Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Background Anastomotic leakage (AL) after esophagectomy for cancer is associated with negative outcomes that could be mitigated by screening and early treatment of the complication. We aimed to assess whether patients with AL diagnosed through systematic radiological screening did already exhibit signs of possible leakage which would have prompted diagnostic testing. Methods Patients undergoing esophagectomy with intrathoracic anastomosis at a tertiary center between 2014 and 2021 were included. Systematic screening consisted of contrast swallow or computed tomography (CT) with per-oral contrast on postoperative days (POD) 4–5. Patients with positive screening were assessed for following signs suggestive of AL from POD 0 to POD 5: C-reactive protein (CRP) ≥ 300mg/L, new-onset leukocytosis with white blood cell count ≥ 10*109/L, temperature ≥ 38°C, tachycardia with ≥ 120 bpm, and presence of atrial dysrhythmia. Results Of 53 patients with intrathoracic AL, 49 (92.5%) underwent systematic screening and 9 (17.0%) were diagnosed at screening (contrast swallow 55.6%, CT 44.4%). In all these patients with positive screening, signs suggestive of AL were already present: elevated CRP in 2 (22%), new-onset leukocytosis in 3 (33.3%), fever in 6 (66.7%), tachycardia in 6 (66.7%), and atrial dysrhythmia in 1 (11.1%). Of note, the 40 (81.6%) patients with negative screening developed AL on median day 9.5 (interquartile range 7-15.25), despite initial screening being negative. Conclusion Although early diagnosis of AL is key to its successful management, systematic screening could only diagnose patients who were already exhibiting symptoms or signs suggestive of leakage. With day of AL-diagnosis varying strongly in our cohort, and screening providing a false sense of security in 81.6% of patients, these results advocate for a more patient-tailored, targeted approach to screening for AL.

BACKGROUND and AIMS To evaluate the feasibility, safety, and impacts of routine surgically placed feeding jejunostomy (FJ) and early enteral feeding (EF) in patients undergoing esophagectomy for esophageal cancer within an Enhanced Recovery Protocol (ERP), focusing on adverse events (FJ-AE and EF-AE). METHODS This monocentric retrospective observational study analyzed 738 consecutive patients with resectable esophageal or gastroesophageal junction carcinoma treated at University Hospitals Leuven from May 2017 to December 2023. All followed an ERP with routine FJ placement during esophagectomy (or pre-neoadjuvant staging laparoscopy in select cases). Data from a prospective database and medical records were reviewed for demographics, weights/BMI, all recorded FJ-AE, EF intolerance during the postoperative course, up to five years after surgery, when available, or date of death. RESULTS The mean age was 65 years (range 24-90), with a majority being male (81%). About 77.5% had adenocarcinoma and were at an advanced stage. Neoadjuvant therapy was performed before surgery in 71%. FJ-AE impacted 361 (48.9%) patients, increasing to 419 (58.5%) when including EF-AE. After categorizing AEs, 310 (42%) were deemed non-serious, while 109 (14.8%) were considered serious, with 7 (0.9%) contributing to mortality. Late, serious complications occurred in 33 (4.5%) patients. The mean EF usage and FJ lifespan varied based on several factors: longer for older patients, those with non-adenocarcinoma, and higher NRS2002 scores, but shorter in minimally invasive approaches and patients with higher BMIs. Patients who experienced an anastomotic leak after surgery or required adjuvant therapy had longer EF usage and FJ duration. CONCLUSIONS Routine FJ placement in esophagectomy yields high AE rates, conflicting with ERP goals of complication reduction. Selective placement in malnourished/high-risk patients, guided by the latest ESPEN/ERAS guidelines, may minimize burdens while preserving nutritional benefits. Multicenter trials are warranted for tailored strategies.

Objective: To establish a lymph node yield (LNY) change-point associated with improvements in overall survival (OS) and disease-free survival (DFS) in patients undergoing esophagectomy following neoadjuvant treatment for esophageal adenocarcinoma. Secondary endpoints include recurrence patterns and survival based on pathological staging. Summary Background Data: LNY has been associated with improved outcomes in esophageal cancer. The extent of lymphadenectomy following neoadjuvant treatment remains unclear. Methods: This multicenter European study included patients undergoing chemotherapy (CT) or chemoradiotherapy (CRT) followed by esophagectomy between 2018 and 2023. RA-CUSUM analysis identified change points between LNY and survival. Bootstrap resampling determined the optimal LNY, and multivariable Cox proportional hazards models analyzed LNY as continuous and categorical variables. A post hoc exploratory subgroup analysis was conducted in CT patients with optimal LNY compared with CRT irrespective of LNY. Recurrence patterns were assessed using the Fisher exact test. Results: A total of 2069 patients were included: 957 CT versus 1112 CRT. Median LNY was 32. CT data set: an optimal threshold of 25 nodes was identified (95% CI: 20–39). Categorical analysis using ≥25 nodes demonstrated 29% mortality reduction (HR: 0.714, P =0.0017). CRT data set: no significant LNY association across any endpoint. Continuous LNY showed a null effect ( P =0.633), and categorical analysis showed no benefit ( P =0.66). CT with ≥25 LNY had ∼44% lower mortality compared with CRT after adjustment for potential confounding variables (HR=0.563, P <0.001). Each positive LN increased the hazard for death by 7.3% in CT and 11.2% in CRT. Disease recurrence occurred in 32.7% of CT versus 38.3% of CRT ( P =0.001). Conclusion: On the basis of this data, there is a clear survival and recurrence benefit to performing a radical lymphadenectomy with a lymph node harvest of at least 25 nodes in patients who have received CT.

Importance:Pathological complete response (pCR) following neoadjuvant therapy is associated with favorable prognosis in esophageal adenocarcinoma. However, whether long-term outcomes differ by neoadjuvant modality among patients achieving pCR remains uncertain. Objective:To compare survival outcomes and recurrence patterns in patients with esophageal or gastroesophageal junction adenocarcinoma achieving pCR after perioperative 5-fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy vs the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study protocol (CROSS). Design, Setting, and Participants:This cohort study was conducted at 14 high-volume European esophagogastric cancer centers between January 2018 and December 2024 with follow-up from surgery to death or last contact among patients with esophageal or junctional adenocarcinoma treated with neoadjuvant therapy followed by curative esophagectomy. Patients with squamous carcinoma, noncurative resection, incomplete pathological response, or 90-day mortality were excluded. Exposure:Neoadjuvant perioperative FLOT chemotherapy or CROSS chemoradiotherapy followed by curative-intent esophagectomy. Main Outcomes and Measures:The primary outcome was overall survival. Secondary outcomes included disease-free survival, recurrence patterns, and nodal stage-stratified survival. Survival was estimated using Kaplan-Meier methods and multivariable Cox proportional hazards models. Results:Among 2717 eligible patients, 297 achieved pCR and were analyzed (mean [SD] age, 64.4 [9.7] years; 256 [79.5%] men). Of these, 150 received CROSS and 147 FLOT. FLOT patients were younger and more frequently clinically node-positive at baseline, while postoperative outcomes were similar. On unadjusted analysis, FLOT was associated with better overall survival (hazard ratio [HR], 0.32; 95% CI, 0.17-0.60; P < .001) and disease-free survival (HR, 0.32; 95% CI, 0.19-0.55; P < .001). After adjustment, FLOT remained independently associated with better overall survival (HR, 0.34; 95% CI, 0.16-0.69; P = .003) and disease-free survival (HR, 0.35; 95% CI, 0.19-0.62; P < .001). Recurrence occurred in 13 of 147 patients receiving FLOT (8.8%) compared with 37 of 150 receiving CROSS (24.7%). Distant metastases predominated in the CROSS group (27 of 37 recurrences [70.3%]), whereas recurrence patterns were more heterogeneous after FLOT (locoregional, 2 of 13 recurrences [15.4%]; distant, 2 of 13 recurrences [38.5%]; both, 6 of 13 recurrences [30.8%]). The median (IQR) time to recurrence was longer after FLOT than CROSS (16.8 [12.3-21.5] vs 12.8 [7.1-26.7] months). In subgroup analyses, FLOT was associated with better survival in cN0 or 1 disease (HR, 0.32; 95% CI, 0.15-0.67; P = .002). Conclusions and Relevance:In this cohort study, perioperative FLOT in patients achieving pCR for esophageal adenocarcinoma was associated with superior survival, lower recurrence risk, and later recurrence compared with CROSS. These findings suggest the prognostic significance of pCR may vary by neoadjuvant modality and should be interpreted in the context of treatment strategy.

OBJECTIVE:To establish a lymph node yield (LNY) change-point associated with improvements in overall survival (OS) and disease-free survival (DFS) in patients undergoing esophagectomy following neoadjuvant treatment for esophageal adenocarcinoma. Secondary endpoints include recurrence patterns and survival based on pathological staging. SUMMARY BACKGROUND DATA:LNY has been associated with improved outcomes in esophageal cancer. The extent of lymphadenectomy following neoadjuvant treatment remains unclear. METHODS:This multicenter European study included patients undergoing chemotherapy (CT) or chemoradiotherapy (CRT) followed by esophagectomy between 2018 and 2023. RA-CUSUM analysis identified change points between LNY and survival. Bootstrap resampling determined the optimal LNY, and multivariable Cox proportional hazards models analyzed LNY as continuous and categorical variables. A post hoc exploratory subgroup analysis was conducted in CT patients with optimal LNY compared with CRT irrespective of LNY. Recurrence patterns were assessed using the Fisher exact test. RESULTS:A total of 2069 patients were included: 957 CT versus 1112 CRT. Median LNY was 32. CT data set: an optimal threshold of 25 nodes was identified (95% CI: 20-39). Categorical analysis using ≥25 nodes demonstrated 29% mortality reduction (HR: 0.714, P=0.0017). CRT data set: no significant LNY association across any endpoint. Continuous LNY showed a null effect (P=0.633), and categorical analysis showed no benefit (P=0.66). CT with ≥25 LNY had ∼44% lower mortality compared with CRT after adjustment for potential confounding variables (HR=0.563, P<0.001). Each positive LN increased the hazard for death by 7.3% in CT and 11.2% in CRT. Disease recurrence occurred in 32.7% of CT versus 38.3% of CRT (P=0.001). CONCLUSION:On the basis of this data, there is a clear survival and recurrence benefit to performing a radical lymphadenectomy with a lymph node harvest of at least 25 nodes in patients who have received CT.

OBJECTIVE:To determine the impact of severity of esophageal anastomotic leak (AL), standardized by ECCG grading, on long-term survival within a contemporary multicenter cohort. SUMMARY BACKGROUND DATA:Historical evidence suggesting AL is associated with increased recurrence and poor survival is limited by heterogeneous definitions and outdated management. This study utilizes the standardized ECCG definition to evaluate the prognostic significance of AL severity under modern perioperative protocols and endoscopic rescue strategies. METHODS:An international multicenter cohort across 17 high-volume European centers. Adult patients with esophageal or junctional cancer treated with neoadjuvant CROSS or FLOT, followed by esophagectomy were included (2018-2023). RESULTS:Out of 2905 patients, 425 (14.6%) developed an AL. AL was associated with a nearly two-fold increase in pulmonary complications (46.8% vs. 26.7%; P<0.001). AL requiring surgical reintervention (type III) was associated with an increased 30- and 90-days mortality rate (7.3% vs. 2.7% and 12.3% vs. 4%, P<0.001) and a significant reduction in median overall survival versus the no leak group (33.9 vs. 69.3; months P<0.001). After multivariable adjustment, type III AL was associated with a greater likelihood of death (HR 1.51; 95% CI: 1.04-2.18; P=0.029). A lower rate of adjuvant therapy administration (33.9% vs. 43.3%; P=0.004) was observe for AL patients. No significant survival deficits were observed for leaks treated conservatively or with no-surgical intervention. CONCLUSIONS:AL requiring surgical reintervention was associated with impaired survival. This relationship identifies a high-risk clinical profile and represents a critical target for future research into strategies for clinical stabilization and risk mitigation.

BACKGROUND Esophageal atresia is a rare congenital condition requiring surgery. In long gap esophageal atresia (LGEA) a primary anastomosis is not possible. The preferred alternative is mainly depending on the centers expertise. In our hospital esophagocoloplasty preceded by esophagostomy and gastrostomy has been used as first choice. Little data is available on very long-term results. The aim is to share the very long-term follow-up on esophagocoloplasty for LGEA. METHODS Data of patients undergoing esophagocoloplasty for LGEA in our center (07/1981-10/2006) were reviewed. A questionnaire containing disease related quality of life questions was sent and already completed by a number of patients as part of a previous study from 1996. RESULTS Twenty-nine esophagocoloplasties for LGEA were performed, without peri-operative mortality. Surgical reintervention for dysphagia was necessary in 28% and endoscopic dilation in 62% (median number of dilations: three). Twenty-three (88%) of the surviving patients completed the questionnaire (mean follow-up = 31 ± 6,6 years). Sixty-five percent can eat a normal bread meal without deglutition problems. A wide spectrum of various symptoms with differing intensity was reported, with difficulties in deglutition and regurgitation being most common. Mean satisfaction score was 8,25 ±1,1 on 10. Comparison with the 1996 questionnaire revealed no functional deterioration over time. CONCLUSIONS This study with over 30-year follow-up after esophagocoloplasty demonstrates a long lasting and stable, high degree quality of life, despite the relatively frequent need for reinterventions. In the search for the optimal solution, this technique remains a valid option for LGEA patients.

Background:Two neoadjuvant treatment strategies exist for esophageal and gastro-esophageal junction (GEJ) adenocarcinoma: Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) chemoradiotherapy or peri-operative FLOT chemotherapy (5-fluorouracil, leucovorin, oxaliplatin, docetaxel). ESOPEC showed improved overall survival (OS) after FLOT. This study aimed to reassess OS after perioperative FLOT and surgery in real-life. Methods:This single center retrospective cohort study included all patients with locally advanced esophageal or GEJ adenocarcinoma (cT1/2N+ or cT3/4N0/+) treated with intended perioperative FLOT and surgery between 2017 and 2023. Primary endpoint was OS. Results:One-hundred forty-four patients were included with mostly high T-stages [cT3 (n=120, 83.3%), cT4 (n=14, 9.7%)] and node-positive tumors [cN1 (n=37, 25.7%), cN2 (n=60, 41.7%), cN3 (n=19, 13.2%)]. Nineteen patients (13.2%) didn't proceed to surgery (PRE), and 19 patients (15.2%) did not receive any postoperative FLOT (PRE-SURG). Finally, 96 (76.8%) started postoperative FLOT (PRE-SURG-POST). Median OS was 53.3 months and after stratification 12.9 months [95% confidence interval (CI): 11.1-14.7] for PRE and 13.0 months (95% CI: 5.6-20.5) for PRE-SURG. Median OS for PRE-SURG-POST was not reached but significantly higher (P<0.001). Median event-free survival (EFS) was 29.6 months for PRE-SURG-POST, compared with 12.4 months (95% CI: 8.8-15.9) for PRE-SURG (P=0.06) and 7.7 months (95% CI: 1.0-14.4) for PRE (P<0.0001). Conclusions:Our results, with predominantly advanced and node positive tumors, corroborate the OS and EFS of perioperative FLOT with surgery observed in the FLOT-4 and ESOPEC-trial. Completion of treatment was associated with improved OS and EFS. This emphasizes the importance of patient selection, high-quality surgery and supportive care to maximize treatment continuation and increasing survival.

Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Background Delayed gastric conduit emptying (DGCE) following esophagectomy with gastric reconstruction is frequent. Although the Konradsson score was developed to standardize the diagnosis of DGCE, its validity and clinical utility remain insufficiently established. This study aimed to evaluate the Konradsson score’s diagnostic performance and to assess its relationship with therapeutic interventions. Methods A retrospective, single-center, observational study included patients who underwent esophagectomy with gastric conduit reconstruction between March 2023 and December 2024. DGCE symptoms were assessed using the Konradsson questionnaire at postoperative day 14, day 22 and at three months. The five key symptoms were early satiety, vomiting, nausea, regurgitation, and inability to meet caloric needs; each graded from 0 to 3 (total score from 0 to 15). A cut-off score of ≥4 could be derived for the diagnosis and severity grading of late DGCE (at least 2 out of 5 symptoms must reach a score ≥ 2). Early DGCE was defined based on nasogastric tube output and chest X-ray while late DGCE was defined as a positive Konradsson score combined with an objective need for treatment. Associations between Konradsson scores, DGCE diagnoses and therapeutic interventions (prokinetics and pyloric dilatations) were analyzed using correlation analyses, chi-square tests, logistic regression and ROC analyses. Results Out of 163 cancer patients who underwent esophagectomy with gastric reconstruction, 102 patients completed at least one questionnaire. Early DGCE occurred in 31.4% of patients, while late DGCE was diagnosed in 27.5% at least once during follow-up. Patients with an intrathoracic anastomosis (OR = 0.051; 95%CI 0.017-0.154) and those undergoing open surgery (OR = 0.051; 95%CI 0.017-0.154) showed a lower likelihood of early DGCE compared with those with a cervical anastomosis and those undergoing minimal invasive surgery. Conversely, there was no association between anastomotic location or surgical approach and late DGCE. Early DGCE did not predict late DGCE at any time point. ROC analyses demonstrated a reasonable discriminative performance for late DGCE (AUC 0.739–0.890), but with an optimal cut-off value closer to 5.5 rather than the proposed threshold of 4. Konradsson scores showed no significant association with the use of prokinetic medication or pyloric dilatation at any time point. Conclusion The Konradsson score demonstrated moderate diagnostic discrimination and showed limited clinical utility as a guide for therapeutic decision-making. Early DGCE did not reliably predict late DGCE. Refinement of the scoring system together with the integration of a pathophysiological classification and a standardized manner of imaging may be required to improve the diagnosis and management of DGCE.

BACKGROUND:Our publication Across the CROSS in daily practice challenged the routine use of neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal adenocarcinoma, showing a comparable 5-year overall survival after primary surgery. Disease-free survival, however, did show a tendency towards higher recurrence rates in the primary surgery group, although not reaching statistical significance. This current study aims to differentiate recurrence patterns and its final impact on overall survival. METHODS:This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT1/2N+ or cT3/4N0/+). Exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. Primary end point was time to recurrence. RESULTS:One hundred and forty-nine propensity score-matched cases were defined in each group. Primary surgery resulted in more recurrences (73.2% vs. 57.0%, p = 0.003). However, nCRT resulted in a shorter time to overall recurrence (6.3 vs. 11.5 months, p = 0.004) and locoregional recurrence (6.3 vs. 13.6 months, p = 0.005). Additionally, overall survival after diagnosis of recurrence was significantly shorter for nCRT than for primary surgery (6.9 vs. 9.6 months, p = 0.03). CONCLUSION:Our propensity score-matched results indicate that both overall and locoregional recurrences occur significantly earlier in nCRT patients and overall survival after recurrence is significantly shorter after nCRT. These findings might explain the comparable 5-year overall and disease-free survival of both groups.Abbreviations: CROSS: trial chemoradiotherapy for oesophageal cancer followed by surgery study; CT scan: computed tomography scan; HR: hazard ratio; nCRT: neoadjuvant chemoradiotherapy.

Brain metastases following esophagectomy for cancer are rare but can greatly affect quality of life. To date, risk factors for, time to development of, and treatment strategies for brain metastasis are not well defined. Consecutive patients treated with esophagectomy for clinical stage I–IVA esophageal cancer from 2010 to 2021 across five centers were included. Logistic regression analyses were performed to identify risk factors for development of solitary brain metastases. Overall survival was assessed using Kaplan–Meier analysis. Of 3191 included patients, 91 (2.9

BACKGROUND:Boerhaave syndrome is defined as a spontaneous perforation of the oesophagus. The mainstay of treatment is resuscitation of the patient, closure of the oesophageal defect, and drainage of perioesophageal and pleural fluid collections. Whether the optimal approach is endoscopic, surgical, or conservative management remains unknown and there are no clear guidelines. The aim of this multicentre retrospective cohort study was to evaluate current treatment strategies and outcomes for Boerhaave syndrome. METHODS:A multicentre retrospective analysis of data from 23 participating European tertiary centres was performed. Patients with Boerhaave syndrome treated between January 2019 and December 2023 were eligible for inclusion. The primary endpoint was the length of ICU stay and secondary endpoints included in-hospital mortality, 90-day mortality, and the length of overall hospital stay. RESULTS:In total, 216 patients were included; 151 were men (70%), the median age was 62 (22-95) years, and 81 (40%) were treated >24 h after the start of symptoms. Seventy (32%) patients were managed endoscopically (group I), 73 (34%) were managed surgically (group II), 67 (31%) were managed using a combination of endoscopy and surgery (group III), and 6 (3%) were managed using other methods (group IV). For patients in groups I-III: the median length of ICU stay was 8 (0-67) days, with no differences between the three groups (P = 0.105); the in-hospital mortality rate and 90-day mortality rate were both 12% (P = 0.490 and P = 0.637, respectively); and the median length of overall hospital stay was 27 (range 1-193) days, with the longest stays observed in patients who received combined treatment (P = 0.032). CONCLUSION:This study provides a comprehensive overview of the current treatment strategies and outcomes for patients with Boerhaave syndrome in Europe.

Patient satisfaction during hospitalization for esophagectomy has been little studied. The aim of this study was to evaluate patients' satisfaction with a newly introduced enhanced recovery protocol (ERP) for esophagectomy. At hospital discharge, patients were invited to complete a questionnaire. This pseudonymized questionnaire contained 5-point Likert scales regarding items on multidisciplinary care (n = 7), information/communication (n = 7), length of stay (n = 1), and specific adaptations of care in the ERP (n = 11). One open question asked for patient experiences and suggestions for improving the ERP. Between May 2017 and December 2021, 521 patients were included in the ERP after esophagectomy. Of them, 327 patients (63%) completed the questionnaire. Response rates were evenly distributed between genders and slightly higher in younger patients (<60 years; 68%) as compared to elderly patients (>70 years; 60%). Quantitative analysis revealed high satisfaction rates for multidisciplinary care (86.8%), information/communication (84.9%), and ERP adaptations (82.2%), and length of stay was considered optimal in 80%. There were no significant differences in satisfaction observed between gender nor age groups. For the qualitative analysis, there were 108 open answers, resulting in 268 statements. Sentiments expressed in these statements were evaluated as negative, positive, or unspecified. Negative sentiments were attributable to alimentation, organizational factors, and communication. Positive sentiments were attributed to interpersonal relations, multidisciplinary care, and ERP. Overall, patients are very satisfied with the ERP for esophagectomy during hospitalization. By incorporating qualitative data, the results of this quantitative analysis are expanded and elucidated, showing areas where improvements to our ERP are possible to increase patient satisfaction.

Approximately 10–12% of patients with oesophageal or gastric cancer (OGC) present with oligometastatic disease at diagnosis. It remains unclear if there is a role for radical surgery in these patients. We aimed to assess the outcomes of OGC patients who underwent simultaneous treatment for the primary tumour and synchronous liver metastases. Patients with OGC who underwent surgical treatment between 2008 and 2020 for the primary tumour and up to five synchronous liver metastases aiming for complete tumour removal or ablation (i.e., no residual tumour) were identified from four institutional databases. The primary outcome was overall survival (OS), calculated with the Kaplan–Meier method. Secondary outcomes were disease-free survival and postoperative outcomes. Thirty-one patients were included, with complete follow-up data for 30 patients. Twenty-six patients (84%) received neoadjuvant therapy followed by response evaluation. Median OS was 21 months [IQR 9–36] with 2- and 5-year survival rates of 43% and 30%, respectively. While disease recurred in 80% of patients (20 of 25 patients) after radical resection, patients with a solitary liver metastasis had a median OS of 34 months. The number of liver metastases was a prognostic factor for OS (solitary metastasis aHR 0.330; p-value = 0.025). Thirty-day mortality was zero and complications occurred in 55% of patients. Long-term survival can be achieved in well-selected patients who undergo surgical resection of the primary tumour and local treatment of synchronous liver metastases. In particular, patients with a solitary liver metastasis seem to have a favourable prognosis.

Enhanced Recovery Programs (ERPs) have revolutionized thoracic surgery by reducing hospital stays and fostering quicker patient recoveries through minimally invasive procedures. However, the perception that patients in ERPs are less complex and require fewer nursing resources is misleading. Despite shorter hospital stays, the complexity of postoperative care remains high, with patients often needing vigilant monitoring and timely interventions. This article challenges the assumption of reduced nursing needs in ERPs, arguing that the fast-paced nature of these programmes intensifies the demand for skilled nursing care. The European Society of Thoracic Surgeons (ESTS) Nurses & Allied Health Professionals Working Group emphasizes that nurse staffing levels must be maintained or even increased to ensure quality care in ERPs. Adequate staffing is crucial for supporting not only the technical aspects of care but also the patient's experience of illness and recovery. Failure to recognize this complexity could compromise patient outcomes, eroding the benefits of ERPs. This paper advocates for a comprehensive approach that balances efficiency with sufficient nursing support to optimize outcomes in thoracic surgery ERPs. It calls for a reassessment of staffing models to meet the evolving demands of these programmes, ensuring that the advantages of shorter recovery times are not undermined by insufficient care.

Abstract Background Minimally invasive esophagectomy (MIE) has demonstrated improved outcomes for fit patients with esophageal/gastro-esophageal junction tumors. However, challenges arise in patients less tolerant of prolonged anesthesia or harboring extensive advanced-stage tumors, which limit the utilization of MIE, increasing the risk of referral to nonsurgical strategies. To date, the criteria for considering left thoraco-abdominal esophagectomy (TAE) and the corresponding outcomes in this specific patient population remain unclear. Therefore, our institutional study aimed to identify clinical characteristics for the consideration of TAE, offering insights into treatment selection strategies for esophageal cancer patients. Additionally, we compared the short-term outcomes between TAE and MIE. Methods We included all consecutive patients who underwent esophagectomy with gastric conduit reconstruction for stage I-IVa esophageal and gastro-esophageal junction tumors at a tertiary referral center from 2015 to 2023. Predictors for considering TAE were identified through a multivariable regression model utilizing multivariate imputation by chain equation for missing data of pulmonary and cardiac function, using the predicted mean matching method. Significant variables were used to develop a stratification model, evaluated through the receiver-operating curve. Differences in outcome were assessed using the Kruskal-Wallis rank sum for continuous and Pearson’s chi-squared or Fischer’s exact test for categorical variables. Results This study included 744 patients; 317 (43%) underwent TAE and 427 (57%) had MIE. Patient characteristics were significantly different. Following multivariable analysis, age (1.04 [1.02-1.06]; p<0.001), ECOG-status (1.43 [1.09-1.87]; p=0.009), comorbidity index (1.26 [1.10-1.46]; p<0.001), DLCO (0.98 [0.97-0.99]; p<0.001), ejection fraction (0.97 [0.94-1.00]; p=0.021), tumor location (GEJ: 1.58 [1.10-2.27], Middle: 0.38 [0.18-0.79]; p<0.001), cStage (II: 2.03 [1.02-4.19], III: 3.29 [1.78-6.33], IVa: 3.42 [1.74-6.97]; p<0.001) and adenocarcinoma (2.44 [1.39-4.55]; p=0.002) were identified as predictors for TAE. The stratification model demonstrated an area-under-the-curve of 0.76 [0.73-0.80]. Leave-one-out-cross-validation demonstrated a 70% accuracy. The short-term outcomes were comparable between TAE and MIE (Table 1). Conclusion Our study demonstrated that age, ECOG status, comorbidity index, diffusion capacity, ejection fraction, tumor location, stage and histology were independent predictors for the consideration of thoraco-abdominal esophagectomy. In this context, our stratification model demonstrated a robust predictive value. Moreover, our model suggests considering MIE below a probability threshold of 30% and TAE above 60%, demonstrating an 85% sensitivity and 90% specificity at these thresholds, respectively. Decisions within the 30% to 60% range should be individualized and based on specific patient and tumor characteristics. Short-term outcomes were comparable between TAE and MIE, emphasizing the significance of adequate stratification before surgery.

Abstract Background Transthoracic open procedure (TTO) was historically the preferred approach for treatment of giant hiatal hernias. However, the last decades transabdominal laparoscopic procedures (TAL) became the standard approach in many centres. The aim of the study was to compare short-term and midterm outcomes, as well as patient-reported outcome measures (PROMs, between TTO and TAL for giant hiatal hernias. Methods A retrospective analysis was conducted on all primary surgeries performed for giant hiatal hernias between 2008 and 2022. Patients who underwent TAL were propensity-matched (n= 36) to those who underwent TTO based on: age, gender, Charlson Comorbidity Score and hernia type. The two groups were compared in terms of surgery duration, length of stay (LOS), Clavien-Dindo score, intrahospital reoperation, hernia recurrence and need for reinterventions. PROMswere compared between total of TTO (n= 187) and TAL (n= 48): for symptom score, QoL-score, overall satisfaction and wound pain. Median clinical follow-up was 365.5 days. Median PROMsfollow-up was 55.3 months. Results Surgery duration (224 vs 177min, P<0.001) and LOS (11 vs 4days, P<0.001) were longer in TTO. Clavien-Dindo scores were alike (P= 0.260). Intrahospital reoperation was not statistically different (8.3% vs 0%, P= 0.239). Midterm recurrence rates suggested a non-significant trend towards lower recurrence in TTO (2.8% vs 16.7%, P= 0.107). Reintervention rates were alike (16.7% vs 11.1%, P= 0.735). QoL-score was inferior for TTO (0.705 vs 0.355, P= 0.036). Wound pain scores were higher in TTO (1 vs 0, P <0.001). Symptom score and satisfaction scores were alike, respectively 0.685 vs 0.760, P= 0.688 and 9 vs 9, P= 0.421. Conclusions TAL for giant hiatal hernias showed superior results compared to TTO for duration of surgery, length of hospital stay, QoL-score and wound pain scores. However, midterm results showed a noticeable trend towards higher recurrence rates for TAL. TAL should be considered when proceeding with surgery for giant hiatal hernias but a possible higher risk of recurrence must be taken into account. Further long-term clinical follow-up and comparison to PROMscould guide future decision-making.

Anastomotic leakage after esophagectomy is one of the most feared complications, which results in increased morbidity and mortality. Our aim was to evaluate the impact of a powered circular stapler on complications after esophagectomy with intrathoracic anastomosis for esophageal cancer. Between May 2019 and July 2021, all consecutive oesophagectomies for cancer with intrathoracic anastomosis in a high-volume center were included in this retrospective study. Surgeons were free to choose either a manual or a powered circular stapler. Preoperative characteristics and postoperative complications were recorded in a prospective database, according to EsoData. Propensity score matching (age, body mass index, Eastern cooperative oncology group (ECOG) performance and neoadjuvant therapy) was conducted to reduce potential confounding. We included 128 patients. Powered and manual circular staplers were used in 62 and 66 patients, respectively. Fewer anastomotic leakages were observed with the powered stapler group (OR = 7.3 (95%CI: 1.58-33.7); [3.2% (n = 2) vs 19.7% (n = 13), respectively; p = 0.004]). After propensity score matching, this remained statistically significant (OR = 8.5 (95%CI: 1.80-40.1); [4.1% (n = 2) vs 20.4% (n = 10), respectively; p = 0.013]). Additionally, anastomotic diameter was significantly higher with the powered stapler (median: 29 mm (63.3%) vs 25 mm (57.1%), respectively; p < 0.0001). There was no significant difference in comprehensive complication index (p = 0.146). A decreased mean length of stay was observed in the powered stapler group (11.1 vs 18.7 days respectively; p = 0.022). Postoperative anastomotic leakage after esophageal resection was significantly reduced after the introduction of the powered circular stapler, consequently resulting in a reduced length of stay. Further evaluation on long-term strictures and quality of life are warranted to support these results.

Background The current gold standard for treatment of locally advanced esophageal adenocarcinoma is neoadjuvant chemotherapy or chemoradiotherapy followed by surgery. The shift toward neoadjuvant chemoradiotherapy (nCRT) was driven by the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial. This study reassessed, in daily practice, the presumed advantage of nCRT followed by surgery on long-term survival compared with primary surgery, in a group of all adenocarcinomas treated through a transthoracic approach with extensive 2-field lymphadenectomy. Methods This retrospective cohort study with propensity score-matched analysis included all surgically treated patients between 2000 and 2018 with locally advanced adenocarcinoma (cT1/2 N+ or cT3/4 N0/+). For appropriate comparison, exclusion criteria of the CROSS trial were applied. Patients were matched on age, Charlson comorbidity score, clinical tumor length, and lymph node status. The primary end point was 5-year overall survival. Results There were 473 eligible patients who underwent primary surgery (225 patients) or nCRT + surgery (248 patients). After propensity score-matched analysis, 149 matched cases were defined in each group for analysis. There was no significant difference after 5 years between the matched groups in median overall survival (32.5 and 35.0 months, P = .41) and median disease-free survival (14.3 and 13.5 months, P = .16). nCRT was associated with significantly more postoperative complications (mean Comprehensive Complication Index score: 21.0 vs 30.5, P < .0001) and longer mean stay in the hospital (14.0 vs 18.2 days, P = .05) and intensive care unit (11.7 vs 37.7 days, P = .05). Conclusions Our propensity score-matched results indicate that primary surgery, performed through transthoracic approach with extensive 2-field lymphadenectomy, can offer a comparable overall and disease-free survival after 5 years, with potentially fewer postoperative complications and shorter hospital and intensive care unit stay compared with nCRT followed by surgery.

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