Publications by authors named "Richard van Hillegersberg"

279 Publications

Lymphovascular invasion quantification could improve risk prediction of lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma.

United European Gastroenterol J 2021 Oct 5. Epub 2021 Oct 5.

Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands.

Aim: To quantify lymphovascular invasion (LVI) and to assess the prognostic value in patients with pT1b esophageal adenocarcinoma.

Methods: In this nationwide, retrospective cohort study, patients were included if they were treated with surgery or endoscopic resection for pT1b esophageal adenocarcinoma. Primary endpoint was the presence of metastases, lymph node metastases, or distant metastases, in surgical resection specimens or during follow-up. A prediction model to identify risk factors for metastases was developed and internally validated.

Results: 248 patients were included. LVI was distributed as follows: no LVI (n = 196; 79.0%), 1 LVI focus (n = 16; 6.5%), 2-3 LVI foci (n = 21; 8.5%) and ≥4 LVI foci (n = 15; 6.0%). Seventy-eight patients had metastases. The risk of metastases was increased for tumors with 2-3 LVI foci [subdistribution hazard ratio (SHR) 3.39, 95% confidence interval (CI) 2.10-5.47] and ≥4 LVI foci (SHR 3.81, 95% CI 2.37-6.10). The prediction model demonstrated a good discriminative ability (c-statistic 0.81).

Conclusion: The risk of metastases is higher when more LVI foci are present. Quantification of LVI could be useful for a more precise risk estimation of metastases. This model needs to be externally validated before implementation into clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ueg2.12151DOI Listing
October 2021

Laparoscopic Versus Open Gastrectomy for Gastric Cancer (LOGICA): A Multicenter Randomized Clinical Trial.

J Clin Oncol 2021 03 6;39(9):978-989. Epub 2021 Jan 6.

Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: The oncological efficacy and safety of laparoscopic gastrectomy are under debate for the Western population with predominantly advanced gastric cancer undergoing multimodality treatment.

Methods: In 10 experienced upper GI centers in the Netherlands, patients with resectable (cT1-4aN0-3bM0) gastric adenocarcinoma were randomly assigned to either laparoscopic or open gastrectomy. No masking was performed. The primary outcome was hospital stay. Analyses were performed by intention to treat. It was hypothesized that laparoscopic gastrectomy leads to shorter hospital stay, less postoperative complications, and equal oncological outcomes.

Results: Between 2015 and 2018, a total of 227 patients were randomly assigned to laparoscopic (n = 115) or open gastrectomy (n = 112). Preoperative chemotherapy was administered to 77 patients (67%) in the laparoscopic group and 87 patients (78%) in the open group. Median hospital stay was 7 days (interquartile range, 5-9) in both groups ( = .34). Median blood loss was less in the laparoscopic group (150 300 mL, < .001), whereas mean operating time was longer (216 182 minutes, < .001). Both groups did not differ regarding postoperative complications (44% 42%, = .91), in-hospital mortality (4% 7%, = .40), 30-day readmission rate (9.6% 9.1%, = 1.00), R0 resection rate (95% 95%, = 1.00), median lymph node yield (29 29 nodes, = .49), 1-year overall survival (76% 78%, = .74), and global health-related quality of life up to 1 year postoperatively (mean differences between + 1.5 and + 3.6 on a 1-100 scale; 95% CIs include zero).

Conclusion: Laparoscopic gastrectomy did not lead to a shorter hospital stay in this Western multicenter randomized trial of patients with predominantly advanced gastric cancer. Postoperative complications and oncological efficacy did not differ between laparoscopic gastrectomy and open gastrectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JCO.20.01540DOI Listing
March 2021

Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses.

Ann Surg Oncol 2021 Sep 5. Epub 2021 Sep 5.

Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.

Objective: The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy.

Background: Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%.

Methods: We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer.

Results: Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m were associated with increased risk for mortality.

Conclusions: Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-021-10734-3DOI Listing
September 2021

Severe lymphopenia acquired during chemoradiotherapy for esophageal cancer: Incidence and external validation of a prediction model.

Radiother Oncol 2021 Aug 25;163:192-198. Epub 2021 Aug 25.

Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: The incidence of grade 4 lymphopenia in patients treated with chemoradiotherapy (CRT) according to Chemoradiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) regimen is unclear. The primary aim was to determine the incidence of grade 4 lymphopenia during CROSS for esophageal cancer. Secondary aims were to externally validate a prediction model for grade 4 lymphopenia and compare overall survival between patients with and without grade 4 lymphopenia.

Methods: Patients who underwent CRT for esophageal cancer between 2014 and 2019 were eligible for inclusion. Patients with a planned radiation dose of 41.4 Gy (CROSS) or 50.4 Gy ("extended-CROSS") and concurrent carboplatin and paclitaxel were included. The primary outcome was the incidence of grade 4 lymphopenia during CRT defined according to Common Terminology Criteria for Adverse Events version 5.0 (i.e. lymphocyte count nadir < 0.2 µL). The secondary outcome measures were the prediction model's external performance (i.e. discrimination and calibration). Overall survival for patients with versus without grade 4 lymphopenia was compared using Kaplan-Meier analysis.

Results: A total of 219 patients were included of whom 176 patients (80%) underwent CROSS and 43 patients (20%) extended-CROSS. The incidence of grade 4 lymphopenia was 11% in CROSS and 33% in extended-CROSS (p < 0.001). External discrimination yielded a c-statistic of 0.80 (95% confidence interval: 0.70-0.89). External calibration of the model was poor in CROSS but fair in extended-CROSS. Adjusted calibration using intercept correction (adjusted for the lower a-priori risk for grade 4 lymphopenia in CROSS) showed fair agreement between the observed and predicted risk for grade 4 lymphopenia. Median overall survival in patients with versus without grade 4 lymphopenia was 12.7 versus 42.5 months (p = 0.045).

Conclusion: The incidence of grade 4 lymphopenia is significantly higher in esophageal cancer patients receiving extended-CROSS compared to those receiving CROSS. The prediction model demonstrated good external performance in the setting of the CROSS-regimen and could be used to identify patients at high-risk for grade 4 lymphopenia who might be eligible for lymphopenia-mitigating strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.radonc.2021.08.009DOI Listing
August 2021

Overall Volume Trends in Esophageal Cancer Surgery Results From the Dutch Upper Gastrointestinal Cancer Audit.

Ann Surg 2021 09;274(3):449-458

Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.

Objective: In the pursuit of quality improvement, this study aimed to investigate volume-outcome trends in oncologic esophagectomy in the Netherlands.

Summary Of Background Data: Concentration of Dutch esophageal cancer care was dictated by introducing an institutional minimum of 20 resections/yr.

Methods: This nationwide cohort study included all esophagectomy patients registered in the Dutch Upper Gastrointestinal Cancer Audit in 2016-2019 from hospitals currently still performing esophagectomies. Annual esophagectomy hospital volume was assigned to each patient and categorized into quartiles. Multivariable logistic regression investigated short-term surgical outcomes. Restricted cubic splines investigated if volume-outcome relationships eventually plateaued.

Results: In 16 hospitals, 3135 esophagectomies were performed. First volume quartile hospitals performed 24-39 resections/yr; second, third, and fourth quartile hospitals performed 40-53, 54-69, and 70-101, respectively. Compared to quartile 1, in quartiles 2 to 4, overall/severe/technical complication, anastomotic leakage, and prolonged hospital/intensive care unit stay rates were significantly lower and textbook outcome and lymph node yield were higher. When raising the cut-off from the first to second quartile, higher-volume centers had less technical complications [Adjusted odds ratio (aOR): 0.82, 95% confidence interval (CI): 0.70-0.96], less anastomotic leakage (aOR: 0.80, 95% CI: 0.66-0.97), more textbook outcome (aOR: 1.25, 95% CI: 1.07-1.46), shorter intensive care unit stay (aOR: 0.80, 95% CI: 0.69-0.93), and higher lymph node yield (aOR: 3.56, 95% CI: 2.68-4.77). For most outcomes the volume-outcome trend plateaued at 50-60 annual resections, but lymph node yield and anastomotic leakage continued to improve.

Conclusion: Although this study does not reflect on individual hospital quality, there appears to be a volume trend towards better outcomes in high-volume centers. Projects have been initiated to improve national quality of care by reducing hospital variation (irrespective of volume) in outcomes in The Netherlands.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004985DOI Listing
September 2021

Robotic-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer training curriculum-a worldwide Delphi consensus study.

Dis Esophagus 2021 Aug 11. Epub 2021 Aug 11.

Department of General, Visceral, Cancer, and Transplantation Surgery, University of Cologne, Cologne, Germany.

Background: Structured training protocols can safely improve skills prior initiating complex surgical procedures such as robotic-assisted minimally invasive esophagectomy (RAMIE). As no consensus on a training curriculum for RAMIE has been established so far it is our aim to define a protocol for RAMIE with the Delphi consensus methodology.

Methods: Fourteen worldwide RAMIE experts were defined and were enrolled in this Delphi consensus project. An expert panel was created and three Delphi rounds were performed starting December 2019. Items required for RAMIE included, but were not limited to, virtual reality simulation, wet-lab training, proctoring, and continued monitoring and education. After rating performed by the experts, consensus was defined when a Cronbach alpha of ≥0.80 was reached. If ≥80% of the committee reached a consensus an item was seen as fundamental.

Results: All Delphi rounds were completed by 12-14 (86-100%) participants. After three rounds analyzing our 49-item questionnaire, 40 items reached consensus for a training curriculum of RAMIE.

Conclusion: The core principles for RAMIE training were defined. This curriculum may lead to a wider adoption of RAMIE and a reduction in time to reach proficiency.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doab055DOI Listing
August 2021

Risk Factors for Tumor Positive Resection Margins After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: Results from the Dutch Upper GI Cancer Audit: A Nationwide Population-Based Study.

Ann Surg 2021 Jul 29. Epub 2021 Jul 29.

Department of Surgery, University Medical Center Utrecht, The Netherlands Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands.

Objective: To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer.

Summary Background Data: Esophagectomy after nCRT is associated with tumor positive resection margins in 4-9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy.

Methods: All patients who underwent an elective esophagectomy following nCRT in 2011-2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins.

Results: In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR:1.1, 95% CI: 1.0-1.1), cT4-stage (OR:3.0, 95% CI: 1.2 - 6.7) and an Ivor Lewis esophagectomy (OR:1.6, 95% CI: 1.0 - 2.6). Predictors associated with a lower risk of tumor positive resection margins were; squamous cell carcinoma (OR:0.4, 95% CI: 0.2 - 0.7), distal tumors (OR:0.5, 95% CI: 0.3 - 1.0), minimally invasive surgery (OR:0.6, 95% CI: 0.4 - 0.9) and a hospital volume of >60 esophagectomies per year (OR:0.6, 95%CI: 0.4 - 1.0).

Conclusions: In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000005112DOI Listing
July 2021

Outcomes of Esophagogastric Cancer Surgery During Eight Years of Surgical Auditing by the Dutch Upper Gastrointestinal Cancer Audit (DUCA).

Ann Surg 2021 11;274(5):866-873

Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands.

Objective: To evaluate changes in treatment and outcomes of esophagogastric cancer surgery after introduction of the DUCA. In addition, the presence of risk-averse behavior was assessed.

Summary Of Background Data: Clinical auditing is seen as an important quality improvement tool; however, its long-term efficacy remains largely unknown. In addition, critics claim that enhancements result from risk-averse behavior rather than positive effects of auditing.

Methods: DUCA data were used from registration start (1-1-2011) until 31-12-2018. Trends in patient, tumor, hospital and treatment characteristics were univariably assessed. Trends in short-term outcomes were investigated using multilevel multivariable logistic regression. Presence of risk aversion was described by the corrected proportion of patients undergoing surgery, using data from the Netherlands Cancer Registry. To evaluate the impact of centralization on time trends identified, the association between hospital volume and outcomes was investigated.

Results: This study included 6172 patients with esophageal and 3,690 with gastric cancer who underwent surgery. Pathological outcomes (lymph node yield, radicality) improved and futile surgery decreased over the years. In-hospital/30-day mortality decreased for esophagectomy (4.2% to 2.5%) and for gastrectomy (7.1% to 4.3%). Reinterventions, (minor) complications and readmissions increased. Risk aversion appeared absent. Between 2011-2018, annual median hospital volumes increased from 38 to 53 for esophagectomy and from 14 to 29 for gastrectomy. Higher hospital volumes were associated with several improved outcomes measures.

Conclusions: During 8 years of auditing, outcomes improved, with no signs of risk-averse behavior. These improvements occurred in parallel with centralization. Feedback on postoperative complications remains the focus of the DUCA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000005116DOI Listing
November 2021

The Influence of Severe Radiation-Induced Lymphopenia on Overall Survival in Solid Tumors: A Systematic Review and Meta-Analysis.

Int J Radiat Oncol Biol Phys 2021 Nov 28;111(4):936-948. Epub 2021 Jul 28.

Departments of Radiation Oncology.

Purpose: Emerging evidence suggests a detrimental prognostic association between radiation-induced lymphopenia (RIL) and pathologic response, progression-free survival, and overall survival (OS) in patients who undergo radiation therapy for cancer. The aim of this study was to systematically review and meta-analyze the prognostic impact of RIL on OS in patients with solid tumors.

Methods And Materials: PubMed/MEDLINE and Embase were systematically searched. The analysis included intervention and prognostic studies that reported on the prognostic relationship between RIL and survival in patients with solid tumors. An overall pooled adjusted hazard ratio (aHR) was calculated using a random-effects model. Subgroup analyses for different patient-, tumor-, treatment-, and study-related characteristics were performed using meta-regression.

Results: Pooling of 21 cohorts within 20 eligible studies demonstrated a statistically significant association between OS and grade ≥3 versus grade 0-2 RIL (n = 16; pooled aHR, 1.65; 95% confidence interval [CI], 1.43-1.90) and grade 4 RIL versus grade 0-3 (n = 5; aHR, 1.53; 95% CI, 1.24-1.90). Moderate heterogeneity among aHRs was observed, mostly attributable to overestimated aHRs in 7 studies likely subject to model-overfitting. Subgroup analysis showed significant prognostic impact of grade ≥3 RIL in 4 brain tumor (aHR, 1.63; 95% CI, 1.06-2.51), 4 lung cancer (aHR, 1.52; 95% CI, 1.01-2.29), and 3 pancreatic cancer (aHR, 1.92; 95% CI, 1.10-3.36) cohorts.

Conclusions: This meta-analysis demonstrates a significant detrimental prognostic association between grade ≥3 lymphopenia and OS in patients receiving radiation therapy for solid tumors. This finding appears consistent for tumors of the brain, thorax, and upper abdomen and provides an imperative to further elucidate the potential survival benefit of lymphopenia-mitigating strategies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijrobp.2021.07.1695DOI Listing
November 2021

An in-silico assessment of the dosimetric benefits of MR-guided radiotherapy for esophageal cancer patients.

Radiother Oncol 2021 Sep 5;162:76-84. Epub 2021 Jul 5.

Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, The Netherlands. Electronic address:

Purpose: To assess the dosimetric benefits of online MR-guided radiotherapy (MRgRT) for esophageal cancer patients and to assess how these benefits could be translated into a local boosting strategy to improve future outcomes.

Methods: Twenty-nine patients were in-silico treated with both a MRgRT regimen and a conventional image guided radiotherapy (IGRT) regimen using dose warping techniques. Here, the inter and intrafractional changes that occur over the course of treatment (as derived from 5 MRI scans that were acquired weekly during treatment) were incorporated to assess the total accumulated dose for each regimen.

Results: A significant reduction in dose to the organs-at-risk (OARs) was observed for all dose-volume-histogram (DVH) parameters for the MRgRT regimen without concessions to target coverage compared to the IGRT regimen. The mean lung dose was reduced by 28%, from 7.9 to 5.7 Gy respectively and V20Gy of the lungs was reduced by 55% (6.3-2.8%). A reduction of 24% was seen in mean heart dose (14.8-11.2 Gy), while the V25Gy of the heart was decreased by 53% (14.3-6.7%) and the V40Gy of the heart was decreased by 69% (3.9-1.2%). In addition, MRgRT dose escalation regimens with a boost up to 66% of the prescription dose to the primary tumor yielded approximately the same dose levels to the OARs as from the conventional IGRT regimen.

Conclusion: This study revealed that MRgRT for esophageal cancer has the potential to significantly reduce the dose to heart and lungs. In addition, online high precision targeting of the primary tumor opens new perspectives for local boosting strategies to improve outcome of the local management of this disease.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.radonc.2021.06.038DOI Listing
September 2021

Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer.

JAMA Surg 2021 09;156(9):836-845

Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom.

Importance: Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions.

Objective: To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes.

Design, Setting, And Participants: In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.

Exposures: Esophageal resection for cancer of the esophagus and gastroesophageal junction.

Main Outcomes And Measures: All-cause postoperative 90-day mortality.

Results: A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort.

Conclusions And Relevance: In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamasurg.2021.2376DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223144PMC
September 2021

Worldwide Practice in Gastric Cancer Surgery: A 6-Year Update.

Dig Surg 2021 1;38(4):266-274. Epub 2021 Jun 1.

Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.

Objectives: The aim of the study was to evaluate the current status of gastric cancer surgery worldwide and update the changes compared to a previous survey in 2014.

Methods: A cross-sectional survey was sent to surgical members of the International Gastric Cancer Association, pilot centers of the World Organization for Specialized Studies on Diseases of the Esophagus, and the Australian and New Zealand Gastric and Oesophageal Surgeons Association in addition to participants of the 2019 International Gastric Cancer and European Society for Diseases of the Esophagus congresses. Topics addressed included hospital volume, staging, perioperative treatment, surgical approach, anastomotic techniques, lymphadenectomy, and palliative management.

Results: Between June 2019 and January 2020, 165 respondents from 44 countries completed the survey. In total, 80% worked in a hospital performing >20 gastrectomies annually. Staging laparoscopy and 18F-fluorodeoxyglucose positron emission tomography with computed tomography were preferred by 68 and 26% for advanced cancer, and 90% offered perioperative chemo(radio)therapy to patients. For early cancer, a minimally invasive surgical approach was preferred by 65% for distal and by 50% for total gastrectomy. For advanced cancer, this was preferred by 39% for distal and by 33% for total gastrectomy. And 84% favored a stapled anastomosis, and 14% created a jejunal pouch as reconstruction during total gastrectomy. A D2 lymphadenectomy was preferred for distal as well as for total gastrectomy, in both early (62 and 71%) and advanced (84 and 89%) cancer.

Conclusion: This international survey demonstrates that perioperative chemotherapy and a D2 lymphadenectomy have now become the preferred treatment for gastric cancer. A minimally invasive surgical approach has gained popularity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000515768DOI Listing
June 2021

Feasibility of sentinel node navigated surgery in high-risk T1b esophageal adenocarcinoma patients using a hybrid tracer of technetium-99 m and indocyanine green.

Surg Endosc 2021 May 27. Epub 2021 May 27.

Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.

Background: Minimally invasive esophagectomy with two-field lymphadenectomy is standard of care for T1b esophageal adenocarcinoma (EAC) with a high risk of lymph node metastasis. Sentinel node navigation surgery (SNNS) is a well-known concept to tailor the extent of lymphadenectomy. The aim of this study was to evaluate the feasibility and safety of SNNS with a hybrid tracer (technetium-99 m/indocyanine green/nanocolloid) for patients with high-risk T1b EAC.

Methods: In this prospective, multicenter pilot study, 5 patients with high-risk T1b EAC were included. The tracer was injected endoscopically around the endoscopic resection scar the day before surgery, followed by preoperative imaging (lymphoscintigraphy/SPECT-CT). During surgery, first the SNs were localized and resected based on preoperative imaging and intraoperative gammaprobe- and fluorescence-based detection, followed by esophagectomy. Primary endpoints were the percentage of patients with detectable SNs, concordance between preoperative and intraoperative SN detection, and the additive value of indocyanine green.

Results: SNs could be identified and resected in all patients (median 3 SNs per patient, range 2-7). There was a high concordance between preoperative and intraoperative SN detection. In 2 patients additional peritumoral SNs were identified with fluorescence-based detection. None of the resected lymph nodes showed signs of (micro)metastases and no nodal metastases were detected in the surgical resection specimen.

Conclusions: SNNS using technetium-99 m/indocyanine green/nanocolloid seems feasible and safe in patients with high-risk T1b EAC. Indocyanine green fluorescence seems to be of additive value for detection of peritumoral SNs. Whether this approach can optimize selection for esophagectomy needs to be studied in future research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08551-6DOI Listing
May 2021

Minimally Invasive Oncologic Upper Gastrointestinal Surgery can be Performed Safely on all Weekdays: A Nationwide Cohort Study.

World J Surg 2021 09 25;45(9):2816-2829. Epub 2021 May 25.

Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Room G6-250, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.

Background: Existing literature suggests deteriorating surgical outcome of esophagogastric surgery as the week progresses. However, these studies were conducted in the pre-centralization and pre-minimally invasive era. In addition, they failed to correct for fixed weekdays of esophagogastric cancer surgery among hospitals. This study aimed to describe the impact of weekday of minimally invasive upper gastrointestinal surgery on short-term surgical outcomes.

Methods: All patients registered in the Dutch Upper Gastrointestinal Cancer Audit who underwent curative minimally invasive esophageal or gastric carcinoma surgery in 2015-2019, were included in this nationwide cohort study. Using multilevel multivariable logistic regression, the impact of weekday of surgery on 14 short-term surgical outcomes was investigated. To correct for interhospital variance in fixed weekday(s) of surgery multilevel analyses was used. Results were adjusted for patient, tumor, and treatment characteristics using multivariable logistic regression analyses.

Results: This study included 4,102 patients undergoing minimally invasive upper gastrointestinal surgery (2,968 esophageal cancer and 1,134 gastric cancer patients). Weekday of surgery did not impact postoperative complications, severe postoperative complications, surgical/technical complications, medical complications, anastomotic leakage, complicated postoperative course, failure to rescue, surgical radicality, lymph node yield, 30-day/in-hospital mortality, reinterventions, length of ICU stay, 30-day readmission, and textbook outcome after neither esophageal cancer nor gastric cancer surgery.

Conclusions: Minimally invasive esophagogastric surgery can be performed safely on all weekdays with respect to short-term surgical outcomes, which is important information for operation room scheduling.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00268-021-06160-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8321995PMC
September 2021

Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process.

Dis Esophagus 2021 Jan 16. Epub 2021 Jan 16.

Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany.

Background: In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology.

Methods: The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed.

Results: Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice.

Conclusion: This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doaa127DOI Listing
January 2021

The Presence of Metastatic Thoracic Duct Lymph Nodes in Western Esophageal Cancer Patients: A Multinational Observational Study.

Ann Thorac Surg 2021 Mar 4. Epub 2021 Mar 4.

Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands. Electronic address:

Background: The thoracic lymphadenectomy during an esophagectomy for esophageal cancer includes resection of the thoracic duct (TD) compartment containing the TD lymph nodes (TDLNs). The role of TD compartment resection is still a topic of debate since metastatic TDLNs have only been demonstrated in squamous cell carcinomas in Eastern esophageal cancer patients. Therefore, the aim of this study was to assess the presence and metastatic involvement of TDLNs in a Western population, in which adenocarcinoma is the predominant type of esophageal cancer.

Methods: From July 2017 to May 2020, all consecutive patients undergoing an open or robot-assisted transthoracic esophagectomy with concurrent lymphadenectomy and resection of the TD compartment in the University Medical Center Utrecht in Utrecht, the Netherlands, and the Città della Salute e della Scienza University Hospital in Turin, Italy, were included. The TD compartment was resected en bloc and was separated in the operation room by the operating surgeon after which it was macroscopically and microscopically assessed for (metastatic) TDLNs by the pathologist.

Results: A total of 117 patients with an adenocarcinoma (73%) or squamous cell carcinoma (27%) of the esophagus were included. In 61 (52%) patients, TDLNs were found, containing metastasis in 9 (15%) patients. No major complications related to TD compartment resection were observed.

Conclusions: This study demonstrates the presence of metastatic TDLNs in adenocarcinomas of the esophagus. This result provides a valid argument to routinely extend the thoracic lymphadenectomy with resection of the TD compartment during an esophagectomy for esophageal cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.02.041DOI Listing
March 2021

Individual risk calculator to predict lymph node metastases in patients with submucosal (T1b) esophageal adenocarcinoma: a multicenter cohort study.

Endoscopy 2021 Feb 24. Epub 2021 Feb 24.

Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, the Netherlands.

Background:  Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC.

Methods:  A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic.

Results:  248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86).

Conclusions:  A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/a-1399-4989DOI Listing
February 2021

Prognosis of Interval Distant Metastases After Neoadjuvant Chemoradiotherapy for Esophageal Cancer.

Ann Thorac Surg 2021 Feb 18. Epub 2021 Feb 18.

Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands. Electronic address:

Background: In esophageal cancer patients, distant metastases develop between the start of neoadjuvant chemoradiotherapy and planned surgery, so-called interval metastases. The primary aim of this study was to assess management, overall survival (OS), and prognostic factors for OS in these patients. A secondary aim was to compare OS with synchronous metastatic patients.

Methods: Esophageal cancer patients with interval distant metastases were identified from the Netherlands Cancer Registry (2010 to 2017). Management was categorized into metastasis-directed therapy (MDT), primary tumor resection, or best supportive care (BSC). The OS was calculated from the diagnosis of the primary tumor. Prognostic factors affecting OS were studied using Cox proportional hazard models. Propensity score-matching (1:3) generated matched cases with synchronous distant metastases.

Results: In all, 208 patients with interval metastases were identified: in 87 patients (42%) MDT was initiated; in 10%, primary tumor resection only; in 7%, primary tumor resection plus MDT; and in 41%, BSC. Median OS was 10 months (interquartile range, 8.6 to 11.1). Compared with BSC, superior OS was independently associated with MDT (hazard ratio [HR] 0.36; 95% confidence interval [CI], 0.26 to 0.49), primary tumor resection (HR 0.55; 95% CI, 0.33 to 0.94), and primary tumor resection plus MDT (HR 0.20; 95% CI, 0.10 to 0.38). Worse OS was independently associated with signet ring cell carcinoma (HR 1.92; 95% CI, 1.12 to 3.28) and poor differentiation grade (HR 1.96; 95% CI, 1.35 to 2.83). The OS was comparable between matched patients with interval and synchronous distant metastases (10.2 versus 9.4 months, P = .760).

Conclusions: In esophageal cancer patients treated with neoadjuvant chemoradiotherapy with interval distant metastases, the OS was poor and comparable to that of synchronous metastatic patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.01.061DOI Listing
February 2021

Expectations of Continuous Vital Signs Monitoring for Recognizing Complications After Esophagectomy: Interview Study Among Nurses and Surgeons.

JMIR Perioper Med 2021 Feb 12;4(1):e22387. Epub 2021 Feb 12.

Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.

Background: Patients undergoing esophagectomy are at serious risk of developing postoperative complications. To support early recognition of clinical deterioration, wireless sensor technologies that enable continuous vital signs monitoring in a ward setting are emerging.

Objective: This study explored nurses' and surgeons' expectations of the potential effectiveness and impact of continuous wireless vital signs monitoring in patients admitted to the ward after esophagectomy.

Methods: Semistructured interviews were conducted at 3 esophageal cancer centers in the Netherlands. In each center, 2 nurses and 2 surgeons were interviewed regarding their expectations of continuous vital signs monitoring for early recognition of complications after esophagectomy. Historical data of patient characteristics and clinical outcomes were collected in each center and presented to the local participants to support estimations on clinical outcome.

Results: The majority of nurses and surgeons expected that continuous vital signs monitoring could contribute to the earlier recognition of deterioration and result in earlier treatment for postoperative complications, although the effective time gain would depend on patient and situational factors. Their expectations regarding the impact of potential earlier diagnosis on clinical outcomes varied. Nevertheless, most caregivers would consider implementing continuous monitoring in the surgical ward to support patient monitoring after esophagectomy.

Conclusions: Caregivers expected that wireless vital signs monitoring would provide opportunities for early detection of postoperative complications in patients undergoing esophagectomy admitted to the ward and prevent sequelae under certain circumstances. As the technology matures, clinical outcome studies will be necessary to objectify these expectations and further investigate overall effects on patient outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/22387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910120PMC
February 2021

Neoadjuvant Chemoradiotherapy Combined with Atezolizumab for Resectable Esophageal Adenocarcinoma: A Single-arm Phase II Feasibility Trial (PERFECT).

Clin Cancer Res 2021 Jun 27;27(12):3351-3359. Epub 2021 Jan 27.

Amsterdam UMC, Department of Medical Oncology, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands.

Purpose: The CROSS trial established neoadjuvant chemoradiotherapy (nCRT) for patients with resectable esophageal adenocarcinoma (rEAC). In the PERFECT trial, we investigated the feasibility and efficacy of nCRT combined with programmed-death ligand-1 (PD-L1) inhibition for rEAC.

Patients And Methods: Patients with rEAC received nCRT according to the CROSS regimen combined with five cycles of atezolizumab (1,200 mg). The primary endpoint was the feasibility of administering five cycles of atezolizumab in ≥75% patients. A propensity score-matched nCRT cohort was used to compare pathologic response, overall survival, and progression-free survival. Exploratory biomarker analysis was performed on repeated tumor biopsies.

Results: We enrolled 40 patients of whom 85% received all cycles of atezolizumab. Immune-related adverse events of any grade were observed in 6 patients. In total, 83% proceeded to surgery. Reasons for not undergoing surgery were progression ( = 4), patient choice ( = 2), and death ( = 1). The pathologic complete response rate was 25% (10/40). No statistically significant difference in response or survival was found between the PERFECT and the nCRT cohort. Baseline expression of an established IFNγ signature was higher in responders compared with nonresponders ( = 0.043). On-treatment nonresponders showed either a high number of cytotoxic lymphocytes (CTL) with a transcriptional signature consistent with expression of immune checkpoints, or a low number of CTLs.

Conclusions: Combining nCRT with atezolizumab is feasible in patients with rEAC. On the basis of our exploratory biomarker study, future studies are necessary to elucidate the potential of neoadjuvant immunotherapy in patient subgroups..
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1158/1078-0432.CCR-20-4443DOI Listing
June 2021

Failure to Cure in Patients Undergoing Surgery for Gastric Cancer: A Nationwide Cohort Study.

Ann Surg Oncol 2021 Aug 23;28(8):4484-4496. Epub 2021 Jan 23.

Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.

Background: This study aimed to describe the incidence of failure to cure (a composite outcome measure defined as surgery not meeting its initial aim), and the impact of hospital variation in the administration of neoadjuvant therapy on this outcome measure.

Methods: All patients in the Dutch Upper Gastrointestinal Cancer Audit undergoing curatively intended gastric cancer surgery in 2011-2019 were included. Failure to cure was defined as (1) 'open-close' surgery; (2) irradical surgery (R1/R2); or (3) 30-day/in-hospital mortality. Case-mix-corrected funnel plots, based on multivariable logistic regression analyses, investigated hospital variation. The impact of a hospital's tendency to administer neoadjuvant chemotherapy on the heterogeneity in failure to cure between hospitals was assessed based on median odds ratios and multilevel logistic regression analyses.

Results: Some 3862 patients from 28 hospitals were included. Failure to cure was noted in 22.3% (hospital variation: 14.5-34.8%). After case-mix correction, two hospitals had significantly higher-than-expected failure to cure rates, and one hospital had a lower-than-expected rate. The failure to cure rate was significantly higher in hospitals with a low tendency to administer neoadjuvant chemotherapy. Approximately 29% of hospital variation in failure to cure could be attributed to different hospital policies regarding neoadjuvant therapy.

Conclusions: Failure to cure has an incidence of 22% in patients undergoing gastric cancer surgery. Higher failure to cure rates were seen in centers administering less neoadjuvant chemotherapy, which confirms the Dutch guideline recommendation on the administration of neoadjuvant chemotherapy. Failure to cure provides short loop feedback and can be used as a quality indicator in surgical audits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-020-09510-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8253712PMC
August 2021

Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit.

Eur J Surg Oncol 2021 Aug 16;47(8):1961-1968. Epub 2021 Jan 16.

Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands. Electronic address:

Introduction: The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes.

Materials And Methods: Patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses.

Results: Between 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0-4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay.

Conclusion: This study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ejso.2021.01.005DOI Listing
August 2021

Surgical anatomy of the upper esophagus related to robot-assisted cervical esophagectomy.

Dis Esophagus 2021 Jan 16. Epub 2021 Jan 16.

Department for General, Visceral, Thoracic, Transplant, and Pediatric Surgery, Kurt Semm Center for Minimal Invasive and Robotic Surgery, University Hospital Schleswig Holstein, Kiel, Germany.

Robot-assisted cervical esophagectomy (RACE) enables radical surgery for tumors of the middle and upper esophagus, avoiding a transthoracic approach. However, the cervical access, narrow working space, and complex topographic anatomy make this procedure particularly demanding. Our study offers a stepwise description of appropriate dissection planes and anatomical landmarks to facilitate RACE. Macroscopic dissections were performed on formaldehyde-fixed body donors (three females, three males), according to the surgical steps during RACE. The topographic anatomy and surgically relevant structures related to the cervical access route to the esophagus were described and illustrated, along with the complete mobilization of the cervical and upper thoracic segment. The carotid sheath, intercarotid fascia, and visceral fascia were identified as helpful landmarks, used as optimal dissection planes to approach the cervical esophagus and preserve the structures at risk (trachea, recurrent laryngeal nerves, thoracic duct, sympathetic trunk). While ventral dissection involved detachment of the esophagus from the tracheal cartilage and membranous part, the dorsal dissection plane comprised the prevertebral compartment harboring the thoracic duct and right intercosto-bronchial artery. On the left side, the esophagus was attached to the aortic arch by the aorto-esophageal ligament; on the right side, the esophagus was bordered by the azygos vein, right vagus nerve, and cardiac nerves. The stepwise, illustrated topographic anatomy addressed specific surgical demands and perspectives related to the left cervical approach and dissection of the esophagus, providing an anatomical basis to facilitate and safely implement the RACE procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doaa128DOI Listing
January 2021

Surgical management of a perforated 'black oesophagus'.

ANZ J Surg 2021 Jul 8;91(7-8):E539-E541. Epub 2021 Jan 8.

Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ans.16565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451825PMC
July 2021

Wireless Remote Home Monitoring of Vital Signs in Patients Discharged Early After Esophagectomy: Observational Feasibility Study.

JMIR Perioper Med 2020 Dec 4;3(2):e21705. Epub 2020 Dec 4.

Department of Anesthesiology, University Medical Center Utrecht, Utrecht, Netherlands.

Background: Hospital stays after major surgery are shorter than ever before. Although enhanced recovery and early discharge have many benefits, some complications will now first manifest themselves in home settings. Remote patient monitoring with wearable sensors in the first days after hospital discharge may capture clinical deterioration earlier but is largely uncharted territory.

Objective: This study aimed to assess the technical feasibility of patients, discharged after esophagectomy, being remotely monitored at home with a wireless patch sensor and the experiences of these patients. In addition, we determined whether observing vital signs with a wireless patch sensor influences clinical decision making.

Methods: In an observational feasibility study, vital signs of patients were monitored with a wearable patch sensor (VitalPatch, VitalConnect Inc) during the first 7 days at home after esophagectomy and discharge from hospital. Vital signs trends were shared with the surgical team once a day, and they were asked to check the patient's condition by phone each morning. Patient experiences were evaluated with a questionnaire, and technical feasibility was analyzed on a daily basis as the percentage of data loss and gap durations. In addition, the number of patients for whom a change in clinical decision was made based on the results of remote vital signs monitoring at home was assessed.

Results: Patients (N=20) completed 7 days each of home monitoring with the wearable patch sensor. Each of the patients had good recovery at home, and remotely observed vital signs trends did not alter clinical decision making. Patients appreciated that surgeons checked their vital signs daily (mean 4.4/5) and were happy to be called by the surgical team each day (mean 4.5/5). Wearability of the patch was high (mean 4.4/5), and no reports of skin irritation were mentioned. Overall data loss of vital signs measurements at home was 25%; both data loss and gap duration varied considerably among patients.

Conclusions: Remote monitoring of vital signs combined with telephone support from the surgical team was feasible and well perceived by all patients. Future studies need to evaluate the impact of home monitoring on patient outcome as well as the cost-effectiveness of this new approach.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2196/21705DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7728408PMC
December 2020

State of the art in esophagectomy: robotic assistance in the abdominal phase.

Updates Surg 2021 Jun 31;73(3):823-830. Epub 2020 Dec 31.

Department of Surgery, University Medical Center Utrecht, POBOX 85500, 3508 GA, Utrecht, The Netherlands.

Over the years, robot-assisted esophagectomy gained popularity. The current literature focused mainly on robotic assistance in the thoracic phase, whereas the implementation of robotic assistance in the abdominal phase is lagging behind. Advantages of adding a robotic system to the abdominal phase include robotic stapling and the increased surgeon's independency. In terms of short-term outcomes and lymphadenectomy, robotic assistance is at least equal to laparoscopy. Yet high quality evidence to conclude on this topic remains scarce. This review focuses on the evidence of robotic assistance in the abdominal phase of esophagectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13304-020-00937-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8184533PMC
June 2021

Long-Term Survival After Minimally Invasive Versus Open Esophagectomy for Esophageal Cancer: A Nationwide Propensity-Score Matched Analysis.

Ann Surg 2020 Dec 23;Publish Ahead of Print. Epub 2020 Dec 23.

Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands Department of Surgery, UMC Utrecht, Utrecht, the Netherlands Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands.

Objectives: This study aimed to compare long-term survival following minimally invasive esophagectomy (MIE) versus open esophagectomy (OE) for esophageal cancer using a nationwide propensity-score matched cohort.

Summary Background Data: MIE provides lower postoperative morbidity and mortality, and similar short-term oncological quality compared to OE.

Methods: Data was acquired from the Dutch Upper Gastrointestinal Cancer Audit. Patients undergoing minimally invasive or open, transthoracic or transhiatal esophagectomy for primary esophageal cancer between 2011-2015 were included. A propensity-score matching analysis for MIE versus OE was performed separately for transthoracic and transhiatal esophagectomies.

Results: A total of 1036 transthoracic MIE and OE patients, and 582 transhiatal MIE and OE patients were matched. Long-term survival was comparable for MIE and OE for both transthoracic and transhiatal procedures (5-year overall survival: transthoracic MIE 49.2% vs. OE 51.1%, p 0.695; transhiatal MIE 48.4% vs. OE 50.7%, p 0.832). For both procedures, MIE yielded more lymph nodes (transthoracic median 21 vs. 18, p < 0.001; transhiatal 15 vs. 13, p 0.007). Post-operative morbidity was comparable after transthoracic MIE and OE (60.8% vs. 64.9%, p 0.177), with a reduced length of stay after transthoracic MIE (median 12 vs. 15 days, p < 0.001). After transhiatal MIE, more postoperative complications (64.9% vs. 56.4%, p 0.034) were observed, without subsequent difference in length of stay.

Conclusion: Long-term survival after minimally invasive esophagectomy was equivalent to open in both propensity-score matched cohorts of patients undergoing transthoracic or transhiatal esophageal resections. Transhiatal minimally invasive esophagectomy was accompanied with more post-operative morbidity. Both transthoracic and transhiatal minimally invasive esophagectomy resulted in a more extended lymphadenectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000004708DOI Listing
December 2020

Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy.

Dis Esophagus 2020 Nov;33(Supplement_2)

Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1-3) started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1-10) and ended at 20% (cases 51-60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/dote/doaa055DOI Listing
November 2020
-->