Implementation of perioperative FLOT compared to ECX/EOX chemotherapy regimens in resectable esophagogastric adenocarcinomas: an analysis of real-world data.

BACKGROUND AND PURPOSE: Perioperative 5-FU, leucovorin, oxaliplatin, and docetaxel (FLOT) is recommended in resectable esophagogastric adenocarcinoma based on randomised trials. However, the effectiveness of FLOT in routine clinical practice remains unknown as randomised trials are subject to selection bias limiting their generalisability. The aim of this study was to evaluate the implementation of FLOT in real-world patients. METHODS: Retrospectively collected data were analysed in consecutive patients treated before or after the implementation of FLOT. The primary endpoint was complete pathological response (pCR) and secondary endpoints were margin-free resection (R0), overall survival (OS), relapse-free survival (RFS) tolerability of chemotherapy and surgical complications. RESULTS: Mean follow-up time for patients treated with FLOT (n = 205) was 37.7 versus 47.0 months for epirubicin, cis- or oxaliplatin, and capecitabine (ECX/EOX, n = 186). Surgical resection was performed in 88.0% versus 92.0%; pCR were observed in 3.8% versus 2.4%; and R0 resections were achieved in 78.0% versus 86.0% (p = 0.03) in the ECX/EOX and FLOT cohorts, respectively. Survival analysis indicated no significant difference in RFS (p = 0.17) or OS (p = 0.37) between the cohorts with a trend towards increased OS in performance status 0 (hazard ratio [HR] = 0.73, 95% confidence interval [CI]: 0.50-1.04). More patients treated with ECX/EOX completed chemotherapy (39% vs. 28%, p = 0.02). Febrile neutropenia was more common in the FLOT cohort (3.8% vs. 11%, p = 0.0086). 90-days mortality (1.2% vs. 0%) and frequency of anastomotic leakage (8% vs. 6%) were equal and low. INTERPRETATION: Patients receiving FLOT did not demonstrate improved pCR, RFS or OS. However, R0 rate was improved and patients in good PS trended towards improved OS.

Laser Speckle Contrast Imaging-based diagnosis of severe mesenteric traction syndrome: Hemodynamics and prostacyclin - A prospective cohort study.

BRIEF ABSTRACT: Today, the diagnosis and grading of mesenteric traction syndrome relies on a subjective assessment of facial flushing. However, this method has several limitations. In this study, Laser Speckle Contrast Imaging and a predefined cut-off value are assessed and validated for the objective identification of severe mesenteric traction syndrome. BACKGROUND: Severe mesenteric traction syndrome (MTS) is associated with increased postoperative morbidity. The diagnosis is based on an assessment of the developed facial flushing. Today this is performed subjectively, as no objective method exists. One possible objective method is Laser Speckle Contrast Imaging (LSCI), which has been used to show significantly higher facial skin blood flow in patients developing severe MTS. Using these data, a cut-off value has been identified. This study aimed to validate our predefined LSCI cut-off value for identifying severe MTS. METHODS: A prospective cohort study was performed on patients planned for open esophagectomy or pancreatic surgery from March 2021 to April 2022. All patients underwent continuous measurement of forehead skin blood flow using LSCI during the first hour of surgery. Using the predefined cut-off value, the severity of MTS was graded. In addition, blood samples for prostacyclin (PGI2) analysis and hemodynamics were collected at predefined time points to validate the cut-off value. MAIN RESULTS: Sixty patients were included in the study. Using our predefined LSCI cut-off value, 21 (35 %) patients were identified as developing severe MTS. These patients were found to have higher concentrations of 6-Keto-PGFaα (p = 0.002), lower SVR (p < 0.001), lower MAP (p = 0.004), and higher CO (p < 0.001) 15 min into surgery, as compared with patients not developing severe MTS. CONCLUSION: This study validated our LSCI cut-off value for the objective identification of severe MTS patients as this group developed increased concentrations of PGI2 and more pronounced hemodynamic alterations compared with patients not developing severe MTS.

Table in the corner: a qualitative study of life situation and perspectives of the everyday lives of oesophageal cancer patients in palliative care.

BACKGROUND: Incurable oesophageal cancer patients are often affected by existential distress and deterioration of quality of life. Knowledge about the life situation of this patient group is important to provide relevant palliative care and support. The purpose of this study is to illuminate the ways in which incurable oesophageal cancer disrupts the patients' lives and how the patients experience and adapt to life with the disease. METHODS: Seventeen patients receiving palliative care for oesophageal cancer were interviewed 1-23 months after diagnosis. The epistemological approach was inspired by phenomenology and hermeneutics, and the method of data collection, analysis and interpretation consisted of individual qualitative interviews and meaning condensation, inspired by Kvale and Brinkmann. RESULTS: The study reveals how patients with incurable oesophageal cancer experience metaphorically to end up at a "table in the corner". The patients experience loss of dignity, identity and community. The study illuminated how illness and symptoms impact and control daily life and social relations, described under these subheadings: "sense of isolation"; "being in a zombie-like state"; "one day at a time"; and "at sea". Patients feel alone with the threat to their lives and everyday existence; they feel isolated due to the inhibiting symptoms of their illness, anxiety, worry and daily losses and challenges. CONCLUSIONS: The patients' lives are turned upside down, and they experience loss of health, function and familiar, daily habits. The prominent issues for the patients are loneliness and lack of continuity. As far as their normal everyday lives, social networks and the health system are concerned, patients feel they have been banished to a "table in the corner". These patients have a particular need for healthcare professionals who are dedicated to identifying what can be done to support the patients in their everyday lives, preserve dignity and provide additional palliative care.

Postoperative complications and survival after surgical resection of esophageal squamous cell carcinoma.

BACKGROUND: Resection of esophageal squamous cell carcinoma (SCC) is associated with a frequent occurrence of postoperative complications. Previously, the impact of complications on long-term survival has been explored primarily in mixed squamous cell and adenocarcinoma (AC) populations with conflicting results. In the present study, the influence of postoperative complications on survival following open esophageal resection was investigated exclusively in a western population with SCC. METHODS: In a retrospective observational study, all patients undergoing open surgical resection for esophageal SCC at our centre between February 2010 and December 2015 were consecutively included. Pre- and perioperative clinical information, mortality and complications were registered. RESULTS: In the study cohort, 133 patients were enrolled. Eighty-nine patients (67%) experienced one or more postoperative complications. The estimated 5-year survival on the entire population was 57%. Patients without complications had a long-term survival of 52%, whereas in patients with one or more complications survival was reduced to 30% (log rank P=0.039). Cox regression analysis revealed that postoperative complications were associated with an increased mortality risk with an adjusted hazard ratio (HR) of 2.02 (95% CI: 1.1-3.7, P=0.025), specifically sepsis/septic shock and anastomotic leakage significantly reduced long-term survival. CONCLUSIONS: We found an improved 5-year survival in patients undergoing surgical resection for SCC compared to previous studies with mixed populations, despite a more frequent occurrence of complications. The presence of postoperative complications significantly reduced the long-term survival with 42%.

Feasibility of a novel liquid fiducial marker for use in image guided radiotherapy of oesophageal cancer.

OBJECTIVE:: To evaluate the feasibility of a new liquid fiducial marker for use in image-guided radiotherapy for oesophageal cancer. METHODS:: Liquid fiducial markers were implanted in patients with metastatic or inoperable locally advanced oesophageal or gastro-oesophageal junction cancer receiving radiotherapy. Markers were implanted using a conventional gastroscope equipped with a 22 G Wang needle. Marker visibility was evaluated on fluoroscopy, CT, MRI and cone beam CT scans. RESULTS:: Liquid markers (n = 16) were injected in four patients. No Grade 2 or worse adverse events were observed in relation to the implantation procedure, during treatment or in the follow-up period. 12/16 (75%) markers were available at the planning CT-scan and throughout the treatment- and follow-up period. The implanted markers were adequately visible in CT and cone beam CT but were difficult to distinguish in fluoroscopy and MRI without information from the corresponding CT image. CONCLUSION:: Liquid fiducial marker placement in the oesophagus proved safe and clinically feasible. ADVANCES IN KNOWLEDGE:: This paper presents the first clinical use of a new liquid fiducial marker in patients with oesophageal cancer and demonstrates that marker implantation using standard gastroscopic equipment and subsequent use in three-dimensional image-guided radiation therapy is safe and clinically feasible.

Re-embodying eating after surgery for oesophageal cancer: Patients' lived experiences of participating in an education and counselling nutritional intervention.

AIMS AND OBJECTIVES: To provide in-depth insight into patients' lived experiences of participating in an education and counselling nutritional intervention after curative surgery for oesophageal cancer. BACKGROUND: Surgery for oesophageal cancer carries a risk of malnutrition. The consequences of nutritional problems may lead to increased morbidity and mortality postoperatively and have consequences for convalescence, rehabilitation and quality of life. DESIGN: Qualitative study based on a phenomenological approach. The theoretical framework was grounded in the philosophy of Merleau-Ponty. METHODS: Qualitative interviews were conducted with 10 patients who participated in an education and counselling nutritional intervention after surgery for oesophageal squamous-cell carcinoma. Data were analysed according to the principles of Kvale and Brinkmann, and their three levels of interpretation were applied. FINDINGS: The essence of experiencing the education and counselling nutritional intervention can be divided into three themes: embodied disorientation, living with increased attention to bodily functions and re-embodying eating. CONCLUSIONS: Patients were living with increased attention to bodily functions and tried to find a balance between the task of eating and nutritional needs. Despite the embodied perceptions of alterations after oesophageal cancer surgery, the patients developed high levels of bodily awareness and skills in self-management. This process was characterised by reconnecting to the body and re-embodying eating. The intervention empowered the patients to regain some control of their own bodies in an effort to regain agency in their own lives. RELEVANCE TO CLINICAL PRACTICE: There is a need for systematic long-term follow-up after surgery for oesophageal cancer regarding nutrition. The findings of this study can inform future supportive nutrition care service development aimed at supporting patients to learn to eat sufficiently after oesophageal resection.

Evaluation of Gastric Microcirculation by Laser Speckle Contrast Imaging During Esophagectomy.

BACKGROUND: Thoracic epidural anesthesia (TEA) may provoke hypotension, and that, as well as the use of vasopressors and the surgical technique, could affect splanchnic microcirculation, in which the surgical target organ is of particular interest. This study used laser speckle contrast imaging (LSCI) to monitor gastric microcirculation during esophagectomy. STUDY DESIGN: Forty-five patients undergoing open esophagectomy were randomized to primary activation (EA; 25 patients) or no intraoperative activation (LA; 20 patients) of TEA. Phenylephrine managed intraoperative hypotension and gastric microcirculation was assessed at antrum and corpus area by LSCI. RESULTS: Antrum microcirculation (mean ± SD) was lower in the EA group at baseline (1,150 ± 189 laser speckle perfusion units [LSPU] vs LA group: 1,265 ± 163 LSPU; p = 0.036). In both groups, antrum microcirculation tended to decrease in response to anesthesia, TEA, and surgical procedure (LA: 1,265 ± 163 to 1,097 ± 184 LSPU, p = 0.021; EA: 1,150 ± 189 to 1,064 ± 177 LSPU, p = 0.093), with no difference between groups during the remaining laparotomy. Corpus microcirculation decreased in both groups from baseline to gastric pull-up in response to anesthesia, TEA, and surgery (LA: 1,081 ± 236 to 649 ± 165 LSPU, p < 0.001; EA: 1,011 ± 208 to 675 ± 178 LSPU, p < 0.001), but recovered after gastric continuity was re-established (EA to 795 ± 162 LSPU, p = 0.027; LA to 815 ± 166 LSPU, p = 0.014), with no significant differences between groups (p > 0.05). The EA group needed continued phenylephrine support to maintain blood pressure (216 ± 86 vs 58 ± 91 minutes; p < 0.001). CONCLUSIONS: During esophagectomy, gastric microcirculation can be followed in real-time by LSCI. Flow changes in the stomach seemed related more to surgery than to TEA/vasopressor support. Laser speckle contrast imaging could form basis for directing procedures to maintain the microcirculation.

A reduced gastric corpus microvascular blood flow during Ivor-Lewis esophagectomy detected by laser speckle contrast imaging technique.

BACKGROUND: Reduced microvascular blood flow is related to anastomotic insufficiency following esophagectomy, emphasizing a need for intraoperative monitoring of the microcirculation. This study evaluated if laser speckle contrast imaging (LSCI) was able to detect intraoperative changes in gastric microcirculation. METHODS: Gastric microcirculation was assessed prior to and after reconstruction of gastric continuity in 25 consecutive patients operated for adenocarcinoma with open Ivor-Lewis esophagectomy while hemodynamic variables were recorded. RESULTS: During upper laparotomy, microcirculation at the corpus decreased by 25% from baseline to mobilization of the stomach (p = .008) and decreased further (to a total decrease of 40%) following gastric pull to the thorax (p = .013). On the other hand, microcirculation at the antrum did not change significantly after gastric mobilization (p = .091). The decrease in corpus microcirculation took place unrelated to central cardiovascular variables. CONCLUSION: Using LSCI technique, we identified a reduced microcirculation at the corpus area during open Ivor-Lewis esophagectomy. LSCI provides an option for real-time assessment of gastric microcirculation and could form basis for intraoperative stabilization of the microcirculation.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study.

AIM: To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy. METHODS: Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy. RESULTS: 216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups. CONCLUSIONS: The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.

Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS).

This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE), produced in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). It addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer. The Scottish Intercollegiate Guidelines Network (SIGN) approach was adopted to define the strength of recommendations and the quality of evidence.The article has been co-published with permission in Endoscopy and the European Respiratory Journal.

Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS).

This is an official guideline of the European Society of Gastrointestinal Endoscopy (ESGE), produced in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS). It addresses the benefit and burden associated with combined endobronchial and esophageal mediastinal nodal staging of lung cancer. The Scottish Intercollegiate Guidelines Network (SIGN) approach was adopted to define the strength of recommendations and the quality of evidence.The article has been co-published with permission in the European Journal of Cardio-Thoracic Surgery and the European Respiratory Journal. Recommendations 1 For mediastinal nodal staging in patients with suspected or proven non-small-cell lung cancer (NSCLC) with abnormal mediastinal and/or hilar nodes at computed tomography (CT) and/or positron emission tomography (PET), endosonography is recommended over surgical staging as the initial procedure (Recommendation grade A). The combination of endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic (esophageal) ultrasound with fine needle aspiration, with use of a gastrointestinal (EUS-FNA) or EBUS (EUS-B-FNA) scope, is preferred over either test alone (Recommendation grade C). If the combination of EBUS and EUS-(B) is not available, we suggest that EBUS alone is acceptable (Recommendation grade C).Subsequent surgical staging is recommended, when endosonography does not show malignant nodal involvement (Recommendation grade B). 2 For mediastinal nodal staging in patients with suspected or proven non-small-cell peripheral lung cancer without mediastinal involvement at CT or CT-PET, we suggest that EBUS-TBNA and/or EUS-(B)-FNA should be performed before therapy, provided that one or more of the following conditions is present: (i) enlarged or fluorodeoxyglucose (FDG)-PET-avid ipsilateral hilar nodes; (ii) primary tumor without FDG uptake; (iii) tumor size ≥ 3 cm (Fig. 3a - c) (Recommendation grade C). If endosonography does not show malignant nodal involvement, we suggest that mediastinoscopy is considered, especially in suspected N1 disease (Recommendation grade C).If PET is not available and CT does not reveal enlarged hilar or mediastinal lymph nodes, we suggest performance of EBUS-TBNA and/or EUS-(B)-FNA and/or surgical staging (Recommendation grade C). 3 In patients with suspected or proven < 3 cm peripheral NSCLC with normal mediastinal and hilar nodes at CT and/or PET, we suggest initiation of therapy without further mediastinal staging (Recommendation grade C). 4 For mediastinal staging in patients with centrally located suspected or proven NSCLC without mediastinal or hilar involvement at CT and/or CT-PET, we suggest performance of EBUS-TBNA, with or without EUS-(B)-FNA, in preference to surgical staging (Fig. 4) (Recommendation grade D). If endosonography does not show malignant nodal involvement, mediastinoscopy may be considered (Recommendation grade D). 5 For mediastinal nodal restaging following neoadjuvant therapy, EBUS-TBNA and/or EUS-(B)-FNA is suggested for detection of persistent nodal disease, but, if this is negative, subsequent surgical staging is indicated (Recommendation grade C). 6 A complete assessment of mediastinal and hilar nodal stations, and sampling of at least three different mediastinal nodal stations (4 R, 4 L, 7) (Fig. 1, Fig. 5) is suggested in patients with NSCLC and an abnormal mediastinum by CT or CT-PET (Recommendation grade D). 7 For diagnostic purposes, in patients with a centrally located lung tumor that is not visible at conventional bronchoscopy, endosonography is suggested, provided the tumor is located immediately adjacent to the larger airways (EBUS) or esophagus (EUS-(B)) (Recommendation grade D). 8 In patients with a left adrenal gland suspected for distant metastasis we suggest performance of endoscopic ultrasound fine needle aspiration (EUS-FNA) (Recommendation grade C), while the use of EUS-B with a transgastric approach is at present experimental (Recommendation grade D). 9 For optimal endosonographic staging of lung cancer, we suggest that individual endoscopists should be trained in both EBUS and EUS-B in order to perform complete endoscopic staging in one session (Recommendation grade D). 10 We suggest that new trainees in endosonography should follow a structured training curriculum consisting of simulation-based training followed by supervised practice on patients (Recommendation grade D). 11 We suggest that competency in EBUS-TBNA and EUS-(B)-FNA for staging lung cancer be assessed using available validated assessment tools (Recommendation Grade D).

[Bronchoscopic lung volume reduction is a treatment offered to patients with severe heterogenous emphysema]. / Bronkoskopisk lungevolumenreduktion er et behandlingstilbud til patienter med svært heterogent emfysem

Introduction of bronchoscopic lung volume reduction as a treatment for severe emphysema has been defined as an area of development by The Danish Health and Medicines Authority. We here present the rationale for treatment, in- and exclusion criteria, and ultimately the organization for assessment, treatment and follow-up in Denmark. The treatment aim is to lower dyspnoea. There is a national protocol for patient selection according to in- and exclusion criteria. Different commercial devices are available, but endobronchial valves have been the devices mostly applied. A national database has been established to evaluate cost-effectiveness.

[Infected bronchogenic cysts may cause recurrence of bronchial infection]. / Inficerede bronkogene cyster kan forårsage recidiverende luftvejsinfektioner.

Bronchogenic cysts are congenital and are caused by an abnormal budding of the endotracheobronchial tree in the first trimester. They are typically located in the thoracic cavity and are often diagnosed in early childhood due to persistent respiratory symptoms such as stridor, cough and dyspnoea. In adults bronchogenic cysts are seldom. Secondary infection is rare. We present two patients with infected bronchogenic cysts. The patients were both treated at the Department of Cardiothoracic Surgery, Rigshospitalet, within a period of six months.

[Endobronchial mediastinal ultrasound with biopsy]. / Endobronkial ultralydsskanning af mediastinum med biopsi.

INTRODUCTION: Endobronchial ultrasound (EBUS) is a minimally invasive diagnostic modality, by which it is possible to visualize and do biopsy of structures adjacent to the trachea and the central bronchial system. EBUS is mostly used for staging of lung cancer patients, but EBUS is now used worldwide as a diagnostic tool in patients with mediastinal tumours or adenopathy. MATERIAL AND METHODS: In this paper, we report of the result of the first 100 EBUS patients referred for further investigation of mediastinal adenopathy or tumour found via CT. All 100 patients underwent EBUS in general anaesthesia, and 95 patients had transbronchial needle aspiration biopsy performed (TBNA). RESULTS: A total of 46 patients were known to have or have had cancer; in 20 of these patients we found cancer in the mediastinum by EBUS-TBNA, 24 patients had lymph node aspirates without cancer and in two patients the aspirate was inconclusive. The remaining 49 patients all had a record of non-malignant medical disease; 22 of these patients were found to have cancer in the mediastinum, one patient had cancer-suspect EBUS-TBNA, 24 had lymph node aspirates without malignancy and in two patients the aspirate was inconclusive. All patients were followed for 6-30 months. The sensitivity was roughly calculated to 94%. No patients suffered any complications. CONCLUSION: We conclude that EBUS-TBNA is a safe and accurate diagnostic tool in the evaluation of mediastinum in patients with cancer as well as in patients with non-malignant disease.