Introduction
Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical ...procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure.
Methods
A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system.
Results
Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure.
Conclusions
The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.
Background
The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer.
...Methods
Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics.
Results
During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %,
p
= 0.049) and 5-year mortality (61.5 % vs. 75.7 %,
p
= 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %,
p
< 0.001) and 5-year mortality (61.5 % vs. 90.8 %,
p
< 0.001).
Conclusions
This study showed that hepatectomy for synchronous gastric cancer hepatic metastases may carry survival benefits in selected patients. The data presented should not be a rationale to change current clinical practice but rather a stimulus to prospectively study the role of surgery in a selected group of patients who are currently treated with palliative chemotherapy.
The aim of this study was to develop a predictive model for overall survival after esophagectomy using pre/postoperative clinical data and machine learning.
For patients with esophageal cancer, ...accurately predicting long-term survival after esophagectomy is challenging. This study investigated survival prediction after esophagectomy using a RandomSurvival Forest (RSF) model derived from routine data from a large, well-curated, national dataset.
Patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales who underwent an esophagectomy were included. Prediction models for overall survival were developed using the RSF method and Cox regression from 41 patient and disease characteristics. Calibration and discrimination (time-dependent area under the curve) were validated internally using bootstrap resampling.
The study analyzed 6399 patients, with 2625 deaths during follow-up. Median follow-up was 41 months. Overall survival was 47.1% at 5 years. The final RSF model included 14 variables and had excellent discrimination with a 5-year time-dependent area under the receiver operator curve of 83.9% 95% confidence interval (CI) 82.6%-84.9%, compared to 82.3% (95% CI 81.1%-83.3%) for the Cox model. The most important variables were lymph node involvement, pT stage, circumferential resection margin involvement (tumor at < 1 mm from cut edge) and age. There was a wide range of survival estimates even within TNM staging groups, with quintiles of prediction within Stage 3b ranging from 12.2% to 44.7% survival at 5 years.
An RSF model for long-term survival after esophagectomy exhibited excellent discrimination and well-calibrated predictions. At a patient level, it provides more accuracy than TNM staging alone and could help in the delivery of tailored treatment and follow-up.
Locally advanced esophageal adenocarcinomas (EACs) are treated with multimodal therapy, namely surgery, neoadjuvant chemotherapy (NAC) or chemoradiotherapy (CRT) depending on patient and tumor level ...factors. Yet, there is little consensus on choice of the optimum systemic therapy. To compare the pathological complete response (pCR) after FLOT, non-FLOT-based chemotherapy and chemoradiotherapy regimes in patients with EACs. A systematic review of the literature was performed using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. Studies were included if they had investigated the use of chemo(radio)therapy regimens in the neoadjuvant setting for EAC and reported the pCR rates. A meta-analysis of proportions was performed to compare the pooled pCR rates between FLOT, non-FLOT and CRT cohorts. We included 22 studies that described tumor regression post-NAC. Altogether, 1,056 patients had undergone FLOT or DCF regimes, while 1,610 patients had received ECF or ECX. The pCR rates ranged from 3.3% to 54% for FLOT regimes, while pCR ranged between 0% and 31% for ECF/ECX protocols. Pooled random-effects meta-meta-analysis of proportions showed a statistically significant higher incidence of pCR in FLOT-based chemotherapy at 0.148 (95%CI: 0.080, 0.259) compared with non-FLOT-based chemotherapy at 0.074 (95%CI: 0.042, 0.129). However, pCR rates were significantly highest at 0.250 (95%CI: 0.202, 0.306) for CRT. The use of enhanced FLOT-based regimens have improved the pCR rates for chemotherapeutic regimes but still falls short of pathological outcomes from CRT. Further work can characterize clinical responses to neoadjuvant therapy and determine whether an organ-preservation strategy is feasible.
Oesophageal injury Antonowicz, Stefan; Maynard, Nick
Surgery (Oxford),
November 2020, 2020-11-00, Letnik:
38, Številka:
11
Journal Article
Recenzirano
Oesophageal injuries are rare, the majority being iatrogenic, spontaneous (Boerhaave's syndrome) or caustic. Partial thickness injuries are usually not serious, and heal. Due to its location, full ...thickness injuries of the oesophagus can have catastrophic consequences, leading to significant morbidity and sometimes death. Effective early treatment in experienced centres can lead to successful outcomes, although this relies on a low index of suspicion and rapid clinical recognition of this uncommon problem. Discussion with a specialist centre is mandatory, and it is usually appropriate to transfer the patient to such a centre. CT scan, contrast swallow and selective use of endoscopy by an experienced endoscopist are the investigations of choice, and a multidisciplinary approach to the management involving interventional radiology, interventional endoscopy and surgery will lead to the best outcomes.
Horton also seeks to condemn an “asymmetry of outrage”.1 We echo this sentiment but have drawn different conclusions of where and how this asymmetry has developed, with reference to persistent ...anti-Palestinian bias in reporting across influential media outlets, both in the past month,3 and extending across several decades.4 Of even greater concern are Horton's unsubstantiated claims that medical clinics in Gaza are “adorned with pictures of Saddam Hussein and Osama bin Laden”.1 This bizarre and dangerously timed statement risks encouraging people who seek to cause violence and attack essential health services. BK is a member of the Oxford Teaching Group; has travelled to Gaza to support medical education and training; and financially supports Medical Aid for Palestinians' medical and humanitarian work. NM is the Chairman of the board of trustees for the International Medical Education Trust (IMET) and receives contributions from IMET for travel to Gaza with the Oxford Teaching Group, and receives support from Medical Aid for Palestinians for travel to Gaza to conduct humanitarian work.
With the military operations of Israeli occupation forces focused to the north and on Gaza City, 70% of Gaza's population of 2·2 million people has been forced southwards, yet civilians fleeing (or ...already displaced) to the south have not been spared.3 What is most concerning is the disregard for international humanitarian law, under which hospitals and medical personnel are specifically protected. Over 51% of Gaza's education facilities have been bombed, including facilities run by UNRWA, where thousands of displaced people are seeking shelter.3 The deliberate targeting of hospitals, water tanks, oxygen production facilities, and solar panels and generators, while minimising essential medical supplies, food, water, and fuel from entering Gaza, has led to a total collapse of the health-care system in Gaza.4 This collapse has meant amputations have been performed without anaesthesia, burns debrided without pain relief, and surgery taking place under light from mobile phones. There is intense fighting around the Al-Shifa and Al-Quds hospitals, and Israeli forces have raided Al-Shifa Hospital and are interrogating patients and medical staff.5 Little or no access to power and oxygen is a potential death sentence for ventilated patients and premature babies in incubators, and in Al-Shifa Hospital, 32 patients (including six premature babies) have already died.4 As a medical community, we know our first responsibility is to save lives, a pledge we work to uphold wherever we are.
OBJECTIVE:Utilizing a standardized dataset with specific definitions to prospectively collect international data to provide a benchmark for complications and outcomes associated with esophagectomy.
...SUMMARY OF BACKGROUND DATA:Outcome reporting in oncologic surgery has suffered from the lack of a standardized system for reporting operative results particularly complications. This is particularly the case for esophagectomy affecting the accuracy and relevance of international outcome assessments, clinical trial results, and quality improvement projects.
METHODS:The Esophageal Complications Consensus Group (ECCG) involving 24 high-volume esophageal surgical centers in 14 countries developed a standardized platform for recording complications and quality measures associated with esophagectomy. Using a secure online database (ESODATA.org), ECCG centers prospectively recorded data on all resections according to the ECCG platform from these centers over a 2-year period.
RESULTS:Between January 2015 and December 2016, 2704 resections were entered into the database. All demographic and follow-up data fields were 100% complete. The majority of operations were for cancer (95.6%) and typically located in the distal esophagus (56.2%). Some 1192 patients received neoadjuvant chemoradiation (46.1%) and 763 neoadjuvant chemotherapy (29.5%). Surgical approach involved open procedures in 52.1% and minimally invasive operations in 47.9%. Chest anastomoses were done most commonly (60.7%) and R0 resections were accomplished in 93.4% of patients. The overall incidence of complications was 59% with the most common individual complications being pneumonia (14.6%) and atrial dysrhythmia (14.5%). Anastomotic leak, conduit necrosis, chyle leaks, recurrent nerve injury occurred in 11.4%, 1.3%, 4.7%, and 4.2% of cases, respectively. Clavien-Dindo complications ≥ IIIb occurred in 17.2% of patients. Readmissions occurred in 11.2% of cases and 30- and 90-day mortality was 2.4% and 4.5%, respectively.
CONCLUSION:Standardized methods provide contemporary international benchmarks for reporting outcomes after esophagectomy.
IntroductionThe risk of dysplasia and cancer increases with age in Barrett’s oesophagus. Advanced endoscopic therapy such as EMR and RFA is indicated in dysplasia and intramucosal cancer, but ...associated with higher risks in older patients. Little guidance is available as to when to stop endoscopic therapy and follow up. Here we summarise the outcomes of endoscopic therapy in the elderly (>80 years) in a tertiary centre.MethodsAll patients aged over 80 who underwent endoscopic therapy for Barrett’s since 2008 were selected. Their Electronic Patient Record (EPR) was searched to establish details and outcomes.ResultsSince 2008, 56 patients over 80 with Barrett’s underwent advanced endoscopic therapy after discussion at UGI MDT. Age range was 80 to 90 years. Only 14% of patients were female. Median Barrett’s length was C2M5. The majority of patients at the time of referral had high-grade dysplasia (57%). 13% had low grade dysplasia, 27% intramucosal cancer and 4% submucosal cancer. Histology at the time of first therapy showed that 8/56 (14%) had more invasive disease than expected and 8/56 (14%) had less invasive disease.75% underwent EMR first, 7% underwent RFA first and 18% had APC only. 18% were on anticoagulation with warfarin or DOAC, 4% on clopidogrel. There was no haemorrhage or perforation following therapy.59% achieved complete resolution of intestinal metaplasia (CR-IM) and 71% achieved complete resolution of dysplasia (CR-D) (table 1). of the 4 patients with submucosal cancer (2 identified pre-therapy and 2 identified post-therapy), 2 patients achieved complete resolution of dysplasia. 17 of the octogenarians died during the 14 year follow-up period with a median survival of 3 years after start of treatment. Only one died from oesophageal cancer and they presented with cancer at the time of first therapy.ConclusionsElderly patients were able to tolerate advanced endotherapy for Barrett’s well, with good resolution of metaplasia and/or dysplasia, similar to the UK Halo registry results in patients with a mean age of 67 years. In patients over 80 with advanced Barrett’s dysplasia or early cancer, in whom surgery is usually not suitable, advanced endotherapy should be considered in the context of their fitness and life expectancy.Abstract P141 Table 1Outcomes post therapy Total patients(n=56) Patients alive with continued follow-up(n=33) CR-IM 33 (59%) 27 (82%) CR-D 40 (71%) 29 (88%) Ongoing LGD 5 (9%) 2 (6%) Ongoing HGD 5 (9%) 2 (6%) Submucosal cancer 6 (11%) 1 (3%) Patient declined further OGD 2 (4%) - Endotherapy stopped due to clinical deterioration 4 (7%) - Lost to FU 2 (4%) - Died during FU period 17 (30%) -
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