Diseases of the Esophagus最新文献

Pneumonia is common following transthoracic esophagectomy (TTE). The diagnosis in the early postoperative period is partly subjective' and may vary among clinicians, with sensitivity reduced by post-operative inflammatory changes and altered thoracic anatomy. Despite its clinical importance, inter-observer agreement in diagnosing post-esophagectomy pneumonia has not been systematically evaluated. This retrospective study evaluated inter-observer variability among four senior specialists (surgeon, radiologist, intensivist, and pulmonologist) in diagnosing pneumonia from chest radiographs of 200 consecutive TTE patients. Using a web-based platform, blinded reviewers independently assessed anonymized chest radiographs from post-operative days 3 and 7 using a three-class scale (yes/no/maybe). When 'maybe' was selected, standardized clinical data (vital signs at 23:00 hours) were automatically provided. Cohen's kappa coefficient quantified pairwise agreement, while Fleiss' kappa assessed overall concordance. Of the 200 patients, pneumonia was documented in 54 (27%) per American Thoracic Society (ATS) criteria. Initial radiographic assessment showed fair inter-observer agreement (κ = 0.207-0.230) compared to the radiologist reference. Diagnostic uncertainty ('maybe' responses) occurred in 307/1600 assessments (19.2%), varying significantly by specialty: surgeon, 41.5%; radiologist, 22.0%; intensivist, 13.0%; pulmonologist, 14.0% (P < 0.001). After clinical correlation, agreement improved modestly: surgeon κ = 0.334, intensivist κ = 0.398, pulmonologist κ = 0.356 (all P < 0.001), but remained in the 'fair' range. Overall multi-rater agreement (Fleiss' κ) improved from 0.270 to 0.421 (+56% improvement, P < 0.001), transitioning from fair to moderate agreement. When clinical data points were made available for equivocal cases, 124 responders (40.4%) changed their initial assessment from 'maybe' to 'yes', indicating a preference for therapy, while 89 (29.0%) changed their unsure response to 'no'. Considerable inter-observer variability in pneumonia diagnosis after TTE exists, with 'fair' interrater agreement in documenting radiologic pneumonia, and 'poor' consistency in determining antibiotic use according to the ATS criteria. Current pneumonia diagnostic criteria are fundamentally limited by poor radiographic inter-observer agreement, indicating the timely need for standardization of definition terminology and supports the development of integrated diagnostic protocols.

In Western Europe, esophageal cancer patients with cervical lymph node metastases are considered to have stage IV disease and are generally not eligible for curative treatment. While cervical ultrasound was part of standard diagnostic workup, its added value after negative 18FDG PET-CT is debated, and ultrasound is no longer in the Dutch guideline as standard workup modality. This study assessed the diagnostic accuracy of ultrasound for the detection of cervical lymph node metastases in esophageal cancer patients. This retrospective cohort study included all esophageal cancer patients referred to or diagnosed at the Amsterdam UMC between January 2014 and January 2021. Radiology and multidisciplinary team meeting reports were reviewed to identify patients with suspicious cervical lymph node(s). Primary outcome was the detection rate of cervical lymph node metastases on ultrasound and/or 18FDG PET-CT. The gold standard was fine needle aspiration. This study included 747 patients; median age was 67 years. Patients were predominantly male (75.5%) and majority had an adenocarcinoma (72.0%). Total of 112 (15.0%) patients had suspicious cervical lymph nodes, with malignancy confirmed in 38 cases. Cervical ultrasound showed high sensitivity (94.7%), but low positive predictive value (37.1%) compared to 18FDG PET-CT, which had 100% sensitivity, 91.3% specificity, and 71.7% PPV. This study demonstrated that cervical ultrasound offers no additional diagnostic value over 18FDG PET-CT alone in the assessment of cervical lymph node metastases during diagnostic workup for esophageal cancer and increases the number of fine needle aspirations conducted for benign cervical lymph nodes.

Patients with eosinophilic esophagitis (EoE) in remission require monitoring, but optimal timing for endoscopic assessment is unknown. We aimed to assess variability in time from remission to surveillance endoscopy and associations with disease outcomes. This retrospective cohort study included patients with EoE who achieved histologic remission (<15 eos/hpf) while on stable treatment and had at least one surveillance endoscopy with biopsy after remission. Time to surveillance was categorized (≤1 year, 1-2 years, >2 years) and compared to a range of EoE clinicopathologic characteristics and disease outcomes. The 91-patient cohort had substantial variability in time to first surveillance endoscopy (mean 1.3 ± 1.0 years; median/IQR 1.0/0.6-1.8; range 0.2-7.3). While most patient characteristics were not associated with time to surveillance, larger dilation size at remission correlated with longer surveillance intervals (R = 0.36, p = 0.03), and EoE Endoscopic Reference Score (EREFS) was inversely associated (R = -0.21, p = 0.07). Outcomes of EREFS, Index of Severity of EoE, and eosinophil count were similar for <1, 1-2, or 2+ years surveillance intervals. However, numerically fewer patients with endoscopy 2+ years after remission maintained histologic response (59% vs. 78% at ≤1 year and 82% at 1-2 years; p = 0.15) and had more ongoing EoE symptoms (47% vs. 34% at ≤1 year and 24% at 1-2 years; p = 0.26). Surveillance timing in EoE remission varies widely and is largely unexplained by clinical features, except for dilation size. While outcomes were similar across intervals, patients with longer surveillance (>2 years) had numerically less histologic response and more persistent symptoms, warranting further study.

Interobserver agreement for the Los Angeles (LA) classification of erosive reflux esophagitis was good in validation studies, but limited agreement data exists from clinical trials (CTs). We conducted a post hoc evaluation of interobserver agreement between CT endoscopists and independent expert adjudicators in a multi-center, randomized controlled trial of a new acid suppression therapy. Trial endoscopists captured endoscopic images/videos and documented esophagitis severity using the LA classification. Adjudicators reviewed images/videos on a web-based platform. If the first two adjudicators disagreed and the third adjudicator did not produce a majority verdict, all three conferred to reach consensus. Cohen's kappa (κ) evaluated interobserver agreement. Cohen's weighted kappa (κw) evaluated agreement corrected for disagreement extent. Of 388 images/videos with adequate quality, trial endoscopists and adjudicators agreed on esophagitis severity in 168 (43.3%) cases, and assigned more severe grades than adjudicators for 185 (47.7%) cases. Agreement was fair between trial endoscopists and adjudicators (κ: 0.27; κw: 0.40), moderate between individual adjudicators (κ: 0.43 to 0.47), and good between adjudicators and final diagnosis (κ: 0.75 to 0.78). After adjusting for disagreement extent, agreement was good between individual adjudicators (κw: 0.63 to 0.66), and very good between adjudicators and final diagnosis (κw: 0.84 to 0.87). Interobserver agreement on esophagitis severity between CT endoscopists and adjudicators was fair. Initial agreement between adjudicators was moderate, but agreement between adjudicators and consensus diagnosis was very good. Accurate esophagitis grading for CTs requires further training on LA classification and a robust central reading protocol.

Gastroesophageal reflux disease (GERD) is driven by anti-reflux barrier (ARB) disruption, requiring precise endoscopic tools to guide diagnosis and management. The Hill classification, based solely on flap valve (FV), lacks precision. The American Foregut Society (AFS) classification, integrating hiatal hernia length (L), hiatal opening diameter (D), and FV (F), offers a comprehensive approach to phenotype esophago-gastric junction (EGJ) dysfunction. This study aims to assess the superiority of the AFS classification over the Hill and to weight the single AFS components contribution. A retrospective analysis of adult patients evaluated with upper-GI endoscopy (EGD), high-resolution manometry, and reflux monitoring study for GERD symptoms at our Institution (2022-2025) was performed. GERD was defined by Lyon 2.0 criteria. EGJ was graded using AFS and Hill classifications. GERD prevalence was compared across AFS and Hill grades and by the number of disrupted AFS components. Logistic regression assessed individual AFS component contributions. Of 249 patients (median age 52 years, 47% male, BMI 23.9 kg/m2), 127 had GERD. At least one AFS component was disrupted in 71.9% of the patients. GERD prevalence differed significantly across AFS grades 1-2 vs. 3 and 3 vs. 4, unlike Hill grades, where 2 and 3 overlapped. Patients with 1 and 2 impaired components were significantly different from those with 3 and 4. Pathologic D (OR = 2.537) and F (OR = 3.336) were independent GERD predictors. ROC analysis confirmed AFS superiority over Hill (AUC 0.750 vs. 0.653, P < 0.001). The AFS classification enhances EGD diagnostic yield, outperforming Hill in EGJ phenotyping. The AFS improves patient stratification for pathophysiological testing and tailored therapies, offering a practical tool for GERD management.

The use of a colonic interposition after major esophageal surgery leads to substantial anatomical changes, but information regarding the effects of these changes on functional outcomes is limited. Objective of this study was to evaluate the presence of gastrointestinal symptoms, nutritional aspects, intestinal absorption capacity, and health-related quality of life (HR-QoL) in adult patients after colon interposition. This single-center study consisted of three parts. Part 1 involved a retrospective review of anthropometric data, dietary patterns, and gastrointestinal symptoms in all consecutive patients who underwent colonic interposition between 2010 and 2021 and in whom at least 6 months of follow-up were available. Patients from part 1 who were still alive in 2021 were invited for an in-depth evaluation of dietary intake and intestinal absorption capacity. This included measuring daily fecal losses of energy (kcal), fat (g), and protein (g) over a 72-hour period. The coefficients of fat and protein absorption (CFA and CNA) were calculated. Energy balance (kcal/day) was determined by subtracting fecal energy loss (kcal/day) and daily estimated total energy expenditure (eTEE) from the dietary energy intake (kcal/day). Part 3 assessed HR-QoL prospectively using the EORTC QLQ-C30 and OG-25 questionnaires. All consecutive patients presenting to the outpatient clinic between 2014 and 2021 were asked to complete these questionnaires. In part 1 of this study, 30 patients were included. Symptoms of steatorrhea/diarrhea (65%) and dysphagia (42%) were most frequently reported, and 31% could not cease enteral nutrition via jejunostomy or nasal tube due to weight loss or gastrointestinal symptoms. Ten patients were included in part 2 of this study. Intestinal malabsorption of fat and protein (CFA and CNA <85%) was found in 70% of patients, and 60% of patients had a negative energy balance. HR-QoL was measured in 20 patients. Median global QoL score (EORTC QLQ-C30) was 63 (IQR 50-83) and the OG-25 symptom score 19 (IQR 6.9-36). In conclusion a colonic interposition after esophagectomy is accompanied by gastrointestinal symptoms, intestinal malabsorption, and an impaired QoL. Adequate counseling of patients and follow-up with a multidisciplinary approach to treat gastrointestinal symptoms and correct for intestinal malabsorption is recommended.

To compare survival outcomes and safety between concurrent chemoradiotherapy (CCRT) and CCRT with concurrent immune checkpoint inhibitor (ICI) in patients with locally advanced esophageal squamous cell carcinoma. This multicenter cohort study enrolled consecutive patients treated between January 2010 and April 2024. Patients were stratified into two groups: CCRT and CCRT+ICI. Of 290 eligible patients, 64 received CCRT+ICI and 226 received CCRT. CCRT followed by ICI maintenance therapy improved disease-free survival compared to CCRT+ICI (hazard ratio [HR] = 2.33, 95% CI: 1.04-5.24; P = 0.040), although it did not improve overall survival (HR = 1.12, 95% CI: 0.45-2.81; P = 0.804). Disease-free survival (HR = 1.25, 95% CI: 0.72-2.16; P = 0.428) and overall survival (HR = 0.94, 95% CI: 0.46-1.93; P = 0.861) were comparable between CCRT alone and CCRT+ICI groups. CCRT+ICI had a higher incidence of grade ≥ 3 leukopenia and neutropenia. Following CCRT, median lymphocyte counts decreased in both CCRT+ICI (1.30 versus 0.35) and CCRT (1.57 versus 0.30) groups. In contrast, monocyte counts increased in the CCRT+ICI group (0.33 versus 0.49), but remained stable in the CCRT group (0.50 versus 0.49). CCRT with concurrent ICI failed to improve survival in patients with locally advanced esophageal squamous cell carcinoma, potentially due to CCRT induced immunosuppression. In contrast, CCRT followed by ICI maintenance therapy showed promise in improving disease-free survival, suggesting that the timing of immunotherapy integration is critical for therapeutic efficacy.

Background: Anastomotic leak (AL) is a severe complication after esophagectomy. Guidelines for the management of AL are lacking. This study aimed to develop a consensus statement for managing AL after esophagectomy. A three-stage modified Delphi study was performed in collaboration with the International Society for Diseases of the Esophagus Guidelines Committee. In Stage 1, a scoping systematic review was performed to identify available literature used to formulate Delphi statements. Stage 2 involved a two-round Delphi survey, distributed globally to surgeons and gastroenterologists. Consensus was defined as ≥80% (strong) (dis)agreement on a Delphi statement. During Stage 3 (guideline development), an international expert panel formulated clinical recommendations based on Delphi consensus and assigned strength in line with Grading of Recommendations Assessment, Development, and Evaluation principles. A clinical care algorithm was developed based on these recommendations. Of 5.843 articles screened, 118 were included to form Delphi statements. The Delphi survey was completed by 106 respondents in the first round and 136 in the second. Based on Delphi consensus and expert panel discussions, 12 diagnostic recommendations were formulated, covering clinical signs, biochemical tests, and imaging strategies. 11 recommendations were formulated regarding treatment strategies, including indications and techniques for supportive care, drainage and defect closure. This led to the development of a clinical care algorithm. A consensus statement for the diagnosis and treatment of AL after esophagectomy was developed. This may aid clinicians in the diagnosis and management of AL and provide a tool for standardizing clinical practice with the aim to improve patient outcomes.

The exact mechanism of sarcopenic dysphagia following esophagectomy, which is associated with reduced pharyngeal contraction, remains unclear. This study measured the maximum pharyngeal constriction area normalized (MPCAn) as a potential indicator of post-esophagectomy sarcopenic dysphagia. Videofluoroscopic examination of swallowing study was conducted in 134 patients with suspected dysphagia following esophagectomy, defined as a score of ≥3 in the 8-point penetration-aspiration scale. The area under the receiver operating characteristic curve of MPCAn was applied to detect dysphagia in comparison with duration and distance of hyoid bone elevation and upper esophageal sphincter opening width. Cutoff MPCAn values were used to compare patient characteristics, including body composition and physical function. Multivariate analysis was employed to evaluate the association of MPCAn with postoperative pneumonia and recurrent laryngeal nerve paralysis (RLNP). MPCAn was an important predictor of dysphagia, compared to the three videofluoroscopic examination of swallowing study parameters (0.874 vs. 0.784, P = 0.006). MPCAn was an independent risk factor for dysphagia at a cutoff value of 14. The patients with a larger MPCAn (N = 58) had significantly lower body mass index and worse timed Up and Go test results than those with a smaller MPCAn (N = 76) (19.76 vs. 21.56 kg/m2, P = 0.021 and 7.25 vs. 5.85 s; P = 0.014, respectively). MPCAn was significantly associated with late-onset pneumonia (odds ratio 2.58, 95% 1.03-6.46; P = 0.044) and was the only significant risk factor for dysphagia in those without RLNP (odds ratio 35.90, 95% confidence interval 6.20-205; P < 0.001). MPCAn was a useful predictor of post-esophagectomy sarcopenic dysphagia, especially in patients without RLNP, and was significantly associated with late-onset pneumonia.

This study seeks to define baseline variation and clinical correlates of body composition in a large international cohort of patients undergoing esophagectomy for cancer. Patients who underwent esophagectomy in 14 high-volume centers between 2007 to 2019 were eligible for inclusion. Skeletal muscle, visceral and subcutaneous adipose tissues within computer tomography images (L3 axial image), acquired routinely at diagnosis, were analyzed in accordance with a standardized protocol. In total, 1716 patients were recruited from three global regions: North America (22%), Europe (55%), and Asia (23%). Patients were predominantly male (79.5%) and adenocarcinoma was the most common histological subtype (66.6%). Characteristics significantly associated with levels of muscle and adiposity were global region, sex, age, and histological subtype (P < 0.001). Compared to adenocarcinoma, squamous cell carcinoma was associated with significantly lower levels of muscle and adiposity, a finding that was independent of global region, sex, and age using a multivariable linear regression model (P < 0.001). Reduced skeletal muscle and an excess of total adiposity at diagnosis was associated with increased 90-day mortality and reduced long-term survival. A prediction model including skeletal muscle, total adiposity at diagnosis and other tumor and patient specific variables was constructed to allow convenient survival prediction. This study adopts a standardized method to define international variation in parameters of body composition in esophageal cancer patients. Findings provide clinically relevant information regarding operative mortality and overall survival and can inform future guidelines for the use of body composition assessment in routine clinical practice.