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.

Routine use of feeding jejunostomy in oesophageal cancer resections: results of a survey in England.

Nutrition and post-operative feeding in oesophageal cancer resections for enhanced recovery remain a controversial subject. Feeding jejunostomy tubes (FJT) have been used post-operatively to address the subject but evidence to support its routine use is contentious. There is currently no data on FJT use in England for oesophageal cancer resections. Knowledge regarding current FJT usage, and rationale for its use may provide a snapshot of the trend and current standing on FJT use by resectional units in England. A standardised survey was sent electronically to all oesophageal resectional units in the United Kingdom (UK) between October 2016 and January 2018. In summary, the questionnaire probes into current FJT use, rationale for its usage, consideration of cessation of its use, and rationale of cessation of its use for units not using FJT. The resectional units were identified using the National Oesophago-Gastric Cancer Audit (NOGCA) progress report 2016 and 1 selected resectional unit from Northern Ireland, Scotland, and Wales, respectively. Performance data of those units were collected from the 2017 NOGCA report. Out of 40 units that were eligible, 32 (80.0%) centres responded. The responses show a heterogeneity of FJT use across the resectional centres. Most centres (56.3%) still place FJT routinely with 2 of 18 (11.1%) were considering stopping its routine use. FJT was considered a mandatory adjunct to chemotherapy in 3 (9.4%) centres. FJT was not routinely used in 9 (28.1%) of centres with 5 of 9 (55.6%) reported previous complications and 4 of 9 (44.4%) cited using other forms of nutrition supplementation as factors for discontinuing FJT use. There were 5 (15.6%) centres with divided practice among its consultants. Of those 2 of 5 (40.0%) were considering stopping FJT use, and hence, a total of 4 of 23 (17.4%) of units are now considering stopping routine FJT use. In conclusion, the wider practice of FJT use in the UK remains heterogenous. More research regarding the optimal post-operative feeding regimen needs to be undertaken.

Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying.

Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.

The implementation and effectiveness of an enhanced recovery programme after oesophago-gastrectomy: a prospective cohort study.

BACKGROUND: Oesophageal resection is notoriously complicated and produces a cohort of patients prone to postoperative complications. Maintaining quality care demands a systematic approach to patient management yet postoperative recovery after oesophagectomy is often needlessly inefficient, heterogeneous and governed by the idiosyncrasies of the operating surgeon. Enhanced recovery after surgery (ERAS) programmes are now well established in colorectal surgery and here we describe the implementation and effectiveness of an ERAS programme for the postoperative management of Ivor Lewis oesophago-gastrectomy (ILOG). METHODS: An ERAS programme was devised and implemented with the support of a dedicated in-hospital task-force. Three consultant surgeons allocated consecutive patients to the programme (ERAS) and outcomes were compared to consecutive patients not on the ERAS programme (non-ERAS) and a pre-ERAS cohort (pre-ERAS). Principal outcome measures were total length of stay (TLOS), Accordion postoperative complication grade and 30-day readmission rate. RESULTS: 75 patients were enrolled on the ERAS programme, 41 continued as a non-ERAS cohort and 80 consecutive pre-ERAS patients were identified. A significant improvement in median TLOS was observed in the ERAS group (10 days r.7-58) compared to pre-ERAS (13 days r. 8-57) (p = <0.001) and non-ERAS patients (13 days r.8-42) (p = <0.001). No significant difference in Accordion scores for postoperative complications or 30-day readmission rates were observed. DISCUSSION: The introduction of an ERAS programme after ILOG can significantly reduce TLOS without jeopardising patient safety or clinical outcomes. The successful introduction of an ERAS programme requires full motivation and support from all team members including the patient.

Assessment and comparison of recovery after open and minimally invasive esophagectomy for cancer: an exploratory study in two centers.

BACKGROUND: Minimally invasive esophagectomy (MIE) may lead to early restoration of health-related quality of life, but few prospective comparative studies have been performed. This exploratory study compared recovery between totally minimally invasive esophagectomy (MIE), laparoscopically assisted esophagectomy (LAE) and open surgery (OE). METHODS: A prospective study in 2 specialist centers recruited consecutive patients undergoing OE, LAE, or MIE for high-grade dysplasia or cancer. Patients completed validated questionnaires, the Multi-Dimensional Fatigue Inventory (MFI-20), modified Katz Scale, and modified Lawton and Brody Scale (assessing activities of daily living) before and 6 weeks and 3 and 6 months after surgery. RESULTS: A total of 97 patients (26 women; median age 64 years) were scheduled for surgery that was abandoned in 11 due to occult low-volume metastatic disease. In the remaining 86 (OE = 19, LAE = 31, and MIE = 36), there were 4 in-hospital deaths (4 %), and 54 postoperative complications (OE = 12, LAE = 19, and MIE = 23). Overall questionnaire compliance was high (77 %) and baseline scores similar in all groups, although clinical differences between groups were observed with earlier tumors and more squamous cell cancers selected for MIE. Following surgery fatigue levels increased dramatically and activity levels reduced in all groups. These gradually recovered to baseline following MIE and LAE within 6 months, but the ability to perform activities of daily living and most parameters of fatigue had not returned to baseline levels in the OE group. CONCLUSIONS: This exploratory prospective nonrandomized study of recovery after different types of surgery for esophageal cancer showed possible small benefits to MIE. A much larger study is needed to confirm these findings.

Health-related quality of life after minimally invasive oesophagectomy.

BACKGROUND: Open oesophagectomy has a detrimental impact on health-related quality of life (HRQL), with recovery taking up to a year. Minimally invasive oesophagectomy (MIO) may enable a more rapid recovery of HRQL. METHODS: Clinical outcomes from consecutive patients undergoing MIO for cancer were recorded between April 2005 and April 2007. Patients completed validated questionnaires, European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OES18, before surgery and at 6 weeks, 3, 6 and 12 months after surgery. RESULTS: MIO for cancer or high-grade dysplasia was planned in 62 patients, but abandoned in four owing to occult metastatic disease. Resection was completed in the remaining 58, two having partial conversion to open surgery. There was one in-hospital death and 29 patients developed complications. At 1 year, 52 of 58 patients were alive. Questionnaire response rates were high at each time point (overall compliance 84 per cent). Six weeks after MIO, patients reported deterioration in functional aspects of HRQL and more symptoms than at baseline. However, most improved by 3 months and had returned to baseline levels by 6 months. These levels were maintained 1 year after surgery, with 85 per cent of patients recovering in more than 50 per cent of the HRQL domains. CONCLUSION: MIO leads to a rapid restoration of HRQL.

Accelerated treatment for post-lobectomy empyema: new indication for an established procedure.

A 68-year-old male underwent a right upper lobectomy for non-small cell lung cancer (NSCLC) complicated by a delayed-onset empyema. The infected pleural space was successfully cleansed,applying the principles of accelerated treatment first described by the Weder group for patients sustaining an empyema after pneumonectomy. This strategy has been proved to be safe and effective even in cases of pleural space infection after minor lung resections, and we therefore recommend it for consideration as an additional treatment option for this patient group alongside the established techniques.

The role of health-related quality of life outcomes in clinical decision making in surgery for esophageal cancer: a systematic review.

BACKGROUND: Esophagectomy for cancer offers a chance of cure but is associated with morbidity, at least a temporary reduction in health-related quality of life (HRQL), and a 5-year survival of approximately 30%. This research evaluated how and whether HRQL outcomes contribute to surgical decision making. METHODS: A systematic review identified randomized trials and longitudinal and cross-sectional studies that assessed HRQL after esophagectomy with multidimensional validated questionnaires. Articles were independently evaluated by two reviewers, and the value of HRQL in clinical decision making was categorized in three ways: (1) the assessment of the quality of HRQL methodology according to predefined criteria; (2) the influence of HRQL outcomes on treatment recommendations and/or informed consent; and (3) the HRQL after esophagectomy for cancer in methodologically robust studies. RESULTS: Eighteen publications were identified, of which 16 (89%) were categorized as having robust HRQL design. Of these studies, 3 concluded that HRQL influenced treatment recommendations and 11 (including the former 3) informed patient consent. The remaining five papers were well designed, but the authors did not use HRQL to influence treatment recommendations or informed consent. After esophagectomy, patients report major deterioration in most aspects of HRQL with slow recovery. CONCLUSION: HRQL outcomes are relevant to surgical decision making. Methods to communicate HRQL outcomes to patients are required to inform consent and clinical practice.

A risk model for lung resection: data from the European Thoracic Database Project.

The development, application and interpretation of risk models is becoming an important activity in a number of surgical disciplines. In this paper, we discuss the many issues that arise when constructing a risk model, with particular reference to the development of a risk model for thoracic surgery. First, we briefly revisit the origins of risk modelling in cardiothoracic surgery.

Short-term outcomes following total minimally invasive oesophagectomy.

BACKGROUND: Minimally invasive oesophagectomy (MIO; thoracoscopy, laparoscopy, cervical anastomosis) is a complex procedure and few substantial series have been published. This study documented the morbidity, mortality and challenges of adopting MIO in a specialist unit in the UK. METHODS: A prospective group of 77 patients was listed consecutively with the intention of performing MIO. Three other patients underwent open oesophagectomy during the study period. RESULTS: MIO was attempted in 77 patients, completed successfully in 70, abandoned in six patients (8 per cent) with unsuspected metastatic disease, and converted to a thoracoscopic anastomosis in one patient. There was one in-hospital death (1 per cent). Complications occurred in 33 patients (47 per cent), including nine gastric conduit-related complications (13 per cent). Median lymph node harvest was 21 (range 7-48) nodes. Mean overall and disease-free survival times were 35 and 33 months respectively. Median disease-free survival for patients with stage III disease was 26 months. CONCLUSION: MIO can be performed with acceptable mortality and morbidity rates in an unselected series of patients. There was more morbidity related to gastric tube ischaemia than was expected.

Recurrence and malignant transformation in solitary fibrous tumour of the pleura.

Solitary fibrous tumours of the pleura are mesenchymal neoplasms and recurrence with malignant progression after complete resection rarely occurs. In the case of a 76-year-old patient we found multifocal recurrence with malignant transformation within six months following primary excision. Even though the vast majority of these tumours are benign, complete resection as well as clinical and radiological follow-up are highly recommended because of the potentially adverse biological behaviour and the lack of radical treatment options other than surgery.

Pleuroperitoneal shunts and tumor seeding.

A 76-year-old man with malignant mesothelioma of the left pleura was referred for surgical palliation. He was dyspneic at rest and had anterior chest pain and a persistent cough. Chest x-ray film revealed an extensive left pleural effusion. A thoracoscopy was performed, and 3L of pleural fluid was drained. Both the pleural surfaces and rhe diaphragm were studded with tumors. On maximal inflation of the lung, the parietal and visceral pleura did not oppose, and therefore a Denver shunt was inserted. At 6 weeks follow-up, the shunt was performing satisfactorily. At follow-up 9 weeks postoperatively, the subcutaneous tunnel was infiltrated by mesothelioma over a distance of some 15 cm.

Bronchopleural fistula complicating group A beta-haemolytic streptococcal pneumonia. Use of a Fogarty embolectomy catheter for selective bronchial blockade.

A 36-year-old woman developed severe group A Streptococcal pneumonia, complicated by a bronchopleural fistula, ARDS and multi-organ failure. We describe the use of selective middle lobe bronchus blockade, with a Fogarty embolectomy catheter, to localise and control the air leak. This allowed effective mechanical ventilation and oxygenation on intensive care and during right middle lobectomy. The patient made a prolonged, but full recovery.

Pulmonary haemorrhage after percutaneous paravertebral block.

We describe the management of a 65-yr-old woman anaesthetized for thoracotomy. The patient suffered a pulmonary haemorrhage after percutaneous paravertebral injection performed using the loss of resistance to saline technique. Thoracotomy at a later date revealed that the lung tissue had become adherent to the chest wall and that the paravertebral space was fibrosed secondary to previous surgery. This particular complication of percutaneous paravertebral block has not been reported previously and raises the question of risk vs benefit of this pre-emptive analgesic technique.

Tracheal obstruction in achalasia: a role for airway stenting?

We describe an 82-year-old woman who presented with acute tracheal obstruction secondary to advanced, asymptomatic achalasia. Conventional treatment of her achalasia failed to relieve recurrent episodes of airway obstruction requiring endotracheal intubation. Because she was not fit for an operation, a Gianturco endotracheal stent was placed bronchoscopically. She remains without respiratory or upper gastrointestinal symptoms 2 years later. Recent information regarding the pathophysiology and surgical treatment of this complication is reviewed.