Outcomes of curative esophageal cancer surgery in elderly:A metaanalysis

BACKGROUND An increasing number of older patients is undergoing curative,surgical treatment of esophageal cancer.Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients,which may lead to patient selection based on age.However,only studies including patients that underwent open esophagectomy were included.Therefore,it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.AIM To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.METHODS Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included.Meta-analysis of studies using a 75-year age threshold are presented in the manuscript,studies using other age thresholds in the Supplementary material.MEDLINE,Embase and the Cochrane Library were searched for articles published between 1995 and 2020.Risk of bias was assessed with the Newcastle-Ottawa Scale.Primary outcomes were anastomotic leak,pulmonary and cardiac complications,delirium,30-and 90-d,and in-hospital mortality.Secondary outcomes included pneumonia and 5-year overall survival.RESULTS Seven studies(4847 patients)using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients.Older patients(9.05%)had higher rates of 90-d mortality compared with younger patients(3.92%),(confidence interval=1.10-5.56).In addition,older patients(9.45%)had higher rates of in-hospital mortality compared with younger patients(3.68%),(confidence interval=1.01-5.91).In the subgroup of 2 studies with minimally invasive esophagectomy,older and younger patients had comparable 30-d,90-d and in-hospital mortality rates.CONCLUSION Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk.Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

Calcineurin Inhibitor Use and Myoclonus Association. Is There a Clinical Implication?

Background: Calcineurin Inhibitors (CNIs) play a pivotal role in anti rejection therapy for transplant patients. Neurotoxicity is a known side effect that usually manifests as encephalopathy but myoclonus has also been described. Perioperative myoclonus as a manifestation of neurotoxicity, has not been well studied. Methods: We retrospectively reviewed data from 842,762 patients from the Nationwide Inpatient Sample (NIS) database from January 2011 to December 2014. Of those records we compared 56,423 patients requiring CNIs and undergoing Heart Transplant (HT) with 786,339 patients undergoing Coronary Artery Bypass Graft (CABG) surgery as controls. The objective was to study the rates of myoclonus in patients undergoing cardiac surgery, especially those requiring CNIs, and study the outcome of those patients with myoclonus. The NIS database from January 2011 to December 2014 was the source for the analysis. Patients with underlying epilepsy or hypo-ischemic encephalopathy based on ICD-9-CM codes were excluded from the study. Results: A total of 147 patients (0.26%) were found to have myoclonus in the HT group versus 338 patients (0.04%) in the CABG group, p < 0.0001. No differences in the demographics were seen except for kidney disease which was higher in the HT group. The difference remained statistically significant after adjusting for confounders. Patients with myoclonus in both groups were more likely to have acute kidney injury and have a prolonged length of stay. Only patients with myoclonus in the CABG group had higher rates of discharge disposition to a nursing home and higher rates of in-Hospital mortality. A trend towards higher in-Hospital mortality was found in patients with myoclonus in the HT group. Conclusion: In this study we have compared the rate of myoclonus found in HT patients versus CABG patients. We have identified calcineurin inhibitors as potentially contributing to myoclonus due to its neurotoxic effects. The study also suggests that other disease processes like renal failure may also have an impact on the rate of myoclonus even in the absence of calcineurin inhibitors. Higher rates of myoclonus were seen in patients undergoing HT when compared to patients undergoing CABG, suggesting that CNIs may increase the risk for myoclonus. Myoclonus may be a clinical indicator of patient overall health including a more permeable blood brain barrier. In-Hospital mortality was higher in patients with myoclonus undergoing CABG and a trend towards significance in the HT group suggesting that it may be a marker of poor prognosis. More studies are needed to corroborate our findings.

Cancer-directed surgery in malignant pleural mesothelioma: extrapleural pneumonectomy and pleurectomy/decortication

Malignant pleural mesothelioma(MPM)is a primary solid malignancy related to inhalational asbestos exposure.Despite advances in therapy,MPM remains challenging to treat with a post-treatment survival of only 15%at 5-year.In recent years,extra-pleural pneumonectomy has decreased in popularity due to a high morbidity rate and mortality compared to pleurectomy/decortication and other therapeutic alternatives.In this review,we will discuss both procedures,outcomes,ongoing studies,and the roles of surgery in the future treatment of this disease.