The aim of the study was to evaluate laser-assisted fluorescent-dye angiography (LAA) to assess perfusion in the gastric graft and to correlate perfusion with subsequent anastomotic leak.
Anastomotic ...leaks are a major source of morbidity after esophagectomy with gastric pull-up (GPU). In large part, they occur as a consequence of poor perfusion in the gastric graft.
Real-time intraoperative perfusion was assessed using LAA before bringing the graft up through the mediastinum. When there was a transition from rapid and bright to slow and less robust perfusion, this site was marked with a suture. The location of the anastomosis relative to the suture was noted and the outcome of the anastomosis ascertained by retrospective record review.
Intraoperative LAA was used to assess graft perfusion in 150 consecutive patients undergoing esophagectomy with planned GPU reconstruction. An esophagogastric anastomosis was performed in 144 patients. A leak was found in 24 patients (16.7%) and were significantly less likely when the anastomosis was placed in an area of good perfusion compared with when the anastomosis was placed in an area of less robust perfusion by LAA (2% vs 45%, P < 0.0001). By multivariate analysis perfusion at the site of the anastomosis was the only significant factor associated with a leak.
Intraoperative real-time assessment of perfusion with LAA correlated with the likelihood of an anastomotic leak and confirmed the critical relationship between good perfusion and anastomotic healing. The use of LAA may contribute to reduced anastomotic morbidity.
Background To determine the optimal follow-up strategy after esophagectomy for adenocarcinoma of the esophagus or gastroesophageal junction by evaluating the timing of recurrence and the method that ...first detected the recurrence. Study Design Between 1991 and 2007, 590 patients had an esophagectomy for adenocarcinoma. Recurrence occurred in 233 (40%) and, of those, 174 had complete follow-up at our center with a protocol that consisted of an office visit with CT scans and laboratory studies every 3 months for 3 years, every 6 months for 2 years, and then annually. A subset of patients had PET annually. Results Recurrence in the 174 patients with complete follow-up was systemic in 104 (60%), locoregional/nodal in 51 (30%), and both in 19 (10%). Recurrence was first suspected by symptoms and/or physical examination in 29 patients (17%), by CT scan in 105 (60%), PET in 32 (18%), and by elevated CEA in 8 (5%). Recurrence was detected at a median of 11 months (range 3 to 72 months) and occurred later after esophagectomy alone compared with patients who received neoadjuvant therapy (12 versus 8 months; p = 0.01), but the pattern of recurrence was similar. More than 90% of recurrences were detected within 2 years after neoadjuvant therapy, compared with 3 years after esophagectomy alone. Median survival after recurrence was 7 months and was significantly longer in patients treated for the recurrence (9 versus 3 months; p = 0.001). Conclusions Frequent early follow-up is appropriate after esophagectomy for adenocarcinoma because >90% of recurrences will occur by 3 years after esophagectomy alone and by 2 years following neoadjuvant therapy. Beyond these time periods, 2% to 3% of recurrences were detected each year, suggesting that annual follow-up is adequate. Survival after recurrence was improved with therapy, confirming the use of careful follow-up in these patients.
Surveillance, Epidemiology and End Results (SEER) data indicate that number of lymph nodes removed impacts survival in gastric cancer. Our aim was to study this relationship in esophageal cancer.
The ...study population included 2303 esophageal cancer patients (1381 adenocarcinoma, 922 squamous) from 9 international centers that had R0 esophagectomy prior to 2002 and were followed at regular intervals for 5 years or until death. Patients treated with neoadjuvant or adjuvant therapy were excluded.
Operations consisted of esophagectomy with (1700) and without (603) thoracotomy. Median number of nodes removed was 17 (IQR10-29). There were 508 patients with stage I, 853 stage II, and 942 stage III. Five-year survival was 40%. Cox regression analysis showed that the number of lymph nodes removed was an independent predictor of survival (P < 0.0001). The optimal threshold predicted by Cox regression for this survival benefit was removal of a minimum of 23 nodes. Other independent predictors of survival were the number of involved nodes, depth of invasion, presence of nodal metastasis, and cell type.
The number of lymph nodes removed is an independent predictor of survival after esophagectomy for cancer. To maximize this survival benefit a minimum of 23 regional lymph nodes must be removed.
Over the past 50 years there has been a remarkable change in the epidemiology of esophageal cancer. Previously rare, adenocarcinoma of the esophagus and gastroesophageal junction is now the most ...common esophageal cancer, and in the United States the incidence is increasing faster than that of any other malignancy. Surveillance in patients with Barrett's esophagus is identifying adenocarcinoma at an earlier, more curable stage in many patients, and at the same time new endoscopic and surgical options are available for the therapy of these localized tumors.
This article is a review of the epidemiology, diagnosis, staging, and treatment options for esophageal and gastroesophageal junction adenocarcinoma.
The epidemiology, prognosis, patterns of lymphatic metastasis, and survival for esophageal and gastroesophageal junction adenocarcinoma suggest that these tumors are similar. New options for therapy, as well as the results of surgical resection with and without chemoradiotherapy, are reviewed.
Surveillance programs for Barrett's are identifying patients with early, curable adenocarcinoma of the esophagus or gastroesophageal junction. Therapy for more advanced tumors hinges on local control of the disease and the eradication of systemic metastases.
Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient ...with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.
Background
Peroral endoscopic myotomy (POEM) is a novel operation for the treatment of achalasia and other esophageal motility disorders. While POEM has shown excellent short-term safety and ...efficacy, the long-term symptomatic outcomes after the procedure are unknown.
Methods
Patients from a single center that underwent POEM for treatment of esophageal motility orders and were greater than 5 years removed from their operation were studied. Patients were contacted to assess current symptoms and encouraged to undergo repeat endoscopy for objective follow-up.
Results
Thirty-six patients underwent POEM from October, 2010 to February, 2012 and current symptom scores were obtained from 29 patients at median 65-month follow-up. In the 23 patients with achalasia, Eckardt scores were significantly improved from preoperative baseline (mean current 1.7 vs. preoperative 6.4,
p
< 0.001). Nineteen patients (83%) with achalasia had a symptomatic success (Eckardt ≤3) and none required retreatment for symptoms. Eckardt scores were dramatically improved at 6 months and maintained at 2 years; however, there was a small but significant worsening of symptoms between 2 and 5-years. Of the five patients with EGJ outflow obstruction, all had current Eckardt scores ≤3 but two needed reintervention for persistent or recurrent symptoms, one with a laparoscopic Heller myotomy and another with an endoscopic cricomyotomy and proximal esophageal myotomy extension. At 6-month follow-up, repeat manometry showed decreased EGJ relaxation pressures and esophagram demonstrated improved emptying. 24-h pH monitoring showed abnormal distal esophageal acid exposure in 38% of patients. Fifteen patients underwent endoscopy at 5-years, revealing erosive esophagitis in two (13%), new hiatal hernia in two, and new non-dysplastic Barrett’s esophagus in one. The patient with Barrett’s underwent a subsequent laparoscopic hiatal hernia repair and Toupet fundoplication.
Conclusions
POEM resulted in a successful palliation of symptoms in the majority of patients after 5 years, though these results emphasize the importance of long-term follow-up in all patients.
Objective The aim of this study was to evaluate alimentary satisfaction, gastrointestinal symptoms, and quality of life ≥10 years after esophagectomy with gastric pull-up. Methods Patients who had ...undergone esophagectomy with gastric pull-up before 2003 were interviewed regarding their alimentary function and completed the Gastrointestinal Quality of Life and RAND short-form, 36-item, questionnaires. Results We identified 67 long-term survivors after esophagectomy and gastric pull-up. Of these, 40 were located, and all agreed to participate. The median age was 75 years, and the median follow-up period was 12 years (interquartile range, 10-19). Most patients (88%) had no dysphagia, 90% were able to eat ≥3 meals/day, and 93% finished ≥50% of a typical meal. The mean alimentary comfort rating was 9 of 10. Dumping, diarrhea ≥3 times/day, or regurgitation occurred in 33% of patients. Six patients (15%) had aspiration episodes requiring hospitalization. The median weight loss after surgery was 26 lbs, and the current median body mass index was 25 kg/m2 . Only 2 patients were underweight (body mass index, <18.5 kg/m2 ). The median Gastrointestinal Quality of Life score was 2.9 of 4. The RAND scores were at the population mean in 1 category (physical function) and above the normal mean in the remaining 7 categories. Conclusions Long-term nutritional status, quality of life, and satisfaction with eating were excellent after esophagectomy with gastric pull-up. Gastrointestinal side effects were common, but serious complications such as aspiration were uncommon. Pessimism regarding the long-term ability to enjoy a meal and live with a good quality of life after esophagectomy is unwarranted.
Background Esophagectomy has been the traditional therapy for high-grade dysplasia and intramucosal adenocarcinoma. New endoscopic approaches allow treatment of these lesions with esophageal ...preservation. The aim of this study was to compare the outcome of endoscopic therapy with esophagectomy for high-grade dysplasia and intramucosal cancer. Methods A retrospective review was performed of all patients treated for high-grade dysplasia or intramucosal adenocarcinoma from 2001 to April 2010. Results Endoscopic therapy was performed in 40 patients (high-grade dysplasia = 22, intramucosal cancer = 18) and esophagectomy in 61 patients (high-grade dysplasia = 13, intramucosal cancer = 48). Endotherapy consisted of 102 endoscopic resections and 79 mucosal ablations (median 3 interventions per patient). In the endotherapy group, intramucosal cancer was completely resected in all patients. At last assessment, 10 patients have been converted to intestinal metaplasia without dysplasia and 21 to no residual intestinal metaplasia. Five patients have follow-up biopsy procedures pending after recent ablation, and esophagectomy was performed in 3 patients for failed endotherapy. A laparoscopic Nissen fundoplication has been performed in 8 patients after eradication of intestinal metaplasia. Esophagectomy resected the mucosal disease with negative margins in all patients. Compared with esophagectomy, endotherapy was associated with significantly lower morbidity (39% vs 0; P < .0001) and similar survival (94% at 3 years in both groups; median follow-up 34 months after esophagectomy vs 17 months after endotherapy; P = .0026). Conclusions Endoscopic therapy for high-grade dysplasia or intramucosal cancer has lower morbidity than an esophagectomy and similar survival during short-term follow-up, but required multiple procedures in most patients. Both therapies are appropriate options, but preservation of the esophagus allows the option of a fundoplication for reflux control, perhaps further improving long-term quality of life.
Objective The Siewert classification system differentiates between adenocarcinoma of the gastroesophageal junction and that of the distal esophagus. The purpose of this study was to evaluate whether ...there were differences in the location and prevalence of lymph node metastases, type of recurrence, and survival with these tumors that warrant distinguishing between them in clinical practice. Methods Records of all patients who underwent resection for adenocarcinoma of the distal esophagus or gastroesophageal junction from 1987 to 2007 were retrospectively reviewed. Based on the endoscopic location of the epicenter of the tumor in relation to the gastroesophageal junction, tumors were categorized in 301 patients as being of the distal esophagus and in 208 as being of the gastroesophageal junction. Results There were no significant differences in age, sex, or body mass index between patients with adenocarcinoma of the distal esophagus or gastroesophageal junction. Patients with adenocarcinoma of the distal esophagus were more likely to have reflux symptoms (75% vs 53%, P < .0001) and peritumoral intestinal metaplasia (73% vs 51%, P < .0001) and be in a surveillance program (54% vs 9%, P = .0005) compared with patients with adenocarcinoma of the gastroesophageal junction. However, the prevalence and location of nodal metastases was similar, and in node-positive patients mediastinal node involvement was present in more than 40% of the patients in each group (distal esophageal adenocarcinoma, 47%; gastroesophageal junction adenocarcinoma, 41%). Survival was similar (5 years: distal esophageal adenocarcinoma, 45%; gastroesophageal junction adenocarcinoma, 38%; P = .14), as was the prevalence and type of recurrence. Conclusion The prevalence and distribution of lymph node metastases in patients with adenocarcinoma of the distal esophagus and gastroesophageal junction were similar, and after esophagectomy, there was no difference in overall survival or recurrence. Efforts to differentiate between these tumors are unnecessary, and both are effectively treated with esophagectomy.
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