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Management of esophageal cancer has evolved since the two last decades. Esophagectomy remains the primary treatment for early stage esophageal cancer although its specific role in superficial cancers is still under debate since the development of endoscopic mucosal treatment. To date, there is strong evidence to consider that locally advanced cancers should be recommended for a multimodal treatment with a neoadjuvant chemotherapy or a combined chemoradiotherapy (CRT) followed by surgery. For locally advanced squamous cell carcinoma or for a part of adenocarcinoma, some centers have proposed treating with definitive CRT to avoid related-mortality of surgery. In case of persistent or recurrent disease, a salvage esophagectomy remains a possible option but this procedure is associated with higher levels of perioperative morbidity and mortality. Despite the debate over what constitutes the best surgical approach (transthoracic versus transhiatal), the current question is if a minimally procedure could reduce the periopertive morbidity and mortality without jeopardizing the oncological results of surgery. Since the last decade, minimally invasive esophagectomy (MIE) or hybrid operations are being done in up to 30% of procedures internationally. There are some consistent data that MIE could decrease the incidence of the respiratory complications and decrease the length of hospital-stay. Nowadays, oncologic outcomes appear equivalent between open and minimally invasive procedures but numerous phase III trials are ongoing.

Background: Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications., Methods: Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results., Results: In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n=13, and herpesvirus simplex, n=1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p=0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications., Conclusions: When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Lung cancer remains the main leading cancer-related cause of death in the world. For early-stage tumor, surgery stands out as the best curative option offering the greatest chance for cure. Despite improvement of per- and postoperative management, surgery continues to carry a high morbidity with a significant mortality. Among postoperative complications, respiratory failures (nosocomial pneumonia and acute respiratory distress syndrome) are currently the most frequent and serious, as well as being the primary cause of hospital death, after a lung resection for cancer. Because infectious etiologies have been highly incriminated in the development of these pulmonary complications, microbial airways colonizations (AWCs) are supposed to be an essential first step in the pathogenesis of these failures occurring in hospitalized and chronically ill individuals. These patients fulfill all the predisposing factors to bronchial colonizations and are particularly exposed to the development of respiratory failures in the postoperative setting, when secretion clearance and cough reflex are impaired. Under immunosuppressive conditions, AWC should act in a manner that increases its ability to stimulate microorganisms and increase the risks of superimposed infections. Few studies have addressed the problem of AWCs in patients submitted for lung cancer surgery. Because of several limitations, especially the lack of exhaustive microbiological studies, the conclusions that can be reached remain inconclusive. This review aims to report the existing literature on this critical and controversial issue, focusing on their specific incidence, their predisposing factors, their correlation with development of respiratory failures, and, in turn, the reliability of the current antibiotic prophylaxis for their prevention., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Respiratory complications are the most frequent concern following oesophagectomy. We aimed to assess the postoperative inflammatory response after oesophagectomy and to determine its reliability to predict the occurrence of pulmonary complications., Methods: A total of 97 patients were enrolled in this prospective observational study. All patients underwent a transthoracic oesophagectomy for cancer. From D0 to D3, plasmatic cytokine levels (interleukin (IL)-1, IL-6, IL-8, IL-10, tumour necrosis factor (TNF)-alpha), short synacthen test (SST), PaO(2)/FiO(2) ratio and clinical factors determining the systemic inflammatory response syndrome (SIRS) were monitored and compared between patients who experienced pulmonary complications (group I) and those who did not (group II)., Results: The overall in-hospital mortality was 5%. Postoperative pulmonary complications occurred in 33 patients (34%). Sputum retention was the first step of pulmonary complications in 26 patients (occurring at a mean of 2.8+/-1 days after the operation), leading to pneumonia in 22 patients (4.7+/-1 days) and acute respiratory distress syndrome (ARDS) in 10 (6.9+/-3 days). At day 2, group I patients had significantly higher plasmatic levels of IL-6, IL-10 and TNF-alpha than group II patients. PaO(2)/FiO(2) was impaired accordingly (215 vs 348; p=0.006). SST was negative in 38% of group I patients and in 30% of group II patients (p=0.51). SIRS was present in 33% and 6% of group I and group II patients, respectively (p< or =0.01). At multivariate analysis, early occurrence of SIRS was the sole significant predictor of pulmonary complications (p=0.005; odds ratio (OR):11.4, confidence interval (CI): 2-63)., Conclusions: The vast majority of postoperative pulmonary complications after oesophagectomy occur after the 4th postoperative day. The earlier detection (first 48 h) of SIRS, high plasmatic cytokine levels and impairment of PaO(2)/FiO(2) predicts the onset of these complications. This finding suggests that early pharmacological intervention may have a beneficial impact., (Copyright 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To assess development of mucosal damage in the esophageal remnant in regard to the level of the esophagogastrostomy reconstruction either in a right chest or in a left neck position., Summary Background Data: Esophagectomy with gastric interposition creates an in vivo human model of pathologic esophageal reflux with the potential for long-term reflux disease complications., Methods: Eighty-four esophagectomy patients were assessed over time by symptoms, endoscopy and biopsies of their esophageal remnant after the operation. The anastomosis was in the right upper chest (n = 36) or in a left cervical position (n = 48). Visual quantification of damage, details of histopathology, and time period since surgery were recorded., Results: Twenty-nine patients (81%) with a right chest reconstruction had reflux symptoms when compared with 25 patients (53%) with a neck reconstruction (P = 0.007). Visualized reflux esophagitis was observed in 31 patients (81%) with chest anastomoses and in 22 patients (46%) with cervical anastomoses (P = 0.006). Documented mucosal damage and columnar lined metaplasia were significantly more frequent in the chest anastomosis group than the cervical group. The median of all mucosal damage and columnar lined metaplastic-free evolution were 13 +/- 3 and 20.5 +/- 6 months for the intrathoracic anastomosis, and 22 +/- 6 months and 40 +/- 8 months for the cervical anastomosis (P = 0.087). Two factors affecting the development of metaplasia were included in the multivariate analysis: an intrathoracic anastomosis (P = 0.018) and the presence of a previous Barrett esophagus (P = 0.064)., Conclusions: When a gastric transplant is used after esophagectomy, a high prevalence of mucosal damage is observed in the esophageal remnant independently of the level of reconstruction. A left cervical anastomosis favors less reflux symptoms, less visualized damage, and delays the development of mucosal damage over time.

Background: Reflux esophagitis is a significant problem after esophagectomy and gastric reconstruction. When mixed reflux damages the esophageal remnant or results in aspiration problems, appropriate medical management is in order. If medical management fails, a surgical option is available. This study reports results of a Roux-en-Y diversion in postesophagectomy patients affected by debilitating reflux complications., Methods: Between 1990 and 2006, 4 of 223 esophagectomy patients required surgical correction for mucosal damage to their esophageal remnant or repeat aspirations. Patient, clinical, operative, histopathologic, and postoperative data were collected., Results: Two of 3 patients with a substernal reconstruction underwent antrectomy with a 60-cm Roux-en-Y diversion. One patient with significant reflux disease and aspiration episodes also had a gastrobronchial fistula. The gastric interposition was defunctionalized, and a staged reconstruction with antrectomy and a Roux-en-Y diversion was completed. One patient with a prevertebral reconstruction had a Roux-en-Y diversion without antrectomy. There was no mortality and minimal morbidity. Two patients are asymptomatic and 2 are improved. Endoscopic assessment documented normal mucosa in the esophageal remnant for 2 of the 4 patients postoperatively; in 2 others, metaplastic columnar mucosa persisted. Active inflammation regressed in all 4 patients., Conclusions: Complete duodenal diversion with a 60-cm Roux-en-Y gastrojejunostomy is an effective operation to correct debilitating reflux complications after esophagectomy. Reflux symptoms are corrected and the mucosa is allowed to heal. The surgical approach is influenced by the position of the gastric transplant. Protection of the vascular supply to the gastric tube is the challenge of the operation.

Objective: Some patients with localised oesophageal cancer are treated with definitive chemoradiotherapy (CRT) rather than surgery. A subset of these patients experiences local failure, relapse or treatment-related complication without distant metastases, with no other curative treatment option but salvage oesophagectomy. The aim of this study was to assess the benefit/risk ratio of surgery in such context., Methods: Review of a single institution experience with 24 patients: 18 men and 6 women, with a mean age of 59 years (+/-9). Histology was squamous cell carcinoma in 18 cases and adenocarcinoma in 6. Initial stages were cIIA (n=5), cIIB (n=1) and cIII (n=18). CRT consisted of 2-6 sessions of the association 5-fluorouracil/cisplatin concomitantly with a 50-75 Gy radiation therapy. Salvage oesophagectomy was considered for the following reasons: relapse of the disease with conclusive (n=11) or inconclusive biopsies (n=7), intractable stenosis (n=3), and perforation or severe oesophagitis (n=3), at a mean delay of 74 days (14-240 days) following completion of CRT., Results: All patients underwent a transthoracic en-bloc oesophagectomy with 2-field lymphadenectomy. Thirty-day and 90-day mortality rates were 21% and 25%, respectively. Anastomotic leakage (p=0.05), cardiac failure (p=0.05), length of stay (p=0.03) and the number of packed red blood cells (p=0.02) were more frequent in patients who received more than 55 Gy, leading to a doubled in-hospital mortality when compared to that of patients having received lower doses. A R0 resection was achieved in 21 patients (87.5%). A complete pathological response (ypT0N0) was observed in 3 patients (12.5%). Overall and disease-free 5-year survival rates were 35% and 21%, respectively. There was no long-term survivor following R1-R2 resections. Functional results were good in more than 80% of the long-term survivors., Conclusion: Salvage surgery is a highly invasive and morbid operation after a volume dose of radiation exceeding 55 Gy. The indication must be carefully considered, with care taken to avoid incomplete resections. Given that long-term survival with a fair quality of life can be achieved, such high-risk surgery should be considered in selected patients at an experienced centre.

Objective: To evaluate the clinical relevance of preoperative airway colonisation in patients undergoing oesophagectomy for cancer after a neoadjuvant chemoradiotherapy., Methods: From 1998 to 2005, 117 patients received neoadjuvant chemoradiotherapy for advanced stage oesophageal cancer. Among them, 45 non-randomised patients underwent a bronchoscopic bronchoalveolar lavage (BAL group) prior to surgery to assess airways colonisation. The remaining patients (n=72) constituted the control group. The two groups were similar with respect to various clinical or pathological characteristics., Results: Thirteen of the 45 BAL patients (28%) had a preoperative bronchial colonisation by either potentially pathogenic micro-organisms (PPMs) (n=7, 16%) or non-potentially pathogenic micro-organisms (n=6, 13%). Cytomegalovirus (CMV) was cultured from BAL in four patients. Pre-emptive therapy was administrated in seven patients: four antiviral and three antibiotic prophylaxes. Postoperatively, 14 patients (19%) developed acute respiratory distress syndrome (ARDS) in the control group and three (7%) in the BAL group (p=0.064). The cause of ARDS was attributed to CMV pneumonia in six control group patients on the basis of the results of open lung biopsies (n=3) or BAL cultures (n=3) versus none of the BAL group patients (p=0.08). Timing for extubation was shorter in the BAL group (mean 13+/-3 h) as compared with the control group (mean 19.5+/-14 h; p=0.039). In-hospital mortality was not significantly lower in BAL group patients when compared to that of control group patients (8% vs 12.5%)., Conclusions: Airway colonisation by PPMs after neoadjuvant therapy is suggested as a possible cause of postoperative ARDS after oesophagectomy. Pre-emptive treatment of bacterial and viral (CMV) colonisation seems an effective option to prevent postoperative pneumonia.

Background: Long-term outcome of patients treated for a spontaneous esophageal rupture (Boerhaave's syndrome) is seldom reported., Methods: From 1989 to 2004, 62 esophageal perforations were treated in a single institution. Eighteen patients presented with a spontaneous esophageal rupture. Among them, 15 could be treated with a transthoracic primary repair and constituted the material of the present study. A chart review was performed with special attention to survival, residual symptoms, and anatomic and motility disorders., Results: Three patients died postoperatively (20%). At last follow-up, 10 patients were alive and 2 had died from unrelated causes. At a median delay of 13 months (3 to 74), 7 patients accepted to undergo complementary investigations. None of them had any anatomic abnormality as checked by barium swallow. Six patients complained of mild symptoms from gastroesophageal reflux. Six patients (85%) presented with esophageal motility disorders on manometry and 4 (54%) had nocturne chronic reflux disease on pH monitoring. Two patients underwent endoscopic ultrasonography, of which one presented with a focal absence of one layer of the esophageal wall within the area of the suture. With time, no patient experienced recurrence, but one developed a cancer in the cervical esophagus., Conclusions: These results suggest that esophageal functional disorders are the rule after primary repair of a Boerhaave's syndrome. Whether or not these findings are causal, coincidental, or related to the surgical treatment remains unclear. However, performance of routine postoperative explorations is strongly encouraged for a better understanding of this challenging condition.