, 1-year survival was 29% and 5-year survival was 6%. There was no significant difference in survival between patients with known preoperative versus intraoperative discovery of M1 disease. Factors associated with improved survival included neoadjuvant treatment, low T stage, and lack of alcohol use., Conclusions: Few patients with stage IV esophageal cancer survive long term after surgical resection, though 5-year survival can occur. Our current recommendation is that esophagectomy should not be performed for stage IV disease., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Pulmonary complications remain a frequent cause of morbidity in patients undergoing oesophagectomy. Risk screening tools assist in patient stratification. Ferguson proposed a risk score system to predict major pulmonary complications after oesophagectomy. Our objective was to externally validate this risk score system., Methods: We analysed our institutional database for patients undergoing oesophagectomy for cancer from August 2009 to December 2012. We analysed patients who had complete documentation of variables used in the Ferguson risk score calculation: forced expiratory volume in the 1 s, diffusion capacity of the lung for carbon monoxide, performance status and age. One hundred and thirty-six patients qualified for analysis in the validation study. Outcome variables measured included major pulmonary complications, defined as need for reintubation for respiratory failure and pneumonia. The risk score was then calculated for each individual based on the model. Incidence of major pulmonary events was assessed in the five risk class groupings to assess the discriminative ability of the Ferguson score., Results: Major pulmonary complications occurred in 35% of patients (47/136). Overall mortality was 6% (8/136). Patients were grouped into five risk categories according to their Ferguson pulmonary risk score: 0-2, 8 patients (6%); 3-4, 24 patients (18%); 5-6, 49 patients (36%); 29 patients (21%); 9-14, 26 patients (19%). The incidence of major pulmonary complications in these categories was 0, 17, 20, 41 and 77%, respectively. The accuracy of the risk score system for predicting major pulmonary complications was 76% (P < 0.0001)., Conclusions: This pulmonary risk scoring system is a reliable instrument to be used during the preoperative phase to differentiate patients who may be at higher risk for pulmonary complications after oesophagectomy. These data can assist in patient selection, and in patient education/informed consent and can guide postoperative management., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Although surgical resection of adenocarcinoma or squamous cell carcinoma of the esophagus is standard practice, the treatment strategy for other malignant rare esophageal cancers is still under debate. The aim of this study was to examine the treatment of rare malignant esophageal cancers and to evaluate the survival of these patients., Methods: A retrospective review of all esophagectomies performed at Mayo Clinic from 1980 to 2014 (approximately 4,000 cases) identified 24 patients with histologic features other than adenocarcinoma or squamous cell carcinoma. Their medical records were reviewed for demographics, presenting symptoms, evaluation, surgical management, pathologic features, and short-term and long-term outcome., Results: Pathologic identifications included small cell carcinoma, lymphoma, and undifferentiated carcinoma in 4 (16.7%) patients each and neuroendocrine, melanoma, leiomyosarcoma, sarcomatoid, sarcoma, and gastrointestinal stromal tumor in 2 (8.3%) patients each. The most common presenting symptoms included dysphasia in 91.7% patients (22/24), pain in 75.0% (18/24), and weight loss in 62.5% (15/24). Preoperative evaluation included barium swallow in 91.7% (22/24), computed tomography in 91.7% (22/24), positron emission tomography in 54.2% (13/24), esophagogastroduodenoscopy in 100% (24/24), and endoscopic ultrasonography in 29.2% (7/24) patients. The location of the tumor was at the gastroesophageal junction in 41.7% (10/24). There was no operative mortality, and 13 patients (54.16%) had at least one postoperative adverse event. The 1-year survival after esophagectomy was 69.7%, the 5-year survival was 42.7%, and the 10-year survival was 37.4%., Conclusions: Esophageal cancer with pathologic features other than squamous cell carcinoma or adenocarcinoma is rare. Esophagectomy for rare types of malignant esophageal cancers should be considered part of the effective treatment paradigm., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) (longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques., Methods: From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed., Results: There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p=0.01) and LS anastomoses had the lowest risk of stricture (p=0.006)., Conclusions: When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ivor-Lewis esophagectomy is associated with significant postoperative analgesic requirements and perioperative complications. A dual-epidural technique may improve perioperative outcomes compared with single thoracic epidural analgesia., Methods: This study identified all cases of Ivor-Lewis esophagectomy over a 3-year period. Eighty-one patients undergoing Ivor-Lewis esophagectomy who received general anesthesia supplemented by neuraxial analgesia with dual-epidural catheters (DECs) were matched 1:1 with patients who received general anesthesia and a single thoracic epidural catheter. Primary outcomes included quality of analgesia at rest and with movement on each of the first 3 postoperative days. Secondary outcomes included adverse events and the incidence of 4 major postoperative complications (anastomotic leak, pulmonary complications, atrial fibrillation, and sepsis)., Results: A DEC technique significantly improved analgesia (evidenced by reduced pain with movement on each of the first 3 postoperative days) when compared with a single epidural catheter technique. The placement of DECs did not increase catheter-related adverse events. A DEC technique was associated with a 50% reduction in the combined rate of major postoperative complications (36% vs. 18%; odds ratio, 0.40; P = 0.01) and increased number of hospital-free days measured at day 28 (21.2 vs. 22.3; P = 0.04)., Conclusions: The DEC technique improved postoperative analgesia and reduced the incidence of major postoperative complications and hospital length of stay in patients undergoing Ivor-Lewis esophagectomy. Future studies should evaluate the efficacy of this technique in a controlled randomized clinical trial.

Background: Esophageal resection is a complex operation often associated with morbidity. Hiatal hernia after esophagectomy is an unusual complication. We reviewed our experience with this complication., Methods: From February 1988 through February 2009 we performed 2,182 esophagectomies. Fifteen (0.69%) patients experienced a hiatal hernia. We reviewed our prospective database for demographics, presentation, operative approaches, and outcomes., Results: There were 14 men and 1 woman with a mean age of 59 years. Hernia developed after Ivor Lewis approach in 9, transhiatal in 5, and substernal colon interposition in 1. Presenting symptoms included pain in 7 patients, obstructive symptoms in 5, high chest tube output in 2, shortness of breath in 2, diarrhea in 1, and cough with dysphagia in 1. Two patients were asymptomatic. Radiographic studies revealed bowel in the left chest in 11 patients, right chest in 2, bilaterally in 1, and posterior mediastinum in 1. Hernia repair was through the abdomen in 14 patients and left chest in 1. All had reduction of the herniated contents and closure of the defect; 2 required mesh. There was no early mortality. Complications included wound infection, deep venous thrombosis, chylothorax, urinary retention, sacral decubiti, atrial arrhythmias, respiratory failure, and empyema. Mean follow-up was 34 months. Ten patients are still alive. There have been two hernia recurrences., Conclusions: Hiatal hernia after esophagectomy is rare. Repair can be accomplished with low mortality; however, there is substantial morbidity. Because of the increased risk of incarceration or strangulation, these herniae should be repaired. Long-term outcome is usually excellent., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: There are few data on whether prior fundoplication has an impact on subsequent esophageal resection and reconstruction. The aim of this study is to review our experience with patients undergoing esophagectomy after previous fundoplication., Methods: Medical records were reviewed of all patients undergoing esophageal resection from 1988 to 2008 at the Mayo Clinic. Patients with a fundoplication before esophagectomy were compared with a matched control group who had esophagectomy alone., Results: There were 2313 esophageal resections, and 80 patients had undergone at least 1 previous anti-reflux surgery. Indications for esophagectomy were benign stricture/perforation in 41 patients, cancer in 28 patients, and dysplasia in 11 patients. The surgical approach was Ivor Lewis in 38 patients, left thoracoabdominal in 29 patients, transhiatal in 10 patients, and McKeown in 3 patients. The conduit used was stomach in 70 patients, jejunum in 6 patients, and colon in 3 patients; 1 patient had a diversion and cervical esophagostomy only. Operative mortality occurred in 3 patients (3.7%). Postoperative complications occurred in 50 patients (62.5%), including anastomotic leak in 17 (21.5%). Sixteen patients (20%) required reoperation for complications. Complication, anastomotic leak, and reoperation rates were significantly higher in patients with anti-reflux surgery before esophagectomy compared with matched controls., Conclusion: Esophagectomy after prior anti-reflux surgery is challenging, but the stomach is usually a suitable conduit for esophageal replacement. Patients with a history of anti-reflux surgery who undergo esophagectomy are at significantly increased risk for postoperative complications, anastomotic leak, and need for reoperation., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background & Aims: Photodynamic therapy (PDT) for high-grade dysplasia (HGD) in Barrett's esophagus is a Food and Drug Administration-approved alternative to esophagectomy. Critical information regarding overall survival of patients followed up long-term after these therapies is lacking. Our aim was to compare the long-term survival of patients treated with PDT with patients treated with esophagectomy., Methods: We reviewed records of patients with HGD seen at our institution between 1994 and 2004. PDT was performed 48 hours following the intravenous administration of a photosensitizer using light at 630 nm. Esophagectomy was performed by either transhiatal or transthoracic approaches by experienced surgeons. We excluded all patients with evidence of cancer on biopsy specimens. Vital status and death date information was queried using an institutionally approved Internet research and location service. Statistical analysis was performed using Kaplan-Meier curves and Cox proportional hazards ratios., Results: A total of 199 patients were identified. A total of 129 patients (65%) were treated with PDT and 70 (35%) with esophagectomy. Overall mortality in the PDT group was 9% (11/129) and in the surgery group was 8.5% (6/70) over a median follow-up period of 59 +/- 2.7 months for the PDT group and 61 +/- 5.8 months for the surgery group. Overall survival was similar between the 2 groups (Wilcoxon test = 0.0924; P = .76). Treatment modality was not a significant predictor of mortality on multivariate analysis., Conclusions: Overall mortality and long-term survival in patients with HGD treated with PDT appears to be comparable to that of patients treated with esophagectomy.

Objective: A paucity of outcome data exists regarding patients with proximal stomach cancer involving the distal esophagus (Siewert type III tumors). This is especially true with regard to long-term survival rates after surgical intervention., Methods: Medical records were reviewed of all patients who underwent total gastrectomy and distal esophagectomy with Roux-en-Y esophagojejunostomy for Siewert type III tumors from January 1975 through December 2000., Results: There were 116 patients (93 men and 23 women). The median age was 66 years (range, 22-87 years). Pathologic stage was 0 (carcinoma in situ) in 1 patient, IB in 13 patients, II in 17 patients, IIIA in 34 patients, IIIB in 10 patients, and IV in 41 patients. Complete resection was achieved in 69 (59.5%) patients. Eleven (9.5%) patients were treated with neoadjuvant therapy, 49 (42.2%) received adjuvant therapy, and 6 (5.2%) received intraoperative radiation. Follow-up was complete in 114 (98.3%) patients, ranging from 1 to 281 months (median, 14 months). Operative mortality was 5.2%. Complications occurred in 51 (43.9%) patients. Clinically significant anastomotic leaks occurred in 15 (12.9%) patients. Median hospitalization was 13 days (range, 8-70 days). Median follow-up was 14 months (range, 1-281 months). Overall median survival was 434 days, with 1-, 5-, and 10-year survivals of 56.2%, 19.0%, and 13.5%, respectively. The only factor associated with increased hospital mortality was anastomotic leakage (P = .002). Incomplete resection, increased tumor stage and grade, and splenic involvement significantly worsened long-term survival., Conclusions: Total gastrectomy and distal esophagectomy for Siewert type III tumors is associated with reasonable mortality and significant morbidity. Although often palliative, surgical intervention can provide long-term survival, especially in patients with completely resected, early-stage, low-grade tumors.

Successful anastomosis is essential for favorable esophagogastrectomy outcomes. Before July 2002, almost all esophagogastric anastomoses at our institution were hand-sewn. We then began using linear stapled anastomotic techniques. This review compares patient outcomes with both techniques. From July 2001 to June 2004, 280 consecutive esophagogastrectomy patients (235 men and 45 women) were reviewed (median age, 65 years). The anastomosis was intrathoracic in 206 patients (74%) and cervical in 74 (26%). Anastomoses were hand-sewn in 205 patients (73%) and linear stapled in 75 (27%). Stapled anastomoses were intrathoracic in 33 patients (16%) and cervical in 42 (57%). Anastomotic leaks occurred in 30 patients (11%); 26 (12.7%) in the hand-sewn and 4 (5.3%) in the linear stapled group (P = .008). Leaks were asymptomatic in 17 patients (57%). Dilatation was required in 70 hand-sewn anastomoses (34%) and in 11 stapled (14.6%) (P = .001). Hand-sewn anastomoses were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67-19.27) and 3.58 (1.66-8.34), respectively. A linear stapled anastomosis is safe and associated with both a significantly lower leak rate and the need for dilatation compared with hand-sewn anastomosis. This nonrandomized series suggests that linear stapled anastomosis is the preferred technique regardless of anastomotic location.

In conclusion, an Ivor Lewis esophagogastrectomy is a safe surgical approach for esophageal cancer. The technique allows direct visualization and resection of most of the lymph node stations at risk. Survival is stage-dependent and, unfortunately, is low in advanced stages. The increased systemic recurrence warrants the continuing search for multimodality therapy. The authors hope that this series can serve as a baseline for comparison of new and more curative therapeutic options.

Esophagectomy is the treatment of choice for cancer or high-grade dysplasia. Although the patients frequently experience symptoms postoperatively, their quality of life is most often comparable to that of a control population. This article provides details of post-esophagectomy symptomatology and examines how quality of life can be measured in these patients.

Objective: We sought to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy., Methods: All patients who had intrathoracic anastomotic leaks after esophagectomy were reviewed. Management and factors affecting outcome were analyzed., Results: From March 1993 through February 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight (6.3%) patients had an anastomotic leak; one refused authorization to review his medical record and was excluded from further analysis. Twenty-four (51.1%) patients had a contained leak. Twenty-seven (57.4%) patients were managed nonoperatively. Twenty (42.6%) patients required surgical intervention that included primary anastomotic repair in 14 patients, reinforcement of the anastomosis with viable tissue in 6 patients, and esophageal diversion in 2 patients. A single reoperation was done in 15 patients, and 5 patients had 2 reoperations. Median hospitalization in the reoperative group was 31 days (range, 15-97 days) and 20 days (range, 10-42 days) in the nonoperative group ( P = .0037). Four (8.5%) patients died. Cause of death was sepsis in 2 patients and multiorgan failure and myocardial infarction in 1 patient each. At follow-up (median, 8 months; range, 1-120 months), 10 (58.8%) patients in the reoperative group were eating a normal diet and 5 (29.4%) patients required at least one dilatation compared with 20 (76.9%) patients in the nonoperative group who were eating a normal diet and 9 (34.6%) who required at least one dilatation. A noncontained leak had an adverse effect on long-term survival ( P = .04)., Conclusion: Intrathoracic anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Contained leaks often can be managed nonoperatively. When surgical management is required, esophagogastric continuity can often be maintained in the majority of patients. Long-term functional results are satisfactory and similar in both the reoperative and nonoperative groups. However, a noncontained leak adversely affected long-term survival.

Background: The optimal treatment for locally advanced esophageal cancer remains controversial. The objective of this study was to determine if preoperative chemoradiation therapy (P-CRT) followed by esophagectomy for patients with clinical stage III adenocarcinoma of the esophagus offered any survival advantage as compared with esophagectomy alone., Methods: Between January 1998 and June 2001, 75 nonrandomized patients with clinical stage III adenocarcinoma of the esophagus underwent either P-CRT and esophagectomy or esophagectomy alone. All patients were staged before initiation of treatment with computed tomography and endoscopic ultrasound., Results: P-CRT followed by esophagectomy was performed in 47 patients (63%) and esophagectomy alone in 28 patients (37%). Although the P-CRT group was younger (median age, 61 years versus 67 years), the two groups were otherwise similar for gender, comorbidities, and symptoms. Overall operative mortality was 4%. Follow-up was complete in all patients and ranged from 5 to 40 months (median, 20 months). Overall, one-, two-, and three-year survivals were 72%, 44%, and 42%, respectively. Three-year survival was identical (42%) for both the P-CRT and surgery alone patients (p = 0.70). Three-year disease-free survival for the P-CRT group was 29% as compared with 33% for the surgery only group (p = 0.51)., Conclusions: Patients with clinical stage III adenocarcinoma of the esophagus do not appear to gain an early overall or disease-free survival advantage when treated with P-CRT followed by surgery as compared with surgery alone. However, long-term follow-up is needed. A large, prospective, randomized trial is warranted to address the question of whether P-CRT offers any survival benefit or impact on pattern of recurrence in patients undergoing esophagectomy for locally advanced disease.

Objective: Preoperative chemoradiation is becoming standard of care for locally advanced esophageal cancer. The objective of this study was to determine if the degree of pathologic response to preoperative chemoradiation could predict survival and recurrence after resection in patients with adenocarcinoma of the distal esophagus., Methods: Between January 1998 and December 2001, 366 patients underwent esophagectomy for adenocarcinoma of the esophagus; 108 (30%) had induction chemoradiation prior to surgery. The records of these 108 patients were reviewed., Results: Histologic examination of the resected specimens documented complete pathologic response (CR) in 24 patients (22%) and residual tumor (RT) in 84 (78%). Operative mortality was 3.7%. Follow-up was complete in all patients and ranged from 1 to 46 months (median, 11 months). Three-year survival for patients with CR was 64% as compared to 34% for patients with RT (P=0.17). Median survival for patients with CR has not yet been reached; however, median survival for patients with RT was 19 months. Three-year cancer free survival for patients with CR was 57% compared to 30% for patients with RT (P=0.03). While median survival free of recurrence for patients with CR has not yet been reached, median survival free of recurrence for patients with RT was 9 months., Conclusion: Complete pathologic response to induction chemoradiation is associated with improved early overall and disease-free survival following esophagectomy for adenocarcinoma of the distal esophagus. Because recurrent cancer still develops in many of these patients, even after complete pathologic response, the search for the optimal treatment continues.

Background: Esophagectomy for high-grade dysplasia in Barrett's esophagus has been advocated. Although long-term survival data exist, little is known about functional outcome and quality of life in this particular subset of patients., Methods: The records of all patients who underwent esophageal resection for high-grade dysplasia from June 1991 through July 1997 were reviewed. Long-term functional outcome and quality of life were assessed using a two-part written survey., Results: There were 54 patients (48 men, 6 women). Median age was 64 years (range, 36 to 83 years). Ivor Lewis esophagogastrectomy was performed in 34 patients (63%), transhiatal esophagectomy in 10 (18%), extended esophagectomy in 8 (15%), and other in 2 (4%). Invasive carcinoma was found in 19 patients (35%). Five patients (9%) were stage 0, 7 (13%) stage I, 3 (6%) stage IIA, 1 (2%) stage IIB, and 3 patients (6%) stage III. There was one operative death (1.8%). Complications occurred in 31 patients (57%). Median hospitalization was 13 days (range, 11 to 44 days). Follow-up was complete in all patients and ranged from 6 months to 9 years (median, 63 months). Overall 5-year survival was 86% and did not differ significantly from a population matched for age and gender. Five-year survival for patients with only high-grade dysplasia was 96% and 68% for patients with cancer (p = 0.017). Quality of life was measured by the Medical Outcomes Study 36-Item Short-Form Health Survey. For patients with only high-grade dysplasia, the role-physical and role-emotional scores were better than for the control population (p < 0.03). For patients with cancer, the health perception score was worse than for the control population (p < 0.03). Scores measuring physical-function, social function, mental health, bodily pain, and energy/fatigue were similar., Conclusions: Although perioperative morbidity is significant, surgical resection of high-grade dysplasia in Barrett's esophagus provides excellent long-term survival with acceptable function and quality of life.

Background: Cancer of the cervical esophagus is uncommon and typically presents with locally advanced disease. Management is challenging and generally involves definitive chemoradiotherapy. A segment of patients will experience locoregional failure after chemoradiotherapy with either persistent or recurrent cancer. The benefit of so-called salvage surgical resection in this group of patients remains unclear and is the focus of this article. Methods: We conducted a retrospective review of all patients who underwent resection for recurrent or persistent squamous cell carcinoma of the proximal esophagus after chemoradiotherapy at the Mayo Clinic, Rochester, Minnesota, between January 1, 1990 and December 31, 2005. Results: Twelve patients were studied: 5 (42%) with recurrent cancer and 7 (58%) with persistent cancer. The median age of the patients was 59 years (range, 42–73 years), and 8 patients were men (67%). Eight patients (67%) underwent pharyngolaryngectomy and 4 patients (33%) underwent McKeown''s esophagectomy. Two patients (17%) had positive margins at the time of resection. Five patients (42%) experienced 1 or more perioperative complications. Median length of hospitalization was 15 days (range, 9–29 days) and median follow-up was 22 months (range, 1–159 months). Overall 1, 3, 5, and 10-year survival rates were 75%, 33%, 17%, and 8%, respectively. Median survival was 21 months. Cause of death was recurrent cancer in 10 patients (83%) and perioperative death in 1 patient (8%). Conclusions: The opportunity for long-term survival after salvage resection for persistent or recurrent cancer of the proximal esophagus exists but is limited and must be thoughtfully balanced with the perioperative morbidity of such challenging resections by both patients and physicians. [Copyright &y& Elsevier]

Abstract: Objective: As part of our ongoing quality improvement effort, we evaluated our conventional approach to post-oesophagectomy management by comparing it to an alternative postoperative management pathway. Methods: Medical records from 386 consecutive patients undergoing oesophagectomy with gastric conduit for oesophageal cancer or Barrett''s oesophagus with high-grade dysplasia were analysed retrospectively (July 2004 to August 2008). The conventional pathway involved a routine radiographic contrast swallow study at 5–7 days after oesophagectomy with initiation of oral intake if no leak was detected. In the alternative pathway, a feeding jejunostomy was placed for enteral feeding and used exclusively until oral intake was gradually initiated at home at 4 weeks after oesophagectomy. No contrast swallow was obtained in the alternative pathway group unless indicated by clinical suspicion of an anastomotic leak. Each group was analysed on an intention-to-treat basis with respect to anastomotic leak rates, length of hospitalisation, re-admission and other complications. Results: A total of 276 (72%) patients underwent conventional postoperative management, 110 (28%) followed the alternative pathway. Patient characteristics were similar in both the groups. The anastomotic leak rate was lower in the alternative pathway with three clinically significant leaks (2.7%) versus 33 in the conventional pathway (12.0%; p = 0.01). Among patients undergoing a radiographic contrast swallow examination, a false-negative rate of 5.8% was observed. The swallow study of 14 patients (5.9%) was complicated by aspiration of oral contrast. Postoperatively, 7.3% of patients suffered from pneumonia. There were no significant differences overall in postoperative pulmonary or cardiac complications associated with either pathway. Median length of hospitalisation was 2 days shorter for the alternative pathway (7 days) than the conventional pathway (9 days; p < 0.001). There was no significant difference in unplanned re-admission rates. Conclusion: An alternative postoperative pathway following oesophagectomy involving delayed oral intake and avoidance of a routine contrast swallow study is associated with a shortened length of hospitalisation without a higher risk of complication after hospital discharge. [Copyright &y& Elsevier]