Major Intraoperative Complications During Minimally Invasive Esophagectomy.

BACKGROUND: Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer. METHODS: Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction. RESULTS: Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%. CONCLUSIONS: This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Patterns of recurrent disease after neoadjuvant chemoradiotherapy and esophageal cancer surgery with curative intent in a tertiary referral center.

BACKGROUND: Recurrence is frequently observed after esophageal cancer surgery, with dismal post-recurrence survival. Neoadjuvant chemoradiotherapy followed by esophagectomy is the gold standard for resectable esophageal tumors in the Netherlands. This study investigated the recurrence patterns and survival after multimodal therapy. METHODS: This retrospective cohort study included patients with recurrent disease after neoadjuvant chemoradiotherapy followed by esophagectomy for an esophageal adenocarcinoma in the Amsterdam UMC between 01 and 01-2010 and 31-12-2018. Post-recurrence treatment and survival of patients were investigated and grouped by recurrence site (loco-regional, distant, or combined loco-regional and distant). RESULTS: In total, 278 of 618 patients (45.0%) developed recurrent disease after a median of 49 weeks. Thirty-one patients had loco-regional (11.2%), 145 distant (52.2%), and 101 combined loco-regional and distant recurrences (36.3%). Post-recurrence survival was superior for patients with loco-regional recurrences (33 weeks, 95%CI 7.3-58.7) compared to distant (12 weeks, 95%CI 6.9-17.1) or combined loco-regional and distant recurrent disease (18 weeks, 95%CI 9.3-26.7). Patients with loco-regional recurrences treated with curative intent had the longest survival (87 weeks, 95%CI 6.9-167.4). CONCLUSION: Recurrent disease after potentially curative treatment for esophageal cancer was most frequently located distantly, with dismal prognosis. A subgroup of patients with loco-regional recurrence was treated with curative intent and had prolonged survival. These patients may benefit from intensive surveillance protocols, and more research is needed to identify these patients.

Health-related quality of life following neoadjuvant chemoradiotherapy versus perioperative chemotherapy and esophagectomy for esophageal cancer: a European multicenter study.

Curative treatment for locally advanced esophageal cancer consists of (neo)adjuvant treatment followed by esophagectomy. Both neoadjuvant chemoradiotherapy and perioperative chemotherapy improve the 5-year overall survival rate compared with surgery alone. However, it is unknown whether these treatment strategies are associated with differences in long-term health-related quality of life (HRQL). The aim of this study is to compare long-term HRQL in patients after esophagectomy treated with neoadjuvant chemoradiotherapy or perioperative chemotherapy. Disease-free cancer patients having undergone esophagectomy and (neo)adjuvant treatment in one of the participating lasting symptoms after esophageal resection (LASER) study centers between 2010 and 2016, were identified from the LASER study dataset. Included patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), EORTC QLQ-OG25, and LASER questionnaires at least 1 year after the completion of treatment. Long-term HRQL was compared between patients treated with neoadjuvant chemoradiotherapy or perioperative chemotherapy, using univariable and multivariable regression and presented as differences in mean score. Among the 565 included patients, 349 (61.8%) received neoadjuvant chemoradiotherapy, and 216 (38.2%) perioperative chemotherapy. Patients treated with perioperative chemotherapy reported more symptomatology for diarrhea (difference in means 5.93), reflux (difference in means 7.40), and odynophagia (difference in means 4.66). The differences did not exceed the 10 points to be of clinical relevance. No significant differences for the LASER key symptoms were observed. The observed differences in long-term HRQL are in favor of patients treated with neoadjuvant chemoradiotherapy compared with patients treated with perioperative chemotherapy; however, the differences were small. Patients need to be informed about long-term HRQL when considering allocation of (neo)adjuvant treatment.

Early mobilization after esophageal cancer surgery: a retrospective cohort study.

A key component of the Enhanced Recovery After Surgery pathway for esophagectomy is early mobilization. Evidence on a specific protocol of early and structured mobilization is scarce, which explains variation in clinical practice. This study aims to describe and evaluate the early mobilization practice after esophagectomy for cancer in a tertiary referral center in the Netherlands. This retrospective cohort study included data from a prospectively maintained database of patients who underwent an esophagectomy between 1 January 2015 and 1 January 2020. Early mobilization entailed increase in activity with the first target of ambulating 100 meters. Primary outcomes were the number of postoperative days (PODs) until achieving this target and reasons for not achieving this target. Secondary outcomes were the relationship between preoperative factors (e.g. sex, BMI) and achieving the target on POD1, and the relationship between achieving the target on POD1 and postoperative outcomes (i.e. length of stay, readmissions). In total, 384 patients were included. The median POD of achieving the target was 2 (IQR 1-3), with 173 (45.1%) patients achieving this on POD1. Main reason for not achieving this target was due to hemodynamic instability (22.7%). Male sex was associated with achieving the target on POD1 (OR = 1.997, 95%CI 1.172-3.403, P = 0.011); achieving this target was not associated with postoperative outcomes. Ambulation up to 100 m on POD1 is achievable in patients after esophagectomy, with higher odds for men to achieve this target. ERAS pathways for post esophagectomy care are encouraged to incorporate 100 m ambulation on POD1 in their guideline as the first postoperative target.

Influence of postoperative complications following esophagectomy for cancer on quality of life: A European multicenter study.

INTRODUCTION: Postoperative complications following major surgery have been shown to be associated with reduced health-related quality of life (HRQL), and severe complications may have profound negative effects. This study aimed to examine whether long-term HRQL differs with the occurrence and severity of complications in a European multicenter prospective dataset of patients following esophagectomy for cancer. METHODS: Disease-free patients following esophagectomy for cancer between 2010 and 2016 from the LASER study were included. Patients completed the LASER, EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires >1 year following treatment. Long-term HRQL was compared between patients with and without postoperative complications, subgroup analysis was performed for severity of complications (no, minor [Clavien-Dindo I-II], severe [Clavien-Dindo ≥ III]), using univariable and multivariable regression. RESULTS: 645 patients were included: 283 patients with no, 207 with minor and 155 with severe complications. Significantly more dyspnea (QLQ-C30) was reported by patients with compared to patients without complications (differenceinmeans6.3). In subgroup analysis, patients with severe complications reported more dyspnea (difference in means 8.3) than patients with no complications. None of the differences were clinically relevant (difference in means ≥ 10 points). LASER-based low mood (OR2.3) was statistically different for minor versus severe complications. CONCLUSION: Comparable HRQL was found in patients with and without postoperative complications following esophagectomy for cancer, after a mean follow-up of 4.4 years. Furthermore, patients with different levels of severity of complications had comparable HRQL. The level of HRQL in esophageal cancer patients are more likely explained by the impact of the complex procedure of the esophagectomy itself.

A proposal for uniformity in classification of lymph node stations in esophageal cancer.

The 11th edition of the "Japanese Classification of Esophageal Cancer" by the Japan Esophageal Society (JES) and the 8th edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) "Cancer Staging Manual" are two separate classification systems both widely used for the clinical and pathological staging of esophageal cancer. Furthermore, the lymph node stations from these classification systems are combined for research purposes in the multinational TIGER study, which investigates the distribution pattern of lymph node metastases. The existing classification systems greatly differ with regard to number, location and anatomical boundaries of locoregional lymph node stations. The differences in these classifications cause significant heterogeneity in studies on lymph node metastases in esophageal cancer. This makes data interpretation difficult and comparison of studies challenging. In this article, we propose a match for these two commonly used classification systems and additionally for the TIGER study classification, in order to be able to compare results of studies and exchange knowledge and to make steps towards one global uniform classification system for all patients with esophageal cancer.

Evaluation of conductive cooling of lactating dairy cows under controlled environmental conditions.

Cooling systems used to reduce heat stress in dairy operations require high energy, water usage, or both. Steady increases in electricity costs and reduction of water availability and an increase in water usage regulations require evaluation of passive cooling systems to cool cows and reduce use of water and electricity. A study was conducted to evaluate the use of heat exchangers buried 25 cm below the surface as components in a conductive system for cooling cows. Six cows were housed in environmentally controlled rooms with tie-stall beds, which were equipped with a heat exchanger and filled with 25 cm of either sand or dried manure. Beds were connected to supply and return lines and individually controlled. Two beds (one per each kind of bedding material) constituted a control group (water off), and the other 4 (2 sand and 2 dried manure) used water at 7°C passing through the heat exchangers (water on). The experiment was divided in 2 periods of 40 d, and each period involved 3 repetitions of 3 different climates (hot and dry, thermo neutral, and hot and humid). Each cow was randomly assigned to a different treatment after each repetition was over. Sand bedding remained cooler than dried manure bedding in all environments and at all levels of cooling (water on or off). Bed temperatures were lower and heat flux higher during the bed treatment with sand and water on. We also detected a reduction in core body temperatures, respiration rates, rectal temperatures, and skin temperatures of those cows during the sand and water on treatment. Feed intake and milk yield numerically increased during the bed treatment with sand and water on for all climates. No major changes were observed in the lying time of cows or the composition of the milk produced. We conclude that use of heat exchangers is a viable adjunct to systems that employ fans, misters, and evaporative cooling methods to mitigate effects of heat stress on dairy cows. Sand was superior to dried manure as a bedding material in combination with heat exchangers.

The effect of premilking udder preparation on Holstein cows milked 3 times daily.

Premilking udder preparation (including forestripping and duration of lag time-the time between first tactile stimulation and attachment of milking unit) might influence milking measures such as milking unit on-time, incidence of bimodality, and milk flow rates in Holstein cows milked 3 times daily. Holstein cows (n=786) from an 1,800-cow commercial dairy herd were enrolled under a restricted randomized design to determine the effect of 9 different premilking routines. Lag times were 0, 60, 90, 120, and 240s and included forestripping or no forestripping for a total of 9 treatments (no forestripping for 0 lag time); the study was conducted from February to November 2008. All cow-treatment combinations were compared with the control: predipping plus forestripping and drying with 90s of lag time. Cows were initially assigned to 1 of 3 treatments for a period of 7d and upon completion of the first 7-d period were reassigned to a different treatment until all treatments had been completed. From one treatment period to the next, cows had to switch stimulation method with no restriction on lag time. Cows did not receive all treatments during the duration of the trial. Early- to mid-lactation cows (EML; 17-167 DIM) and late-lactation cows (LL; 174-428 DIM) were housed in 2 different pens. Milk yield was significantly different between dip + forestrip and dip+dry for 2 of the treatments for EML cows compared with dip + forestrip and 90 s of lag-time (DF90); however, this was not thought to be due to treatment because the significant lag times were very different (60 and 240 s) and neither was an extreme value. Milk yield did not differ with treatment for the LL cows. Milking unit on-time did not differ when comparing all treatments for EML with treatment DF90; however, an increase in milking unit on-time occurred when lag time was 60s or less for LL cows. The highest incidence of bimodal milk curves was when lag time = 0 and this was independent of stage of lactation; a lag time of 240 s had the second-highest incidence of bimodal milk curves for EML and LL cows. Milk harvested in the first 2 min was lower for lag times of 0 and 240 s when compared with DF90. Increasing the lag time for all cows appeared to improve overall milking time efficiency (although lag time had no effect on EML cows).