Preoperative risk modelling for oesophagectomy: A systematic review

BACKGROUND Oesophageal cancer is a frequently observed and lethal malignancy worldwide.Surgical resection remains a realistic option for curative intent in the early stages of the disease.However,the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality.Therefore,appropriate patient selection,counselling and resource allocation is important.Many tools have been developed to aid surgeons in appropriate decision-making.AIM To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.METHODS A systematic review of the MEDLINE,EMBASE and Cochrane databases was conducted from 2000-2020.The search terms applied were((Oesophagectomy)AND(Risk OR predict OR model OR score)AND(Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)).The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy.The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score,cardiopulmonary fitness or pre-operative sarcopenia.Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures.The articles generated from each search were collated,processed and then reported in accordance with PRISMA guidelines.All risk models were appraised for clinical credibility,methodological quality,performance,validation,and clinical effectiveness.RESULTS The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process.After title and abstract screening,197 potentially relevant texts were retrieved for detailed review.Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data.Most models examined were clinically credible and were constructed with sound methodological quality,but model performance was often insufficient to prognosticate patient outcomes.Three risk models were identified as being promising in predicting perioperative mortality,including the National Quality Improvement Project surgical risk calculator,revised STS score and the Takeuchi model.Two studies predicted perioperative major morbidity,including the predicting postoperative complications score and prognostic nutritional index-multivariate models.Many of these models require external validation and demonstration of clinical effectiveness.CONCLUSION Whilst there are several promising models in predicting perioperative oesophagectomy outcomes,more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.

Combined and intraoperative risk modelling for oesophagectomy:A systematic review

BACKGROUND Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis.Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages.However,the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration.Appropriate patient selection,counselling and resource allocation is essential.Numerous risk models have been devised to guide surgeons in making these decisions.AIM To evaluate which multivariate risk models,using intraoperative information with or without preoperative information,best predict perioperative oesophagectomy outcomes.METHODS A systematic review of the MEDLINE,EMBASE and Cochrane databases was undertaken from 2000-2020.The search terms used were[(Oesophagectomy)AND(Model OR Predict OR Risk OR score)AND(Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)].Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy.Articles were excluded if they only required preoperative or any post-operative data.Studies appraising univariate risk predictors such as preoperative sarcopenia,cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded.The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model.All captured risk models were appraised for clinical credibility,methodological quality,performance,validation and clinical effectiveness.RESULTS Twenty published studies were identified which examined eleven multivariate risk models.Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values.Only two risk models were identified as promising in predicting mortality,namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity(POSSUM)and POSSUM scores.A further two studies,the intraoperative factors and Esophagectomy surgical Apgar score based nomograms,adequately forecasted major morbidity.The latter two models are yet to have external validation and none have been tested for clinical effectiveness.CONCLUSION Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes,there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Vascular calcification does not predict anastomotic leak or conduit necrosis following oesophagectomy

BACKGROUND Anastomotic leaks(AL)and gastric conduit necrosis(CN)are serious complications following oesophagectomy.Some studies have suggested that vascular calcification may be associated with an increased AL rate,but this has not been validated in a United Kingdom population.AIM To investigate whether vascular calcification identified on the pre-operative computed tomography(CT)scan is predictive of AL or CN.METHODS Routine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed.Calcification of the proximal aorta,distal aorta,coeliac trunk and branches of the coeliac trunk was scored by two reviewers.The relationship between these calcification scores and occurrence of AL and CN was then analysed.The Esophagectomy Complications Consensus Group definition of AL and CN was used.RESULTS Complication data were available in n=411 patients,of whom 16.7%developed either AL(15.8%)or CN(3.4%).Rates of AL were significantly higher in female patients,at 23.0%,compared to 13.9%in males(P=0.047).CN was significantly more common in females,(8.0%vs 2.2%,P=0.014),patients with diabetes(10.6%vs 2.5%,P=0.014),a history of smoking(10.3%vs 2.3%,P=0.008),and a higher American Society of Anaesthesiologists grade(P=0.024).Out of the 14 conduit necroses,only 4 occurred without a concomitant AL.No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes.Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes.However,the stepwise approach did not select any factors for inclusion in the final models.The analysis was repeated for composite outcomes of those patients with either AL or CN(n=69,16.7%)and for those with both AL and CN(n=10,2.4%)and again,no significant associations were detected.In the subset of patients that developed these outcomes,no significant associations were detected between calcification and the severity of the complication.CONCLUSION Calcification scoring was not significantly associated with Anastomotic Leak or CN in our study,therefore should not be used to identify patients who are high risk for these complications.

Real-time outcome monitoring following oesophagectomy using cumulative sum techniques

AIM:To examine the feasibility of prospective,realtime outcome monitoring in a United Kingdom oesophago-gastric cancer surgery unit.METHODS:The first 100 hybrid(laparoscopic abdominal phase,open thoracic phase) Ivor-Lewis oesophagectomies performed by a United Kingdom oesophagogastric cancer surgery unit were assessed retrospectively using cumulative sum(CUSUM) techniques.The monitored outcome was 30-d post-operative mortality,with the accepted mortality risk defined as 5%.A variable life adjusted display(VLAD) was constructed by plotting a graph of cumulative mortality minus cumulative mortality risk on the y axis vs sequential case number on the x axis.This was modified to a zeroed VLAD by preventing the plot from crossing the y = 0 axis essentially creating two plots,one examining trends where cumulative mortality was higher than mortality risk(i.e.,worse than expected outcomes) where y > 0,and vice versa.Alert lines were set at y = ± 2.At any point where a plot breaches an alert line,it is felt that the 30-d post-operative mortality rate has deviated significantly from that expected and an internal review should be performed.RESULTS:One hundred cases were assessed,with a mean age of 66.4 years,mean T stage of 2.1,and mean N stage of 0.48.Three cases were commenced using a laparoscopic technique and converted to open surgery due to technical factors.Median length of inpatient stay was 15 d.The crude 30 d mortality was 5% and the incidence of clinically significant anastomotic leak was 6%.The VLAD demonstrated a plot of cumulative mortality minus cumulative mortality risk(i.e.,5% per case) which remained in the range-1.4 to +0.5 excess mortalities.With the alert set at two greater or fewer than predicted mortalities,this method does not approach the point of triggering internal review.It is however arguable that a run of performance that is better than expected,causing the plot to be well below y = 0,would mask a subsequent run of poor performance by requiring a rise of greater than two excess mortalities to trigger the alert line.The zeroed VLAD removes this problem by preventing the plot that is examining above expected mortality from passing below y = 0,and vice versa.In this study period,no audit triggers were reached.It is therefore possible to independently assess runs of good,or poor performance and so target internal audit to the appropriate series of cases.It is important to note this technique allows targeted internal review,in response to both above and below average outcomes.This study has demonstrated the feasibility of prospective outcome monitoring using the above techniques,actual real-time implementation has the potential to pick up and reinforce good practices when performance is better than predicted,and provide an early warning system for when performance falls below that predicted.Further development is possible,including more patient specific risk adjustment using the oesophago-gastric surgery physiological and operative severity score for the enumeration of mortality and morbidity score.CONCLUSION:CUSUM techniques provide a potential method of prospective,real-time outcome monitoring in oesophageal cancer surgery.

Post-oesophagectomy gastric conduit outlet obstruction following caustic ingestion,endoscopic management using a SX-ELLA biodegradable stent: A case report

BACKGROUND Benign oesophageal strictures secondary to caustic ingestion are rare and difficult to manage. They often present with symptoms such as chest pain,dysphagia and vomiting. Surgical resection is often not justified in majority of these cases who later presents with recurrent benign stricture.CASE SUMMARY We present a unique case of a patient who presented with post-oesophagectomy gastric conduit outlet obstruction(POGO) secondary to caustic ingestion. Our patient had already undergone two stage oesophagectomy with pyloroplasty for operable oesophageal cancer with curative intent 5 years prior. This is a distinctive case,where a successful deployment of a SX-ELLA biodegradable(BD) stent(019-10 A-28/23/28-080) after failed dilatations. We have briefly reviewed literature with regards to the role BD stents in patients with recurrent benign stricture and discussed management dilemma.CONCLUSION We recommend the attending gastroenterologist should bear the usefulness of BD stents in the management of refractory POGO after oesophagectomy.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives

Minimally invasive surgery is increasingly indicated in the management of malignant disease.Although oesophagectomy is a difficult operation,with a long learning curve,there is actually a shift towards the laparoscopic/thoracoscopic/robotic approach,due to the advantages of visualization,surgeon comfort(robotic surgery)and the possibility of the whole team to see the operation as well as and the operating surgeon.Although currently there are still many controversial topics,about the surgical treatment of patients with gastro-oesophageal junction(GOJ)adenocarcinoma,such as the type of open or minimally invasive surgical approach,the type of oesophago-gastric resection,the type of lymph node dissection and others,the minimally invasive approach has proven to be a way to reduce postoperative complications of resection,especially by decreasing pulmonary complications.The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach.The short-term and long-term results,as well as the benefits for the patient-reduced surgical trauma,quick and easy recovery-offer this type of surgical treatment the premises for future development.This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

Oesophageal flap valvuloplasty and wrapping suturing prevent gastrooesophageal reflux disease in dogs after oesophageal anastomosis

AIM:To examine the efficiency of oesophageal flap valvuloplasty and wrapping suturing technique in decreasing the rate of postoperative gastrooesophageal reflux disease in a dog model.METHODS:We operated on 10 dogs in this study.First,we resected a 5-cm portion of the distal oesophagus and then restored the continuity of the oesophageal and gastric walls by end-to-end anastomosis.A group of five dogs was subjected to the oesophageal flap valvuloplasty and wrapping suturing technique,whereas another group(control)of five dogs was subjected to the stapling technique after oesophagectomy.The symptom of gastrooesophageal reflux was recorded by 24-h p H oesophageal monitoring.Endoscopy and barium swallow examination were performed on all dogs.Anastomotic leakage was observed by X-ray imaging,whereas benign anastomotic stricture and mucosal damage were observed by endoscopy.RESULTS:None of the 10 dogs experienced anastomotic leakage after oesophagectomy.Four dogs in the new technology group resumed regular feeding,whereas only two of the dogs in the control group tolerated solid food intake.p H monitoring demonstrated that25%of the dogs in the experimental group exhibited reflux and that none had mucosal damage consistent with reflux.Conversely,both reflux and mucosal damage were observed in all dogs in the control group.CONCLUSION:The oesophageal flap valvuloplasty and wrapping suturing technique can improve the postoperative quality of life through the long-term elimination of reflux oesophagitis and decreased stricture formation after primary oesophageal anastomosis.

Oesophageal adenocarcinoma:In the era of extended lymphadenectomy,is the value of neoadjuvant therapy being attenuated?

BACKGROUND Neoadjuvant chemotherapy(NACT)and oesophagectomy is the standard of care for resectable oesophageal adenocarcinomas.Survival outcomes following resection have been improving over time while NACT remain largely unchanged.Indeed,a recent meta-analysis of randomized control trials did not demonstrate a survival benefit in adding NACT,raising the possibility that improved surgical techniques may be reducing the perceived effectiveness of NACT.AIM To compare the effect of addition of NACT to a standardized surgery and lymphadenectomy on overall and disease-free survival in patients undergoing curative oesophagectomy for oesophageal adenocarcinoma.METHODS Patient data were analysed from a prospectively maintained surgical survival database.Demographic,surgical,and survival outcomes were compared between groups according to treatment and nodal count.RESULTS The data of 243 consecutive patients were identified.79 patients were given NACT and 162 had surgery only.The NACT group were younger,and there was less frequent stage I adenocarcinoma.Overall survival was similar between NACT and surgery only groups(5YS:48.7%vs 42.5%;P=0.113),as was diseasefree survival(5YS:40.6%vs 39.9%;P=0.635).There were≥30 nodes removed in 46 patients,and<30 in 197 patients,but were otherwise similar.There was improved survival in patients with≥30 nodes removed than those with<30 nodes(5YS:64.4%vs 40.7%;P=0.015),and a better disease-free survival that neared significance(5YS:54.9%vs 36.6%;P=0.078).CONCLUSION NACT did not appear to affect overall or disease-free survival.However,an overall survival benefit was observed in patients with≥30 lymph nodes removed,and a benefit in disease-free survival which was not significant.

Feasibility of Home Jejunal Feeding Following Discharge after Major Gastrointestinal Surgery—A Randomised Controlled Trial

Purpose: Following major upper gastrointestinal surgeries, patients often struggle to eat after discharge from hospital. Home jejunal feeding is a potential nutrition support method, but few studies have explored such practice. The aim of this study is to quantitatively and qualitatively assess the feasibility of home jejunal feeding. Methods: Thirteen people having had major upper gastrointestinal surgeries were recruited and randomised into one of two isocaloric nutrition support interventions;oral supplement (OS) or jejunal feeding (JF), for one month post-discharge at home. Anthropometric, patient-generated subjective global assessment, food intake and quality of life surveys were collected at baseline, one month and three months post-discharge. Qualitative interviews were conducted with 6 participants after the three month review. Results: No statistically significant baseline differences were found between the two groups. At one month post-discharge, median weight loss was found to be significantly greater in OS group compared to JF group, 7.7% (inter-quartile range (IQR) = 7.3) and 0.5% (IQR = 3.5) respectively (p = 0.035). No significant differences were found in other parameters. Qualitative interviews showed positive feelings towards JF, while OS was deemed as not very helpful. Conclusions: This preliminary research shows the use of home JF is feasible when compared to oral nutrition support. This parallels with the limited existing literature, which indicate that JF is clinically beneficial. Larger studies are required to validate clinical and quality of life outcomes.

The Importance of Nutrition during Treatment for Oesophageal Cancer—The Patient’s Perspective

Background and Objectives: Nutritional issues are prevalent in patients with oesophageal cancer (OC) across all aspects of treatment, including chemoradiotherapy (CRT) and surgery. There are limited studies investigating nutritional issues faced by people undergoing neoadjuvant or definitive CRT from the patient’s perspective. This study aimed to explore the importance that people with OC place upon nutrition during their treatment which included neoadjuvant or definitive CRT, explore the nutritional issues faced in this patient group and identify areas for improvement of dietetic services. Methods and Study Design: Nine people who had undergone curative treatment for OC in the previous 2 - 25 months participated in semi-structured phone interviews. Interviews were tape-recorded and transcribed verbatim and analysed using an inductive thematic analysis approach. Results: Interviews revealed severe difficulties in food consumption during and following CRT and a period of struggling to adjust eating habits post oesophagectomy. There was significant difficulty in following nutrition advice and, despite participants expressing the importance of nutrition;this was not reflected in attitudes towards weight loss. The medical team significantly influenced the perceptions of some participants in regards to their weight loss. Conclusions: Implications for clinical practice include the need for dietetic services before, during and after treatment for OC, irrespective of treatment type. Patient education regarding detrimental effects of rapid weight loss and effects on body composition is crucial, and this should be consistent from all members of the healthcare team.