Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity.
Although ...the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival.
Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival.
A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication ie, (re)intervention, organ dysfunction, or death. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found.
The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.
Background
The impact of total minimally invasive esophagectomy (MIE) on early postoperative outcome and patient’s survival is a matter of recent discussion.
Methods
We performed a 1:2 propensity ...score-matched comparison of 20 patients who underwent 3D-MIE and high intrathoracic esophagogastrostomy with 40 patients who underwent hybrid esophagectomy (HYBRID) with laparoscopic gastric mobilization and open transthoracic esophagectomy and the same anastomosis for esophageal adenocarcinoma in 2014 and 2015. Matching criteria were tumor localization, age, gender, and neoadjuvant treatment.
Results
Both groups did not differ regarding overall postoperative complications (MIE 55% vs. HYBRID 50%,
p
= 0.715) and anastomotic leakage (MIE 15% vs. HYBRID 5%,
p
= 0.186). A significant difference was seen regarding the rate of postoperative pneumonia (MIE 5% vs. HYBRID 27.5%;
p
= 0.040) and the postoperative ICU stay (MIE median 1 day vs. HYBRID median 2 days,
p
< 0.001). The R0-resection rate was 100% in both groups and median number of dissected lymph nodes was 32 for MIE and 35 for HYBRID (
p
= 0.236). Significant differences between both groups were noticed for postoperative number of patients with use of opiate demand medication and numeric rating scale for pain (NRSP maximum pain, median) both in favor of the MIE group (MIE 25%, NRSP 2 vs. HYBRID 60%, NRSP 4;
p
= 0.011,
p
< 0.001). Overall 2-year survival rate was 85% in both groups.
Conclusion
Total minimally invasive esophagectomy is superior to hybrid esophagectomy in regard of postoperative pain and rate of pneumonia. No differences exist for postoperative surgical complications or short-term prognosis.
Postoperative complications represent a major public health burden worldwide. Without standardized, clinically relevant and universally applied endpoints, the evaluation of surgical interventions ...remains ill-defined and inconsistent, opening the door for biased interpretations and hampering patient-centered health care delivery. We conducted a Jury-based consensus conference incorporating the perspectives of different stakeholders, who based their recommendations on the work of nine panels of experts. The recommendations cover the selection of postoperative outcomes from the perspective of patients and other stakeholders, comparison and interpretation of outcomes, consideration of cultural and demographic factors, and strategies to deal with unwarranted outcomes. With the recommendations developed exclusively by the Jury, we provide a framework for surgical outcome assessment and quality improvement after medical interventions, that integrates the main stakeholders' perspectives.
Serious games enable the simulation of daily working practices and constitute a potential tool for teaching both declarative and procedural knowledge. The availability of educational serious games ...offering a high-fidelity, three-dimensional environment in combination with profound medical background is limited, and most published studies have assessed student satisfaction rather than learning outcome as a function of game use.
This study aimed to test the effect of a serious game simulating an emergency department ("EMERGE") on students' declarative and procedural knowledge, as well as their satisfaction with the serious game.
This nonrandomized trial was performed at the Department of General, Visceral and Cancer Surgery at University Hospital Cologne, Germany. A total of 140 medical students in the clinical part of their training (5th to 12th semester) self-selected to participate in this experimental study. Declarative knowledge (measured with 20 multiple choice questions) and procedural knowledge (measured with written questions derived from an Objective Structured Clinical Examination station) were assessed before and after working with EMERGE. Students' impression of the effectiveness and applicability of EMERGE were measured on a 6-point Likert scale.
A pretest-posttest comparison yielded a significant increase in declarative knowledge. The percentage of correct answers to multiple choice questions increased from before (mean 60.4, SD 16.6) to after (mean 76.0, SD 11.6) playing EMERGE (P<.001). The effect on declarative knowledge was larger in students in lower semesters than in students in higher semesters (P<.001). Additionally, students' overall impression of EMERGE was positive.
Students self-selecting to use a serious game in addition to formal teaching gain declarative and procedural knowledge.
Background
Gastroparesis (GP) occurs in patients after upper gastrointestinal surgery, in patients with diabetes or systemic sclerosis and in idiopathic GP patients. As pyloric dysfunction is ...considered one of the underlying mechanisms, measuring this mechanism with EndoFLIP™ can lead to a better understanding of the disease.
Methods
Between November 2021 and March 2022, we performed a retrospective single-centre study of all patients who had non-surgical GP, post-surgical GP and no sign of GP after esophagectomy and who underwent our post-surgery follow-up program with surveillance endoscopies and further exams. EndoFLIP™ was used to perform measurements of the pylorus, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling.
Results
We included 66 patients, and successful application of the EndoFLIP™ was achieved in all interventions (
n
= 66, 100%). We identified 18 patients suffering from non-surgical GP, 23 patients suffering from GP after surgery and 25 patients without GP after esophagectomy. At 40, 45 and 50 ml balloon filling, the mean distensibility in gastroparetic patients was 8.2, 6.2 and 4.5 mm
2
/mmHg; 5.4, 5.1 and 4.7 mm
2
/mmHg in post-surgical patients suffering of GP; and 8.5, 7.6 and 6.3 mm
2
/mmHg in asymptomatic post-surgical patients. Differences between symptomatic and asymptomatic patients were significant.
Conclusion
Measurement with EndoFLIP™ showed that asymptomatic post-surgery patients seem to have a higher pyloric distensibility. Pyloric distensibility and symptoms of GP seem to correspond.
Background
The aim of this retrospective study was to compare the prognosis of patients with esophageal cancer after non-curative endoscopic resection (ER) followed by esophagectomy (ER + S) with ...that of patients after primary surgery (PS).
Methods
Between 2000 and 2015, 287 patients had esophagectomy for T1 esophageal cancer. 81 of these patients underwent at least one ER in curative intention before surgery (7 squamous cell carcinomas, 74 adenocarcinomas). Indications for esophagectomy were R1-resection, submucosal infiltration, multifocality, long-segment Barrett esophagus, recurrence, postinterventional stenosis or a combination of these factors. Using propensity-score matching with gender, age, year of diagnosis, tumor localization, mucosal/submucosal infiltration and histology, the clinicopathologic and survival data of these patients were compared to those of 81 patients after PS (median follow-up: 5.5 years).
Results
There were no significant differences between both groups concerning number of resected lymph nodes and percentage of nodal metastasis (9.3% total). 9% of esophagectomy specimens after ER showed pT2/pT3-tumors. The 5-year survival rate was 86% in the PS and 85% in the ER + S group (
p
= 0.498). The disease-free survival was 85% in patients with ER + S and 98% in PS (
p
< 0.005). The recurrence rate after esophagectomy was higher after ER + S compared to PS (
p
= 0.015). More than 3 months time delay between ER and surgery was associated with reduced survival, but only within the first postinterventional year.
Conclusions
As the disease-free survival was inferior in the ER + S compared to the PS group the indication for ER, especially repeated ERs, should be restricted to cases with high expectation of success.
Currently 4 surgical techniques are performed for transthoracic esophagectomy (open esophagectomy (OE), hybrid esophagectomy (HE), conventional minimally invasive esophagectomy (MIE) and robot ...assisted minimally invasive esophagectomy (RAMIE). Aim of this study was to compare these 4 different esophagectomy approaches regarding postoperative complications and short term oncologic outcomes.
Between 2008 and 2019, consecutive patients who underwent esophagectomy with gastric conduit reconstruction were included in this single center study. The primary outcome of this study was the incidence of postoperative complications.
Overall 422 patients (OE (n = 107), HE (n = 101), MIE (n = 91) and RAMIE (n = 123)) were evaluated. Uncomplicated postoperative course was observed in 27% (OE), 34% (HE), 53% (MIE), and 63% (RAMIE) of patients (p < 0.001). Pulmonary complications were observed in 57% (OE), 44% (HE), 28% (MIE), and 21% (RAMIE) of patients (p < 0.001). Cardiac complications were present in 25% (OE), 23% (HE), 9% (MIE), and 11% (RAMIE) of patients (p < 0.001). MIE and RAMIE were associated with fewer wound infections (p < 0.001). Median hospital stay after MIE (13 days) and RAMIE (12 days) was shorter compared to OE (20 days) and HE (17 days) (p < 0.001). A median number of 21 (OE), 23 (HE), 23 (MIE), and 31 (RAMIE) lymph nodes was harvested (p < 0.001).
Total minimally invasive esophagectomy (MIE, RAMIE) was associated with a lower overall, pulmonary, cardiac and wound complication rate as well as a shorter hospital stay compared to open or hybrid approach (OE, HE). RAMIE resulted in higher lymph node harvest than MIE.
Abstract
Background
Two multimodal strategies are available for the treatment of esophageal cancer: neoadjuvant chemotherapy (CT) and chemoradiotherapy (CTRT). The higher rate of pathological ...complete response (pCR) after CTRT is an argument to support this treatment. However, previous studies have failed to demonstrate a survival benefit of CTRT for adenocarcinoma (ADC) and the correlation between pathological tumor response (pTR) and survival is unclear.
Methods
This multicenter retrospective cohort study included data from 2 high-volume centers. Only patients with ADC who underwent CT or CTRT and surgery between 2012 and 2019 were included. The correlation between pTR and survival after both treatments was evaluated using Kaplan–Meier analysis. The 5-year overall (OS) and disease-free survivals (DFS) of patients showing pCR after the 2 treatments were compared. pTR was assessed using the Mandard tumor regression grade (TRG).
Results
Overall, 424 patients were included, 236 received CT and 188 CTRT. The incidence of pCR was 12.7% in the CT group and 26.1% after CTRT (p = 0.0005). At 5-years the OS rate after CT was 85.6% for TRG1 patients, 75.5% for TRG2, 57% for TRG3 and 42% for TRG4–5 (p = 0.004). After CTRT it was 72.8% for TRG1, 60.8% for TRG2, 39% for TRG3 and 27% for TRG4–5 (p = 0.0003) (figure 1). The OS of patients with pCR was not significantly different after CT and CTRT (p = 0.65). The 5-years DFS of pCR patients was higher in the CT group (86% vs. 70%, p = 0.05).
Conclusion
Despite a lower rate of pCR, both OS and, especially, DFS of pCR patients were improved after CT compared to CTRT. TRG showed to be significantly associated with survival in both treatment groups. The effectiveness of long-term disease control after CT and CTRT should be further analyzed in ADC.
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