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IntroductionSeveral studies reported the advantages of minimally invasive esophagectomy over the conventional open approach, particularly in terms of postoperative morbidity and mortality. The literature regarding the elderly population is however scarce and it is still not clear whether elderly patients may benefit from a minimally invasive approach as the general population. We sought to evaluate whether thoracoscopic/ laparoscopic (MIE) or fully robotic (RAMIE) Ivor-Lewis esophagectomy significantly reduces postoperative morbidity in the elderly population.MethodsWe analyzed data of patients who underwent open esophagectomy or MIE/RAMIE at Mainz University Hospital and at Padova University Hospital between 2016 and 2021. Elderly patients were defined as those ≥ 75 years old. Clinical characteristics and the postoperative outcomes were compared between elderly patients who underwent open esophagectomy or MIE/RAMIE. A 1-to-1 matched comparison was also performed. Patients < 75 years old were evaluated as a control group.ResultsAmong elderly patients MIE/RAMIE were associated with a lower overall morbidity (39.7% vs. 62.7%, p=0.005), less pulmonary complications (32.8 vs. 56.9%, p=0.003) and a shorter hospital stay (13 vs. 18 days, p=0.03). Comparable findings were obtained after matching. Similarly, among < 75 years-old patients, a reduced morbidity (31.2% vs. 43.5%, p=0.01) and less pulmonary complications (22% vs. 36%, p=0.001) were detected in the minimally invasive group.DiscussionMinimally invasive esophagectomy improves the postoperative course of elderly patients reducing the overall incidence of postoperative complications, particularly of pulmonary complications.

Esophageal perforation (EP) is characterized by high morbidity and mortality. The Pittsburgh Severity Score (PSS) is a scoring system based on clinical factors at the time of EP presentation, intended to guide treatment. The aim of the study is to verify PSS usefulness in stratifying EP severity and in guiding clinical decisions.All patients referred to our unit for EP between January 2005 and January 2020 were enrolled. Patients were stratified according to their PSS into three groups (PSS ≤ 2, 3-5, and5): the postoperative outcomes were compared. The predictive value of the PSS was evaluated by simple linear and logistic regression for the following outcomes: need for surgery, complications, in-hospital mortality, intensive care unit (ICU) and hospital stay, time to refeeding, and need for reintervention.Seventy-three patients were referred for EP (male/female, 46/27). Perforations were more frequently iatrogenic (41.1%) or spontaneous (38.3%). The median PSS was 4 (interquartile range, 2-6). Surgery was required in 60.3% of cases. Pittsburgh Severity Score was associated with ICU admission, hospital stay, need for surgery and reintervention, postperforation complications and mortality. After regression analysis, PSS was significantly predictive of postperforation complications (p0.01), in-hospital mortality (p = 0.01), ICU admission (p0.01), need for surgical treatment (p0.01), and need for reintervention (p = 0.02).Pittsburgh Severity Score is useful in stratifying patients in risk groups with different morbidity and mortality. It is also useful in guiding the therapeutic conduct, selecting patients for nonoperative management. Prospective studies are needed to confirm the role of the PSS in the treatment of esophageal perforation.Management, Therapeutic/Care; level IV.

Supplemental Material, sj-doc-1-gsj-10.1177_21925682211005737 for Pharyngo-Esophageal Perforation Following Anterior Cervical Spine Surgery: A Single Center Experience and a Systematic Review of the Literature by Lucia Moletta, Elisa Sefora Pierobon, Renato Salvador, Francesco Volpin, Francesco Massimiliano Finocchiaro, Giovanni Capovilla, Alfredo Piangerelli, Eleonora Ciccioli, Gianpietro Zanchettin, Mario Costantini, Stefano Merigliano and Michele Valmasoni in Global Spine Journal

We evaluated our experience of subtotal parathyroidectomy (SP) for secondary hyperparathyroidism (SHP) cases. We evaluated retrospectively our 150 SP operations due to SHP. Serious hypocalcemia (< 6.5 mg/dL) developed in 23 (15.3%) patients, and we performed cryopreserved parathyroid cell autotransplantation in four cases with successful results. Recurrent hyperparathyroidism developed in 3 (2%) cases, and persistent hyperparathyroidism was observed in 22 (14.6%) cases. Upon reoperation in nine persistent hyperparathyroidism cases, we found supernumerary parathyroid glands in three cases, remnant tissue hyperplasia in four cases, and ectopic parathyroid glands in two cases. Among cases in which four glands cannot be found during surgery, the permanent HP rate is high. Serious hypocalcemia may develop postoperatively, and cryopreserved parathyroid autotransplantation may be inevitable in some of these cases.

Aim The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophago-gastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient and highly reproducible, however the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog ears and therefore increase the risk of anastomotic leakage (AL). We describe a simple modification of the CS technique that avoid the formation of staple lines intersection. Background and Methods We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Our technical modification consists in folding the linear esophageal transection line with a stitch around the anvil shaft, in order to include the staple line in the resection during the EEATM firing (figure 1). Feasibility has been evaluated as the percentage of cases in which the improved anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure related complications. Results MIE was performed in ten patients using our modified CS technique, median age was 55 years. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complication. Only one patient developed a postoperative AL, that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusions Our modified CS technique is simple, feasible and safe. Further studies are needed to evaluate its efficacy in preventing the occurrence of anastomosis leakage.

Background We designed this study with the aim of comparing POEM and laparoscopic Heller myotomy+Dor fundoplication (LHD) by matching 2 groups of consecutive patients, treated in 2 high-volume Centers, with the propensity score (PS). Methods Patients undergoing treatment for achalasia from 2014 to 2017 were selected: by applying the PS, 140 patients in both centers were matched. LHD and POEM were performed following established techniques. Patients were followed with clinical, endoscopic and pH-manometry evaluations. Results POEM required a shorter operation time (47 min [35-57]) and postoperative stay (2 days [2-2]) compared to LHD (95 min [85-105] and 3 days [3-3], respectively, p 90% for both groups (98.2% for POEM and 93.9% for LHD, p=0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; however, 24-h pH-monitoring showed an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p

Aim Primary aim is to evaluate the relationship between pathological response after CROSS regimen for locally advanced esophageal adenocarcinomas and overall and disease-free survival. Secondary endpoint is to analyze the principal sites of relapse after surgery in this group of patients. Background & Methods The CROSS trial showed an improvement of overall survival after neoadjuvant chemoradiation and subsequent surgical resection compared to surgery alone for patients with esophageal cancer, representing the benchmark [1]. Patients submitted to CROSS regimen for adenocarcinoma of the esophagus and cardia followed by esophagectomy with a transthoracic extended lymphadenectomy were analyzed. The patients were treated in 4 centers part of Italian Group for the Study of Esophageal Diseases (SISME). Actuarial Overall survival (OS) and actuarial disease-free survival (DFS) were analyzed and stratified according to yp Stage (1 – stage I and II; 2 – stage IIIA and IIIB and 3 - stage IVA) as described in the 8th edition of TNM. Kaplan-Meier method was used to estimate overall and progression-free survival, with the log-rank test to ascertain significance (p Results 132 patients, from January 2014 to February 2019, were analyzed. Median age was 63 years (range 42-82). The site of the neoplasm was the distal esoghagus-EGJ in 127 cases and the middle esophagus in 5. Ivor Lewis was the procedure adopted. Fifty-month OS and DFS were respectively 42% and 6.7% respectively. No difference emerged when overall survival was analyzed according to yp Stages. Time to relapse is significantly longer for ypStage I and II. Recurrence occurred in 48 cases (36.3%) with 9 months as median time to relapse. Local and distal relapse were 10 (paratracheal nodes) and 38 respectively (7.5% and 28.7%, p Conclusion Pathological response after CROSS regimen doesn’t relate to OS and DFS. Time to recurrence is significantly longer for yp Stage 1 e 2 rather than other ypStages. Chemoradiotherapy in a neoadjuvant setting may influence the site of relapse.

Aim Pharyngo-oesophageal perforation is a rare, life-threatening complication of cervical spine surgery. Only isolated cases are reported in the English literature and correct management of these patients remains poorly defined. The aim of this study is to review our experience to better clarify the appropriate treatment of this dreadful complication. Background and Methods Data regarding demographics, clinical course, diagnosis, management and outcomes of 13 patients (8 M, 5F, mean age 49 years) with oesophageal perforation after cervical spine surgery were collected during the period from 2002 to 2019. Results Pharyngo-oesophageal perforation occurred at a median of 8 days (range 0-4745 days) after cervical spine surgery. Clinical manifestations included neck abscess in 7 cases, fever in 3 cases, dysphagia and regurgitation in 3 cases. In 2 patients conservative management with fasting and antibiotics was attempted but, in both cases, a subsequent surgical intervention was required. All patients underwent surgical treatment. A step-up approach with initial surgical drainage of a purulent cervical collection was performed in 7 patients, delaying definitive surgery after resolution of cervical infection. Definitive surgical treatment with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty (either with sternocleidomastoid or pectoralis major muscle flap) was performed in 10 patients. Perforation recurred in two cases, requiring further surgical management. At a median follow-up of 23 months (range 5-149 months) all patients exhibited permanent resolution of the perforation. Conclusions Pharyngo-oesophageal perforation following cervical spine surgery is a rare but dreadful complication: prompt recognition and treatment of these injuries is critical to minimize morbidity and mortality. Partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients.

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.

Background. The growing prevalence of hepatitis C virus (HCV) infection in the general population has resulted in an increased frequency of potential organ donors that carry the virus. Given the significant disparity between organ supply and demand for transplantation, it becomes essential to consider whether livers from anti-HCV-positive donors may be considered suitable for transplantation. Methods. Based on a multicenter European database, 694 patients with HCV-related cirrhosis underwent liver transplantation and 11% of them received the graft from anti-HCV-positive donors. Of this group, we selected 63 patients (study group) and, after a 1:1 case-control approach, compared them with 63 patients that received an anti-HCV-negative donor graft (control group). Only grafts with preperfusion liver biopsy results with a fibrosis score of not more than 1 were used for transplantation. Results. Patients who received anti-HCV-positive grafts had a cumulative survival rate of 83.6% and 61.7% at 1 and 5 years, respectively, vs. 95.1% and 68.2% for the control group. In comparing overall patient and graft survival, there was no statistically significant difference between the two groups (P = 0.22 and 0.11). Recurrence of hepatitis C tended to be more rapid in the group of patients who received anti-HCV-positive grafts, although it did not reach statistical significance (P = 0.07). Conclusions. We do not recommend the indiscriminate use of anti-HCV-positive donors, especially if HCV-RNA positive, as the use of this kind of graft could be linked to an advanced stage of fibrosis, the main risk factor we observed for earlier hepatitis C recurrence.