C. Doddoli

Respiratory complications after oesophagectomy for cancer do not affect disease-free survival

OBJECTIVES Recent studies have suggested that postoperative complications could have a potential negative effect on long-term outcome after oesophagectomy for cancer. Because respiratory failures represent the most frequent postoperative complication, we have investigated the prognostic impact of these complications on disease-free survival (DFS). METHODS From a prospective single-institution database of 405 consecutive patients who underwent transthoracic oesophagectomy for cancer, we retrospectively analysed medical charts of all patients with microscopically complete resection (R0, n = 384 patients). Complications were graded according to the modified Clavien classification. Respiratory complications were defined as atelectasis, pneumonia or acute respiratory distress syndrome in the absence of early surgical complications. Patients with grade 5 (postoperative mortality, n = 43, 11%) were excluded from the analysis. The remaining 341 patients were analysed for estimation of DFS according to the Kaplan-Meier method. Logistic regression analysis was conducted to discriminate predictive factors affecting DFS. RESULTS According to the modified Clavien classification, postoperative complications rates were grade 0: 147 (44%), grade 1: 7 (2%), grade 2: 56 (16%), grade 3: 69 (20%) and grade 4: 62 (18%). Five-year DFS rates were not significantly different between grade 0 (no complication, 38%, n = 147) and other grades (grade 1, 2, 3 and 4 (64, 45, 56 and 48%, respectively)). Respiratory complications occurred in 107 patients (31%) and the 5-year DFS in this subgroup was 47% compared with 38% observed in grade 0 patients (P = 0.75). Clavien classification and respiratory complications did not come out in the univariate analysis of factors affecting DFS. On logistic regression, only two variables affected DFS: c-N stage and extracapular lymph node involvement. CONCLUSIONS When postoperative mortality is excluded, postoperative complications do not affect DFS in patients with complete resection. This deserves substantial information regarding the prognosis of subgroup of patients in critical situations where incrementing intensive care is debated.

Body mass index kinetics and risk factors of malnutrition one year after radical oesophagectomy for cancer

OBJECTIVE Malnutrition is common after oesophageal cancer surgery. This study aims to investigate body mass index (BMI) kinetics and the risk factors of malnutrition among 1-year disease-free survivors after radical transthoracic oesophagectomy for cancer. METHODS From a prospective single-institution database, 118 1-year disease-free survivors having undergone a R0 transthoracic oesophagectomy with gastric tubulization between 2000 and 2008 were identified retrospectively. BMI values were collected at the onset of the disease (pre-treatment BMI), at the time of surgery (preoperative BMI), at postoperative 6 months and 1 year after oesophagectomy (1-year BMI). Logistic regression was performed with adjustment for confounders to estimate odds ratios of the factors associated with a 1-year weight loss (WL) of at least 15% of the pre-treatment body weight (BW). RESULTS At the onset of the disease, 5 patients (4%) were underweighted (BMI < 8.5 kg/m²), 65 (55%) were normal (BMI = 18.5-24.9 kg/m²), 36 (31%) were overweighted (BMI > 25 kg/m²) and 12 (10%) were obese (BMI > 30 kg/m²). Mean pre-treatment, preoperative, postoperative 6-month and 1-year BMI values were 24.64 ± 4 kg/m², 23.55 ± 3.8 kg/m², 21.7 ± 3 kg/m² and 21.97 ± 4 kg/m², respectively. One-year WL ≥ 15% of the pre-treatment BW was present in 29 patients (25%): 18 among the 48 patients (37%) with a pre-treatment BMI ≥ 25 and 11 among the 70 patients (15%) with pre-treatment BMI < 25 (P = 0.006). On logistic regression, initial overweighting was the sole independent prognosticator of 1-year postoperative WL of at least 15% of the pre-treatment BW (P = 0.039; OR: 2.96, [1.06-8.32]). CONCLUSIONS Postoperative malnutrition remains a severe problem after oesophageal cancer resection, even in long-term disease-free survivors. Overweight and obese patients are the segment population most exposed to this postoperative malnutrition, suggesting that such surgery could have substantial bariatric effect. A special vigilance programme on the nutritional status of this sub-group of patients should be the rule.

Adenocarcinoma of the esophagus and esophagogastric junction in patients older than 70 years: Results of neoadjuvant radiochemotherapy followed by transthoracic esophagectomy

AIM The standard treatment of locally-advanced esophageal adenocarcinoma consists of neoadjuvant radiochemotherapy followed by surgical resection. Very little data are available concerning the feasibility of this strategy in patients older than 70 years of age. PATIENTS AND METHODS Between 1996 and 2008, 118 patients underwent transthoracic esophagectomy with lymphadenectomy for adenocarcinoma of the esophagus and gastric cardia (Siewert I and II). These were divided into three groups for comparison: Group I (age less than 70 years, neoadjuvant treatment followed by surgery; n=66); Group II (age greater or equal to 70 years, surgery alone; n=32); Group III (age greater or equal to 70 years, neoadjuvant treatment followed by surgery; n=20). Data concerning comorbidities, type of intervention, morbidity, mortality, survival and quality of life were analyzed. RESULTS There was no difference among the three groups with regard to comorbidity and preoperative evaluation. The patients in Groups I and III had more locally-advanced tumors (P<0.001). There was some disparity between the types of surgery proposed. The Lewis-Santy esophagectomy was most commonly used (90%, 50%, and 65% respectively). The 90-day mortality was 8%, 15%, and 15% respectively. There was no statistically significant difference in the incidence of postoperative pulmonary, cardiac, or digestive complications among the three groups. No difference was found in 5-year survival and quality of life. CONCLUSIONS Neoadjuvant radiochemotherapy for elderly patients (age above 70 years) with esophageal adenocarcinoma did not seem to increase postoperative morbidity or mortality, nor was there any difference in quality of life, nor any effect on survival, no matter what the age of the patient.

Molecular Detection of Microorganisms in Distal Airways of Patients Undergoing Lung Cancer Surgery

BACKGROUND Whereas proximal airways of patients undergoing lung cancer surgery are known to present specific microbiota incriminated in the occurrence of postoperative respiratory complications, little attention has been paid to distal airways and lung parenchyma considered to be free from bacteria. We have hypothesized that molecular culture-independent techniques applied to distal airways should allow identification of uncultured bacteria, virus, or emerging pathogens and predict the occurrence of postoperative respiratory complications. METHODS Microbiological assessments were obtained from the distal airways of resected lung specimens from a prospective cohort of patients undergoing major lung resections for cancer. Microorganisms were detected using real-time polymerase chain reaction (PCR) assays targeting the bacterial 16s ribosomal RNA gene and Herpesviridae, cytomegalovirus (CMV), and herpesvirus simplex. All postoperative microbiological assessments were compared with the PCR results. RESULTS In all, 240 samples from 87 patients were investigated. Colonizing agents were exclusively Herpesviridae (CMV, n=13, and herpesvirus simplex, n=1). All 16s ribosomal RNA PCR remained negative. Thirteen patients (15%) had a positive CMV PCR (positive-PCR group), whereas the remaining 74 patients constituted the negative-PCR group. Postoperative pneumonia occurred in 24% of the negative-PCR group and in 69% of the positive-PCR group (p=0.003). Upon stepwise logistic regression, performance status, percent of predicted diffusion lung capacity for carbon monoxide, and positive PCR were the risk factors of postoperative respiratory complications. The CMV PCR had a positive predictive value of 0.70 in prediction of respiratory complications. CONCLUSIONS When tested by molecular techniques, lung parenchyma and distal airways are free of bacteria, but CMV was found in a high proportion of the samples. Molecular CMV detection in distal airways should be seen as a reliable marker to identify patients at risk for postoperative respiratory complications.

Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study†

OBJECTIVES: It has been suggested that laparoscopic Ivor Lewis (IL) oesophagectomy reduces postoperative morbidity and mortality rates. However, data related to the long-term outcomes of this hybrid minimally invasive procedure are scarce. METHODS: All of the patients who had an IL oesophagectomy for cancer were extracted from a prospective database. Patients were matched one to one according to the surgical approach (laparoscopy versus laparotomy) and on the basis of a propensity score including eight variables: age, gender, American Society of Anaesthesiologists score, forced expiratory volume in 1 s, surgery (first-line treatment, after neoadjuvant treatment and salvage surgery), histology, location and pathological stage. The first end point was the assessment of the 5-year survival and disease-free survival rates. The secondary end points were R0 resection rate, number of resected lymph nodes (LNs) and patterns of recurrence. RESULTS: Over a 12-year period, 272 IL oesophagectomies were performed. A total of 140 patients were matched in two homogeneous groups: laparotomy (n = 70) and laparoscopy (n = 70). The 5-year overall survival and disease-free survival rates were 65% and 48% in laparotomy group and 73% and 51% in the laparoscopy group (P = 0.891; P = 0.912). R0 resection rates were, respectively, 93% vs 97% (P = 0.441). The number and distribution of resected LNs were similar between the groups except at the level of the celiac axis (P < 0.001). Depending on the surgical approach, the patterns of recurrence were similar in both groups. CONCLUSIONS: Laparoscopic IL oesophagectomy does not compromise the long-term oncological outcome compared to open IL oesophagectomy. The quality of the operations is similar for both techniques except for the number of resected LNs at the level of the celiac trunk. Further randomized controlled trials are necessary to confirm these results.

Stratégie chirurgicale : quelles nouvelles techniques ? La chirurgie minimalement invasive (RATS/VATS). Les exérèses d’épargne parenchymateuse. Les parcours de soin accélérés

Resume La chirurgie thoracique a beneficie de nombreuses innovations techniques au cours des dernieres decennies. En parallele les programmes de depistage permettent de diagnostiquer des cancers bronchiques primitifs a des stades plus precoces. Les pratiques chirurgicales se sont donc modifiees d’une part par la generalisation des voies mini-invasives, d’autre part par l’apparition des resections anatomiques infralobaires (segmentectomies) que l’on pourraient qualifier de « chirurgie de precision » qui apparaissent comme des alternatives valables a la lobectomie dans des situations definies, et enfin par la mise en place de parcours de soins acceleres et personnalises, parfois meme ambulatoires. L’objet de cette revue, sera de detailler ces aspects modernes de la chirurgie thoracique au travers de ces trois points, intrinsequement lies les uns aux autres.

Cancers bronchiques non à petites cellules opérables : voies d’abord et techniques chirurgicales en 2014

Resume Les exereses pulmonaires pour cancer bronchique non a petites cellules reposent sur une resection anatomique adaptee a la taille et a la topographie de la tumeur pour permettre une resection histologiquement complete, associee systematiquement a une lymphadenectomie. Depuis les dernieres recommandations de la Societe francaise de chirurgie thoracique et cardiovasculaire (SFCTCV) en 2009, on constate l’evolution des pratiques concernant les voies d’abord et l’etendue des resections parenchymateuses. Les voies d’abord tendent vers une chirurgie minimalement invasive, notamment dans le traitement des tumeurs de stades precoces. Ces approches incluent la chirurgie thoracique video-assistee (CTVA), la chirurgie robotique et la chirurgie a trocart unique. On constate aussi le renouveau des resections infralobaires anatomiques, ou segmentectomies, largement utilisees il y a un demi-siecle pour le traitement de la tuberculose, en consequence du diagnostic plus precoce des cancers du poumon, alors que des politiques nationales de depistage s’organisent en Amerique du Nord et en Europe. On observe enfin l’augmentation du nombre de lesions en verre depoli qui correspondent souvent a des adenocarcinomes peu invasifs. Les techniques d’exereses conservatrices (lobectomie bronchoplastique et/ou angioplastique) permettent dans certaines conditions d’eviter la pneumonectomie. Enfin l’interet du curage systematique par rapport a l’evaluation ganglionnaire a ete recemment remis en question dans des groupes de patients selectionnes pour des tumeurs de stade precoces.

Résections pulmonaires majeures par vidéothoracoscopie: un nouveau standard pour le traitement chirurgical des cancers primitifs de stades précoces ?

Resume La chirurgie pulmonaire thoracoscopique a ete initialement limitee a des gestes simples, comme la resection de nodules peripheriques. Les techniques developpees pour les resections majeures (lobectomie-pneumonectomie) etaient nombreuses, heterogenes, et incluaient parfois une petite thoracotomie avec ecartement intercostal, leur faisant perdre leur potentiel benefice sur les suites operatoires, tout en ne levant pas certains doutes quant a leur efficacite oncologique. Un consensus s’est fait en faveur de techniques ayant en commun l’absence d’ecartement intercostal, et un controle visuel du champ operatoire indirect par les ecrans video. La diffusion de cette chirurgie « totalement thoracoscopique » est lente en Europe, contrairement aux Etats-Unis et au Japon. Deux meta-analyses suggerent pourtant une reduction du risque operatoire comparee a celui de la thoracotomie, ainsi qu’une non-inferiorite oncologique. La faisabilite des segmentectomies offre une option supplementaire dans la prise en charge des tumeurs de petite taille (cT1a) et des opacites pulmonaires en verre depoli, dont l’incidence est en augmentation avec la diffusion du depistage par tomodensitometrie. Dans un domaine devenu concurrentiel avec l’apparition de la radiotherapie stereotaxique et de la radiofrequence pulmonaire, la chirurgie minimalement invasive pourrait devenir le nouveau standard de traitement des cancers primitifs du poumon de stades precoces.