Arul Immanuel

Management and outcomes of anastomotic leaks after oesophagectomy

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high‐volume institution that did not use stenting as a primary treatment modality.

The presence of lymphovascular and perineural infiltration after neoadjuvant therapy and oesophagectomy identifies patients at high risk for recurrence

Background:In patients treated for oesophageal cancer the importance of lymphovascular and perineural invasion (PNI) after neoadjuvant therapy has yet to be established. The aim of this study was to assess the incidence and prognostic significance of these factors in a consecutive series of patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) who underwent neoadjuvant therapy followed by oesophagectomy.Methods:Clinical and pathology results from patients with potentially curable adenocarcinoma, or squamous cell carcinoma of the oesophagus or GOJ were reviewed. Patients were treated with neoadjuvant chemotherapy or chemoradiation followed by transthoracic oesophagectomy and two-field lymphadenectomy. The presence of venous invasion (VI), lymph vessel invasion (LI) and perineural invasion (PNI) were correlated with clinical outcomes.Results:A total of 396 patients underwent oesophagectomy after neoadjuvant therapy for oesophageal cancer. Venous invasion was identified in 150 (38%) of patients, LI in 203 (51%) patients and PNI in 204 (52%) patients. In all, 123 (31%) patients had no evidence of either VI, LI or PNI. A total of 96 (24%) had a combination of two factors and 94 (24%) had all three factors. The presence of VI, LI and PNI was significantly related to tumour stage (P=0.001). Median overall survival was 170.8 months when all three factors were absent, 44.0 months when one factor was present, 27.1 months when two factors were present and 16.0 months when all were present. Multivariate analyses revealed VI, LI and PNI or a combination of these factors were independent predictors of prognosis.Conclusions:In oesophageal cancer patients treated with neoadjuvant therapy followed by oesophagectomy the presence of VI, LI and PNI has an important prognostic impact and may identify patients at high risk of recurrence who would benefit from adjuvant therapies.

Prognostic Significance of the Location of Lymph Node Metastases in Patients With Adenocarcinoma of the Distal Esophagus or Gastroesophageal Junction

Objective: To identify the prognostic significance of the location of lymph node metastases in patients with esophageal or gastroesophageal junction (GEJ) adenocarcinoma treated with neoadjuvant therapy followed by esophagectomy. Background: Detection of lymph node metastases in the upper mediastinum and around the celiac trunk after neoadjuvant therapy and resection does not alter the TNM classification of esophageal carcinoma. The impact of these distant lymph node metastases on survival remains unclear. Methods: Between March 2003 and September 2013, 479 consecutive patients with adenocarcinoma of the distal esophagus or GEJ who underwent transthoracic esophagectomy with en bloc 2-field lymphadenectomy after neoadjuvant therapy were included, and survival was analyzed according to the location of positive lymph nodes in the resection specimen. Results: Two hundred fifty-three patients had nodal metastases in the resection specimen. Of these patients, 92 patients had metastases in locoregional nodes, 114 patients in truncal nodes, 21 patients in the proximal field of the chest, and 26 patients had both positive truncal and proximal field nodes. Median disease-free survival was 170 months in the absence of nodal metastases, 35 months for metastases limited to locoregional nodes, 16 months for positive truncal nodes, 15 months for positive nodes in the proximal field, and 8 months for nodal metastases in both truncal and the proximal field. On multivariate analysis, location of lymph node metastases was independently associated with survival. Conclusions: Location of lymph node metastases is an independent predictor for survival. Relatively distant lymph node metastases along the celiac axis and/or the proximal field have a negative impact on survival. Location of lymph node metastases should therefore be considered in future staging systems of esophageal and GEJ adenocarcinoma.

Management and outcomes of leaks after oesophagectomy

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high‐volume institution that did not use stenting as a primary treatment modality.

Barrett's Adenocarcinoma 52 Years After Subtotal Esophagectomy for Pediatric Peptic Stricture

Barretts esophagus results from the long-term effects of both acid and bile reflux. After subtotal esophagectomy and reconstruction with a gastric tube, many patients experience profound reflux. Development of Barretts epithelium in the esophageal remnant has been reported. Here we report the case of a man who was diagnosed with adenocarcinoma in his esophageal remnant on a background of Barretts change 52 years after undergoing one of the first esophageal resections for benign disease as a child.

Trainee Involvement in Ivor Lewis Esophagectomy Does Not Negatively Impact Outcomes

Objective: The aim of the present study was to determine whether trainee involvement in esophageal cancer resection is associated with adverse patient outcomes. Background: Operative experience for surgical trainees is under threat. A number of factors have been implicated in this leading to fewer hours for training. Esophagogastric cancer training is particularly vulnerable due to the publication of individual surgeon results and a perception that dual consultant operating improves patient outcomes. Resectional surgery is increasingly viewed as a subspeciality to be developed after completion of the normal training pathway. Methods: Data from a prospectively maintained database of consecutive patients undergoing trans-thoracic esophagectomy for potentially curable carcinoma of the esophagus or gastroesophageal junction were reviewed. Patients were divided into 4 cohorts, according to whether a consultant or trainee was the primary surgeon in either the abdominal or thoracic phase. Outcomes including operative time, lymph node yield, blood loss, complications graded by Accordion score, and mortality were recorded. Results: A total of 323 patients underwent esophagectomy during 4 years. The overall in-hospital mortality rate was 1.5%. At least 1 phase of the surgery was performed by a trainee in 75% of cases. There was no significant difference in baseline demographics of age, stage, neoadjuvant treatment, and histology between cohorts. There was no significant difference in blood loss (P = 0.8), lymph node yield (P = 0.26), length of stay (P = 0.24), mortality, and complication rate according to Accordion scores (P = 0.21) between cohorts. Chest operating time was a median 25 minutes shorter when performed by a consultant (P < 0.001). Conclusions: These findings demonstrate that patient outcomes are not compromised by supervised trainee involvement in transthoracic esophagectomy. Training is an essential role of all surgical units and training data should be more widely reported especially in areas of high-risk surgery.

Systemic inflammatory markers and outcome in patients with locally advanced adenocarcinoma of the oesophagus and gastro-oesophageal junction

Raised levels of systemic inflammatory markers are associated with poor survival in patients with cancer. The aim of this study was to assess the prognostic value of markers of systemic inflammation in patients with adenocarcinoma of the oesophagus or gastro‐oesophageal junction.

Prognostic impact of extracapsular lymph node involvement after neoadjuvant therapy and oesophagectomy.

The significance of extracapsular lymph node involvement (LNI) is unclear in patients with oesophageal cancer who have undergone neoadjuvant treatment followed by oesophagectomy. The aim of this study was to assess the incidence and prognostic significance of extracapsular LNI in a large multicentre series of consecutive patients with oesophageal cancer treated by neoadjuvant chemotherapy or chemoradiotherapy and surgery.

Surgical Management of Gastric Gastrointestinal Stromal Tumours: Comparison of Outcomes for Local and Radical Resection

Gastrointestinal stromal tumours (GISTs) most commonly originate from the stomach. Their treatment is dependent on size and whether they are symptomatic. Curative treatment requires surgery, which may be preceded by neoadjuvant imatinib if it is felt that this will aid in achieving clear (R0) resection margins. The aim of this study was to evaluate outcomes from patients that underwent a “local” organ-preserving operation, with those that required a more radical resection, and the influences on selecting a more radical resection. A retrospective review of patients undergoing surgery for symptomatic gastric GISTs from a single institution over 9 years was carried out. Patients were divided into three cohorts dependent on whether they had a “local” resection, “anatomical” resection, or “extended” resection. 71 patients were included. Overall, 5-year survival was 92%. Operating time, blood loss, and length of stay were significantly lower in the group undergoing local resection (p < 0.05). Tumour size was also smaller in the local group (median 4 cm versus 5 cm p < 0.05). Tumour location also influenced the type of surgery performed, with tumours at the cardia, gastroesophageal junction, and antrum all having “anatomical” resections. Lymphadenectomy did not appear to impact on outcomes. These findings indicate that local excision, where possible, does not impair oncological outcomes.

PTH-159 The relevance of lymph node metastases in the proximal field of the chest in patients with adenocarcinoma of the gastro-oesophageal junction treated with neoadjuvant therapy followed by transthoracic oesophagectomy

Introduction The prognosis of gastroesophageal junction adenocarcinoma is unquestionably related to the extent of nodal involvement. Not only the amount of positive lymph nodes but also the location of postive nodes negatively influence survival. Earlier small studies revealed a poor survival for patients with positive nodes in the proximal field of the chest when treated with surgery alone. It is thus far unknown what the relevance of these nodes is after neoadjuvant therapy. The aim of the present study was to identify the incidence and prognostic significance of lymph node metastases in the proximal part of the chest in patients who underwent a transthoracic oesophagectomy after neoadjuvant therapy. Method From a prospectively collected database, a consecutive series of patients in two high volume centres in Europe was analysed. All patients with potentially curable adeno carcinoma of the gastro-oesophageal junction were treated with neoadjuvant chemo (radiation)therapy therapy followed by transthoracic oesophagectomy and two-field lymphadenectomy. Results Between January 2000 and September 2013 a consecutive series of 208 patients underwent an oesophagectomy after neoadjuvant therapy for adenocarcinoma of the gastro-oesophageal junction. 80 (38.5%) patients had no evidence of lymph node metastases (N0). There were 128 patients (61.5%) with positive nodes (N1=41 (19.7%), N2=44 (21.2%), N3=43 (20.7%)). Of the node positive patients, 25 (19.5%) had positive nodes in the proximal field of the chest (paratracheal, subcarinal, bronchial and aorto-pulmonary window lymph nodes). More advanced N-stage was significantly associated with positive nodes in the proximal field of the chest (p < 0.001). Median survival was significantly (p = 0.003) worse for patients with positive nodes in the proximal part of the chest (12.4 months (95% CI: 11.4–13.32)) compared with patients with positive nodes on other locations (28.3 months (95% CI: 22.7–33.9)). Conclusion Lymph node metastases in the proximal part of the chest in patients is a common phenomonemon and a sign of advanced disease. Radical surgical resection can only be achieved with an extended transthoracic resection. Even after neoadjuvant therapy followed by transthoracic resection long-term survival is poor. Disclosure of interest None Declared.