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While preoperative tobacco cessation has been associated with decreased pulmonary complications in lung cancer patients in the postoperative period, this relationship has not been explored among patients undergoing esophagectomy in this era of increasingly prevalent tobacco cessation campaigns and enhanced recovery after surgery. Methods We reviewed ever-smokers who underwent esophagectomy at a single institution from January 2004 through June 2019 for esophageal cancer. Occurrence of Clavien-Dindo classification ≥3 major postoperative morbidity (MPM), including anastomotic leak, chylothorax, reoperation, organ dysfunction, respiratory failure, and ICU readmission was calculated. In an effort to evaluate an effect of smoking cessation on outcome, never-smokers were excluded from analyses. Multivariable logistic regression with backwards stepwise elimination was completed to determine the optimal cessation interval associated with reduction in MPM. Robust standard errors were used to account for clustering among surgeons. Results 725 patients met inclusion criteria, including 666 (92%) with adenocarcinoma and a smaller proportion with squamous cell carcinoma. Most patients were male (650, 90%), and the median age was 63 years (IQR 57–69). Records showed that 505 patients (60%) had quit >5 years prior to esophagectomy, and 82 (11%) were current smokers or had quit within the month preceding esophagectomy. MPM occurred in 213 (29%). After univariate regression, age, gender, pack-year history, operative duration, and FEV1 were included in a multivariable model. While age remained associated wtih MPM, preoperative tobacco cessation of any interval was not associated with outcomes. Conclusion Our previous publication showed increased complication risk for smokers undergoing esophagectomy compared to non-smokers. However, among ever-smokers, no specific interval of preoperative cessation demonstrated decreased MPM. In a setting of active tobacco cessation programs, patients who have not completely achieved abstinence may still be offered surgery with equivalent perioperative outcomes.

Most patients undergoing esophagectomy will experience intermittent reflux of gastric and biliary content into the remnant esophagus over the course of their lives. The incidence of new or recurrent intestinal metaplasia (IM) following chemoradiation and surgery has not been well-described. Furthermore, post-resection guidelines do not exist regarding surveillance for IM in the esophageal remnant. We hypothesized that the incidence of IM in patients who underwent active post-treatment surveillance would be low. Methods Patients undergoing Ivor Lewis esophagectomy after concurrent chemoradiation for a diagnosis of esophageal adenocarcinoma at a single institution from 2006–2018 were identified. Pathology records were reviewed for the presence of IM on pretreatment biopsies, surgical specimen, or post-resection biopsies. Categorical variables were compared using Pearson’s chi-square test or Fisher’s exact test, where appropriate, and continuous variables were compared using Kruskal-Wallis test. Time-to-event outcomes were assessed using the Kaplan–Meier method. Results 621 patients were included, and 242 (39%) were known to have had IM prior to esophagectomy. An additional 26 (4%) patients without a preexisting diagnosis of IM were found to have IM in the surgical specimen. During a median follow-up of 62 months, development of new IM was rare, occurring only in 12 (2%) patients, 7 of whom had a prior history of IM(Table); incidence was 0.6 cases per patient-years. Of these 12, 3 (25%) developed local adenocarcinoma recurrence. Overall, local recurrence of adenocarcinoma was uncommon, and occurred at similar rates in patients with and without a history of IM(p = 0.774). Conclusion Despite several factors predisposing to mucosal damage following esophagectomy, occurrence of new IM after trimodality therapy in our patient population appears to be rare, even among patient with a previous history of metaplasia.

Summary Pretreatment clinical staging in esophageal cancer influences prognosis and treatment strategy. Current staging strategies utilize multiple imaging modalities, and often the results are contradictory. No studies have examined the implications of concordance of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) when used for the evaluation of nodal disease. The objective of this study was to determine if concordance of CT, PET, or EUS for nodal disease predicts worse overall survival. We reviewed 615 esophageal cancer patients with pretreatment CT, PET, and EUS that underwent esophagectomy for survival outcomes based on concordance of studies for nodal disease. Concordant N+ is defined as two or three studies positive for nodal disease; non-concordant N+ is defined as only one positive study. Node-positive disease by any study predicted shorter survival than node-negative disease (42% vs. 73% 5-year survival; P < 0.001). Additionally, non-concordant N+ patients had shorter survival than N− patients (52% vs. 73% 5-year survival; P < 0.001). Concordant N+ patients had shorter survival than non-concordant N+ patients (38- vs. 61-month median survival; P = 0.017). There were no statistically significant differences in survival based on specific combinations of studies. When PET was disregarded, patients with both CT+ and EUS+ had shorter survival than patients with either CT+ or EUS+ (39- vs. 58-month median survival; P = 0.029). Pretreatment CT, PET, or EUS concordance for node-positive disease predicts shorter overall survival in patients that undergo esophagectomy for esophageal cancer. Predicting survival in esophageal cancer should consider the synergistic capabilities of CT, PET, and EUS in evaluating nodal status.

Minimally invasive esophagectomy (MIE) is used with hope to decrease the morbidity associated with an open esophagectomy. Reflux and dumping syndromes are the most important functional complaints in patients after esophagectomy. This study compares the functional benefits of MIE with open esophagectomy. The study enrolled patients who underwent either minimally invasive or open esophagectomy for cancer between 2004 and 2009. No patients in the MIE group had a pyloroplasty or myotomy. Each patient in the MIE group was paired to a patient in the open esophagectomy group via propensity matching. Matching variables included age, race, gender, preoperative treatment, history of prior cancer, American Society of Anesthesiologists Risk Scale, performance status, clinical stage, body mass index, histology, level of anastomosis, and time elapsed since surgery. The patients were asked to answer 26 questions about their reflux and dumping using validated questionnaires. A total of 181 patients were included in the study. From this group, 44 pairs of patients were created and used for the analysis. The median follow-up was 12.1 months for the MIE group and 18.3 months for the open group. The reflux score was slightly worse in the MIE group (5.5 versus 3.5, P= 0.021). There was no difference in the dumping symptoms between the two groups. The most common complaints seen in the dumping questionnaire in almost one-third of all patients were early satiety, abdominal discomfort, nausea, and diarrhea. Of the patients, 77% were satisfied or very satisfied with their condition in the MIE group compared with 93% in the open group (P= 0.287). Reflux, dumping, and overall satisfaction after MIE without pyloroplasty are comparable with those obtained after open esophagectomy with a pyloric drainage procedure.

SUMMARY. Thromboembolic event (TEE) is the most common complication and a second cause of mortality in cancer patients. Multiple hypotheses for occurrence of TEE have been proposed. There are no reports on the frequency/impact of TEE in localized gastroesophageal cancer patients. We hypothesized that TEE at baseline and during chemoradiotherapy (CTRT) in gastroesophageal cancer patients would have an impact on overall survival (OS) of these patients. All consecutive patients with gastroesophageal cancer undergoing CTRT from 2001 to 2004 were eligible for this analysis. Baseline and subsequent TEEs were documented and correlated with patient characteristics and OS. One hundred ninety-eight patients were analyzed. TEEs were documented in 9.6% of the patients. At baseline, TEEs were documented in 4.0% of the patients. During CTRT, TEEs were documented in 6.1% of the patients. Pulmonary embolism (43.5%) and lower extremity venous thromboses (39%) were the most frequent TEEs. Median OS for patients with a TEE occurring at anytime was 17.7 versus 32.0 months for patients who never developed a TEE (P = 0.014). TEEs at baseline correlated with poor median survival: 13.1 versus 30.7 months for those without a TEE (P = 0.029). In a multivariable analysis, TEE at baseline and/or during CTRT was an independent predictor of OS (hazard ratio, 1.818; P = 0.040). Our data are the first to document the frequency of TEE in gastroesophageal cancer patients undergoing CTRT, and that TEE is an independent prognosticator of OS. Active research to prevent and treat TEEs is needed to improve survival of patients with localized gastroesophageal cancer.

Summary Trimodality therapy with neoadjuvant chemoradiation followed by surgery significantly improves the survival of locally advanced (clinical stage IIA–III) esophageal cancer patients compared to treatment with surgery alone. This has resulted in an increased use of neoadjuvant therapy in recent years, yet little is known regarding how this increase has impacted the utilization of surgery in the treatment of locally advanced disease. Although previous reports of experimental protocols suggest that 90–95% of patients complete trimodality therapy including a surgical resection, trimodality therapy completion among adenocarcinoma patients eligible for curative resection has not been evaluated in a nonprotocol setting. We sought to (i) assess the completion of trimodality therapy among locally advanced esophageal adenocarcinoma patients; (ii) characterize the reasons for avoiding surgery; and (iii) identify factors associated with failure to complete trimodality therapy. We identified 296 patients with locally advanced esophageal adenocarcinoma eligible for trimodality therapy at our institution. All patients were evaluated in a multidisciplinary setting and considered eligible for curative resection after initial staging and physiologic assessment. Multivariable logistic regression was used to identify factors associated with failure to complete trimodality therapy. Of 296 trimodality-eligible patients, 33% (97/296) did not complete trimodality therapy. Reasons for not undergoing surgery included patient choice (27.8%, 27/97), distant progression of disease during chemoradiation (23.7%, 23/97), and physician preference for surveillance (23.7%, 23/97). In addition, 17.5% (17/97) of patients had physical deterioration in performance status, and treatment-related deaths occurred in 7.2% (7/97) prior to surgery. In the total study population (n = 296), multivariable logistic regression identified older age (≥70 years: odds ratio [OR] = 6.611, 95% confidence interval [CI]: 2.900–15.071), pretreatment standard uptake value (6.8–10.1: OR = 2.393, 95% CI: 1.050–5.455; ≥15.8: OR = 3.623, 95% CI: 1.604–8.186), and a radiation dose of 50.4 Gy (OR = 5.312, 95% CI: 2.365–11.929) as being significantly associated with failure to complete trimodality therapy. Among the subgroup of patients that successfully completed chemoradiation (n = 266), older patients (≥70 years: OR = 9.606, 95% CI: 3.637–25.372), those with a comorbidity score of 2 or higher (OR = 4.059, 95% CI: 1.257–13.103), and those that received a radiation dose of 50.4 Gy (OR = 4.878, 95% CI: 1.974–12.054) were at a significantly higher risk of not completing trimodality therapy. Trimodality therapy completion among patients with locally advanced esophageal adenocarcinoma in a nonprotocol setting is considerably lower than what has previously been reported in clinical trials. Our findings suggest that a selective approach to surgery is commonly utilized in clinical practice. Trimodality-eligible patients that are older and have a higher comorbidity score are at risk for not completing trimodality therapy.