Christophe Doddoli

Esophageal cancer resection in the elderly.

OBJECTIVE Esophageal cancer is a disease whose prognosis is dismal and its surgery involves considerable risks, consequently the opportunity of esophageal resection in elderly patients with esophageal cancer is questionnable. The aim of this study was to analyze, with respect to their age, the outcome of 386 consecutive patients who underwent esophagectomy and simultaneous replacement for cancer. METHODS A chart review of all patients with esophageal carcinoma admitted to our institution was undertaken for the period January 1979-December 1994. RESULTS The portion of patients of 70 years of age and older (14.5%) has slightly increased during the period. Location to the lower third of the esophagus and adenocarcinoma type were prevalent in the 56 elderly patients (group I), but their postsurgical TNM staging was identical to that of the 330 younger patients (group II). Other clinical features, i.e. preoperative weight loss and the presence of co-morbid diseases, however, were comparable in the two groups. Pulmonary function, as assessed by spirometry, was significantly worse among the older patients, but blood gas determinations were not different. Operative mortality was comparable, between the two groups (10.7% vs 11.2%). Major morbidity included anastomotic leak (10.7% vs 13.6%) and pulmonary complications (17.9% vs 20.6%) in both groups. Excellent palliation of dysphagia was achieved in 92% of the 50 group I patients who survived the operation. Long-term survival was not different in elderly patients (5-year rate: 17%) when compared with that of younger patients (18.9%). CONCLUSION These data suggest that esophagectomy can be performed safely in selected septuagenarian patients, thus allowing a substantial survival with excellent functional status in a portion of these patients.

Indications and outcome of salvage surgery for oesophageal cancer

OBJECTIVE Some patients with localised oesophageal cancer are treated with definitive chemoradiotherapy (CRT) rather than surgery. A subset of these patients experiences local failure, relapse or treatment-related complication without distant metastases, with no other curative treatment option but salvage oesophagectomy. The aim of this study was to assess the benefit/risk ratio of surgery in such context. METHODS Review of a single institution experience with 24 patients: 18 men and 6 women, with a mean age of 59 years (+/-9). Histology was squamous cell carcinoma in 18 cases and adenocarcinoma in 6. Initial stages were cIIA (n=5), cIIB (n=1) and cIII (n=18). CRT consisted of 2-6 sessions of the association 5-fluorouracil/cisplatin concomitantly with a 50-75 Gy radiation therapy. Salvage oesophagectomy was considered for the following reasons: relapse of the disease with conclusive (n=11) or inconclusive biopsies (n=7), intractable stenosis (n=3), and perforation or severe oesophagitis (n=3), at a mean delay of 74 days (14-240 days) following completion of CRT. RESULTS All patients underwent a transthoracic en-bloc oesophagectomy with 2-field lymphadenectomy. Thirty-day and 90-day mortality rates were 21% and 25%, respectively. Anastomotic leakage (p=0.05), cardiac failure (p=0.05), length of stay (p=0.03) and the number of packed red blood cells (p=0.02) were more frequent in patients who received more than 55 Gy, leading to a doubled in-hospital mortality when compared to that of patients having received lower doses. A R0 resection was achieved in 21 patients (87.5%). A complete pathological response (ypT0N0) was observed in 3 patients (12.5%). Overall and disease-free 5-year survival rates were 35% and 21%, respectively. There was no long-term survivor following R1-R2 resections. Functional results were good in more than 80% of the long-term survivors. CONCLUSION Salvage surgery is a highly invasive and morbid operation after a volume dose of radiation exceeding 55 Gy. The indication must be carefully considered, with care taken to avoid incomplete resections. Given that long-term survival with a fair quality of life can be achieved, such high-risk surgery should be considered in selected patients at an experienced centre.

Stent placement in the management of oesophageal leaks

OBJECTIVE To examine retrospectively the patients of our department who had a self-expandable totally covered metal stent placed for oesophageal leak. METHODS Patients hospitalised in our department for oesophageal cancer and/or oesophageal perforation between 2004 and 2006. All medical records were retrospectively reviewed. Seventy-two patients underwent oesophageal resection for oesophageal cancer and 16 were managed for oesophageal perforations. RESULTS Eight out of 72 patients submitted to resection for oesophageal cancer had postoperative leaks, while one patient developed tracheo-oesophageal fistula (TEF) due to prolonged mechanical ventilation. Six of them had stent placement in first intention, whereas two received the procedure after an unsuccessful repeat operation. The mean stent placement time was 18.4 days (SD=15.2 days), whereas the median was 14 days. The leak was managed efficiently by the stent in seven patients, whereas two patients needed repeat operations (one with TEF). The mean stent removal time was 56.8 days (SD=30.5 days) and the median was 40 days. None developed anastomotic stricture. On the other hand, three out of 16 patients with perforation had a stent, two of them for Boerhaave syndrome and one for iatrogenic rupture after bariatric surgery. One of them required the stent 17 days after surgical repair with excellent results, while the other two patients had the stent placed immediately, but still needed thoracotomy to control the leak. CONCLUSIONS Stent placement can prove very useful in the management of post-oesophagectomy anastomotic leaks, but its contribution needs to be evaluated with caution in cases of oesophageal perforations or TEF. Larger series and prospective comparative clinical trials could eventually clarify the role of stents in clinical practice of surgical patients.

An early inflammatory response to oesophagectomy predicts the occurrence of pulmonary complications

BACKGROUND Respiratory complications are the most frequent concern following oesophagectomy. We aimed to assess the postoperative inflammatory response after oesophagectomy and to determine its reliability to predict the occurrence of pulmonary complications. METHODS A total of 97 patients were enrolled in this prospective observational study. All patients underwent a transthoracic oesophagectomy for cancer. From D0 to D3, plasmatic cytokine levels (interleukin (IL)-1, IL-6, IL-8, IL-10, tumour necrosis factor (TNF)-alpha), short synacthen test (SST), PaO(2)/FiO(2) ratio and clinical factors determining the systemic inflammatory response syndrome (SIRS) were monitored and compared between patients who experienced pulmonary complications (group I) and those who did not (group II). RESULTS The overall in-hospital mortality was 5%. Postoperative pulmonary complications occurred in 33 patients (34%). Sputum retention was the first step of pulmonary complications in 26 patients (occurring at a mean of 2.8+/-1 days after the operation), leading to pneumonia in 22 patients (4.7+/-1 days) and acute respiratory distress syndrome (ARDS) in 10 (6.9+/-3 days). At day 2, group I patients had significantly higher plasmatic levels of IL-6, IL-10 and TNF-alpha than group II patients. PaO(2)/FiO(2) was impaired accordingly (215 vs 348; p=0.006). SST was negative in 38% of group I patients and in 30% of group II patients (p=0.51). SIRS was present in 33% and 6% of group I and group II patients, respectively (p< or =0.01). At multivariate analysis, early occurrence of SIRS was the sole significant predictor of pulmonary complications (p=0.005; odds ratio (OR):11.4, confidence interval (CI): 2-63). CONCLUSIONS The vast majority of postoperative pulmonary complications after oesophagectomy occur after the 4th postoperative day. The earlier detection (first 48 h) of SIRS, high plasmatic cytokine levels and impairment of PaO(2)/FiO(2) predicts the onset of these complications. This finding suggests that early pharmacological intervention may have a beneficial impact.

Is malignant pleural mesothelioma a surgical disease? A review of 83 consecutive extra-pleural pneumonectomies

OBJECTIVE To report on the experience with radical surgery, with emphasis on the long-term outcome, for malignant pleural mesothelioma (MPM) at a single institution. METHODS From our prospective database over a 17-year period, we reviewed 83 consecutive patients undergoing radical surgery for MPM in a multimodality programme. The long-term overall survival was analysed using the Kaplan-Meier method. RESULTS A total of 83 patients (65 males, median age: 60 years) underwent an extra-pleural pneumonectomy (EPP) with a curative intent. Epitheliod MPM was the most frequent (82%) cause. A right-sided disease was present in half of the cases (n=42). The International Mesothelioma Interest Group (IMIG) stage of the disease was 2 in 36%, 3 in 45% and 4 in 9% of the cases. Preoperative chemotherapy consisting of a doublet cisplatin-pemetrexed (mean of three cycles) was offered to 10 patients (12%). Postoperative therapies, either chemotherapy or radiotherapy, were given in 25 patients (30%). The 30-day and 90-day mortality rates were 4.8% and 10.8%, respectively. Postoperative complications occurred in 39.8% and were major in 23 patients (27.7%). Re-operation was necessary in 12 cases (14.5%) for one of the following reasons: broncho-pleural fistula (n=4), bleeding (n=3), diaphragmatic patch rupture (n=3), oesophago-pleural fistula (n=1) and empyaema (n=1). The mean hospital stay was 43 days. The median survival was 14.5 months, while the overall 1-, 2- and 5-year survival rates were 62.4%, 32.2% and 14.3%, respectively. CONCLUSIONS These results concur with the published data of the most experienced centre with regards to the mortality and morbidity after EPP for MPM. In line with the biggest series reported in the past, the observed 5-year survival rate of almost 15% is disappointing.

Airways colonizations in patients undergoing lung cancer surgery

Lung cancer remains the main leading cancer-related cause of death in the world. For early-stage tumor, surgery stands out as the best curative option offering the greatest chance for cure. Despite improvement of per- and postoperative management, surgery continues to carry a high morbidity with a significant mortality. Among postoperative complications, respiratory failures (nosocomial pneumonia and acute respiratory distress syndrome) are currently the most frequent and serious, as well as being the primary cause of hospital death, after a lung resection for cancer. Because infectious etiologies have been highly incriminated in the development of these pulmonary complications, microbial airways colonizations (AWCs) are supposed to be an essential first step in the pathogenesis of these failures occurring in hospitalized and chronically ill individuals. These patients fulfill all the predisposing factors to bronchial colonizations and are particularly exposed to the development of respiratory failures in the postoperative setting, when secretion clearance and cough reflex are impaired. Under immunosuppressive conditions, AWC should act in a manner that increases its ability to stimulate microorganisms and increase the risks of superimposed infections. Few studies have addressed the problem of AWCs in patients submitted for lung cancer surgery. Because of several limitations, especially the lack of exhaustive microbiological studies, the conclusions that can be reached remain inconclusive. This review aims to report the existing literature on this critical and controversial issue, focusing on their specific incidence, their predisposing factors, their correlation with development of respiratory failures, and, in turn, the reliability of the current antibiotic prophylaxis for their prevention.

Airway colonisation and postoperative pulmonary complications after neoadjuvant therapy for oesophageal cancer

OBJECTIVE To evaluate the clinical relevance of preoperative airway colonisation in patients undergoing oesophagectomy for cancer after a neoadjuvant chemoradiotherapy. METHODS From 1998 to 2005, 117 patients received neoadjuvant chemoradiotherapy for advanced stage oesophageal cancer. Among them, 45 non-randomised patients underwent a bronchoscopic bronchoalveolar lavage (BAL group) prior to surgery to assess airways colonisation. The remaining patients (n=72) constituted the control group. The two groups were similar with respect to various clinical or pathological characteristics. RESULTS Thirteen of the 45 BAL patients (28%) had a preoperative bronchial colonisation by either potentially pathogenic micro-organisms (PPMs) (n=7, 16%) or non-potentially pathogenic micro-organisms (n=6, 13%). Cytomegalovirus (CMV) was cultured from BAL in four patients. Pre-emptive therapy was administrated in seven patients: four antiviral and three antibiotic prophylaxes. Postoperatively, 14 patients (19%) developed acute respiratory distress syndrome (ARDS) in the control group and three (7%) in the BAL group (p=0.064). The cause of ARDS was attributed to CMV pneumonia in six control group patients on the basis of the results of open lung biopsies (n=3) or BAL cultures (n=3) versus none of the BAL group patients (p=0.08). Timing for extubation was shorter in the BAL group (mean 13+/-3 h) as compared with the control group (mean 19.5+/-14 h; p=0.039). In-hospital mortality was not significantly lower in BAL group patients when compared to that of control group patients (8% vs 12.5%). CONCLUSIONS Airway colonisation by PPMs after neoadjuvant therapy is suggested as a possible cause of postoperative ARDS after oesophagectomy. Pre-emptive treatment of bacterial and viral (CMV) colonisation seems an effective option to prevent postoperative pneumonia.

Long-term results of redo gastro-esophageal reflux disease surgery

OBJECTIVE To review the long-term results of redo gastro-esophageal reflux disease (GERD) surgery with special emphasis on residual acid-suppressing medications, pH monitoring results, and quality of life. METHODS Retrospective analysis of 52 patients (24 males) who underwent redo GERD surgery between 1986 and 2006 through a transthoracic (n=14), or a transabdominal (n=38) approach. Indications were recurrent GERD in 41 patients, and complication of the initial surgery in 11. Quality of life was evaluated by telephone enquiry using a validated French questionnaire (reflux quality score, RQS). RESULTS Postoperative complications occurred in 18 patients (35%), resulting in one death (2%). Reoperation was required in seven patients. At 1 year, 26 patients (51%) had 24h pH monitoring, among whom 2 (8%) were proved to have recurrence of GERD. RQS values were calculated in 38 patients with a mean follow-up of 113 months. Fifty percent of this subgroup had a RQS value beyond 26/32, indicating an excellent quality of life. Among these 38 patients, 20 (53%) had acid-suppressing medications whatever their RQS values. Patients who underwent transthoracic GERD surgery had the highest RQS values (p=0.02), a lower rate of complications (p=0.06) and a lower rate of reoperation (p=0.04). CONCLUSION Our experience confirms that selection of candidates for redo GERD surgery is a challenging issue. A transthoracic approach seems to produce better results and lower rates of complications.

Colon interposition for oesophageal replacement.

The choice of the colon as an oesophageal substitute results primarily from the unavailability of the stomach. However, given its durability and function, colon interposition keeps elective indications in patients with benign or malignant oesophageal disease who are potential candidates for long survival. The choice of the colonic portion used for oesophageal reconstruction depends on the required length of the graft, and the encountered colonic vascular anatomy, the last being characterised by the near-invariability of the left colonic vessels, in contrast to the vascular pattern of the right side of the colon. Accordingly, the transverse colon with all or part of the ascending colon is the substitute of choice, positioned in the isoperistaltic direction, and supplied either from the left colic vessels for long grafts or middle colic vessels for shorter grafts. Technical key points are: full mobilisation of the entire colon, identification of the main colonic vessels and collaterals, and a prolonged clamping test to ensure the permeability of the chosen nourishing pedicle. Transposition through the posterior mediastinum in the oesophageal bed is the shortest one and thereby offers the best functional results. When the oesophageal bed is not available, the retrosternal route is the preferred alternative option. The food bolus travelling mainly by gravity makes straightness of the conduit of paramount importance. The proximal anastomosis is a single-layer hand-fashioned end-to-end anastomosis to prevent narrowing. When the stomach is available, the distal anastomosis is best performed at the posterior part of the antrum for the reasons of pedicle positioning and reflux prevention, and a gastric drainage procedure is added when the oesophagus and vagus nerves have been removed. In the other cases, a Roux-en-Y jejunal loop is preferable to prevent bile reflux into the colon. Additional procedures include re-establishment of the colonic continuity, a careful closure of the mesentery to avoid a further internal hernia, and routine appendectomy. When applying these technical aids, the chances of achieving a viable and well-functioning colon graft are excellent.