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Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P <0.0001 and 17% vs. 12%; P <0.0001, respectively) and postoperative blood transfusion (26.7%–11%; P <0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10–23) in TC compared with 10 days (IQR 8–14) in ERP patients (P <0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P =0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P =0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P =0.0001), anastomotic leak (P =0.047), several infectious complications (P =0.01–0.034), blood transfusion (P =0.001), Comprehensive Complications Index (P =0.01), and length of stay (P =0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates. [ABSTRACT FROM AUTHOR]

The accepted importance of a positive circumferential resection margin (CRM) (defined as R1 in the TNM classification) is based on histopathology of the resection specimen obtained after primary surgery in esophageal cancer patients. The aim of this study is to look for the prognostic value of CRM after neoadjuvant chemoradiotherapy and to compare the clinical significance of a histologically CRM < 1 mm from the cut margin (Royal College of Pathologists definition of R1) to a positive cut margin (College of American Pathologists definition of R1) and to ≥1 mm margin (R0) resections in patients with ypT3-esophageal tumors after neoadjuvant chemoradiotherapy. Between 2000 and 2014, 458 patients who received esophagectomy after neoadjuvant chemoradiation therapy were selected. Overall (OS) and disease-free survival (DFS) were calculated by means of Kaplan-Meier curves and compared by Cox regression analysis. There were 163 (35.9%) patients who had a ypT3 tumor; in 118 (72.4%) resection was complete (R0). In 37 (22.7%) patients a CRM < 1 mm was found and 8 (4.9%) had a circumferential R1-resection. CRM involvement was inversely correlated with tumor regression grading, lymph node capsular involvement, and number of positive lymph nodes. On univariate analysis, no statistically significant difference was found between R0-resection and CRM < 1 mm (P = 0.103) for OS, but DFS showed a significant difference (P = 0.025). Circumferential R1-resections showed a significant difference compared to R0-resections for OS and DFS (both P = 0.002). In multivariate analysis, extracapsular lymph node involvement and circumferential R1-resection were withheld as independent prognosticators for OS, whereas extracapsular lymph node involvement, absence of regression on the primary tumor and circumferential R1-resection were withheld for DFS. After correcting for different variables in the multivariate model, CRM < 1 mm showed no statistical difference compared to R0-resections neither for OS nor for DFS. After neoadjuvant chemoradiotherapy, CRM is correlated with biological behavior of the tumor and with therapy response. Furthermore it is an independent prognosticator for OS and DFS. HoweverCRM<1mm itself is no independent prognosticator for OS nor DFS survival in multivariable analysis. These results suggest that the definition of R1-resection should be limited to true invasion of the section plane. [ABSTRACT FROM AUTHOR]

Recurrent disease after esophagectomy bears an infaust prognosis, especially when multiple recurrences are present. But little is known about survival in patients with limited recurrence (solitary locoregional recurrence or solid organ metastasis). Herein, we report our experience with these subgroups. We analyzed 1754 consecutive patients surgically treated with curative resection for esophageal cancer and cancer of the gastroesophageal junction between 1990 and 2012. Seven subgroups were defined according to the recurrence type (locoregional vs. organ metastasis), the site of recurrence (abdominal, thoracic, cervical for lymph nodes and lung, liver, adrenals and others for organ metastasis) and also the number of lesions (one vs. multiple lymph node stations or organ metastasis) Of these groups; clinical isolated locoregional recurrence (ciLR) was defined as solitary lymph-node recurrence confined to one compartment (cervical, thoracic or abdominal, within or outside surgical dissection-field) at clinical staging. Clinical solitary solid organ metastasis (csSOM) was defined as metastasis in a resectable solid organ, i.e. liver, lung, brain or adrenal. Salvage therapies were grouped in five categories. Kaplan-Meier curves were used to calculate survival. Recurrent disease was observed in 766 patients (43.7%) with overall 5-year survival of 4.5% after diagnosis of recurrence. Fifty-seven patients (7.4%) showed ciLR and 110 (14.4%) csSOM. Median timeto-recurrence was 16.8 months in ciLR and 9.9 months in csSOM (P=0.0074). Survival is significantly improved compared to supportive therapy when local therapy is possible (P<0.0001). In 25 (15%) of ciLR or csSOM patients, surgical therapy with or without systemic therapy, yielded a 5-year survival of 49.9% (median 54.8 months) after diagnosis of recurrence. When surgery was impossible or contraindicated, the combination of chemoradiotherapy appeared to be superior to chemotherapy alone (respectively 27.0% vs. 4.6% 5-year survival) or radiotherapy alone (no 5-year survival). Recurrent disease after esophagectomy is a common problem with poor overall survival. However prolonged survival could be obtained in selected patients if the recurrent disease is limited to ciLR or csSOM, if surgery (+/- systemic therapy) can be performed. If not a combination of chemoradiotherapy seems to offer the second best option. Patients presenting with a ciLR or csSOM should be discussed in a dedicated multidisciplinary team meeting as to evaluate and define the place of salvage treatment which in well selected cases could offer a perspective of prolonged survival. [ABSTRACT FROM AUTHOR]

Objective: Very few studies have examined post-operative morbidity after resection of oesophageal carcinoma, especially in patients treated with induction chemo- and radiotherapy for locally advanced stages. This study assessed the effects of induction chemoradiotherapy on post-operative course after resection of locally advanced oesophageal carcinoma (cT3–4+cM1lymph). Methods: Induction therapy consisted of 5-fluorouracil days 1–5 and days 21–25, cisplatin day 1+day 21 and concomitant radiotherapy 18–20 fractions of 2 Gy (total dose 36–40 Gy). Induction chemoradiotherapy was completed in 109 patients. Surgery was performed in 90 patients (operability: 90/109=83%): 85 patients underwent resection with curative intent (resectability: 85/109=78%), bypass operation was performed in five patients. Nineteen patients could not be operated on. Results were compared to a matched group of pT3M1LYM/pT4 patients (n=86) who underwent primary surgery in the same period. Results: Resection was complete (R0) in 68 patients (68/90=76%). Mean duration of surgery was 428 min (range: 240–690). Peroperative complications were haemorrhage in three patients (3/90=3.3%), tracheobronchial perforation in three patients (3/90=3.3%). Median total hospital stay was 20.5 days (range: 8–355). Mean duration of intubation was 7 days (range: 1–190); 67 patients (67/90=74.4%) were intubated for less than 24 h. Non-tumour related hospital mortality after resection was 8.3% (7/84 patients). Mortality after two-field lymphadenectomy was 5.2 versus 11.7% after three-field lymphadenectomy. After primary surgery (n=86) overall mortality was 2.3% (P=0.015) and nil after two- and three-field lymphadenectomy (P=0.011). Medical morbidity consisted of pneumonia in 43 patients (43/90=48%), atelectasis in ten patients (10/90=11%), dysrhythmia in 21 patients (21/90=23%), sepsis in 11 patients (11/90=12%) and adult respiratory distress syndrome in ten patients (10/90=11%). Surgical morbidity included pleural effusion in 16 patients (16/90=18%), tracheal fistula in two patients (2/90=2%), chylothorax in two patients (2/90=2%) and acute pancreatitis in one patient (1/90=1%). Ten patients (10/90=11%) had a radiologically confirmed anastomotic leak; however only in four out of them with clinical manifestation; treatment was conservative in all four patients. Major morbidity occurred in 27 patients (27/90=30%). Overall rate of morbidity was significantly higher after three-field lymphadenectomy (85%) as compared to two-field lymphadenectomy (68.7%; P=0.023). Conclusions: Chemoradiotherapy followed by resection of cT3–4 +/− cM1lymph oesophageal carcinoma is feasible with acceptable mortality. Mortality, however, seems to be significantly higher when compared to a group of pT3M1LYM/pT4 patients who underwent primary surgery (8.3 versus 2.3%; P=0.015) in the same period in our department. [Copyright &y& Elsevier]

Focuses on the clinical significance of gastroplasty in gastric drainage procedure. Discussion on gastric pull-up; Details on bilateral vagotomy; Medical conditions requiring gastroplasty.

Keywords:end-stage renal disease; cadaveric kidney transplantation; paroxysmal nocturnal haemoglobinuria [ABSTRACT FROM PUBLISHER]