The COVID-19 Era Is Associated With Delays in Esophageal Cancer Diagnosis and Treatment.

INTRODUCTION: The coronavirus disease-2019 (COVID-19) pandemic has substantially affected the delivery of healthcare globally. The purpose of this study was to evaluate the association of this era with the timeline of care in esophageal cancer patients. METHODS: We performed a retrospective chart-review of patients presenting to a single high-volume tertiary care center with the diagnosis of esophageal cancer. COVID era was defined as March 2020-December 2020 and compared with the year before (3/2019-12/2019). RESULTS: In total, 117 patients presented in the COVID-era versus 190 in pre-COVID. Stage 3 + 4 disease was found in 77.8% of the patients in the COVID-era compared to 68.9% in the pre-COVID era (P = 0.34). Diagnoses through emergency department admission were 35.5% in the COVID versus 26.7% in the pre-COVID group (P = 0.15). In the COVID era it took a median of 78 d to visit primary care provider (versus 52 d, P = 0.12 in pre-COVID), 45 d to endoscopy (versus 18 d, P = 0.004) and 38 d to treatment initiation (versus 36 d, P = 0.48). Thirty-five percent of the patients underwent esophagectomy compared to 26% in the pre-COVID-era. Median days of intensive-care-unit (ICU) (2 versus 3, P = 0.16) and hospital stay (14 versus 15, P = 0.28) were similar in both groups as well as postoperative 30-day morbidities (63 versus 63%, P = 0.48). One-year follow-up showed 83.7% (95% confidence interval [CI]: 73.8%-90.1%) survival in the COVID-group compared to 76.4% (95% CI: 66.9%-83.5%) in the pre-COVID-group (P = 0.58). Only three patients had a positive COVID result. CONCLUSIONS: Our institution treated fewer esophageal cancer patients during COVID-19 accompanied by a delay in endoscopic diagnosis. Postoperative outcomes and 1-year survival remained similar.

Hazardous giant pharyngoesophageal liposarcoma.

A man in his early 80s presented to the otorhinolaryngology department with progressively worsening dysphagia to solids and a recent episode of difficulty breathing accompanied by a very brief expulsion of a solid mass from the mouth. Based on the endoscopic appearance of a fatty lesion of an elongated mass with a thick stalk on the posterior pharyngeal wall, a diagnosis of the benign fibrovascular polyp was given after clinical and radiological correlation. The pharyngeal polyp was resected at the base of its pedicle by transoral endoscopy with a thunder beat vessel sealing device. Histopathological examination of the mass revealed a well-differentiated liposarcoma composed of mature adipocytes. Following surgical excision, the patient made a full recovery. This case signifies the integrated role of preoperative biopsy, new surgical technologies and targeted therapies in managing pharyngoesophageal polyps.

The safety of esophageal cancer surgery during COVID-19.

BACKGROUND: The ongoing coronavirus disease 2019 (COVID-19) pandemic has drastically challenged the safety of on esophageal cancer (EC) surgery during COVID-19. The study aimed to evaluate the safety of EC surgery during the COVID-19 pandemic. METHODS: This systematic review was performed in accordance with the PRISMA-P 2015 guidelines and registered in PROSPERO (registration number: CRD42022335164). A systematic search of PubMed, Embase, Cochrane Library, Web of Science, Medline, Chinese National Knowledge Infrastructure database, Chinese Scientific Journal database, and Wan Fang database was conducted to identify potentially relevant publications from January 2020 to May 2022. All data were independently extracted by two researchers. We will apply a fixed-effect model or random effect model basis on the heterogeneity test and employ with RevMan 5.4.1 software for data synthesis. The dichotomous surgical outcomes used risk ratios or risk differences, and for continuous surgical outcomes, mean differences (MD) or standardized MD, both with 95% confidence intervals were used. The primary outcomes were postoperative complications, anastomotic leaks, and mortality. The secondary outcomes were total hospital stay, postoperative stay, preoperative waiting, operation time, blood loss, transfusion, postoperative intensive care unit (ICU) stay, number of patients needing ICU stay, and 30-day readmission. RESULTS: This study will comprehensively summarize the high-quality trials to determine the safety of EC surgery during COVID-19. CONCLUSION: Our systematic review and meta-analysis will present evidence for the safety of EC surgery during COVID-19.

Safe oesophageal stent deployment using a checklist system instead of fluoroscopy.

BACKGROUND: Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature. METHODS: We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion. RESULTS: Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks). CONCLUSIONS: Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

Minimally Invasive Ivor-Lewis Esophagectomy for Esophageal Cancer After Gastric Bypass.

The increasing prevalence of morbid obesity in the United States has been accompanied by a concomitant rise in bariatric surgery to help combat the epidemic. The relationship between obesity and certain cancers, such as esophageal adenocarcinoma, is well established. The need for minimally invasive techniques to treat esophageal cancer in patients with previous bariatric surgery is growing and can present a unique surgical challenge. This report presents the case of a 55-year-old woman with a previous Roux-en-Y gastric bypass who was shown by endoscopy to have an invasive adenocarcinoma located in the distal thoracic esophagus. This necessitated an excision of the thoracic esophagus and the gastric pouch. A laparoscopic and thoracoscopic Ivor-Lewis esophagogastrectomy was performed for this complex patient with esophageal adenocarcinoma. The remnant stomach was fashioned into a gastric conduit using a 60-mm linear stapler with a staple height of 4.1 mm (Echelon, Ethicon Endosurgery, Blue Ash, OH). The reconstruction was performed using a 25-mm Orvil (Covidien, Minneapolis, MN, USA) and EEA 25-mm DST XL (Covidien) to create a circular stapled thoracic esophagogastric anastomosis. A feeding jejunostomy was placed in the residual 130-cm Roux limb. The study demonstrated that minimally invasive esophagectomy is safe and technically feasible with appropriate oncologic outcomes for patients with previous gastric bypass. This cohort of patients will undoubtedly continue to grow in the coming years.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

[Impact of COVID-19 on oncological surgery of the upper gastrointestinal tract]. / Auswirkungen von COVID-19 auf die onkologische Chirurgie des oberen Gastrointestinaltrakts.

BACKGROUND: The outbreak of the coronavirus disease 2019 (COVID-19) pandemic imposed limitations for elective surgery, impacting the associated hospital standards worldwide. As certain treatment windows must be adhered to in oncological surgery, the limited intensive care unit (ICU) capacity had to be critically distributed in order to do justice to both acutely ill and oncology patients. This manuscript summarizes the impact of COVID-19 on the management of oncological surgery of the upper gastrointestinal tract and particularly esophageal surgery in German medical centers. MATERIAL AND METHODS: A survey of German centers for esophageal surgery was performed on the impact of COVID-19 on operative management for esophageal surgery during the first lockdown. After inspection, assessment, critical analysis and interpretation, the results were compared to the international literature. RESULTS AND DISCUSSION: Initial recommendations of international societies warned for caution and restraint regarding interventions of the upper gastrointestinal tract that were not absolutely necessary. Oncological surgery should be performed under strict restrictions, especially only after negative testing for COVID-19 and only with sufficiently available personal protective equipment for the personnel. Furthermore, minimally invasive procedures were preferably not recommended. In diseases with alternative treatment options, such as definitive chemoradiotherapy of esophageal squamous cell carcinoma, these should be given priority when possible. In the further development of the pandemic, it was shown that due to a high standardization of preoperative management, postoperative results comparable to pre-pandemic times could be achieved particularly with respect to the diagnostics of infections.

Safety of Esophageal Cancer Surgery During the First Wave of the COVID-19 Pandemic in Europe: A Multicenter Study.

BACKGROUND: Many hospitals postponed elective surgical care during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. Some centers continued elective surgery, including esophageal cancer surgery, with the use of preoperative screening methods; however, there is no evidence supporting the safety of this strategy as postoperative outcomes after esophageal cancer surgery during the COVID-19 pandemic have not yet been investigated. METHODS: This multicenter study in four European tertiary esophageal cancer referral centers included consecutive adult patients undergoing elective esophageal cancer surgery from a prospectively maintained database in a COVID-19 pandemic cohort (1 March 2020-31 May 2020) and a control cohort (1 October 2019-29 February 2020). The primary outcome was the rate of respiratory failure requiring mechanical ventilation. RESULTS: The COVID-19 cohort consisted of 139 patients, versus 168 patients in the control cohort. There was no difference in the rate of respiratory failure requiring mechanical ventilation (13.7% vs. 8.3%, p = 0.127) and number of pulmonary complications (32.4% vs. 29.9%, p = 0.646) between the COVID-19 cohort and the control cohort. Overall, postoperative morbidity and mortality rates were comparable between both cohorts. History taking and reverse transcription polymerase chain reaction (RT-PCR) were used as preoperative screening methods to detect a possible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in all centers. No patients were diagnosed with COVID-19 pre- or postoperatively. CONCLUSION: Esophageal cancer surgery during the first wave of the COVID-19 pandemic was not associated with an increase in pulmonary complications as no patients were diagnosed with COVID-19. Esophageal cancer surgery can be performed safely with the use of adequate preoperative SARS-CoV-2 screening methods.

COVID-19 Pneumonia on Post-Operative Day 2 after Esophagectomy: Performing Esophago-Gastric Junction Cancer Surgery during the SARS-Cov-2 Second Wave.

The coronavirus disease 2019 (COVID-19) pandemic has had a substantial impact on the provision of medical healthcare. Due to an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) transmission, elective surgical treatment has been suspended in many centers. The effects of COVID-19 in the early post-operative period after esophagectomy remains unknown. In this report, we present three cases of patients diagnosed with esophago-gastric junction cancer who were scheduled for elective esophagectomy with a curative intention during second wave of COVID-19 pandemic in a single high-volume tertiary center. Despite all available safety measures, one of the patients developed COVID-19 pneumonia on post-operative day two, leading to an impaired respiratory function and increased pleural fluid collection from the chest tube, resulting in a prolonged time of hospital stay. Finding a good balance between the COVID-19-related perioperative risks and consequences of delaying surgical treatment in patients diagnosed with esophago-gastric cancer is a challenge. In order to achieve the best possible outcome, care must be taken to ensure availability of necessary treatment options and to reduce the risk of SARS-Cov-2 transmission perioperatively.

Successful maintenance of process and outcomes for oesophageal cancer surgery in Ireland during the first wave of the COVID-19 pandemic.

INTRODUCTION: The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019. METHODS: Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared. RESULTS: In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period. CONCLUSIONS: Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.

Impact of COVID-19 outbreak on esophageal cancer surgery in Northern Italy: lessons learned from a multicentric snapshot.

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.

Emergency surgical gastrostomy in an esophageal cancer patient unable to receive COVID-19 treatment due to obstruction, and operating room measures as per pandemic guidelines: Case report.

We present here a gastrostomy procedure performed on a patient diagnosed with COVID-19 with no oral intake due to esophageal cancer in order to permit the initiation of COVID-19 treatment, and the COVID-19 protocols followed as per the pandemic guidelines. A 55-year-old female patient diagnosed recently with esophageal squamous-cell carcinoma was consulted for a surgical gastrostomy in the absence of oral intake due to complete esophageal obstruction prior to neoadjuvant chemotherapy. The patient had a new-onset cough and elevated body temperature (38°C) on admission to our clinic, and so was tested for COVID-19, with the final diagnosis established with PCR. In order to initiate COVID-19 treatment, a surgical gastrostomy was performed under semi-emergency conditions, following COVID-19 infection prevention guidelines. COVID-19 treatment, nutrition, and supportive therapy were initiated through the gastrostomy catheter. The patient is clinically stable on day 7 of treatment. A COVID-19 patient may require emergency surgical intervention during the fight against pandemic. When a surgical procedure is performed, all guidelines defined to protect healthcare workers from COVID-19 infection should be followed.

Short-term outcomes after Ivor Lewis oesophagectomy for cancer during the COVID-19 pandemic.

INTRODUCTION: Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. METHODS: We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24-48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. RESULTS: Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. CONCLUSIONS: ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.

Modeling the impact of delaying surgery for early esophageal cancer in the era of COVID-19.

BACKGROUND: Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma. METHODS: A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. RESULTS: Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%. CONCLUSIONS: Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.

Clinical outcomes of radical gastrectomy following trastuzumab-based chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer.

PURPOSE: Patients who receive trastuzumab (T-mab) plus chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer sometimes respond remarkably well and can undergo radical surgery. However, the clinical outcomes of preoperative T-mab combined chemotherapy with radical gastrectomy remain unclear. We conducted this study to investigate the clinical outcomes of this multimodal treatment. METHODS: From among a total of 199 patients who received T-mab-based chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer between 2011 and 2018, the subjects of this retrospective analysis were 20 patients who subsequently underwent radical gastrectomy. RESULTS: Seven patients had gastroesophageal junction cancer and 13 had gastric cancer. Eleven patients had unresectable stage IV cancer and 9 had resectable metastatic disease. Chemotherapy regimens included capecitabine, cisplatin + T-mab (11 patients), and S-1, oxaliplatin + T-mab (nine patients). The median number of chemotherapy cycles before surgery was three (range, 2-62). During preoperative chemotherapy, grade 3/4 adverse events developed in six patients. None suffered grade ≥ 3b postoperative complications. The 3-year relapse-free survival (RFS) and overall survival (OS) rates were 58.9% and 89.5%, respectively. CONCLUSION: Combined preoperative T-mab-based chemotherapy and surgery appears to be safe and effective for stage IV HER2-positive gastric or gastroesophageal junction cancer, with a clinically meaningful impact on RFS and OS.

Delivering esophago-gastric cancer care during the COVID-19 pandemic in the United Kingdom: a surgical perspective.

BACKGROUND: The COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center. METHODS: All patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated. RESULTS: Overall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications. CONCLUSION: Care must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care.