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Optimal treatment for resectable esophageal squamous cell carcinoma (ESCC) is controversial, especially in the context of potential benefit of combining PD-1 blockade with neoadjuvant therapy. This phase 2 study aimed to assess neoadjuvant camrelizumab plus chemotherapy in this population. Patients (clinical stage II-IVA) received two cycles of neoadjuvant chemoimmunotherapy (NIC) with camrelizumab (200 mg on day 1) plus nab-paclitaxel (260 mg/m2 in total on day 1 and day 8) and cisplatin (75 mg/m2 in total on days 1-3) of each 21-day cycle. Surgery was performed approximately 6 weeks after completion of NIC. Primary endpoint was complete pathologic response (CPR) rate in primary tumor. Secondary endpoints were objective response rate (ORR) per RECIST v1.1, 2-year progression-free survival (PFS) rate after surgery, PFS, overall survival (OS) and safety during NIC and perioperative period. Between 17 January 2020 and 8 December 2020, 56 patients were enrolled, and 51 received esophagectomy. Data cutoff date was 25 August 2021. The CPR rate was 35.3% (95% CI, 21.7%-48.9%). NIC had an ORR of 66.7% (95% CI, 40.0%-70.4%) and treatment-related adverse events (TRAEs) of low severity (grade 1-2, 75.0%; grade 3, 10.7%; grade 4-5, no). No perioperative mortality occurred. Three (5.9%) patients had tumor recurrence and one (2.0%) patient died. The 2-year PFS rate, median PFS and median OS had not been reached yet. Camrelizumab plus neoadjuvant chemotherapy in resectable ESCC demonstrates promising efficacy with acceptable toxicity, providing a feasible and effective option. Study is ongoing for long-term survival analyses. ispartof: INTERNATIONAL JOURNAL OF CANCER vol:151 issue:1 pages:128-137 ispartof: location:United States status: published

ispartof: JOURNAL OF THORACIC DISEASE vol:15 issue:1 pages:204-213 ispartof: location:China status: published

BACKGROUND Tumor response and lymph node involvement are the most important prognosticators in resected patients with esophageal adenocarcinoma after neoadjuvant chemoradiation (nCRT). We hypothesise that lymph node response (LNR) is also a valuable prognosticator in these patients, potentially revealing the added effect of nCRT. METHODS Hematoxylin-eosin slides of 193 esophageal adenocarcinoma patients with clinical suspicion of lymph node involvement (cN+) and treated with nCRT between 2008 and 2015 were assessed. Lymph nodes containing viable tumor cells were considered ypN+ and those negative for viable tumor were ypN0. LNR was also described according to an earlier defined method. Three groups were obtained: ypN0/LNR-, ypN0/LNR+ and ypN+. They were compared to 188 cN+ patients being pN0 (n=45) or pN+ (n=143) after upfront esophageal resection. RESULTS 44 patients were ypN0/LNR-, 55 ypN0/LNR+ and 94 ypN+. Median overall survival was respectively 96.4, 31.2 and 20.6 months and was significantly different between ypN0/LNR- and ypN0/LNR+ groups (p=0.020). Survival was comparable between ypN0/LNR- and pN0 (104.2 months) groups (p=0.519) and between ypN+ and pN+ (21,6 months) groups (p=0,966). In ypN0 patients, risk of death in LNR+ patients was tripled compared to LNR- patients. CONCLUSIONS In cN+ esophageal adenocarcinoma patients treated with nCRT with postoperative final pathology being ypN0, median overall survival is tripled when no signs of LNR were found and comparable to cN+/pN0 upfront esophagectomy patients, suggesting that 23% of patients treated with nCRT were in fact true N0 and overtreated by nCRT. ypN+ patients have no survival benefit compared to pN+ patients. ispartof: The Annals of Thoracic Surgery vol:112 issue:6 pages:1-28 ispartof: location:Netherlands status: Published online

The technique for bronchial stump suturing following lung resection which is currently applied in the Department of Thoracic Surgery at the University Hospitals Leuven, Belgium owes its name to the Dutch surgeon Dr. Klinkenbergh (1891-1985). A true pioneer of cardiothoracic surgery in Europe, Dr. Klinkenbergh dedicated himself to the surgical treatment of pulmonary tuberculosis. His work was praised by his peers for his precision and the reasoning behind every gesture. The Klinkenbergh technique consists in performing two running sutures which cross each other 'in the same manner as the laces of a shoe' to close the bronchus, limiting the occurrence of broncho-pleural fistulas. In our experience with more than 100 patients in the last 5 years (2016-2020) who underwent open pneumonectomy for benign or malignant disease, less than 2% developed post-operative broncho-pleural fistulas. ispartof: ACTA CHIRURGICA BELGICA vol:121 issue:6 pages:449-454 ispartof: location:England status: published

Summary This study aimed to investigate the survival impact of the number of lymph nodes dissection (LND) in patients receiving neoadjuvant chemotherapy (NCT) for esophageal squamous cell carcinoma (ESCC). We retrospectively analyzed the clinical pathological data and survival of 407 ESCC patients who underwent esophagectomy after NCT between January 2015 and December 2016. The relationship between the number of LNDs and 5-year overall survival (OS) or disease-free survival (DFS) was plotted by using restricted cubic spline analysis. A Cox proportional hazards regression model was used to identify prognostic factors of OS and DFS. We observed an obvious non-linear relationship between LND and the hazard ratios (HRs) for OS (P = 0.0015) and DFS (P

BACKGROUND: The reporting of surgical techniques is of mixed quality, with most at a very minimal level. Reporting guidelines that could be applied to guide surgical technique reporting vary in methodology for development, discipline coverage, dimension coverage and detail requested. However, a scoping review that could indicate the gaps and efforts needed in surgical technique reporting guidelines is lacking and warranted. This study aims to design a methodological rigour protocol to guide the development of a scoping review of surgical technique reporting guidelines. METHODS: This protocol is designed following the 2020 manual proposed by the Joanna Briggs Institute. To further ensure the soundness of the protocol, we also included multidisciplinary professionals (including methodologists, clinicians, and journal editors) to refine the protocol. DISCUSSION: Seven key steps for developing the scoping review are identified and presented in detail, including (I) identifying the research questions; (II) inclusion criteria; (III) search strategy; (IV) source of evidence selection; (V) data extraction; (VI) analysis of the evidence; and (VII) presentation of the results. Guided by this protocol, the subsequent scoping review will inform us the overview of surgical technique reporting guidelines and precisely guide our direction and next steps in improving surgical technique reporting guidelines. TRIAL REGISTRATION: This protocol is not registered as the PROSPERO database only accepts registration of systematic review protocols while does not accept registration of scoping review protocols. ispartof: GLAND SURGERY vol:10 issue:7 pages:2325-2333 ispartof: location:China (Republic : 1949- ) status: published

Robotic-assisted lobectomy (RAL) is increasingly employed as an alternative to video-assisted lobectomy (VAL) for resectable non-small-cell lung cancer (NSCLC). However, there is little evidence for any difference in the postoperative health-related quality of life (HRQoL) between these two approaches.Is robotic-assisted lobectomy (RAL) superior to video-assisted lobectomy (VAL) in improving quality of life in patients with resectable non-small-cell lung cancer (NSCLC)?We performed a single-center, open-label randomized clinical trial from May 2017 to May 2020 with 320 patients undergoing RAL or VAL for resectable NSCLC enrolled (RVlob trial, NCT03134534). Postoperative pain was evaluated with the visual analogue score (VAS) or numeric rating score (NRS) on postoperative day 1 and at weeks 4, 24, and 48. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30), EORTC Quality of Life Questionnaire in Lung Cancer (QLQ-LC13), and the European Quality of Life 5 Dimensions (EQ-5D) questionnaire were also administered at weeks 4, 24 and 48 after surgery.157 patients underwent RAL and 163 had VAL. The mean pain score of patients after RAL was statistically lower at week 4 (2.097 ± 0.111 vs 2.431 ± 0.108, p=0.032). QLQ-C30 and QLQ-LC13 summary scores (p0.05) were similar for both RAL and VAL during the first 48 weeks of follow-up. HRQoL score assessed with the EQ-5D questionnaire was also comparable between the two groups (p＞0.05) during the whole study period.Both RAL and VAL showed satisfactory and comparable HRQoL and postoperative pain up to 48 weeks after surgery, despite some minor statistical differences at week 4.NCT03134534 (http://www.gov).

Background To investigate the safety and activity of preoperative pembrolizumab combined with chemoradiotherapy for resectable oesophageal squamous cell carcinoma (ESCC) ( ClinicalTrials.gov number, NCT03792347). Methods Twenty resectable ESCC patients, regardless of programmed death ligand-1 status, received preoperative pembrolizumab with concurrent chemoradiotherapy (PPCT). Preoperative therapy includes carboplatin (area under the curve of 2 mg per milliliter per minute, once a week for 5 weeks), paclitaxel (50 mg/m2, once a week for 5 weeks), radiotherapy (23 fractions of 1.8 Gy, 5 fraction a week) and pembrolizumab (2 mg/kg) on days 1 and 22. Within 4–6 weeks after preoperative therapy, patients underwent surgery. The primary end-point was safety and secondary outcome measures were feasibility, pathologic complete response (pCR) rate and radiographic response. Immune signature of CD8+ T cells was evaluated in surgical specimens using immunohistochemistry and immunofluorescence. Results All patients have received PPCT successfully, except one patient who missed the last dose of chemotherapy due to leukopenia. Grade III and higher adverse events (AEs) were observed in 13 patients (13/20, 65%), and one patient had a grade V AE. The most frequent grade III AE was lymphopenia (12/13, 92%). Eighteen patients underwent surgery within 4–9 weeks after PPCT and the pCR rate was 55.6% (10/18). The percentage of transcription factor 1 positive cells was significantly higher in specimens of pCR group than those of non-pCR group (p value = 0.010). Conclusions PPCT was safe, did not delay surgery, and induced a pCR in 55.6% of resected tumours. A phase II multicentre study is undergoing for further confirmation of efficacy (NCT04435197).

Transhiatal esophagectomy facilitates esophageal resection without the need for thoracotomy. However, this procedure carries the risks of blind and blunt dissection within the mediastinum. More recently, video-assisted or mediastinoscopic transhiatal esophagectomy was introduced to mobilize the esophagus under direct visualization. Even though, the procedure is technically demanding and animal studies have shown that the CO2 pneumomediastinum may be associated with hemodynamic instability. By further developing already established techniques, we pioneered the transhiatal esophageal mobilization by using hybrid gastroscope (Fig. 1). Laparo-gastroscopic esophagectomy, which integrates gastroscope and laparoscope for esophageal mobilization, was successfully implemented on an esophageal cancer patient with a history of lung cancer surgery. The operative duration was 240 minutes with an estimated blood loss of 110 mL. The patient experienced an uneventful recovery and was discharged on postoperative day 9. Further studies will be required to confirm the surgical and oncological efficacy of this innovation. ispartof: ANNALS OF SURGERY vol:275 issue:4 pages:E659-E663 ispartof: location:United States status: published

Objectives Aspirations are common after esophagectomy. Data are lacking regarding its long-term radiological manifestations. The purpose of this study is to determine the incidence and radiological patterns of aspirations among long-term survivors and evaluate their clinical significance. Methods The records of all patients who underwent esophagectomy between October 2003 and December 2011 and survived more than 3 years were reviewed. Preoperative, first routine postoperative, and latest chest computed tomography (CT)scans were reviewed. Imaging studies were reviewed for radiological signs suspicious of aspirations, conduit location, anastomotic site, and maximal intrathoracic diameter. Data regarding patients' complaints during clinic visits were also collected. Results A total of 578 patients underwent esophagectomy during the study period. One-hundred twenty patients met the inclusion criteria. Median follow-up was 83.5 months. Cervical and intrathoracic anastomoses were performed in 103 and 17 patients, respectively. A higher rate of CT findings was found in postoperative imaging (n = 51 [42.5%] vs. n = 13 [10.8%] respectively, p Conclusions A significantly higher rate of new CT findings was found in postoperative imaging of this post-esophagectomy cohort, suggesting a high incidence of aspirations. The locations of the conduit, rather than anastomosis site, seem to play a role in the development of these findings. Further research is needed to evaluate the clinical significance of these findings.

Lung cancer has changed significantly during the past 2 decades in its epidemiology and treatment. This retrospective analysis used data from 7 major areas of China over 10 years to evaluate clinicopathologic and surgical treatment trends of lung cancer in China during the past decade.Data from 7184 patients with primary lung cancer who were treated between 2005 and 2014 in 8 provinces of China were retrospectively collected. Their clinicopathologic features and surgical treatment information were recorded. Simple linear regression models and the Cochrane-Armitage trend test were used to assess temporal trends.The proportion of female patients (from 57.4% to 59.6%; P.001) and nonsmoking patients (from 37.1% to 48.9%; P.001) and of patients with a family history of malignant tumors (from 7.0% to 11.5%; P.001) increased significantly. The percentage of adenocarcinomas increased significantly (from 36.4% to 53.5%; P.001), with a decrease in squamous cell carcinomas (from 45.4% to 34.4%; P.001). After 2008, the application of minimally invasive surgery significantly increased in China (from 2.4% in 2008 to 34.4% in 2014; P.001), with a decline in the rate of conversion to open operation (from 14.3% in 2008 to 4.8% in 2014; P = .146) and an increase in the proportion of systematic mediastinal lymph node dissection (from 50.0% in 2008 to 84.1% in 2014; P = .001).This study investigated recent 10-year trends in the clinicopathologic features and surgical treatment of lung cancer in China and found significant important changes. These findings provide valuable information and evidence for the future control of the disease in China.

OBJECTIVE: To determine whether RAL affects perioperative outcomes and long-term efficacy in NSCLC patients, compared with traditional VAL. SUMMARY OF BACKGROUND DATA: RAL is a promising treatment for NSCLC. However, its efficacy has not been fully evaluated. METHODS: A single-center, open-labeled prospective randomized clinical trial was launched in May 2017 to compare the efficacy of RAL and VAL. By May 2020, 320 patients were enrolled. The perioperative results of RAL and VAL were compared. RESULTS: The 320 enrolled patients were randomly assigned to the RAL group (n = 157) and the VAL group (n = 163). Perioperative outcomes were comparable between the 2 groups, including the length of hospital stay (P = 0.76) and the rate of postoperative complications (P = 0.45). No perioperative mortality occurred in either group. The total amount of chest tube drainage {830 mL [interquartile range (IQR), 550-1130 mL] vs 685 mL [IQR, 367.5-1160 mL], P = 0.007} and hospitalization costs [$12821 (IQR, $12145-$13924) vs $8009 (IQR, $7014-$9003), P < 0.001] were significantly higher in the RAL group. RAL group had a significantly higher number of LNs harvested [11 (IQR, 8-15) vs 10 (IQR, 8-13), P = 0.02], higher number of N1 LNs [6 (IQR, 4-8) vs 5 (IQR, 3-7), P = 0.005], and more LN stations examined [6 (IQR, 5-7) vs 5 (IQR, 4-6), P < 0.001]. CONCLUSIONS: Both RAL and VAL are safe and feasible for the treatment of NSCLC. RAL achieved similar perioperative outcomes, together with higher LN yield. Further follow-up investigations are required to evaluate the long-term efficacy of RAL. (ClinicalTrials.gov identifier: NCT03134534). ispartof: ANNALS OF SURGERY vol:275 issue:2 pages:295-302 ispartof: location:United States status: published

ispartof: INTERACTIVE CARDIOVASCULAR AND THORACIC SURGERY vol:34 issue:5 pages:721-722 ispartof: location:England status: published

ispartof: JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY vol:162 issue:3 pages:699-699 ispartof: location:United States status: published

BACKGROUND: Neoadjuvant treatment followed by esophagectomy is standard practice in locally advanced esophageal cancer. However, not all patients who started neoadjuvant treatment will undergo esophageal resection. The purpose of our study was to investigate the group of patients, scheduled for neoadjuvant treatment followed by esophagectomy, who never made it to esophageal resection. METHODS: We retrospectively analyzed patients treated between 2002 and 2015 for locally advanced esophageal cancer, who did not undergo esophagectomy after neoadjuvant treatment. Subanalysis was performed according to time period (2002-2010 versus 2011-2015) and histology (adenocarcinoma versus squamous cell carcinoma). RESULTS: In 114 of 679 patients (16.8%), surgery was not performed after neoadjuvant treatment. Reasons for cancelation were disease progression (50 patients, 43.9%), poor general condition (26 patients, 22.8%), irresectability (14 patients, 12.3%), patients' own decision (15 patients, 13.2%), and death during neoadjuvant treatment (9 patients, 7.9%). In the second time period, there were less irresectable tumors (17.7% versus 5.8%; p = 0.044). Median overall survival was not different over time (9.2 versus 12.5 months; p = 0.937). Irresectability (p = 0.032), patients' refusal (p = 0.012), and poor general condition (p = 0.002) were more frequent as reasons for cancelation in squamous cell carcinoma patients. Median overall survival was, respectively, 12.5 and 9.9 months for adenocarcinoma and squamous cell carcinoma patients (p = 0.441). The majority of patients refusing surgery had a clinical complete response (73.3%). They had a median overall survival of 33.2 months. CONCLUSIONS: One in six patients starting neoadjuvant treatment for locally advanced esophageal cancer never made it to esophagectomy, more than half of them for oncological reasons, but also 1.3% because of death during treatment. Over time, irresectability as reason decreased. As a result, the relative weight of medical inoperability increased, indicating the importance of upfront testing of medical operability. Cancelation of surgery was significantly more common in patients with a squamous cell carcinoma, and this histology seems to represent a more complex oncological and functional entity. Refusal of esophagectomy based on clinical complete response showed a significant survival benefit compared to those who did not undergo esophagectomy because of other reasons. ispartof: World J Surg Oncol vol:17 issue:89 pages:1-9 ispartof: location:England status: Published online

The current study aims to examine the impact of extracapsular lymph node involvement (EC-LNI) on survival for both esophageal adenocarcinoma (AC) and squamous cell carcinoma (SCC) treated with neoadjuvant chemoradiation therapy (nCRT) followed by surgery. Studies have demonstrated the negative prognostic value of EC-LNI in primary surgery, but its impact after nCRT remains unclear. From the databases of 6 European high-volume centers 1505 patients with R0 resections were withheld. Oncologic variables, including ypT, ypN, number of positive lymph nodes, and lymph node capsular status: EC-LNI and intracapsular lymph node involvement (IC-LNI), were examined. Statistical analysis was performed by Cox proportional hazards modeling. In SCC 182 patients (31.6%) had positive lymph nodes, of whom 60 (33.0%) showed EC-LNI. In AC 391 patients (42.1%) had positive lymph nodes, of whom 147 (37.6%) showed EC-LNI. Overall 5-year survival (O5YS) in SCC was 42.0%. Presence of EC-LNI meant a significantly worse O5YS than IC-LNI or pN0 (10.6%, 39.5%, and 47.4%, respectively; P < 0.05). O5YS in AC was 41.2%. No significant difference was observed between EC-LNI and IC-LNI (P = 0.322). In the multivariate analysis, among the examined possible prognosticators, presence of EC-LNI showed the highest hazard ratio (2.29, confidence interval: 1.52-3.47) as an independent prognosticator for overall survival in SCC, but it was not in AC. Based on this international multicenter study, the presence of EC-LNI after nCRT is at least as important as N-stage for survival and EC-LNI is the strongest prognosticator for overall survival in SCC but not in AC

The introduction of anesthesia in 1846 created unseen opportunities for surgeons. By the end of the 19th century limited esophageal resection outside the chest had already been performed and the race for successful intrathoracic esophagectomy was on. The credit for the first successful esophagectomy for an intrathoracic cancer goes to Franz Torek of New York in 1913. But it was the introduction of double lumen intubation that really boosted the number of successful esophagectomies all over the world. In the second half of the 20th century progress in surgical techniques and perioperative management resulted in a substantial reduction of postoperative mortality. Introduction of multimodality therapies has further improved long term survival. The turn of the millennium saw the development of minimally invasive esophagectomy (MIE) improving postoperative quality of life. Undoubtly new technologies and newer drugs (e.g., immunotherapy) will further allow for refinements and more personalized targeted therapies. In this manuscript, the authors provide a deep dive into the history and development of esophageal surgery, with emphasis on the innovative pioneers that brought the field of esophageal surgery to the front line of surgery. ispartof: ANNALS OF TRANSLATIONAL MEDICINE vol:9 issue:10 ispartof: location:China status: published

Founded in 1958 the UEMS (Union Européenne des Médecins Spécialistes-European Union of Medical Specialists) has become the largest European Medical organization representing over 1.5 million specialists of 43 Specialties in 39 countries. The primary goal of UEMS is to defend the interests of Specialists in the broadest sense of the word. This includes promoting the highest quality of care, the highest standards of training, continuous professional development (CPD) and continuous medical education (CME). For the latter the European Accreditation Council for Continuous Medical Education (EACCME) is one of the main assets of UEMS. The UEMS Section of Thoracic Surgery was created in 2013 and has substantially contributed to the improvement of the identity of Thoracic Surgery as a specialty throughout Europe. Its main activities are focusing on harmonization of training and organization of the format of the UEMS Board in Thoracic Surgery as well as further molding of the specialty via an intense collaboration with all involved stakeholders over the specialty boundaries. ispartof: JOURNAL OF THORACIC DISEASE vol:13 issue:3 pages:2021-2028 ispartof: location:China status: published

BACKGROUND: Standardized and transparent reporting of surgical technique is the cornerstone of effective dissemination, implementation and improvement. However, current reporting of surgical techniques is inadequate. The existing guidelines potentially applied to guide surgical technique reporting are with a minimal highlight of the surgical technique, lack requirements explaining what extent and dimensions need to be described in detail, or are unlikely to extrapolate to a wide range of surgical techniques. This study aims to formulate a rigorous protocol to develop a surgical technique reporting checklist and standards (SUPER) that defines what a clear, comprehensive and detailed surgical technique report should be contained. METHODS: This protocol is designed following the classic guidance for developing reporting guidelines recommended by the EQUATOR network. RESULTS: The development team will consist of surgeons (~80%), methodologists, and journal editors. The draft checklist sources will include a scoping review of existing reporting guidelines related to surgical technique, surgical technique articles from 15 top journals published in the last year, and brainstorming by the multidisciplinary development team. The final SUPER checklist will be formed after three rounds of Delphi surveys, one round of face-to-face meeting, and a month-long pilot test. The SUPER checklist will be published as open-access and be used in combination with existing reporting guidelines related to surgical techniques (e.g., IDEAL). This protocol will steer the SUPER checklist's development, allowing us to further elaborate surgical technique reporting for all surgical specialties, and enabling a more favorable experience for surgeons, nurses, medical students, residents, editors, and reviewers. TRIAL REGISTRATION: This trial is registered at the EQUATOR network on December 18th, 2020. Available at: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/. ispartof: GLAND SURGERY vol:10 issue:8 pages:2591-2599 ispartof: location:China (Republic : 1949- ) status: published

Summary The optimal perioperative fluid management during esophagectomy is still not clear. Liberal regimens have been associated with higher morbidity and respiratory complications. Restrictive regimens might raise concerns for kidney function and increase the need to associate vasopressors. The aim of this study was to investigate retrospectively the perioperative fluid administration during esophagectomy and to correlate this with postoperative respiratory outcome. All patients who underwent esophagectomy between January and December 2016 were retrospectively analyzed. Patient characteristics, type of surgery and postoperative course were reviewed. Fluid administration and vasopressor use were calculated intraoperatively and during the postoperative stay at the recovery unit. Fluid overload was defined as a positive fluid balance of more than 125 mL/m2/h during the first 24 hours. Patients were divided in 3 groups: GRP0 (no fluid overload/no vasopressors); GRP1 (no fluid overload/need for vasopressors); GRP2 (fluid overload with/without vasopressors). Postoperative complications were prospectively recorded according to Esophagectomy Complications Consensus Group criteria. A total of 103 patients were analyzed: 35 (34%) GRP0, 50 (49%) GRP1 and 18 (17%) GRP2. No significant differences were found for age, treatment (neoadjuvant vs. primary), type of surgery (open/minimally invasive), histology nor comorbidities. There were significant (P ≤ 0.001) differences in fluid balance/m2/h (75 ± 21 mL; 86 ± 22 mL and 144 ± 20 mL) across GRP0, GRP1 and GRP2, respectively. We found differences in respiratory complications (GRP0 (20%) versus GRP1 (42%; P = 0.034) and GRP0 (20%) versus GRP2 (61%; P = 0.002)) and “Comprehensive Complications Index” (GRP0 (20.5) versus GRP1 (34.6; P = 0.015) and GRP0 (20.5) versus GRP2 (35.1; P = 0.009)). Multivariable analysis (binary logistic regression) for “any respiratory complication” was performed. Patients who received fluid overload (GRP2) had a 10.24 times higher risk to develop postoperative respiratory complications. When patients received vasopressors alone (GRP1), the chances of developing these complications were 3.57 times higher compared to GRP0. Among patients undergoing esophagectomy, there is a wide variety in the administration of fluid during the first 24 hours. There was a higher incidence of respiratory complications when patients received higher amounts of fluid or when vasopressors were used. We believe that a personalized and protocolized fluid administration algorithm should be implemented and that individual risk factors should be identified.

J Thorac Dis. 2018 May;10(5):2771-2778. doi: 10.21037/jtd.2018.04.136. ypT0N+: the unusual patient with pathological complete tumor response but with residual lymph node disease after neoadjuvant chemoradiation for esophageal cancer, what's up? Depypere LP1, Vervloet G1, Lerut T1, Moons J1, De Hertogh G2, Sagaert X2, Coosemans W1, Van Veer H1, Nafteux PR1. Author information Abstract Background: Little is known about the prognostic significance of residual nodal disease in otherwise complete pathologic responders (ypT0N+) after neoadjuvant chemoradiation (nCRT) for esophageal cancer (EC). The purpose is to analyze the long-term outcomes of EC patients with ypT0N+ following nCRT and esophagectomy. Methods: From a single institution database, 466 consecutive EC patients undergoing esophagectomy after nCRT were collected (1996-2016). ypT0N+ responders were compared to pathological complete responders (ypT0N0) and to pathological non-complete responders (ypT+N0 and ypT+N+). Results: There were 149 ypT0N0, 31 ypT0N+, 141 ypT+N0 and 145 ypT+N+. Median overall survival (OS) was worse in ypT0N+ (21.7 months) and ypT+N+ (16.8 months) compared to ypT0N0 (55.2 months) and ypT+N0 (42.0 months). Stratification by histology revealed a significant difference in prevalence of ypT0: 62.5% in 184 squamous cell carcinomas (SCC) compared to 23.0% in 282 adenocarcinomas (ADC) (P

Objective: Our objective was to evaluate the impact of early oral feeding (EOF) on postoperative cardiac, respiratory, and gastrointestinal (CRG) complications after McKeown minimally invasive esophagectomy for esophageal cancer. Summary Background Data: Nil-by-mouth with enteral tube feeding is routinely practiced after esophagectomy. Methods: Patients were randomly allocated to receive oral feeding on the first postoperative day (EOF group) or late oral feeding (LOF group) 7 days after surgery. The primary endpoint was the occurrence of postoperative CRG complications, and the secondary outcomes included bowel function recovery and short-term quality of life (QOL). Results: Between February 2014 and October 2015, 280 patients were enrolled in this study. There were 140 patients in the EOF group and 140 patients in the LOF group. EOF was noninferior to LOF for CRG complications (30.0% in the EOF group vs. 32.9% in the LOF group; 95% confidence interval of the difference: -13.8% to 8.0%). Compared with the LOF group, the EOF group showed significantly shorter time to first flatus (median of 2 days vs. 3 days, P = 0.001) and bowel movement (median of 3 vs. 4 days, P < 0.001). Two weeks after the operation, patients in the EOF group reported higher global QOL and function scores and lower symptom scores than patients in the LOF group. Conclusions: In patients after McKeown minimally invasive esophagectomy is noninferior to the standard of care with regard to postoperative CRG complications. In addition, patients in the EOF group had a quicker recovery of bowel function and improved short-term QOL.

Although endoscopic resection (ER) may be sufficient treatment for early-stage esophageal cancer, additional treatment is recommended when there is a high risk of cancer recurrence. It is unclear whether delaying esophagectomy by performing and assessing the success of ER affects outcomes as compared with immediate esophagectomy without ER. Additionally, long-term survival after sequential ER and esophagectomy required further investigation. Between 2011 and 2015, 48 patients with stage T1 esophageal cancer underwent esophagectomy after ER with curative intent at our institution. Two-to-one propensity score methods were used to identify 96 matched-control patients who were treated with esophagectomy only using baseline patient, tumor characteristics and surgical approach. Time from initial evaluation to esophagectomy, relapse-free survival, overall survival, and postoperative complications were compared between the propensity-matched groups. In the ER + esophagectomy group, the time from initial evaluation to esophagectomy was significantly longer than in the esophagectomy only group (114 vs. 8 days, p

Surgery for esophageal carcinoma and carcinoma of the gastro-esophageal junction (GEJ) is considered as one of the most complex and challenging interventions on the digestive tract. This is due to the intimate relations with vital structures in the chest and the tendency of early lymphatic dissemination via a dense and complex submucosal network. This review article discusses the different aspects of surgical access routes in the light of the ever-evolving techniques, in particular the minimally invasive esophagectomy (MIE). The aspects of surgical approach are inextricably linked to the still ongoing debate on extent of lymphadenectomy, a debate that is obtaining a new dimension in view of the widely applied neoadjuvant therapy protocols as well as in view of the increasing importance of quality of life aspects after surgery. Finally, the authors provide a practical and patient tailored approach as applied in their center. ispartof: Annals of cardiothoracic surgery vol:6 issue:2 pages:152-158 ispartof: location:China status: published

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (

BACKGROUND: The aim of the current study was to investigate the impact of early oral feeding (EOF) on inflammatory cytokine levels after McKeown minimally invasive esophagectomy (MIE) for cancer. METHODS: This study was based on a randomized controlled trial (NCT01998230). Patients with esophageal cancer who received McKeown MIE were randomly allocated into a group that started oral feeding on postoperative day (POD) 1 (EOF group) or a second group that received nil by mouth until 7 days after operation (late oral feeding [LOF] group). We chose 86 patients, 46 patients in the EOF group and 40 patients in the LOF group, in which to analyze inflammatory cytokine levels (interleukin [IL]-6, IL-8, tumor necrosis factor-a [TNF-α], and monocyte chemotactic protein-1 [MCP-1]). RESULTS: The EOF and LOF groups exhibited similar preoperative IL-6, IL-8 TNF-α, and MCP-1 levels. The levels of the four inflammatory cytokines at PODs 1 and 3 were significantly higher than the preoperative levels (all p

Esophagectomy followed by reconstruction is considered one of the most challenging interventions on the alimentary tract. Today most esophagectomies are performed for cancer of the esophagus and gastroesophageal junction. Other indications are decompensated achalasic megaeesophagus, sequelae of caustic burns, after multiple redo surgeries for reflux. The stomach, shaped into a narrow gastric tube, is the most commonly used conduit for reconstruction due to its favorable length, reliable vascular supply, the need for only one single anastomosis, and, in general, good to excellent sustainable quality of deglutition and life. However, dependent on each individual patient's particularities, reconstruction may require to choose another conduit. Colon and jejunum—sometimes to be used as an isolated loop with free vascular anastomosis or as composite grafts—are the available alternatives. Tubular skin flaps in an extremely rare situation may become the last resort option. Combined with a multitude of different access routes, including the recent minimally invasive techniques, as well as different levels of anastomosis, it is clear that there are myriad options available when planning an esophagectomy and reconstruction. A tailored approach for each individual patient guided by an experienced surgical team that is familiar with all conduits available and able to adapt to every situation in order to offer the patient the best possible type of reconstruction is the key to success. This chapter provides an in-depth description of the techniques and results of the whole spectrum of options for esophageal replacement.

At present there is controversy regarding the optimal surgical method for esophageal cancer. Specifically, whether combined thoracoscopic-laparoscopic esophagectomy is superior to open esophagectomy with respect to the surgical wound, perioperative morbidities and mortality, and the overall survival rate is of great concern. This article aimed to compare thoracoscopic-laparoscopic esophagectomy versus open esophagectomy on the perioperative morbidities and long-term survival. PubMed, Embase, and Google Scholar databases were searched for relevant studies comparing combined thoracoscopic-laparoscopic esophagectomy with open esophagectomy using the Preferred Reporting Items for Systemic Reviews and Meta-Analyses standards. Odds ratios were extracted to give pooled estimates of the perioperative effect of the two surgical procedures. Hazard ratios were extracted to compare overall survival between the two surgical procedures. Thirteen studies involving 1549 patients were included in this meta-analysis. We found that patients that underwent combined thoracoscopic-laparoscopic esophagectomy had lower total complication rates (relative risk 1.20; 95 % CI 1.08–1.34; p = 0.0009), wound infection rates, pulmonary complications, and less intraoperative blood loss. Moreover, our study also showed combined thoracoscopic-laparoscopic esophagectomy did not compromise the 5-year survival rate (hazard risk 0.920; 95 % CI 0.720–1.176; p = 0.505) and even improved 2-year survival rate. The 30-day mortality and other common morbidities, including anastomotic leakage, anastomotic stricture, pulmonary infection, chylothorax, arrhythmia, or recurrent laryngeal nerve injury, were not significantly different between combined thoracoscopic-laparoscopic esophagectomy and traditional open esophagectomy (p > 0.05). Combined thoracoscopic-laparoscopic esophagectomy is a feasible and reliable surgical procedure that can achieve uncompromising long-term survival rates and reduce perioperative complications.

Each year world-wide approximately 400,000 cancers of the esophagus are registered. Half of them are occurring in China being squamous cell cancer (SCC) in over 90% the patients. This is in contrast with the Western experience where adenocarcinoma is the predominant cancer type.

The trachea is one of the most difficult organs to transplant because its segmental blood supply involves blood vessels that are too small to allow for microvascular anastomosis. Through an ingenious sequence of revascularization and wound-healing mechanisms under temporary immunosuppression, the authors have developed a tracheal allotransplantation technique that allows the creation of a true chimeric trachea. The donor component of this chimeric trachea is tolerated permanently based on immune ignorance. This technique holds great promise for the development of a standardized approach for the repair of large tracheal defects.

Background Despite integrated positron emission tomography and computed tomography screening before and after neoadjuvant treatment in patients with locally advanced esophageal cancer, unexpected metastatic disease is still found in some patients during surgery. Should then esophagectomy be aborted or is there a place for palliative resection? Methods Between 2002 and 2015, 681 patients with potentially resectable esophageal cancer were sheduled for neoadjuvant therapy and subsequent esophagectomy. In 552 patients, a potentially curative esophagectomy was performed. In 12 patients, unexpected disease was discovered during surgery but esophagectomy was performed with synchronous resection of metastases; 10 of them had oligometastatic disease (≤4 single-organ metastases). Esophagectomy was not performed in 117 patients (because of disease progression in 50); 14 were also single-organ oligometastatic. Data of 10 single-organ oligometastatic patients who underwent esophageal resection (group 1) were compared those of 10 non-resected but treated counterparts (group 2) and with 228 patients who underwent potentially curative esophagectomy with persistent pathological lymph nodes (group 3). Results Five oligometastatic esophagectomy patients had lung metastases: 1 peritoneal, 2 adrenal, 1 pleural, and 1 pancreatic. Two oligometastatic non-resected patients had lung, 5 liver, and 3 brain metastases. Median overall survival was 21.4, 12.1, and 20.2 months in the respective groups (group 1 vs. group 2 p = 0.042; group 2 vs. group 3 p = 0.002; group 1 vs. group 3 p = 0.88). Conclusions Survival is longer in patients undergoing palliative esophagectomy with unexpected single-organ oligometastatic disease and comparable to survival in patients with persistent pathological lymph nodes. Palliative resection in these patients seems to be justified.

Background Screening is an important tool in staging esophageal cancer as only patients without suspicion of metastases are considered for surgery-based treatment. Nevertheless unexpected metastatic disease is still found in some patients during surgery. In these cases should esophagectomy be aborted, or is there a place for palliative resection? Methods Between 2002 and 2015, 681 patients with locally advanced potentially resectable esophageal cancer were scheduled for neoadjuvant therapy and subsequent esophagectomy. In 552 patients potentially curative esophagectomy was performed. In twelve patients, unexpected disease was discovered during surgery but esophagectomy was performed with synchronous resection of the metastases. Ten of them were oligometastatic (≤ 4 single organ metastases). In 117 patients esophagectomy was not performed with among them 50 patients because of disease progression. Fourteen of these patients were also single organ oligometastatic and ten of them received systemic treatment. 10 single organ oligometastatic patients that underwent esophageal resection (group1) were compared to 10 non-resected—but treated—counterparts (group2) and to 228 patients that underwent a potentially curative esophagectomy with persistent pathological lymph nodes (group3). Clinicopathological data were retrospectively reviewed and survival of the three groups was compared from date of pathological diagnosis. Results In the oligometastatic esophagectomy patients, 5 had lung metastases, 1 peritoneal, 2 adrenal, 1 pleural, and 1 pancreatic. In the oligometastatic non-resected patients, 2 had lung metastases, 5 liver and 3 brain metastases. Median overall survival was 21.4, 12.1 and 20.2 months in the respective groups. (group1 vs group2: P = 0.042; group2 vs group3: P = 0.002; group1 vs group3: P = 0.88). Conclusion Survival is prolonged in patients undergoing palliative esophagectomy in case of unexpected single organ oligometastatic disease during surgery and is comparable to survival of patients with persistent pathological lymph nodes. Palliative resection in unexpected oligometastatic disease seems to be justified. Disclosure All authors have declared no conflicts of interest.

The trachea is one of the most difficult organs to transplant because its segmental blood supply involves blood vessels that are too small to allow for microvascular anastomosis. Through an ingenious sequence of revascularization and wound-healing mechanisms under temporary immunosuppression, the authors have developed a tracheal allotransplantation technique that allows the creation of a true chimeric trachea. The donor component of this chimeric trachea is tolerated permanently based on immune ignorance. This technique holds great promise for the development of a standardized approach for the repair of large tracheal defects.

OBJECTIVE: Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study.DESIGN: In 13 European centres, patients with BO ≤ 12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (OUTCOMES: complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review.RESULTS: 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically.CONCLUSIONS: In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up.TRIAL REGISTRATION NUMBER: NTR 1211, http://www.trialregister.nl.

OBJECTIVES: We developed a new algorithm to identify high-risk patients for underweight after oesophagectomy for cancer. Patients were assigned to an age–gender-specific body mass index percentile (AG-BMI) which is then used in a survival analysis. This model was able to identify patients more at risk for being underweight in comparison with the classically used BMI. It shows a worse overall survival (OS) in patients with a preoperative AG-BMI < 10th percentile. The aim of this study is to validate this new model based on a cohort of patients from an external high-volume institution specialized in oesophageal cancer surgery. METHODS: The validation cohort consists of 407 patients operated on between 1999 and 2012 with the prerequisite data to calculate AGBMI and OS. The base cohort consisted of 642 consecutive patients, operated on in our institution between 2005 and 2010. Age, gender, height and weight on the day before surgery were used to calculate the BMI and the AG-BMI. OS was analysed and a multivariate analysis was performed. RESULTS: Incidence rates of the AG-BMI < 10th percentile risk-patients in the validation cohort showed similar results to our original results (17.8 vs 17.2% for the base cohort) with a similar significant OS difference between at-risk patients and not-at-risk patients (P < 0.001). Multivariate analysis found the same five independent prognosticators for OS in both datasets: age, early versus advanced disease, resection status, number of positive lymph nodes and the AG-BMI 10th percentile, but not BMI itself. In the validation cohort, gender was identified as an additional independent prognosticator. The worse OS survival in AG-BMI < 10th percentile in both patient populations was related to a significantly higher number of deaths without oesophageal cancer recurrence. CONCLUSIONS: This study validates the newly developed AG-BMI model to predict more accurately a subgroup of patients at risk for worse survival after oesophagectomy. Improved perioperative identification of risk factors for poorer OS could help to develop perioperative strategies to reduce these risks.

Introduction: Perioperative complications influence long- and short-term outcomes after esophagectomy. The absence of a standardized system for defining and recording complications and quality measures after esophageal resection has meant that there is wide variation in evaluating their impact on these outcomes. Methods: The Esophageal Complications Consensus Group comprised 21 high-volume esophageal surgeons from 14 countries, supported by all the major thoracic and upper gastrointestinal professional societies. Delphi surveys and group meetings were used to achieve a consensus on standardized methods for defining complications and quality measures that could be collected in institutional databases and national audits. Results: A standardized list of complications was created to provide a template for recording individual complications associated with esophagectomy. Where possible, these were linked to preexisting international definitions. A Delphi survey facilitated production of specific definitions for anastomotic leak, conduit necrosis, chyle leak, and recurrent nerve palsy. An additional Delphi survey documented consensus regarding critical quality parameters recommended for routine inclusion in databases. These quality parameters were documentation on mortality, comorbidities, completeness of data collection, blood transfusion, grading of complication severity, changes in level of care, discharge location, and readmission rates. Conclusions: The proposed system for defining and recording perioperative complications associated with esophagectomy provides an infrastructure to standardize international data collection and facilitate future comparative studies and quality improvement projects.

To clarify the biologic behavior of esophageal signet ring cell (SRC) carcinomas of the esophagus and gastroesophageal junction (GEJ). To evaluate the accuracy of pretreatment biopsies in diagnosing true SRC carcinoma.In contrast with gastric cancer, little is known about the biologic behavior and prognosis of SRC.All adenocarcinomas (ADC) of the esophagus and GEJ-patients undergoing primary resection between 1990 and 2009 were included (n = 920). Specimens containing SRCs (n = 114) were classified according to World Health Organization criteria (50% SRC or50% SRC).Thirty-two patients showed more than 50% SRC and 71 patients showed less than 50% SRC. Overall cancer-specific 5-year survival was worse for SRC (22.4%, P0.0001) and for SRC50% (13.6%, P = 0.0001) compared with ADC. Complete resection was achieved in 86.5% of patients (n = 697) in ADC, 69.5% (n = 57) in SRC50%, and 78.1% (n = 25) in SRC50% (vs ADC, respectively, P0.0001 and P = 0.1801). In 379 pN + R0 patients, the median number of positive lymph nodes was comparable between ADC and SRC50% (4 vs 5, P = 0.207) or SRC50% (4 vs 8, P = 0.077). Compared with ADC, SRC50% showed more pN3's (30% vs 61%, P = 0.006), higher recurrence (56% vs 42% for ADC, P = 0.003), and local-regional recurrences (29% vs 16%, P = 0.002). Pretreatment biopsies were unreliable to define the presence of SRC50% (sensitivity = 56.3%, positive predictive value = 43.9%).SRCs are aggressive neoplasms associated with poorer prognosis than other ADCs after primary esophagectomy. Because our data suggest that pretreatment biopsies failed to reliably define presence of SRC50%, presence of SRCs in pretreatment biopsies seems to be of no use to define treatment strategy or prognosis.

Esophagectomy followed by reconstruction is one of the most complex interventions in surgery of the alimentary tract. Over several decennia dedicated surgeons have realized a constant decrease in 30-day mortality being now well below 5% in expert hands. However quality of life after such intervention is often jeopardized by the high incidence of complications in particular pulmonary infections. The introduction and presently widespread use of total minimally invasive esophagectomy (MIE) has re resulted in a substantial decrease of these pulmonary complications along with a decrease of the need for ICU admission and a decrease of length of hospital stay. But still a non-negligible share of patients may suffer from, sometimes severe, posthoracotomy pain. A problem that is thought to be the result of the manipulation of instruments at the port sites causing damage to the intercostal nerves. The growing popularity of uniportal video-assisted thoracoscopic surgery (VATS) in particular in lung surgery claims to diminish this problem. Currently there is little experience in the use of uniportal VATS for esophagectomy which seems to be in part related to its higher degree of technical complexity. As a result there are no published data on the results but there are a few dedicated centers that are building up their experience. Their preliminary results seem to hold promising perspectives in relation to overcome the pain problem using a single small port site. Future will tell what the place will be of uniportal VATS versus other techniques e.g., robotic esophagectomy, endoscopic interventions on the esophagus and new emerging avenues in molecular biology.