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Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence. [ABSTRACT FROM AUTHOR]

Abstract Purpose Minimally invasive oesophagectomy is a technically demanding procedure, and the learning curve for this procedure should be explored. A survival analysis should also be performed. Methods A total of 214 consecutive patients who underwent minimally invasive oesophagectomy were retrospectively reviewed. To evaluate the development of thoracoscopic-laparoscopic oesophagectomy and compare mature minimally invasive oesophagectomy and open oesophagectomy, we comprehensively studied the clinical and surgical parameters. The cumulative sum (CUSUM) plot was used to evaluate the learning curve for systemic lymphadenectomy. Cox proportional hazards regression analysis was performed to explore the clinical factors affecting survival. Results The bleeding volume, operation time, and postoperative mortality within 3 months significantly decreased after 20 patients. The rise point for node dissection was visually determined to occur at patient 57 in the CUSUM plots. Patients who underwent mature thoracoscopic-laparoscopic oesophagectomy had better surgical data and short-term benefits than patients who underwent an open procedure. Cox proportional hazards regression analysis showed that the maximum diameter of the tumour cross-sectional area and the number of positive nodes significantly influenced survival. Conclusions The results suggest that thoracoscopic-laparoscopic oesophagectomy has short-term benefits. There was no evidence that it was associated with a significantly better prognosis for patients with oesophageal cancer. ClinicalTrials Gov ID: NCT04217239; January 2, 2020 retrospectively registered.

Purpose: Minimally invasive oesophagectomy is a technically demanding procedure, and the learning curve for this procedure should be explored. A survival analysis should also be performed.Methods: A total of 214 consecutive patients who underwent minimally invasive oesophagectomy were retrospectively reviewed. To evaluate the development of thoracoscopic-laparoscopic oesophagectomy and compare mature minimally invasive oesophagectomy and open oesophagectomy, we comprehensively studied the clinical and surgical parameters. The cumulative sum (CUSUM) plot was used to evaluate the learning curve for systemic lymphadenectomy. Cox proportional hazards regression analysis was performed to explore the clinical factors affecting survival.Results: The bleeding volume, operation time, and postoperative mortality within 3 months significantly decreased after 20 patients. The rise point for node dissection was visually determined to occur at patient 57 in the CUSUM plots. Patients who underwent mature thoracoscopic-laparoscopic oesophagectomy had better surgical data and short-term benefits than patients who underwent an open procedure. Cox proportional hazards regression analysis showed that the maximum diameter of the tumour cross-sectional area and the number of positive nodes significantly influenced survival.Conclusions: The results suggest that thoracoscopic-laparoscopic oesophagectomy has short-term benefits. There was no evidence that it was associated with a significantly better prognosis for patients with oesophageal cancer. ClinicalTrials Gov ID: NCT04217239; January 2, 2020 retrospectively registered. [ABSTRACT FROM AUTHOR]

Abstract Background Acquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital Episodes Statistics search for ADFs. Methods A prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention. Results Four patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction. Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months. Conclusions Surgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is present, within a multi-disciplinary setting.

Objective: This study aimed to develop and validate robust predictive models for patients with oesophageal cancer who achieved a pathological complete response (pCR) and those who did not (non-pCR) after neoadjuvant therapy and oesophagectomy., Design: Clinicopathological data of 6517 primary oesophageal cancer patients who underwent neoadjuvant therapy and oesophagectomy were obtained from the National Cancer Database for the training cohort. An independent cohort of 444 Chinese patients served as the validation set. Two distinct multivariable Cox models of overall survival (OS) were constructed for pCR and non-pCR patients, respectively, and were presented using web-based dynamic nomograms (graphical representation of predicted OS based on the clinical characteristics that a patient could input into the website). The calibration plot, concordance index and decision curve analysis were employed to assess calibration, discrimination and clinical usefulness of the predictive models., Results: In total, 13 and 15 variables were used to predict OS for pCR and non-pCR patients undergoing neoadjuvant therapy followed by oesophagectomy, respectively. Key predictors included demographic characteristics, pretreatment clinical stage, surgical approach, pathological information and postoperative treatments. The predictive models for pCR and non-pCR patients demonstrated good calibration and clinical utility, with acceptable discrimination that surpassed that of the current tumour, node, metastases staging system., Conclusions: The web-based dynamic nomograms for pCR (https://predict-survival.shinyapps.io/pCR-eso/) and non-pCR patients (https://predict-survival.shinyapps.io/non-pCR-eso/) developed in this study can facilitate the calculation of OS probability for individual patients undergoing neoadjuvant therapy and radical oesophagectomy, aiding clinicians and patients in making personalised treatment decisions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Swine models had been popular in paediatric oesophageal surgery in the past. Although being largely replaced by rodent models, swine experienced a revival with the establishment of minipig models. However, none of them has ever been investigated for similarity to humans. We conducted a pilot study to determine whether three-week old Pietrain piglets and three-month old Aachen Minipigs are suitable for experimental paediatric oesophageal atresia surgery. We tested the operation's feasibility, performed a necropsy, weighed organs, measured organ length and calculated relative weights and lengths, and measured laboratory parameters. We used multidimensional scaling to assess the similarity of the swine breeds with previously published human data. Pietrain piglets had a higher a priori bodyweight than Aachen Minipigs (Δ = 1.31 kg, 95% confidence interval (CI): 0.37–2.23, p = 0.015), while snout-to-tail length was similar. Pietrain piglets had higher absolute and relative oesophageal lengths (Δ = 5.43 cm, 95% CI: 2.2–8.6; p = 0.0062, q 1 * = 0.0083 and Δ = 11.4%, 95% CI: 5.1–17.6; p = 0.0025, q 3 * = 0.0053). Likewise, absolute and relative small intestinal lengths were higher in Pietrains, but all other parameters did not differ, with the exception of minor differences in laboratory parameters. Multidimensional scaling revealed three-week old Pietrain piglets to be similar to two-month old humans based on their thoracoabdominal organ weights. This result indicates three-week old Pietrain piglets are a suitable model of paediatric oesophageal atresia surgery, because clinically many procedures are performed at around eight weeks age. Three-month old Aachen Minipigs were more dissimilar to eight-week old humans than three-week old Pietrain piglets. [ABSTRACT FROM AUTHOR]

Background: 8-week old Sprague Dawley rats represent the standard rodent model of oesophageal surgery, which is challenging and might be eased by larger oesophageal lengths. Therefore, we aimed to analyse whether oesophageal length would linearly increase with bodyweight and ensure comparable experimental conditions. Methods: We analysed 41 8-week old Sprague Dawley rats of both sexes by linear regression of oesophageal length with sex as an interaction term for bodyweight. Based on exploratory investigations, analyses were powered to 80% for a deviation of the regression's slope from zero. Results: Linear regression was statistically significant with F(3,37) = 3.29, P=0.0312 with an adjusted R² of 0.15 (95% CI: 0.02-0.43). Oesophageal length could be modelled by 4.56 (95% CI: 1.45-6.69)+0.007 (95% CI:-0.002-0.019) x bodyweight in grams+6.7 (95% CI: 1.86-11.1) x sex (1=male) - 0.02 (95% CI:-0.04-(-0.005)) x bodyweight x sex. Exploration of the interaction revealed that oesophageal length increased with bodyweight for female rats, but decreased in males. Conclusions: Sex represents a major interaction for oesophageal length in an age-adjusted cohort of Sprague Dawley rats. This may have relevant implications for reproducibility of rat models of oesophageal surgery, but may be different in inbred strains. [ABSTRACT FROM AUTHOR]

Background: Acquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital Episodes Statistics search for ADFs.Methods: A prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention.Results: Four patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction. Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months.Conclusions: Surgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is present, within a multi-disciplinary setting. [ABSTRACT FROM AUTHOR]

Maksymilian Rutkowski (1867–1947) was a distinguished graduate of the Jagiellonian University and a pioneer in the early days of surgery in interwar Poland. He was a long-standing leader in both clinical and academic surgery. In addition, he played an important role in the founding of the School for Nurses and Healthcare Workers in Cracow supported by the Rockefeller Foundation. Among his best known surgical techniques, one may list the novel procedure of bladder exstrophy, new techniques of gastroenterostomy and plastic restoration of the oesophagus. Although Rutkowski’s reputation as a medical figure is well established within Polish medical history, his achievements are hardly recognized by international scholars. Thus, in the absence of adequate historical information on this eminent surgeon, we have researched the main facts about his life and seminal contribution to Polish and international surgery. [ABSTRACT FROM AUTHOR]

Introduction The optimal time between end of neoadjuvant chemoradiotherapy (nCRT) and oesophagectomy is unknown. The aim of this study was to assess the association between this interval and pathologic complete response rate (pCR), morbidity and 30-day/in-hospital mortality. Methods Patients with oesophageal cancer treated with nCRT and surgery between 2011 and 2016 were selected from a national database: the Dutch Upper Gastrointestinal Cancer Audit (DUCA). The interval between end of nCRT and surgery was divided into six periods: 0–5 weeks (n = 157 ;A), 6–7 weeks (n = 878 ;B), 8–9 weeks (n = 972 ;C), 10–12 weeks (n = 720 ;D), 13–14 weeks (n = 195 ;E) and 15 or more weeks (n = 180 ;F). The association between these interval groups and outcomes was investigated using univariable and multivariable analysis with group C (8–9 weeks) as reference. Results In total, 3102 patients were included. The pCR rate for the groups A to F was 31%, 28%, 26%, 31%, 40% and 37%, respectively. A longer interval was associated with a higher probability of pCR (≥10 weeks for adenocarcinoma: odds ratio [95% confidence interval]: 1.35 [1.00–1.83], 1.95 [1.24–3.07], 1.64 [0.99–2.71] and ≥13 weeks for squamous cell carcinoma: 2.86 [1.23–6.65], 2.67 [1.29–5.55]. Patients operated ≥10 weeks after nCRT had the same probability for intraoperative/postoperative complications. Patients from groups D and F had a higher 30-day/in-hospital mortality (1.80 [1.08–3.00], 3.19 [1.66–6.14]). Conclusion An interval of ≥10 weeks for adenocarcinoma and ≥13 weeks for squamous cell carcinoma between nCRT and oesophagectomy was associated with a higher probability of having a pCR. Longer intervals were not associated with intraoperative/postoperative complications. The 30-day/in-hospital mortality was higher in patients with extended intervals (10–12 and ≥15 weeks); however, this might have been due to residual confounding. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The standard of care for achalasia remains laparoscopic Heller myotomy with partial fundoplication. Peroral endoscopic myotomy (POEM) has been introduced as an alternative, but safety and long-term comparative efficacy are not yet established. We report our experience in developing a POEM program using a novel hybrid approach. METHODS: We developed a hybrid approach to POEM with a POEM followed by laparoscopic evaluation, extension of the myotomy, if necessary, and partial fundoplication. We reviewed the results of the programme from April 2012 until May 2015. Starting in 2014, we began offering patients stand-alone POEM. Patient data were collected. Preoperative and postoperative Eckardt scores were compared. RESULTS: A total of 28 patients underwent POEM or POEM plus laparoscopic evaluation with partial fundoplication. Patient characteristics and perioperative and postoperative data were recorded. The median preoperative Eckardt score was 6 (range 4-11). The mean follow-up period was 136 days (range 41-330) and the median postoperative Eckardt score was 0 (range 0-6) at 6 weeks. Of our initial 10 patients, 6 required laparoscopic extension of the myotomy; 7 subsequent patients did not require an additional myotomy. Three patients who underwent POEM without laparoscopy continued to have dysphagia postoperatively. One patient had an attempted POEM that was aborted secondary to bleeding, and a standard laparoscopic modified Heller myotomy with partial fundoplication was performed. CONCLUSIONS: The excellent results of laparoscopic myotomy with partial fundoplication are challenging to duplicate during the initial adoption of a POEM approach. We present a program developed to steepen the learning curve and enhance patient safety while implementing this new procedure. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Evaluation of complex, acquired, non-malignant tracheo/broncho-oesophageal fistulas (TEF) repaired by extrathoracic pedicled muscle flaps that were, in addition to their interposition between the airways and the gastro-intestinal tract, patched into gastrointestinal or airway defects if primary closure seemed risky. METHODS: A single institution experience of patients treated between 2003 and 2015. Twenty-two patients required TEF repair following oesophageal surgery (18), Boerhaave syndrome (1), chemotherapy for mediastinal lymphoma (1), carinal resection and irradiation (1) and laryngectomy (1); 64% of them underwent prior radio- or chemotherapy and 50% prior airway or oesophageal stenting. RESULTS: Airway defects were closed by muscle flap patch (n = 12), lobectomy (n = 4), airway resection/anastomosis (n = 2), pneumonectomy (n = 1), segmentectomy (n = 2) or primary suture (n = 1). Gastro-intestinal defects were repaired by oesophageal diversion (n = 9), muscle flap patch (n = 8) or primary suture (n = 5). A muscle flap patch was used to close airway and gastro-intestinal defects in 55% and 36% of cases, respectively. The 90-day postoperative mortality and TEF recurrence rates were 18% and 4.5%. Airway healing and breathing without tracheal appliance was obtained in 95% of patients and gastro-intestinal healing in 77% of those without oesophageal diversion. Five of nine patients with oesophageal diversion underwent intestinal restoration by retrosternal colon transplants. CONCLUSIONS: Complex TEF arising after oesophageal surgery, radio-chemotherapy or failed stenting can be successfully closed using extrathoracic muscle flaps that can, in addition to their interposition between the airway and the gastro-intestinal tract, also be patched into gastro-oesophageal or airway defects if primary closure seems hazardous. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery programmes improve outcomes in surgery, but their implementation after upper gastrointestinal resection has been limited. The aim of this study was to compare short-term outcomes for patients undergoing oesophagogastric surgery in an enhanced recovery programme (EROS).Methods: EROS was developed after a multidisciplinary meeting by multiple rounds of revision. EROS was applied to all patients undergoing major upper GI resection at a university teaching hospital in the UK from 20/9/13, with data reviewed at 18/09/15. EROS was assessed to identify predictors for compliance.Results: One hundred six patients underwent major upper GI resection including 81 oesophagectomies, 24 gastrectomies and 1 colonic interposition graft. Major complications (Clavien Dindo ≥3) occurred in 12 patients with 1 in-hospital death. Thirty-five patients (44%) were discharged on target day 8 of the EROS programme. Age and complications were independently associated with missing this discharge target.Conclusion: Enhanced recovery is feasible and safe after major upper gastrointestinal surgery. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study is to analyse the effect of delayed diagnosis on mortality rates, and evaluate the role of delayed diagnosis as a new prognostic factor in patients with oesophageal atresia (OA), especially in developing countries.Methods: The records of 80 consecutive patients with OA (2008-2013) were reviewed. Patients were divided into two groups according to the time of diagnosis. As we demonstrated the effect of delayed diagnosis on mortality, we decided to develop a new classification that will be utilised to predict the prognosis of OA. The discrimination ability of the new prognostic classification was compared with those of the Waterston, Montreal and Spitz classifications using the area under the curve.Results: The parameters of the new prognostic classification were birth weight less than 2000 g, the presence of major cardiac/life-threatening anomalies and delay in diagnosis. Class I consisted of patients with none or one of these parameters. Class II consisted of patients with two or three of these parameters. The area under the curve of the new classification was better than those of the other classifications in determining the prognosis of patients with OA.Conclusions: Delayed diagnosis of OA significantly led to morbidity and mortality. Although delayed diagnosis is not a characteristic of newborn or a marker of severity for OA and is a health care system issue in developing countries, we here point out that it is a prognostic factor in its own right. Our new classification has a superior discriminatory ability compared to the above-mentioned classifications. [ABSTRACT FROM AUTHOR]

Background: Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy.Materials and Methods: This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture.Results: Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041).Conclusions: Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer. [ABSTRACT FROM AUTHOR]

Pulmonary complications are frequently observed after transthoracic oesophagectomy. These complications may be reduced by sparing the vagus nerve branches to the lung. However, current descriptions of the regional anatomy are insufficient. Therefore, we aimed to provide a highly detailed description of the course of the pulmonary vagus nerve branches. In six fixed adult human cadavers, bilateral microscopic dissection of the vagus nerve branches to the lungs was performed. The level of branching and the number, calibre and distribution of nerve branches were described. Nerve fibres were identified using neurofilament immunohistochemistry, and the nerve calibre was measured using computerized image analysis. Both lungs were supplied by a predominant posterior and a smaller anterior nerve plexus. The right lung was supplied by 13 (10-18) posterior and 3 (2-3) anterior branches containing 77% (62-100%) and 23% (0-38%) of the lung nerve supply, respectively. The left lung was supplied by a median of 12 (8-13) posterior and 3 (2-4) anterior branches containing 74% (60-84%) and 26% (16-40%) of the left lung nerve supply, respectively. During transthoracic oesophagectomy with en bloc lymphadenectomy and transection of the vagus nerves at the level of the azygos vein, 68-100% of the right lung nerve supply and 86-100% of the inferior left lung lobe nerve supply were severed. When vagotomy was performed distally to the last large pulmonary branch, 0-8% and 0-13% of the nerve branches to the right middle/inferior lobes and left inferior lobe, respectively, were lost. In conclusion, this study provides a detailed description of the extensive pulmonary nerve supply provided by the vagus nerves. During oesophagectomy, extensive mediastinal lymphadenectomy denervates the lung to a great extent; however, this can be prevented by performing the vagotomy distal to the caudalmost large pulmonary branch. Further research is required to determine the feasibility of sparing the pulmonary vagus nerve branches without compromising the completeness of lymphadenectomy. [ABSTRACT FROM AUTHOR]

Thoracic anastomotic leak is associated with significant postoperative morbidity and mortality. Routine contrast oesophagograms are consequently employed by a number of centres to routinely screen for this complication yet there exists little consensus as to if and when this assessment should occur. We have demonstrated within this BestBET analysis of five level IV case series that routine contrast oesophagograms lack adequate sensitivity or positive predictive value to be effective as screening tools, with leaks often arising clinically prior to scheduled routine assessment. We additionally demonstrate the significant risk of aspiration associated with contrast swallow use. The use of contrast swallow studies as diagnostic tools in patients for whom a leak is considered likely on the basis of clinical examination is nevertheless supported by relatively greater negative predictive values and specificity reported within the literature. There is additional evidence to support the use of CT imaging with oral contrast and endoscopic assessment of the anastomosis as valuable tools to assess for anastomotic integrity. [ABSTRACT FROM AUTHOR]

OBJECTIVES The minimally invasive oesophagectomy (MIO) approach offers a number of advantages over open approaches including reduced discomfort, shorter length of stay and a faster recovery to baseline status. On the other hand, minimally invasive procedures typically are longer and consume greater disposable instrumentation, potentially resulting in a greater overall cost. The objective of this study was to compare costs associated with various oesophagectomy approaches for oesophageal cancer. METHODS An institutional Resource Information Management System (RIMS) was queried for cost data relating to hospital expenditures (as opposed to billings or collections). The RIMS was searched for patients undergoing oesophagectomy for oesophageal cancer between 2003 and 2012 via minimally invasive, open transthoracic (OTT) (including Ivor Lewis, modified McKeown or thoracoabdominal) or transhiatal approaches. Patients that were converted from minimally invasive to open, or involved hybrid procedures, were excluded. RESULTS A total of 160 oesophagectomies were identified, including 61 minimally invasive, 35 open transthoracic and 64 transhiatal. Costs on the day of surgery averaged higher in the MIO group ($12 476 ± 2190) compared with the open groups, OTT ($8202 ± 2512, P < 0.0001) or OTH ($5809 ± 2575, P < 0.0001). The median costs associated with the entire hospitalization also appear to be higher in the MIO group ($25 935) compared with OTT ($24 440) and OTH ($15 248). The average length of stay was lowest in the MIO group (11 ± 9 days) compared with OTT (19 ± 18 days, P = 0.006) and OTH (18 ± 28 days P = 0.07). The operative mortality was similar in the three groups (MIO = 3%, OTT = 9% and OTH = 3%). CONCLUSIONS The operating theatre costs associated with minimally invasive oesophagectomy are significantly higher than OTT or OTH approaches. Unfortunately, a shorter hospital stay after MIO does not consistently offset higher surgical expense, as total hospital costs trend higher in the MIO patients. In an increasingly strained health care economy, efforts to reduce costs associated with the minimally invasive approach should address the inpatient hospitalization as well as operating theatre expenses. [ABSTRACT FROM AUTHOR]

OBJECTIVES Free jejunal transfer (FJT) has been preferentially used for pharyngo-oesophageal reconstruction. The success of FJT typically depends on the security of the vascular anastomoses. Arterial anastomosis is usually performed in an end-to-end fashion, with the exception of cases lacking an adequate donor artery due to radiation therapy or infection. At our institution, end-to-side arterial anastomosis to the common carotid artery has been successfully used in FJT for both primary and secondary cervical pharyngo-oesophageal reconstruction. METHODS From 1995 to 2010, 41 FJTs were performed by end-to-side arterial anastomosis in 39 patients. Medical records and the follow-up data were retrospectively reviewed. RESULTS Thirty-one patients underwent FJT for cancer, 7 for corrosive injury, and 1 for perforation by a foreign body. The graft survival rate was 90.2% (37of 41). The jejunal mesenteric artery was anastomosed in an end-to-side manner to the common carotid artery in 39 cases, and to the innominate artery in 2. The mesenteric vein was likewise anastomosed in an end-to-side manner to the internal jugular vein in 36 cases and to the innominate vein in 2. In 3 cases, the mesenteric vein was anastomosed to the external jugular vein in an end-to-end manner. Graft failure occurred in 4 patients due to venous thrombosis (3 cases) or arterial rupture due to uncontrolled infection (1 case). Two of these patients underwent redo FJT, while the remaining two underwent gastric pull-up surgery after removal of the graft. CONCLUSIONS FJT is a good option for primary or secondary reconstruction of pharyngo-oesophageal defects. End-to-side arterial anastomoses in FJT can be successfully performed without sacrificing the recipient artery. [ABSTRACT FROM AUTHOR]

OBJECTIVES Gastric tube necrosis is a major cause of mortality after oesophagectomy. The construction of the gastric tube used for oesophageal reconstruction involves a division of several arteries leading to a reduction in the blood supply at the fundus, which is used for the oesophageal anastomosis. This study was undertaken to determine the effect of thoracic epidural anaesthesia and intravenous phenylephrine on haemodynamics and blood flow in the tubularized stomach. METHODS Ten patients undergoing an oesophagectomy were prospectively studied. Pulmonary artery catheters were used to measure haemodynamic changes, and laser Doppler flow probes were used to measure gastric blood flow. The effects of an intraoperative thoracic epidural and subsequent intravenous phenylephrine infusion were documented. RESULTS The administration of a thoracic epidural bolus of bupivacaine 0.25% at 0.1 ml kg resulted in a significant reduction in flux at the anastomotic end of the newly formed gastric tube from a median of 57–41 perfusion units (P = 0.003). A subsequent intravenous phenylephrine infusion titrated to restore mean arterial pressure significantly increased the flux at the anastomotic end from a median of 41–66 perfusion units (P = 0.009). CONCLUSIONS An intravenous phenylephrine infusion can reverse the epidural bolus-induced reduction in blood flow at the anastomotic end of the newly formed gastric tube. [ABSTRACT FROM PUBLISHER]

OBJECTIVES The objective of this study was to clarify the factors influencing pleural drainage volume after transthoracic oesophagectomy and to determine criteria for the selection of patients who would benefit from the early removal of chest drains. METHODS Clinicopathological characteristics of 155 patients who underwent transthoracic oesophagectomy were prospectively collected, and the daily drainage volume of each patient was retrospectively reviewed. Potential risk factors were compared between the high-output group (n = 39) and low-output group (n = 116), which were dichotomized using the 75th percentile of total pleural drainage volume of the total study population. Multivariate logistic regression analyses were used to identify independent risk factors. RESULTS The median duration of drainage was 10 days, with a median total drainage volume of 2258 ml. Of 27 potential risk factors influencing the drainage volume, creatinine clearance (P = 0.04), operative approach (P = 0.03) and thoracic duct removal (P = 0.01) were significantly associated with the total pleural drainage volume. The removal of the thoracic duct (P = 0.02; odds ratio, 4.02; 95% confidence interval 1.20–13.41) and lower creatinine clearance (P = 0.04; odds ratio, 1.02; 95% confidence interval 1.00–1.04) was independent risk factors for increased pleural drainage volume after transthoracic oesophagectomy. CONCLUSIONS The early removal of chest drains may be possible in patients without these risk factors. [ABSTRACT FROM PUBLISHER]

Introduction: Several studies have proven an ameliorated prognosis after a neoadjuvant therapy for locally advanced Barrett's carcinoma in case of response. The necessary amount of neoadjuvant chemotherapy within a multimodal therapy concept with following oesophageal resection has never been evaluated so far.Methods: The clinical course of 122 patients with Barrett's carcinoma, who all underwent a neoadjuvant chemotherapy with cisplatin, five fluorouracil and leucovorin and following oesophagectomy, was reviewed. The pretherapeutic clinical and postoperative histopathological staging, histopathological response, clinical course, recurrence rates and long-term survival were retrospectively analysed and compared to the data of 30 patients, who were included in the same multimodal therapy concept, but who had to cease the chemotherapy early because of toxicity.Results: Postoperative pathological staging showed that the response rate correlates with the N and R status. The responding patients benefit from longer survival. Comparing the two subgroups, we could not find a significant difference in response rate, tumour staging, resection rate, long-term survival or pattern of recurrent disease. However, postoperative morbidity and mortality did not correlate with severe chemotherapy-induced toxicity.Conclusions: This is the first study on the necessary number of chemotherapy cycles in terms of a neoadjuvant therapy for Barrett's carcinoma. We could show a similar downstaging effect, a good histopathological response and a comparable ameliorated long-term survival of patients with one compared to patients with three chemotherapy cycles. A biological selection seems to determine the course of the disease already at this early stage. [ABSTRACT FROM AUTHOR]

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]

Abstract: Objective: Underwater seal drainage of the pleural cavity has been standard practice after transthoracic oesophagectomy. However these chest tubes cause pain and hamper mobility, thereby causing significant morbidity and delaying recovery. We postulated that if complete lung expansion and optimum pulmonary function could be achieved and maintained following a transthoracic oesophagectomy using simple gravity aided transabdominal tube drainage of the pleural cavity, then these may be a simpler alternative to the conventional underwater seal chest drains. Methods: A total of 50 patients had transthoracic oesophagectomy for oesophageal cancer. Of the cohort, 44 patients were fitted with the transabdominal drain described and hence had ‘modified pleural drainage’ following the oesophagectomy. All patients had a posterior mediastinal drain placed in either the right or the left pleural cavity during the oesophagectomy. The tube drain was inserted into the pleural cavity from the abdomen and placed into the desired position across the diaphragmatic hiatus. The drain was managed in the conventional manner and patients were monitored postoperatively for any developing pleural collections through serial chest X-rays. Respiratory function was closely monitored. Results: The drains were removed without any significant respiratory complications by the 8th postoperative day in 86% of the patients. Only three patients (7%) developed clinically significant recurrent pleural effusions, causing respiratory compromise meriting further drainage. This was easily and safely managed using fine bore pigtail drains inserted under ultrasound guidance. Conclusion: Transabdominal gravity aided tube drainage of the mediastinum and the pleural cavity is an effective and safe means of draining the chest, following uncomplicated transthoracic oesophagectomy. [Copyright &y& Elsevier]

Abstract: Objective: Heller myotomy results for the treatment of sigmoid achalasia are worse than those achieved for fusiform achalasia. We retrospectively examined two groups of sigmoid achalasia patients, in which we performed (1) the standard Heller–Dor procedure (no pull-down) and (2) the Heller–Dor plus a technique apt to obtain the verticality of the oesophageal axis (pull-down). We verified whether the latter technique improved long-term results. Materials and methods: We considered 33 patients affected by primitive oesophageal sigmoid achalasia operated upon consecutively (1979–2005). Diagnosis was based on symptoms, manometry, radiology and endoscopy. After 1987, we routinely isolated 360° of the gastro-oesophageal junction and the lower oesophagus and applied U stitches at the right side of the lower oesophagus to pull down and rotate the gastro-oesophageal junction toward the right. Fifteen patients underwent the no pull-down and 18 patients underwent the pull-down technique. Postoperative follow-up included objective clinical and instrumental evaluation (questionnaire filled by a surgeon including the assessment of symptoms and endoscopic reflux oesophagitis according to a semi-quantitative scale) and subjective evaluation (self-evaluation SF-36 questionnaire). Results: The mean follow-up period was 89 months (range 12–261 months). The postoperative dysphagia score was significantly improved in the entire group. Excellent results were present in 12 patients (36.4%), good in 11 (33.3%), fair in 3 (9.1%) and insufficient in 7 patients (21.2%). No statistically significant differences were observed between the two groups with regard to the postoperative symptoms and oesophagitis. Postoperative radiological measurements of oesophageal diameter and residual barium column were significantly improved in the whole group and within each group with respect to the radiological variables measured preoperatively (p =0.000). In the comparison of the two groups, statistically significant differences were observed with regard to mean oesophageal diameter (p =0.030) (pull-down, 4±0.9cm; no pull-down, 4.7±0.6cm) and residual barium column (p =0.048) (pull-down, 6.2±3.4cm; no pull-down, 9.6±5.8cm). Conclusions: The Heller–Dor operation is effective in the presence of sigmoid achalasia. The clinical objective and subjective evaluations show a trend toward the improvement of results with the pull-down technique. Stronger statistical significance would probably be obtained from a larger case series. [Copyright &y& Elsevier]

Abstract: Objective: There are limited and conflicting data available concerning the incidence of inadvertent splenectomy and its impact on the outcome in patients who have undergone oesophagectomy. The aim of this study is to identify the factors associated with a likelihood of inadvertent splenectomy and its influence on early and long-term outcome in patients having oesophagectomy for oesophageal carcinoma. Methods: A consecutive series of 738 oesophagectomies performed between 1991 and 2004 was analysed. In our practice, the spleen was removed only if damaged intraoperatively. Routine chemo- and immunoprophylaxis would subsequently be used. Multivariate analysis with logistic and Cox models determined significant variables. Results: Of the 738 oesophagectomies, 48 (6.5%) had splenectomy. Neoadjuvant chemotherapy was administered to a minority of patients; none subsequently had splenectomy. There were significant differences between types of operation (Ivor–Lewis 18 (9.0%), left thoracolaparotomy 14 (9.9%) and left thoracophrenotomy 15 (3.9%), p =0.01). Splenectomy was more common with advanced N stage disease (OR=0.44 [0.20–0.95]; p =0.04). Splenectomy resulted in more blood transfusions (median, 2 units vs 0 units; p =0.03) more anastomotic leaks (7 [14.6%] vs 42 [6.1%]; p =0.02) but not an increase in pulmonary complications (p =0.64) or in-hospital mortality (1 [4.6%] vs 37 [5.4%]; p =0.30). Splenectomy did not significantly affect median survival (551 [332–770] days vs 627 [554–700] days; p =0.63). Conclusion: Although inadvertent splenectomy increased the morbidity of oesophagectomy, it did not impair survival. Type of operation and advanced N stage are important risks for splenectomy. Though best avoided, most of the consequences of splenectomy can be managed. An unexpected relationship between splenectomy and anastomotic leaks needs further investigation. [Copyright &y& Elsevier]

In this review we discuss the different strategies to improve surgical outcomes after potentially curative resection for oesophageal adenocarcinoma. For tumours of the distal oesophagus, there is a 17% survival benefit after transthoracic resection with two-field lymph node dissection when compared with transhiatal resection. This survival benefit is absent for tumours of the gastro-oesophageal junction or gastric cardia. These patients should, in the absence of tumour-positive lymph nodes at or proximal to the carina, undergo a transhiatal resection to minimise peri-operative complications. New developments include endoscopic resection or minimally invasive oesophagectomy, but these therapies should still be considered experimental. Copyright © 2005 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Abstract: Objective: To determine the optimum management of anastomotic leaks after oesophagectomy. Methods: We undertook a retrospective review of 23 patients who developed anastomotic leakage, out of 389 patients undergoing oesophagectomy with gastric interposition. The presentation, diagnosis, and treatment of the leaks, and patient outcomes are analysed. Results: Leaks occurred from 3 to 23 (median=7.5) days after surgery. Clinical features included fever (57%), leucocytosis (52%), dysphagia (4%), coughing bile (4%), wound infection (13%), pneumothorax (35%), pleural effusion (70%) and septicaemia (70%). All but one leak was due to variable degree of gastric tip necrosis. Contrast swallow showed leakage in only 14 (61%) patients, whereas oesophagoscopy confirmed all the leaks. Surgical treatment (resection of necrotic stomach and either immediate or staged re-anastomosis, or end-oesophageal exteriorisation) was the primary treatment in 17 patients of whom 15 survived to discharge. Two out of the 6 patients treated non-surgically died. Conclusions: Diagnosis of anastomotic leakage after oesophagectomy is difficult due to its variable presentation and the unreliability of contrast swallow. Gastric tip necrosis is by far the most common cause. We feel our preferred strategy of immediate surgical treatment of symptomatic leaks is justified by the favourable outcome in the majority of patients. [Copyright &y& Elsevier]

Objective: Although several studies have examined early outcome following redo antireflux surgery, there is little data on the long-term efficacy of these procedures. We reviewed our experience of these operations in order to assess the long-term results which can be achieved by choosing redo antireflux procedures based on the results obtained from pre-operative oesophageal function testing. Methods: The case notes of 26 patients who underwent a repeat antireflux procedure between 1981 and 2000 were reviewed. Clinical history, examination, endoscopy, pH studies, oesophageal manometry and video barium contrast studies were performed on all patients prior to re-operation. In all cases, a standardised pre-formulated algorithm, based on the results of the pre-operative oesophageal function tests, was used to determine the choice of surgical procedure. Post-operatively, patients were classified into three groups: Group A (those with no symptoms), Group B (symptoms controlled by medication) and Group C (symptoms refractory to medical treatment). Patients in Groups B and C underwent repeat oesophageal function studies. Results: In all cases, the indication for re-operation was gastro-oesophageal reflux symptoms refractory to medical treatment. Twenty-one patients (81%) underwent a left thoracotomy, of whom 11 patients (42%) underwent a gastroplasty. The mean follow-up period was 8.27 years (range 1.5–19.8 years), after which 14 patients (54%) were classified as Group A; 10 patients (38%) as Group B; and 2 patients (8%) as Group C. Within Groups B and C, manometry showed that re-operation had increased basal lower oesophageal sphincter pressure (4.6 vs 12.7mmHg, pre- vs post-operative P=0.03), and in all, but one case pH studies showed no evidence of recurrent acid reflux. Conclusions: Redo antireflux surgery can provide complete symptomatic relief in approximately 50% of patients and symptomatic improvement over 90% of patients. We advocate a tailored approach in the selection of re-operative procedures based on the results of pre-operative oesophageal function testing. [Copyright &y& Elsevier]

Objectives: Recurrent laryngeal nerve lymph node dissection (LND) has been incorporated into oesophagectomy for patients with oesophageal squamous cell carcinoma, but with uncertain oncological efficacy., Methods: The data of patients with oesophageal squamous cell carcinoma, including who underwent upfront surgery (surgery group) and those who received neoadjuvant therapy followed by surgery (neoadjuvant chemoradiotherapy group), were retrospectively examined. The overall survival (OS) and disease-free survival (DFS) were compared between patients with and without recurrent laryngeal nerve LND., Results: Among the 312 patients, no significant differences were found in 3-year OS and DFS between patients with and without recurrent laryngeal nerve LND in the entire cohort (OS: 57% vs 52%, P = 0.33; DFS: 47% vs 41%, P = 0.186), or the surgery group (n = 173, OS: 69% vs 58%, P = 0.43; DFS: 52% vs. 48%, P = 0.30) and the neoadjuvant chemoradiotherapy group (n = 139, OS: 44% vs 43%, P = 0.44; DFS: 39% vs 32%, P = 0.27). However, among patients with clinical positive recurrent laryngeal nerve lymph node involvement before treatment, there was significant OS and DFS differences between patients with and without recurrent laryngeal nerve LND (OS: 62% vs 33%, P = 0.029; DFS: 49% vs 26%, P = 0.031)., Conclusions: Recurrent laryngeal nerve LND is not a significant prognostic factor in patients with oesophageal squamous cell carcinoma; however, it is associated with better outcomes in patients with pre-treatment radiological evidence of recurrent laryngeal nerve lymph node involvement., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy., Methods: This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs)., Results: A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables., Conclusion: Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery., (© 2021 Wiley Periodicals LLC.)