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Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy

Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy Hindawi Publishing Corporation Journal of Oncology Volume 2008, Article ID 389394, 7 pages doi:10.1155/2008/389394 Clinical Study Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy Charles E. Woodall, Ryan Duvall, Charles R. Scoggins, Kelly M. McMasters, and Robert C. G. Martin Division of Surgical Oncology, Department of Surgery, James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY 40292, USA Correspondence should be addressed to Robert C. G. Martin, robert.martin@louisville.edu Received 30 May 2008; Revised 17 October 2008; Accepted 27 November 2008 Recommended by Bruce Baguley Background. Esophagectomy for esophageal cancer is being practiced routinely with favorable results at many centers. We sought to determine if tumor histology is a powerful surrogate marker for perioperative morbidity. Methods.Seventy threeconsecutive patients managed operatively were reviewed from our prospectively maintained database. Results. Adenocarcinoma (AC) was present in 52 (71%) and squamous cell (SCC) in 21 (29%). The use of neoadjuvant therapy was similar for the AC (34.62%) and SCC (42.86%) groups. The SCC group had a higher incidence of prior pulmonary disease than the AC group (23.8% versus 5.8%, resp.; P = .03). SCC patients were more likely to have a prolonged ICU stay than AC patients (P = .004) despite similar complication rates, EBL, and prognostic nutritional index. The SCC group did, however, experience higher grades of complications (P = .0053). Conclusions. Presence of SCC was the single best predictor of prolonged ICU stay and more severe complications as defined by this study. Only a past history of pulmonary disease was different between the two histologic subgroups. Copyright © 2008 Charles E. Woodall et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Introduction pulmonary complications might then be of some benefit, not only in predicting their potential for morbidity, but Esophagectomy for esophageal cancer is being practiced rou- also in choosing the approach that may mitigate these tinely with favorable results at many centers. Improvements risks. Many feel that a minimally invasive approach may be in surgical technique and perioperative care have permitted the answer. Recently, investigators have reported promising a procedure once associated with high mortality rates to results with minimally invasive approaches [3, 4]. While now be practiced with a low risk of postoperative death. there is little debate regarding the role of surgical tech- However, studies continue to report high morbidity and nique and comorbid conditions on the development of there is now a focused effort to identify factors that may postoperative complications, little is known about the impact predict perioperative outcome. of tumor biology on morbidity. Based on recent a report Pulmonary complications are a major contributor to suggesting that the esophageal histology may impact peri- mortality in esophageal cancer and efforts to improve operative outcome [5], we sought to further delineate this pulmonary hygiene have contributed to reduced periop- relationship. This study is an attempt to recognize that tumor erative mortality [1]. As an adjunct to further decrease histology alone can identify patients more likely to suffer these complications, the necessity of a thoracic incision a complication and perhaps guide perioperative decision when performing esophagectomy has long been debated. making. Proponents have often argued that its use enables a more complete lymphadenectomy, while opponents feel it con- 2. Methods tributes significantly to perioperative morbidity but this has not been shown to affect long-term prognosis [2]. The records of patients included in a prospectively main- Given the importance of pulmonary status on outcome, tained upper gastrointestinal malignancy database were the ability to predict those patients at higher risk for reviewed for this institutional review board approved study. 2 Journal of Oncology All patients undergoing esophagogastrectomy for esophageal Table 1: Adenocarcinoma and squamous cell carcinoma groups patient demographics. carcinoma were included in the study, and all patients under- went a standard combined thoracic and abdominal esoph- Adenocarcinoma, Squamous cell P-value agogastrectomy (Ivor-Lewis type) procedure. This review n (%) carcinoma, n (%) was performed under an IRB approved protocol from the n 52 (71%) 21 (29%) University of Louisville Human Subjects Protection Office. Median age 59 63 .21 All patients had undergone complete preoperative evaluation Caucasian race 44 (8462%) 10 (47.62%) .0004 with CT chest/abdomen/ pelvis, endoscopic ultrasound, and in some, PET scanning. Most patients with preoperative Male gender 45 (86.54%) 10 (47.62%) .0007 T2 or greater, or N1 (by imaging) were given neoadjuvant Alcohol abuse 6 (11.54%) 8 (38.1%) .012 chemoradiation with either 5-fluorouracil or combined 5 Tobacco use 36 (69.23%) 13 (61.9%) .5492 fluorouracil with cisplatin depending on the histology of the Prior cardiac 13 (25%) 4 (19.05%) .573 disease and standard radiation therapy dosing of 5040 cGy. disease Operative techniques were consistent across this study with Prior pulmonary 3 (5.77%) 5 (23.81%) .034 the esophagogastrectomy performed through an abdominal disease incision first, with mobilization, celiac and supraceliac FEV1 <75% 3 (5.77%) 4 (19%) .06 lymphadenectomy, pyloroplasty, and gastric conduit for- mation followed by a thoracic incision, with mobilization, thoracic lymphadenectomy, tumor resection, and thoracic to determine significance, and a P-value <.05 was considered anastomosis. significant in this study. Variables evaluated included demographics (age, race, and gender), smoking history, alcohol history, histology, cancer staging, grade and type of complications, nutritional 3. Results status, length of intensive care unit stay, and operative factors including estimated blood loss. Comorbidities, such as prior Seventy three consecutive patients undergoing combined cardiac and pulmonary disease as well as history of tobacco abdominal and thoracic esophagogastrectomy for cancer and alcohol abuse as reported by the patient were also were identified and included in the study, with a median recorded. The prognostic nutritional index (PNI) advocated age was 61 (range 26 to 80). 55 (75.3%) were male and 18 by Onodera et al. [6] was calculated to investigate the preop- female (24.7%). Fifty four patients (74%) were Caucasian, erative nutritional condition of the patients in both groups. 12 (16%) were African-American, and the race of 7 (9%) It is calculated from the formula (giving a percentage) (10 was not recorded. There were 3 (4.1%) perioperative deaths, × Albumin) + (0.005 × absolute lymphocyte count). Prior all occurring in the AC group. Adenocarcinoma (AC) was cardiac history was defined as any patient with a history of present in 52 (71%) and squamous cell (SCC) in 21 (29%). In angina, previous coronary artery disease defined by cardiac Caucasians, AC occurred more often than SCC (84% versus catheterization, previous myocardial infarction, cardiac valve 47%, resp.; P = .004). Adenocarcinoma was also much more dysfunction requiring medication, or a history of congestive common in males (86%) than SCC (47%; P = .0007). The heart failure or tachyarrhythmia. Prior pulmonary disease AC patients were slightly younger (59 versus 63) than those history was defined as any patient with abnormal pulmonary in the SCC group (P = .21) (Table 1). function tests, history of asthma requiring daily meter dosed Patients in the SCC group were significantly more likely inhalers, or tobacco use greater than a 25-pack year history. to have a history of alcohol abuse (8/21, 38.1%) versus those All postoperative complications and the length of hos- in the AC group (6/52, 11.5%; P = .012). They were also pital stay were prospectively entered into the database. more likely to have a history of pulmonary disease (asthma, Complications were identified prospectively and assigned a COPD, pneumonia) than the AC group (23.8% versus grade from 1 to 5 based on an established scale [7]. Examples 5.77%; P = .034). Interestingly, there was no difference in of the grading of complications includes (1) uncomplicated the rate of COPD between the two groups (2.8% versus urinary tract infection; (3) small, contained anastomotic 3.9%; P = .133) and no difference in rates of tobacco use leak requiring no further operative therapy or drainage (61.9% versus 69.2%; P = .5492), mean pack years (56.6% procedures; (5) death. In instances where the grading was versus 51.0%; P = .573), or prior cardiac disease history unclear, a score was assigned after review of the records (CAD, atrial fibrillation, prior MI, or percutaneous coronary and discussion between two of the senior authors. All intervention (PCI); 19.1% versus 25.1%; P = .5806). At the in hospital and 90-day postoperative complications were time of operation, median estimated blood loss was similar evaluated with the most severe complication level recorded. for both groups (551 mL for AC and 600 mL for SCC, P = Infectious complications were defined by a positive fluid .7626). (sputum, wound, urine, etc.) culture, with some criteria of a In the AC group, there were two (3.9%) patients with in systemic inflammatory response (i.e., tachycardia, fever, and situ disease, five (9.8%) with T0 disease, five (9.8%) T1s, 10 hypoxia) (19.6%) T2s, 27 (52.9%) with T3 disease, and 2 (3.9%) with Statistical analysis was performed with JMP software T4 disease on final pathology (Table 2). The SCC group had (SAS Institute, Cary, NC, USA ). Analysis of variance, log- a similar distribution: 2 (9.5%) T0s, 4 (19.0%) T1s, 2 (9.5%) rank analysis, and Pearson correlation coefficient were used T2s, 9 (42.8%) T3s, and 4 (19.1%) T4s; the differences were Journal of Oncology 3 Table 2: Adenocarcinoma and squamous cell carcinoma tumor features and perioperative data. Adenocarcinoma, n (%) Squamous cell carcinoma, n (%) P-value Tstage .2032 T0 5 (9.80%) 2 (9.52%) Tis 2 (3.92%) 0 T1 5 (9.80%) 4 (19.05%) T2 10 (19.61%) 2 (9.52%) T3 27 (52.94%) 9 (42.86%) T4 2 (3.92%) 4 (19.05%) Nstage .1933 N0 24 (47.06%) 14 (66.67%) N1 25 (49.02%) 7 (33.33%) N2 2 (3.92%) 0 Neoadjuvant therapy 18 (34.62%) 9 (42.86%) .5114 Weight loss 29 (55.77%) 13 (61.90%) .6301 Mean BMI 26.72 22.89 .0299 Mean PNI 33.61 33.00 .6921 Epidural anesthesia 44 (85%) 18 (87%) .78 Anastomosis .8892 Stapled 17 (33.33%) 6 (31.58%) Sewn 34 (66.67%) 13 (68.42%) Mean EBL 551.065 600.000 .7626 Margin Pos 1 (2%) 1 (4%) .08 Time from OP to extubation 0.5 (0–48) 1 (0–72) .86 Complications 34 (65.38%) 18 (85.71%) .0693 Grade of complications .0053 1 or 2 15 (44.12%) 6 (35.29%) 3, 4, or 5 19 (55.88%) 11 (64.71%) ICU stay >3 days 23 (47.92%) 16 (76.19%) .0259 not significant (P = .2). Nodal staging for the AC group There were 65 independently identified complications consisted of 24 patients (47%) with N0 disease, 25 (49%) among 52 of the 73 patients comprising the cohort (Table 3). with N1 disease, and 2 (3.9%) patients with N2 disease. Complications were graded on the basis of an established In the SCC group, there were 14 (66.7%) with N0 disease scale. Seventy percent of patients experienced some sort of and 7 (33.3%) with N1 disease. There were no patients complication: 9 (12%) were grade 1, 12 (16%) were grade with N2 disease in the SCC group. The differences were 2, 23 (31.5%) were grade 3, 1 (1%) was grade 4, and 6 not statistically significant (P = .25). Metastatic disease was (8%) were grade 5. The grade 5 complications included found in one patient in each group (P = .5). the three aforementioned deaths. The rate of complications The use of neoadjuvant chemoradiation between the between the AC and SCC groups (65.4% versus 85.7%) AC and SCC groups was similar. Overall, 36% of patients approached statistical significance (P = .0693). However, received preoperative therapy: 18 (34%) of the AC group and when the patients with no complications were excluded, the 9 (42%) of the SCC group (P = .5). A similar proportion of distribution of the most severe complication in each patient patients in each group had experienced weight loss prior to (grade 1 or 2 versus grade 3, 4, or 5) revealed a statistically undergoing operative therapy: 55.7% (29) of AC and 61.9% significant disproportion with more severe complications (13) of SCC. There was a trend in patients with AC to have a occurring the SCC group versus the AC group (64.7% BMI greater than 20, while patients with SCC tended to have versus 55.9%, P = .0053). No difference existed among a BMI less than 20 (P = .056). The difference in mean BMI races or genders in complications. Pulmonary complications among groups was significant, however. In the AC group, the (including pneumonia) were the most predominant, com- mean was 26.7 while in the SCC group it was 22.889 (P = prising 29.3% of all complications. These were most strongly .0299). Also, female patients tended to have a decreased BMI associated with prior cardiac disease (P = .056), and not (81.2%) versus male patients (36.7%); this was significant with prior COPD history (P = .225), pulmonary history (P = .002) as well. The African-American patients also had (P = .336), histologic subtype (P = .503), or increasing lower BMI (80% less than 20) than Caucasians (42.8% less pack-year history of tobacco (P = .609). Esophageal leak than 20; P = .06). (a grade 3 complication) was the second most common 4 Journal of Oncology complication, with 10 (13.7%) occurrences. There was no Table 3: All inhospital and 90-day postoperative complications and grade by histology. significant difference in leak rate among histologic groups (P = .805) or anastomosis type (P = .965). Complication Adeno SCC Among the patients in the SCC group, the median PNI 34/52 17/21 was 40.95 (range 27.56 to 61.36); in the AC group the median (65%) (81%) was 39.78 (range 27.75 to 57.16; P = .6983). PNI did not Grade 1: 6 3 appear to affect morbidity. In the group of patients with a PNI less than 40, there was a complication rate of 70.83%; Pneumonia — in those with a PNI greater than 40, the rate was 79.17% Fever 1 (P = .5042). The distribution by grade of complications was Partial cord paralysis — 1 equivalent between those patients with a PNI of greater than Anastomotic leak 1 — 40 versus those with a PNI less than 40 (P = .9986). Patients Hypertension 1 with a PNI less than 40 were also not any more likely to have a major (grade 3, 4, or 5) complication versus those with a PNI — Decubitus ulcer 1 greater than 40 (P = .9396). The differences in distributions Hypovolemia 1 of pulmonary (P = .7452) and anastomotic leak (P = Urinary tract infection 1 — .1501) were also not statistically significant between the PNI Grade 2: 9 3 groups. Fever 1 1 Despite the similarities among the groups in total complications, SCC patients were more likely to have a 3- Mediastinitis — 1 day or longer ICU stay than AC patients (P = .004). The Prolonged enteral feeding — higher incidence of pulmonary disease in these patients was Excessive pain 1 the largest contributor to this finding (P = .0016). However, Pneumonia 2 prior tobacco use (P = .8254), total pack years (P = .1286) or cardiac disease (P = .5803) were not associated with a Pleural effusion 1 prolonged ICU course. SCC was more likely in patients and Readmission 1 — 60 years of age (P = .004) but age was not an independent Anastomotic leak 1 — factor for prolonged ICU stay. Atrial fibrillation 2 — Grade 3: 15 8 4. Discussion Pleural effusion, pneumonia — Advances in technique and patient care have lead to overall Anastomotic leak, EtOH withdrawal — decreases in esophagectomy mortality in the last 5 years Anastomotic leak, pleural effusion — 1 [8]. However, morbidity remains high (60% in some series) Anastomotic leak 3 2 and appears to be associated with tumor histology. Thus Delayed gastric emptying — the aim of the present study was to delineate the role of tumor histology in regards to perioperative morbidity and Pleural effusion 1 possibly preoperative decision making. Our study suggests Respiratory compromise 1 that tumor histology may be a significant predictor of Confusion, esophageal leak 1 morbidity, primarily as a surrogate for increased pulmonary Confusion, pneumonia, respiratory failure 1 complications. These findings are supported by a similar Pleural effusion, atelectasis 1 — study from the United Kingdom [9], and might function as an adjunct to other prognostic scoring systems [10]. Anastomotic leak, pneumonia 1 — Despite advances in surgical technique and perioperative Anastomotic leak, pneumonia, SVT 1 care, the types of complications in esophageal cancer are Anastomotic leak, evisceration 1 fairly consistent [11](Table 4). Pulmonary morbidity and Anastomotic leak, paraesophageal hernia 1 anastomotic leaks remain the most common [12]; both of which can significantly effect a patient’s long-term quality SVT 1 of life [13] when they occur. Pulmonary complications con- Pneumonia 1 tribute to most cases of mortality in esophageal cancer and Hemorrhage 1 — active efforts to minimize their effects have been attributed as Grade 4: 1 one of the most significant causes of decreased perioperative Anastomotic leak 1 — mortality [14]. The historically dreaded anastomotic leak has Grade 5: 3 3 been delegated to a lesser standing; this is in large part due to new minimally invasive endoscopic techniques that have 1 Anastomotic leak — been described for the management of leaks [15], making Pneumonia — 1 what was once a devastating problem somewhat more easily Pulmonary embolus 1 — managed and no longer a source of increased mortality or Death 2 1 decreased long-term survival [16]. However, the pulmonary Journal of Oncology 5 Table 4: Recent studies of morbidity in SCC patients undergoing esophagectomy. SCC SCC anastomotic SCC median SCC ICU SCC Author Year n SCC % SCC approach pulmonary leak EBL (mL) stay (days) mortality Whooley 2001 710 100% TTE (100%) 32% 3.5% 832 — 11% Ferguson 2002 290 34.5% — 39% — — — — Fang 2003 441 >90% 3 Field (100%) 7.3% 32.65% 587.5–642.1 — 2.5% Law 2004 421 100% TTE (83%) 15.9% 3.1% 700 — 1.4% Alexiou 2006 621 31.72% TTE (55%) 18.3% 8.6% — — 8.1% Woodall 2007 73 29% TTE (100%) 28.57% 26.32% 600 6 0% problems aremoredifficult in a population in which, at least and consideration for supplementation should be given in in the case of SCC, patients are more likely to be smokers and this population as well. Fortunately, increasing patient BMIs thus more likely to carry a diagnosis of underlying COPD. has not been associated with poorer operative or disease This was likely the root cause of the prolonged intensive care related outcomes. Also, in at least one large study of 400 unit stays seen in the SCC cohort in this study. patients, nutritional status as determined by BMI, PNI, The perioperative risks for patients with COPD are weight loss, and other factors had no value in predicting well known [17]. However, age, operative duration, and perioperative complications [22]. proximal tumor location have also been identified as factors Over time, multimodality treatment of esophageal cancer contributing to pulmonary morbidity [18], of which all has improved, offering increased long-term survival [23]. are more likely to be associated with SCC histology than Better results have been noted for factors most would identify AC. Despite an efficient resection, patients who suffer as predictive of long-term success in any cancer, including complications are at increased risk of surgical oncotaxis low AJCC stage, R0 resection, and M0 status. Neoadjuvant [19], the acceleration of their disease caused by opera- therapy is gaining acceptance, as it can be given safely, tive factors. The patients reported in this study by Hirai is generally better tolerated than adjuvant therapy, and et al. had earlier metastasis and poorer long-term out- does not affect operative morbidity or mortality. SCC can comes. Therefore, at least from one study, minimizing be treated safe and effectively with multimodality therapy, morbidity is important not only from a short-term peri- providing durable results even for patients with positive operative perspective but also from a long-term cancer nodal disease as well as those from Asian studies discovered prognosis standpoint. Although it should be noted that to have early tumors. Regardless of the physician’s opinion another study, by Ferri et al., showed an increased short- in regards to the timing of additional therapy, most agree term mortality in SCC patients suffering a complication, that esophageal squamous and adenocarcinoma are not there are no long-term effects in those that survived [20]. purely surgically treated diseases and that some form of Nutrition remains the focus in many studies of multimodality treatment is needed to extend quality of life esophagectomy, but its role in morbidity is somewhat time. Therefore, from a surgical perspective, optimizing unclear. Few other malignancies affect the nutritional status patient selection and operative technique are important of the patient prior to diagnosis more than esophageal so that patients may recover quickly and go on to their cancer, and are thus a potential powerful marker of surgical additional therapy. outcome. Most surgeons would associate esophageal cancer Technical advances have allowed for refinement in the with malnutrition, noting the diminution in the ability of techniques in esophageal surgery to reduce perioperative the patient to take in adequate calories in addition to the morbidity and mortality [24]. What technology to apply on wasting normally seen with other malignancies, and thus a case-to-case basis is a somewhat more difficult question try to supplement feedings. Advocates of this approach to answer. Recent studies have also served to benchmark stress the benefits of preoperative enteral supplementation. expected courses for patients with AC, and the outcomes The perioperative advantages of this were identified in a for all esophageal resections has improved significantly [25]. paper by Nozoe demonstrating decreased complications and Because of this, any changes in techniques or approach better long-term survival in patients with higher prognostic need to be critically reviewed. Choice of operative approach nutritional index (PNI), a mathematical computation of the has been extensively studied, but until recently has focused patients albumin and absolute lymphocyte count [21]. As on the transhiatal versus transthoracic approach [2]or discussed by Onodera in the initial description of PNI, a technical factors such as the location of the conduit in minimum value of 40 is recommended prior to undertaking the mediastinum. With the public’s growing interest in an esophageal resection. In the present study, a PNI of less minimally invasive approaches, coupled with new techniques than 40 did not adversely affect outcomes and led to no and instrumentation, minimally invasive esophagectomy has increase in morbidity. been proven safe and feasible both in the United States At the opposing end of the spectrum, increasing BMI and abroad [3]. It also does not adversely affect long- has been attributed to the increasing incidence of AC. Even term survival, a question that has been repeatedly raised significantly, overweight patients may be relatively catabolic when laparoscopic approaches are used to address surgical 6 Journal of Oncology oncology diagnoses. The difficulty is that there are a variety is it worth the risk of multiorgan resection?” Journal of the American College of Surgeons, vol. 194, no. 5, pp. 568–577, of techniques and combinations of approaches reported as “minimally invasive,” with no standardized definition and [8] J. B. Dimick, R. M. Wainess, G. R. Upchurch Jr., M. D. any real benefit over traditional techniques has yet to be Iannettoni, and M. B. Orringer, “National trends in outcomes proven. Most advocates of this approach perceive decreased for esophageal resection,” Annals of Thoracic Surgery, vol. 79, pulmonary morbidities and improved pulmonary therapy as no. 1, pp. 212–216, 2005. the main advantages, but some studies have questioned this [9] C.Alexiou,O.A.Khan, andE.Black,“Survival after benefit. Preoperative pulmonary evaluations have tended to esophageal resection for carcinoma: the importance of the focus on pulmonary factors alone, including smoking and histologic cell type,” Annals of Thoracic Surgery, vol. 82, no. COPD. However, given these factors in a high-risk subgroup 3, pp. 1073–1077, 2006. (SCC), there might be more of an advantage for minimally [10] M. K. Ferguson and A. E. Durkin, “Preoperative prediction invasive techniques and perhaps we should evaluate these of the risk of pulmonary complications after esophagectomy patients for this approach. for cancer,” Journal of Thoracic and Cardiovascular Surgery, vol. The limitations of this study are the small sample size 123, no. 4, pp. 661–669, 2002. of the SCC patients. This limits the impact of the data [11] S. M. Griffin, I. H. Shaw, and S. M. Dresner, “Early complica- presented, but does not limit the fact that these two types of tions after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management,” Journal of histologies are both biologically different and physiologically the American College of Surgeons, vol. 194, no. 3, pp. 285–297, different and treating physicians should be aware of these differences and the impact that these play on perioperative [12] J. D. Urschel, “Esophagogastrostomy anastomotic leaks com- outcomes. plicating esophagectomy: a review,” American Journal of Surgery, vol. 169, no. 6, pp. 634–640, 1995. [13] P. Viklund, M. Lindblad, and J. Lagergren, “Influence of 5. Conclusion surgery-related factors on quality of life after esophageal or cardia cancer resection,” World Journal of Surgery, vol. 29, no. The presence of SCC was the single best predictor of 7, pp. 841–848, 2005. prolonged intensive care unit stay and more severe com- [14] B. Z. Atkins and T. A. D’Amico, “Respiratory complications plications as defined by this study. Only a past history of after esophagectomy,” Thoracic Surgery Clinics,vol. 16, no.1, pulmonary disease was different between the two histologic pp. 35–48, 2006. subgroups. No other factor, including sex, gender, age, or [15] D. Schubert, M. Pross, G. Nestler, et al., “Endoscopic nutritional status was predictive of this outcome. Esophageal treatment of mediastinal anastomotic leaks,” Zentralblatt fur ¨ histology should therefore be considered in the perioperative Chirurgie, vol. 131, no. 5, pp. 369–375, 2006. care of patients and may in the future be used to guide [16] L. W. Martin, S. G. Swisher, W. Hofstetter, et al., “Intrathoracic operative strategies. leaks following esophagectomy are no longer associated with increased mortality,” Annals of Surgery, vol. 242, no. 3, pp. 392–402, 2005. References [17] W.-J.Jiao, T.-Y.Wang, M. Gong,H.Pan,Y.B.Liu,and Z. H. Liu, “Pulmonary complications in patients with [1] B. Z. Atkins and T. A. D’Amico, “Respiratory complications chronic obstructive pulmonary disease following transtho- after esophagectomy,” Thoracic Surgery Clinics, vol. 16, no. 1, racic esophagectomy,” World Journal of Gastroenterology, vol. pp. 35–48, 2006. 12, no. 16, pp. 2505–2509, 2006. [2] J. B. F. Hulscher, J. W. van Sandick, A. G. E. M. de Boer, et al., [18] S. Law, K.-H. Wong, K.-F. Kwok, K.-M. Chu, and J. Wong, “Extended transthoracic resection compared with limited “Predictive factors for postoperative pulmonary complica- transhiatal resection for adenocarcinoma of the esophagus,” tions and mortality after esophagectomy for cancer,” Annals The New England Journal of Medicine, vol. 347, no. 21, pp. of Surgery, vol. 240, no. 5, pp. 791–800, 2004. 1662–1669, 2002. [19] T. Hirai, H. Matsumoto, K. Yamashita, et al., “Surgical [3] J. D. Luketich, M. Alvelo-Rivera, P. O. Buenaventura, oncotaxis–excessive surgical stress and postoperative compli- et al., “Minimally invasive esophagectomy: outcomes in 222 cations contribute to enhancing tumor metastasis, resulting in patients,” Annals of Surgery, vol. 238, no. 4, pp. 486–495, 2003. a poor prognosis for cancer patients,” Annals of Ahoracic and [4] F. Delgado Gomis, S. A. Gomez ´ Abril, M. Manuel, and J. M. Cardiovascular Surgery, vol. 11, no. 1, pp. 4–6, 2005. Guallar Rovira, “Assisted laparoscopic transhiatal esophagec- [20] L. E. Ferri, S. Law, K.-H. Wong, K.-F. Kwok, and J. Wong, tomy for the treatment of esophageal cancer,” Clinical and “The influence of technical complications on postoperative Translational Oncology, vol. 8, no. 3, pp. 185–192, 2006. outcome and survival after esophagectomy,” Annals of Surgical [5] C. Alexiou, O. A. Khan, E. Black, et al., “Survival after Oncology, vol. 13, no. 4, pp. 557–564, 2006. esophageal resection for carcinoma: the importance of the [21] T. Nozoe, Y. Kimura, M. Ishida, H. Saeki, D. Korenaga, histologic cell type,” Annals of Thoracic Surgery, vol. 82, no. and K. Sugimachi, “Correlation of pre-operative nutritional 3, pp. 1073–1077, 2006. condition with post-operative complications in surgical treat- [6] T.Onodera,N.Goseki, andG.Kosaki, “Prognosticnutritional ment for oesophageal carcinoma,” European Journal of Surgical index in gastrointestinal surgery of malnourished cancer Oncology, vol. 28, no. 4, pp. 396–400, 2002. patients,” Nippon Geka Gakkai Zasshi, vol. 85, no. 9, pp. 1001– 1005, 1984. [22] I. J. M. Han-Geurts,W.C.Hop,T.C.K.Tran, andH.W. Tilanus, “Nutritional status as a risk factor in esophageal [7] R.C.MartinII, D. P. Jaques,M.F.Brennan, andM.Karpeh, “Achieving R0 resection for locally advanced gastric cancer: surgery,” Digestive Surgery, vol. 23, no. 3, pp. 159–163, 2006. Journal of Oncology 7 [23] W. Hofstetter, S. G. Swisher, A. M. Correa, et al., “Treatment outcomes of resected esophageal cancer,” Annals of Surgery, vol. 236, no. 3, pp. 376–385, 2002. [24] G. Dionigi, F. Rovera, L. Boni, G. Carrafiello, M. Mangini, and R. Dionigi, “The surgeon’s approach to preoperative evaluation of esophageal cancer: recent developments,” Rays, vol. 30, no. 4, pp. 351–356, 2005. [25] C. Mariette, G. Taillier, I. Van Seuningen, and J.-P. Triboulet, “Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma,” Annals of Thoracic Surgery, vol. 78, no. 4, pp. 1177–1183, 2004. 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Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy

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Copyright © 2008 Charles E. Woodall et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Publishing Corporation Journal of Oncology Volume 2008, Article ID 389394, 7 pages doi:10.1155/2008/389394 Clinical Study Esophageal Carcinoma Histology Affects Perioperative Morbidity Following Open Esophagogastrectomy Charles E. Woodall, Ryan Duvall, Charles R. Scoggins, Kelly M. McMasters, and Robert C. G. Martin Division of Surgical Oncology, Department of Surgery, James Graham Brown Cancer Center, University of Louisville School of Medicine, Louisville, KY 40292, USA Correspondence should be addressed to Robert C. G. Martin, robert.martin@louisville.edu Received 30 May 2008; Revised 17 October 2008; Accepted 27 November 2008 Recommended by Bruce Baguley Background. Esophagectomy for esophageal cancer is being practiced routinely with favorable results at many centers. We sought to determine if tumor histology is a powerful surrogate marker for perioperative morbidity. Methods.Seventy threeconsecutive patients managed operatively were reviewed from our prospectively maintained database. Results. Adenocarcinoma (AC) was present in 52 (71%) and squamous cell (SCC) in 21 (29%). The use of neoadjuvant therapy was similar for the AC (34.62%) and SCC (42.86%) groups. The SCC group had a higher incidence of prior pulmonary disease than the AC group (23.8% versus 5.8%, resp.; P = .03). SCC patients were more likely to have a prolonged ICU stay than AC patients (P = .004) despite similar complication rates, EBL, and prognostic nutritional index. The SCC group did, however, experience higher grades of complications (P = .0053). Conclusions. Presence of SCC was the single best predictor of prolonged ICU stay and more severe complications as defined by this study. Only a past history of pulmonary disease was different between the two histologic subgroups. Copyright © 2008 Charles E. Woodall et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Introduction pulmonary complications might then be of some benefit, not only in predicting their potential for morbidity, but Esophagectomy for esophageal cancer is being practiced rou- also in choosing the approach that may mitigate these tinely with favorable results at many centers. Improvements risks. Many feel that a minimally invasive approach may be in surgical technique and perioperative care have permitted the answer. Recently, investigators have reported promising a procedure once associated with high mortality rates to results with minimally invasive approaches [3, 4]. While now be practiced with a low risk of postoperative death. there is little debate regarding the role of surgical tech- However, studies continue to report high morbidity and nique and comorbid conditions on the development of there is now a focused effort to identify factors that may postoperative complications, little is known about the impact predict perioperative outcome. of tumor biology on morbidity. Based on recent a report Pulmonary complications are a major contributor to suggesting that the esophageal histology may impact peri- mortality in esophageal cancer and efforts to improve operative outcome [5], we sought to further delineate this pulmonary hygiene have contributed to reduced periop- relationship. This study is an attempt to recognize that tumor erative mortality [1]. As an adjunct to further decrease histology alone can identify patients more likely to suffer these complications, the necessity of a thoracic incision a complication and perhaps guide perioperative decision when performing esophagectomy has long been debated. making. Proponents have often argued that its use enables a more complete lymphadenectomy, while opponents feel it con- 2. Methods tributes significantly to perioperative morbidity but this has not been shown to affect long-term prognosis [2]. The records of patients included in a prospectively main- Given the importance of pulmonary status on outcome, tained upper gastrointestinal malignancy database were the ability to predict those patients at higher risk for reviewed for this institutional review board approved study. 2 Journal of Oncology All patients undergoing esophagogastrectomy for esophageal Table 1: Adenocarcinoma and squamous cell carcinoma groups patient demographics. carcinoma were included in the study, and all patients under- went a standard combined thoracic and abdominal esoph- Adenocarcinoma, Squamous cell P-value agogastrectomy (Ivor-Lewis type) procedure. This review n (%) carcinoma, n (%) was performed under an IRB approved protocol from the n 52 (71%) 21 (29%) University of Louisville Human Subjects Protection Office. Median age 59 63 .21 All patients had undergone complete preoperative evaluation Caucasian race 44 (8462%) 10 (47.62%) .0004 with CT chest/abdomen/ pelvis, endoscopic ultrasound, and in some, PET scanning. Most patients with preoperative Male gender 45 (86.54%) 10 (47.62%) .0007 T2 or greater, or N1 (by imaging) were given neoadjuvant Alcohol abuse 6 (11.54%) 8 (38.1%) .012 chemoradiation with either 5-fluorouracil or combined 5 Tobacco use 36 (69.23%) 13 (61.9%) .5492 fluorouracil with cisplatin depending on the histology of the Prior cardiac 13 (25%) 4 (19.05%) .573 disease and standard radiation therapy dosing of 5040 cGy. disease Operative techniques were consistent across this study with Prior pulmonary 3 (5.77%) 5 (23.81%) .034 the esophagogastrectomy performed through an abdominal disease incision first, with mobilization, celiac and supraceliac FEV1 <75% 3 (5.77%) 4 (19%) .06 lymphadenectomy, pyloroplasty, and gastric conduit for- mation followed by a thoracic incision, with mobilization, thoracic lymphadenectomy, tumor resection, and thoracic to determine significance, and a P-value <.05 was considered anastomosis. significant in this study. Variables evaluated included demographics (age, race, and gender), smoking history, alcohol history, histology, cancer staging, grade and type of complications, nutritional 3. Results status, length of intensive care unit stay, and operative factors including estimated blood loss. Comorbidities, such as prior Seventy three consecutive patients undergoing combined cardiac and pulmonary disease as well as history of tobacco abdominal and thoracic esophagogastrectomy for cancer and alcohol abuse as reported by the patient were also were identified and included in the study, with a median recorded. The prognostic nutritional index (PNI) advocated age was 61 (range 26 to 80). 55 (75.3%) were male and 18 by Onodera et al. [6] was calculated to investigate the preop- female (24.7%). Fifty four patients (74%) were Caucasian, erative nutritional condition of the patients in both groups. 12 (16%) were African-American, and the race of 7 (9%) It is calculated from the formula (giving a percentage) (10 was not recorded. There were 3 (4.1%) perioperative deaths, × Albumin) + (0.005 × absolute lymphocyte count). Prior all occurring in the AC group. Adenocarcinoma (AC) was cardiac history was defined as any patient with a history of present in 52 (71%) and squamous cell (SCC) in 21 (29%). In angina, previous coronary artery disease defined by cardiac Caucasians, AC occurred more often than SCC (84% versus catheterization, previous myocardial infarction, cardiac valve 47%, resp.; P = .004). Adenocarcinoma was also much more dysfunction requiring medication, or a history of congestive common in males (86%) than SCC (47%; P = .0007). The heart failure or tachyarrhythmia. Prior pulmonary disease AC patients were slightly younger (59 versus 63) than those history was defined as any patient with abnormal pulmonary in the SCC group (P = .21) (Table 1). function tests, history of asthma requiring daily meter dosed Patients in the SCC group were significantly more likely inhalers, or tobacco use greater than a 25-pack year history. to have a history of alcohol abuse (8/21, 38.1%) versus those All postoperative complications and the length of hos- in the AC group (6/52, 11.5%; P = .012). They were also pital stay were prospectively entered into the database. more likely to have a history of pulmonary disease (asthma, Complications were identified prospectively and assigned a COPD, pneumonia) than the AC group (23.8% versus grade from 1 to 5 based on an established scale [7]. Examples 5.77%; P = .034). Interestingly, there was no difference in of the grading of complications includes (1) uncomplicated the rate of COPD between the two groups (2.8% versus urinary tract infection; (3) small, contained anastomotic 3.9%; P = .133) and no difference in rates of tobacco use leak requiring no further operative therapy or drainage (61.9% versus 69.2%; P = .5492), mean pack years (56.6% procedures; (5) death. In instances where the grading was versus 51.0%; P = .573), or prior cardiac disease history unclear, a score was assigned after review of the records (CAD, atrial fibrillation, prior MI, or percutaneous coronary and discussion between two of the senior authors. All intervention (PCI); 19.1% versus 25.1%; P = .5806). At the in hospital and 90-day postoperative complications were time of operation, median estimated blood loss was similar evaluated with the most severe complication level recorded. for both groups (551 mL for AC and 600 mL for SCC, P = Infectious complications were defined by a positive fluid .7626). (sputum, wound, urine, etc.) culture, with some criteria of a In the AC group, there were two (3.9%) patients with in systemic inflammatory response (i.e., tachycardia, fever, and situ disease, five (9.8%) with T0 disease, five (9.8%) T1s, 10 hypoxia) (19.6%) T2s, 27 (52.9%) with T3 disease, and 2 (3.9%) with Statistical analysis was performed with JMP software T4 disease on final pathology (Table 2). The SCC group had (SAS Institute, Cary, NC, USA ). Analysis of variance, log- a similar distribution: 2 (9.5%) T0s, 4 (19.0%) T1s, 2 (9.5%) rank analysis, and Pearson correlation coefficient were used T2s, 9 (42.8%) T3s, and 4 (19.1%) T4s; the differences were Journal of Oncology 3 Table 2: Adenocarcinoma and squamous cell carcinoma tumor features and perioperative data. Adenocarcinoma, n (%) Squamous cell carcinoma, n (%) P-value Tstage .2032 T0 5 (9.80%) 2 (9.52%) Tis 2 (3.92%) 0 T1 5 (9.80%) 4 (19.05%) T2 10 (19.61%) 2 (9.52%) T3 27 (52.94%) 9 (42.86%) T4 2 (3.92%) 4 (19.05%) Nstage .1933 N0 24 (47.06%) 14 (66.67%) N1 25 (49.02%) 7 (33.33%) N2 2 (3.92%) 0 Neoadjuvant therapy 18 (34.62%) 9 (42.86%) .5114 Weight loss 29 (55.77%) 13 (61.90%) .6301 Mean BMI 26.72 22.89 .0299 Mean PNI 33.61 33.00 .6921 Epidural anesthesia 44 (85%) 18 (87%) .78 Anastomosis .8892 Stapled 17 (33.33%) 6 (31.58%) Sewn 34 (66.67%) 13 (68.42%) Mean EBL 551.065 600.000 .7626 Margin Pos 1 (2%) 1 (4%) .08 Time from OP to extubation 0.5 (0–48) 1 (0–72) .86 Complications 34 (65.38%) 18 (85.71%) .0693 Grade of complications .0053 1 or 2 15 (44.12%) 6 (35.29%) 3, 4, or 5 19 (55.88%) 11 (64.71%) ICU stay >3 days 23 (47.92%) 16 (76.19%) .0259 not significant (P = .2). Nodal staging for the AC group There were 65 independently identified complications consisted of 24 patients (47%) with N0 disease, 25 (49%) among 52 of the 73 patients comprising the cohort (Table 3). with N1 disease, and 2 (3.9%) patients with N2 disease. Complications were graded on the basis of an established In the SCC group, there were 14 (66.7%) with N0 disease scale. Seventy percent of patients experienced some sort of and 7 (33.3%) with N1 disease. There were no patients complication: 9 (12%) were grade 1, 12 (16%) were grade with N2 disease in the SCC group. The differences were 2, 23 (31.5%) were grade 3, 1 (1%) was grade 4, and 6 not statistically significant (P = .25). Metastatic disease was (8%) were grade 5. The grade 5 complications included found in one patient in each group (P = .5). the three aforementioned deaths. The rate of complications The use of neoadjuvant chemoradiation between the between the AC and SCC groups (65.4% versus 85.7%) AC and SCC groups was similar. Overall, 36% of patients approached statistical significance (P = .0693). However, received preoperative therapy: 18 (34%) of the AC group and when the patients with no complications were excluded, the 9 (42%) of the SCC group (P = .5). A similar proportion of distribution of the most severe complication in each patient patients in each group had experienced weight loss prior to (grade 1 or 2 versus grade 3, 4, or 5) revealed a statistically undergoing operative therapy: 55.7% (29) of AC and 61.9% significant disproportion with more severe complications (13) of SCC. There was a trend in patients with AC to have a occurring the SCC group versus the AC group (64.7% BMI greater than 20, while patients with SCC tended to have versus 55.9%, P = .0053). No difference existed among a BMI less than 20 (P = .056). The difference in mean BMI races or genders in complications. Pulmonary complications among groups was significant, however. In the AC group, the (including pneumonia) were the most predominant, com- mean was 26.7 while in the SCC group it was 22.889 (P = prising 29.3% of all complications. These were most strongly .0299). Also, female patients tended to have a decreased BMI associated with prior cardiac disease (P = .056), and not (81.2%) versus male patients (36.7%); this was significant with prior COPD history (P = .225), pulmonary history (P = .002) as well. The African-American patients also had (P = .336), histologic subtype (P = .503), or increasing lower BMI (80% less than 20) than Caucasians (42.8% less pack-year history of tobacco (P = .609). Esophageal leak than 20; P = .06). (a grade 3 complication) was the second most common 4 Journal of Oncology complication, with 10 (13.7%) occurrences. There was no Table 3: All inhospital and 90-day postoperative complications and grade by histology. significant difference in leak rate among histologic groups (P = .805) or anastomosis type (P = .965). Complication Adeno SCC Among the patients in the SCC group, the median PNI 34/52 17/21 was 40.95 (range 27.56 to 61.36); in the AC group the median (65%) (81%) was 39.78 (range 27.75 to 57.16; P = .6983). PNI did not Grade 1: 6 3 appear to affect morbidity. In the group of patients with a PNI less than 40, there was a complication rate of 70.83%; Pneumonia — in those with a PNI greater than 40, the rate was 79.17% Fever 1 (P = .5042). The distribution by grade of complications was Partial cord paralysis — 1 equivalent between those patients with a PNI of greater than Anastomotic leak 1 — 40 versus those with a PNI less than 40 (P = .9986). Patients Hypertension 1 with a PNI less than 40 were also not any more likely to have a major (grade 3, 4, or 5) complication versus those with a PNI — Decubitus ulcer 1 greater than 40 (P = .9396). The differences in distributions Hypovolemia 1 of pulmonary (P = .7452) and anastomotic leak (P = Urinary tract infection 1 — .1501) were also not statistically significant between the PNI Grade 2: 9 3 groups. Fever 1 1 Despite the similarities among the groups in total complications, SCC patients were more likely to have a 3- Mediastinitis — 1 day or longer ICU stay than AC patients (P = .004). The Prolonged enteral feeding — higher incidence of pulmonary disease in these patients was Excessive pain 1 the largest contributor to this finding (P = .0016). However, Pneumonia 2 prior tobacco use (P = .8254), total pack years (P = .1286) or cardiac disease (P = .5803) were not associated with a Pleural effusion 1 prolonged ICU course. SCC was more likely in patients and Readmission 1 — 60 years of age (P = .004) but age was not an independent Anastomotic leak 1 — factor for prolonged ICU stay. Atrial fibrillation 2 — Grade 3: 15 8 4. Discussion Pleural effusion, pneumonia — Advances in technique and patient care have lead to overall Anastomotic leak, EtOH withdrawal — decreases in esophagectomy mortality in the last 5 years Anastomotic leak, pleural effusion — 1 [8]. However, morbidity remains high (60% in some series) Anastomotic leak 3 2 and appears to be associated with tumor histology. Thus Delayed gastric emptying — the aim of the present study was to delineate the role of tumor histology in regards to perioperative morbidity and Pleural effusion 1 possibly preoperative decision making. Our study suggests Respiratory compromise 1 that tumor histology may be a significant predictor of Confusion, esophageal leak 1 morbidity, primarily as a surrogate for increased pulmonary Confusion, pneumonia, respiratory failure 1 complications. These findings are supported by a similar Pleural effusion, atelectasis 1 — study from the United Kingdom [9], and might function as an adjunct to other prognostic scoring systems [10]. Anastomotic leak, pneumonia 1 — Despite advances in surgical technique and perioperative Anastomotic leak, pneumonia, SVT 1 care, the types of complications in esophageal cancer are Anastomotic leak, evisceration 1 fairly consistent [11](Table 4). Pulmonary morbidity and Anastomotic leak, paraesophageal hernia 1 anastomotic leaks remain the most common [12]; both of which can significantly effect a patient’s long-term quality SVT 1 of life [13] when they occur. Pulmonary complications con- Pneumonia 1 tribute to most cases of mortality in esophageal cancer and Hemorrhage 1 — active efforts to minimize their effects have been attributed as Grade 4: 1 one of the most significant causes of decreased perioperative Anastomotic leak 1 — mortality [14]. The historically dreaded anastomotic leak has Grade 5: 3 3 been delegated to a lesser standing; this is in large part due to new minimally invasive endoscopic techniques that have 1 Anastomotic leak — been described for the management of leaks [15], making Pneumonia — 1 what was once a devastating problem somewhat more easily Pulmonary embolus 1 — managed and no longer a source of increased mortality or Death 2 1 decreased long-term survival [16]. However, the pulmonary Journal of Oncology 5 Table 4: Recent studies of morbidity in SCC patients undergoing esophagectomy. SCC SCC anastomotic SCC median SCC ICU SCC Author Year n SCC % SCC approach pulmonary leak EBL (mL) stay (days) mortality Whooley 2001 710 100% TTE (100%) 32% 3.5% 832 — 11% Ferguson 2002 290 34.5% — 39% — — — — Fang 2003 441 >90% 3 Field (100%) 7.3% 32.65% 587.5–642.1 — 2.5% Law 2004 421 100% TTE (83%) 15.9% 3.1% 700 — 1.4% Alexiou 2006 621 31.72% TTE (55%) 18.3% 8.6% — — 8.1% Woodall 2007 73 29% TTE (100%) 28.57% 26.32% 600 6 0% problems aremoredifficult in a population in which, at least and consideration for supplementation should be given in in the case of SCC, patients are more likely to be smokers and this population as well. Fortunately, increasing patient BMIs thus more likely to carry a diagnosis of underlying COPD. has not been associated with poorer operative or disease This was likely the root cause of the prolonged intensive care related outcomes. Also, in at least one large study of 400 unit stays seen in the SCC cohort in this study. patients, nutritional status as determined by BMI, PNI, The perioperative risks for patients with COPD are weight loss, and other factors had no value in predicting well known [17]. However, age, operative duration, and perioperative complications [22]. proximal tumor location have also been identified as factors Over time, multimodality treatment of esophageal cancer contributing to pulmonary morbidity [18], of which all has improved, offering increased long-term survival [23]. are more likely to be associated with SCC histology than Better results have been noted for factors most would identify AC. Despite an efficient resection, patients who suffer as predictive of long-term success in any cancer, including complications are at increased risk of surgical oncotaxis low AJCC stage, R0 resection, and M0 status. Neoadjuvant [19], the acceleration of their disease caused by opera- therapy is gaining acceptance, as it can be given safely, tive factors. The patients reported in this study by Hirai is generally better tolerated than adjuvant therapy, and et al. had earlier metastasis and poorer long-term out- does not affect operative morbidity or mortality. SCC can comes. Therefore, at least from one study, minimizing be treated safe and effectively with multimodality therapy, morbidity is important not only from a short-term peri- providing durable results even for patients with positive operative perspective but also from a long-term cancer nodal disease as well as those from Asian studies discovered prognosis standpoint. Although it should be noted that to have early tumors. Regardless of the physician’s opinion another study, by Ferri et al., showed an increased short- in regards to the timing of additional therapy, most agree term mortality in SCC patients suffering a complication, that esophageal squamous and adenocarcinoma are not there are no long-term effects in those that survived [20]. purely surgically treated diseases and that some form of Nutrition remains the focus in many studies of multimodality treatment is needed to extend quality of life esophagectomy, but its role in morbidity is somewhat time. Therefore, from a surgical perspective, optimizing unclear. Few other malignancies affect the nutritional status patient selection and operative technique are important of the patient prior to diagnosis more than esophageal so that patients may recover quickly and go on to their cancer, and are thus a potential powerful marker of surgical additional therapy. outcome. Most surgeons would associate esophageal cancer Technical advances have allowed for refinement in the with malnutrition, noting the diminution in the ability of techniques in esophageal surgery to reduce perioperative the patient to take in adequate calories in addition to the morbidity and mortality [24]. What technology to apply on wasting normally seen with other malignancies, and thus a case-to-case basis is a somewhat more difficult question try to supplement feedings. Advocates of this approach to answer. Recent studies have also served to benchmark stress the benefits of preoperative enteral supplementation. expected courses for patients with AC, and the outcomes The perioperative advantages of this were identified in a for all esophageal resections has improved significantly [25]. paper by Nozoe demonstrating decreased complications and Because of this, any changes in techniques or approach better long-term survival in patients with higher prognostic need to be critically reviewed. Choice of operative approach nutritional index (PNI), a mathematical computation of the has been extensively studied, but until recently has focused patients albumin and absolute lymphocyte count [21]. As on the transhiatal versus transthoracic approach [2]or discussed by Onodera in the initial description of PNI, a technical factors such as the location of the conduit in minimum value of 40 is recommended prior to undertaking the mediastinum. With the public’s growing interest in an esophageal resection. In the present study, a PNI of less minimally invasive approaches, coupled with new techniques than 40 did not adversely affect outcomes and led to no and instrumentation, minimally invasive esophagectomy has increase in morbidity. been proven safe and feasible both in the United States At the opposing end of the spectrum, increasing BMI and abroad [3]. It also does not adversely affect long- has been attributed to the increasing incidence of AC. Even term survival, a question that has been repeatedly raised significantly, overweight patients may be relatively catabolic when laparoscopic approaches are used to address surgical 6 Journal of Oncology oncology diagnoses. The difficulty is that there are a variety is it worth the risk of multiorgan resection?” Journal of the American College of Surgeons, vol. 194, no. 5, pp. 568–577, of techniques and combinations of approaches reported as “minimally invasive,” with no standardized definition and [8] J. B. Dimick, R. M. Wainess, G. R. Upchurch Jr., M. D. any real benefit over traditional techniques has yet to be Iannettoni, and M. B. Orringer, “National trends in outcomes proven. Most advocates of this approach perceive decreased for esophageal resection,” Annals of Thoracic Surgery, vol. 79, pulmonary morbidities and improved pulmonary therapy as no. 1, pp. 212–216, 2005. the main advantages, but some studies have questioned this [9] C.Alexiou,O.A.Khan, andE.Black,“Survival after benefit. Preoperative pulmonary evaluations have tended to esophageal resection for carcinoma: the importance of the focus on pulmonary factors alone, including smoking and histologic cell type,” Annals of Thoracic Surgery, vol. 82, no. COPD. However, given these factors in a high-risk subgroup 3, pp. 1073–1077, 2006. (SCC), there might be more of an advantage for minimally [10] M. K. Ferguson and A. E. Durkin, “Preoperative prediction invasive techniques and perhaps we should evaluate these of the risk of pulmonary complications after esophagectomy patients for this approach. for cancer,” Journal of Thoracic and Cardiovascular Surgery, vol. The limitations of this study are the small sample size 123, no. 4, pp. 661–669, 2002. of the SCC patients. This limits the impact of the data [11] S. M. Griffin, I. H. Shaw, and S. M. Dresner, “Early complica- presented, but does not limit the fact that these two types of tions after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management,” Journal of histologies are both biologically different and physiologically the American College of Surgeons, vol. 194, no. 3, pp. 285–297, different and treating physicians should be aware of these differences and the impact that these play on perioperative [12] J. D. Urschel, “Esophagogastrostomy anastomotic leaks com- outcomes. plicating esophagectomy: a review,” American Journal of Surgery, vol. 169, no. 6, pp. 634–640, 1995. [13] P. Viklund, M. Lindblad, and J. Lagergren, “Influence of 5. Conclusion surgery-related factors on quality of life after esophageal or cardia cancer resection,” World Journal of Surgery, vol. 29, no. The presence of SCC was the single best predictor of 7, pp. 841–848, 2005. prolonged intensive care unit stay and more severe com- [14] B. Z. Atkins and T. A. D’Amico, “Respiratory complications plications as defined by this study. Only a past history of after esophagectomy,” Thoracic Surgery Clinics,vol. 16, no.1, pulmonary disease was different between the two histologic pp. 35–48, 2006. subgroups. No other factor, including sex, gender, age, or [15] D. Schubert, M. Pross, G. Nestler, et al., “Endoscopic nutritional status was predictive of this outcome. Esophageal treatment of mediastinal anastomotic leaks,” Zentralblatt fur ¨ histology should therefore be considered in the perioperative Chirurgie, vol. 131, no. 5, pp. 369–375, 2006. care of patients and may in the future be used to guide [16] L. W. Martin, S. G. Swisher, W. Hofstetter, et al., “Intrathoracic operative strategies. leaks following esophagectomy are no longer associated with increased mortality,” Annals of Surgery, vol. 242, no. 3, pp. 392–402, 2005. References [17] W.-J.Jiao, T.-Y.Wang, M. Gong,H.Pan,Y.B.Liu,and Z. H. Liu, “Pulmonary complications in patients with [1] B. Z. Atkins and T. A. D’Amico, “Respiratory complications chronic obstructive pulmonary disease following transtho- after esophagectomy,” Thoracic Surgery Clinics, vol. 16, no. 1, racic esophagectomy,” World Journal of Gastroenterology, vol. pp. 35–48, 2006. 12, no. 16, pp. 2505–2509, 2006. [2] J. B. F. Hulscher, J. W. van Sandick, A. G. E. M. de Boer, et al., [18] S. Law, K.-H. Wong, K.-F. Kwok, K.-M. Chu, and J. Wong, “Extended transthoracic resection compared with limited “Predictive factors for postoperative pulmonary complica- transhiatal resection for adenocarcinoma of the esophagus,” tions and mortality after esophagectomy for cancer,” Annals The New England Journal of Medicine, vol. 347, no. 21, pp. of Surgery, vol. 240, no. 5, pp. 791–800, 2004. 1662–1669, 2002. [19] T. Hirai, H. Matsumoto, K. Yamashita, et al., “Surgical [3] J. D. Luketich, M. Alvelo-Rivera, P. O. Buenaventura, oncotaxis–excessive surgical stress and postoperative compli- et al., “Minimally invasive esophagectomy: outcomes in 222 cations contribute to enhancing tumor metastasis, resulting in patients,” Annals of Surgery, vol. 238, no. 4, pp. 486–495, 2003. a poor prognosis for cancer patients,” Annals of Ahoracic and [4] F. Delgado Gomis, S. A. Gomez ´ Abril, M. Manuel, and J. M. Cardiovascular Surgery, vol. 11, no. 1, pp. 4–6, 2005. Guallar Rovira, “Assisted laparoscopic transhiatal esophagec- [20] L. E. Ferri, S. Law, K.-H. Wong, K.-F. Kwok, and J. Wong, tomy for the treatment of esophageal cancer,” Clinical and “The influence of technical complications on postoperative Translational Oncology, vol. 8, no. 3, pp. 185–192, 2006. outcome and survival after esophagectomy,” Annals of Surgical [5] C. Alexiou, O. A. Khan, E. Black, et al., “Survival after Oncology, vol. 13, no. 4, pp. 557–564, 2006. esophageal resection for carcinoma: the importance of the [21] T. Nozoe, Y. Kimura, M. Ishida, H. Saeki, D. Korenaga, histologic cell type,” Annals of Thoracic Surgery, vol. 82, no. and K. Sugimachi, “Correlation of pre-operative nutritional 3, pp. 1073–1077, 2006. condition with post-operative complications in surgical treat- [6] T.Onodera,N.Goseki, andG.Kosaki, “Prognosticnutritional ment for oesophageal carcinoma,” European Journal of Surgical index in gastrointestinal surgery of malnourished cancer Oncology, vol. 28, no. 4, pp. 396–400, 2002. patients,” Nippon Geka Gakkai Zasshi, vol. 85, no. 9, pp. 1001– 1005, 1984. [22] I. J. M. Han-Geurts,W.C.Hop,T.C.K.Tran, andH.W. Tilanus, “Nutritional status as a risk factor in esophageal [7] R.C.MartinII, D. P. Jaques,M.F.Brennan, andM.Karpeh, “Achieving R0 resection for locally advanced gastric cancer: surgery,” Digestive Surgery, vol. 23, no. 3, pp. 159–163, 2006. Journal of Oncology 7 [23] W. Hofstetter, S. G. Swisher, A. M. Correa, et al., “Treatment outcomes of resected esophageal cancer,” Annals of Surgery, vol. 236, no. 3, pp. 376–385, 2002. [24] G. Dionigi, F. Rovera, L. Boni, G. Carrafiello, M. Mangini, and R. Dionigi, “The surgeon’s approach to preoperative evaluation of esophageal cancer: recent developments,” Rays, vol. 30, no. 4, pp. 351–356, 2005. [25] C. Mariette, G. Taillier, I. Van Seuningen, and J.-P. Triboulet, “Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma,” Annals of Thoracic Surgery, vol. 78, no. 4, pp. 1177–1183, 2004. 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