Diseases of the Esophagus最新文献

We aimed to evaluate the demographic, clinical, procedural, and histopathologic factors associated with stricture development following esophageal endoscopic submucosal dissection (ESD). We conducted a retrospective cohort study of patients undergoing ESD for esophageal lesions from 2019 to 2024 at St. Michael's Hospital, in Toronto, Canada. The primary outcome was stricture formation, defined as a symptomatic luminal narrowing at the ESD site confirmed on follow-up endoscopy, requiring intervention. Strictures requiring dilation developed in 24% of patients, 85% of which were impassable with a standard gastroscope (9.9 mm diameter). Stricture rates increased with defect circumferential involvement: <50% (7.7%), 50%-74% (11.5%), 75%-89% (23.1%), and ≥90% (57.7%). Intraprocedural local triamcinolone acetate (LTA) injection was administered in 40 of 108 patients (37%), with a mean defect circumferential size of 87.5%. Among patients receiving LTA, stricture rates varied based on defect size: for <50% circumferential defect involvement (n = 1) and 50%-74% (n = 3), no strictures developed; for 75%-90% (n = 17), 6 patients (35%) developed strictures, 5 of which were impassable; and for 90%-100% (n = 19), 11 patients (58%) developed strictures, all of which were impassable. Patients selectively discharged on prophylactic steroids demonstrated varied stricture rates depending on the steroid regimen: prednisone (61.5%), oral budesonide (26.9%), and combination therapy (7.7%). Independent predictors of stricture formation included defect circumferential involvement (OR 1.07, 95% CI 1.03-1.12, p < 0.001), length of hospitalization (OR 1.88, 95% CI 1.11-3.16, p = 0.018), and presence of deep mural injury (OR 6.28, 95% CI 1.10-35.88, p = 0.039). Stricture formation post-ESD is strongly associated with lesion and procedural characteristics, including defect circumferential involvement, deep mural injury, and length of hospitalization.

Known predictors of recurrence and survival include the total number of nodes and positive nodes resected, tumor stage, histology, and tumor differentiation. Patients with a complete response have the best survival, but residual tumor in the esophagus, nodes, or both may influence survival. This study assesses the risk of recurrence and survival of esophageal adenocarcinoma after trimodal therapy based upon the location residual disease in the resected specimen. Multicenter, retrospective study of patients with esophageal adenocarcinoma undergoing induction chemoradiation and transthoracic esophagectomy from 2010 to 2017. Overall survival (OS) and recurrence were compared based on the residual disease location using Kaplan-Meier analysis. Clinical factors associated with OS and time to recurrence were also assessed. There were 504 patients with a median follow-up of 63.4 months 95% confidence interval (CI):60.8-70.5 and an estimated overall 5-year survival of 55.8%. When subdivided by residual disease location, the estimated 5-year survival in patients with complete pathologic response and residual disease of only the esophagus was 68.3% and 65.0% hazard ratio (HR) = 1.05; P = 0.81. With increasing nodal positivity there was decreasing survival, 45.8% (N1) and 20.1% (N2). N3 patients did not survive past 36 months. Multivariable analysis demonstrates that any residual disease in the lymph nodes (HR = 3.14), taxane and fluoropyrimidine chemotherapy (HR = 3.34), neoadjuvant radiation dose <50 Gy (HR = 2.35), and fluoropyrimidine chemotherapy (HR = 1.88) were predictive of worse OS. Overall survival and recurrence are influenced by the location of residual disease. Residual disease in the esophagus and pathologic complete response behaves similarly. Survival is reduced as nodal counts increase.

High-resolution esophageal manometry (HRM) is the gold standard test for evaluation and diagnosis of esophageal motility disorders. While the Chicago Classification offers a standardized protocol for performing and interpreting HRM studies, it does not provide guidance on catheter placement techniques, nor the specific skillset required to conduct the test. At most centers nationally and globally, HRMs are performed by a trained nurse or medical technician. However, in selected centers, physicians perform HRMs alongside a clinical care assistant. Direct physician involvement in performing HRM offers unique clinical insights that can potentially enhance diagnostic accuracy, procedural efficiency, and patient experience. Based on our more than two-decade experience with physician-performed HRMs, we share various tips and techniques to provide step-by-step guidance on performing a high-quality HRM. In addition, we provide reflections from our experience on several benefits of physician-performed manometries including continued continuity of care, real-time interpretation with ability to perform adjunctive testing, and improved patient tolerance.

Transoral incisionless fundoplication (TIF) 2.0 using the EsophyX device is an increasingly recognized endoscopic treatment for symptomatic gastro-esophageal reflux disease (GORD). However, to date, there is no evidence on the learning curve for procedural efficiency and adoption into routine practice. In this UK-based, retrospective cohort study, we describe our single-operator learning curve and experience on procedural implementation following the introduction of TIF. Consecutive patients undergoing TIF were analyzed between 2019 and 2024. Patient demographics, baseline reflux assessments, and procedural details were recorded. The primary outcome was procedural efficiency and mastery based on a single operator learning curve using non-linear regression and CUSUM analysis. Secondary descriptive outcomes were technical success, change in clinical status, and adverse events. In total, 82 patients underwent TIF with a median age of 51 (IQR 37-64) and 28.1% were female. Technical success was 97.6% with an average procedure time of 48.9 minutes (SD 19.1). Procedural efficiency was achieved after 14 cases and mastery 35 cases. Among patients with ≥6-months follow-up (n = 58), 70.7% achieved a reduction in anti-acid therapy and/or quality of life score over 18.8 months (SD 9.9). Stratifying by our learning curve led to a non-significant improvement in symptoms at both procedural efficiency (n = 14; 64.3% vs 72.7%; P = 0.19) and mastery (n = 35; 62.9% vs 82.6%; P = 0.11). Adverse events were reported in 12.2% (6.1% AGREE grade IIIa). This study demonstrates the procedural learning curve required for efficiency and mastery of TIF2.0 and underscores the importance of collaboration between surgeons and endoscopists for successful service implementation.

Colonic interposition following esophageal resection remains challenging. Few studies have investigated the risk factors for postoperative complications and the prognostic factors in patients who underwent this type of surgery. We evaluated 83 patients who underwent esophagectomy with colonic interposition for esophageal and esophagogastric junction cancers. We analyzed factors associated with postoperative complications using logistic regression analysis and prognostic factors using Cox regression analysis. Postoperative complications occurred in 53.0% of patients, including anastomotic leakage in 22.9%, pneumonia in 19.3%, superficial surgical site infection in 7.2%, and deep surgical site infection in 7.2%. Preoperative malnutrition (odds ratio 5.31, 95% confidence interval 1.64-20.1, P = 0.005), synchronous gastrectomy (odds ratio 7.46, 95% confidence interval 2.15-31.5, P = .001), and upper (odds ratio 4.79, 95% confidence interval 1.05-25.1, P = .044) and middle (odds ratio 2.96, 95% confidence interval 1.01-9.33, P = .049) tumor locations were significantly associated with a higher incidence of postoperative complications. In addition, postoperative complications were independently associated with poor overall survival (hazard ratio 2.17, 95% confidence interval 1.13-4.17, P = .021) and cancer-specific survival (hazard ratio 2.52, 95% confidence interval 1.05-6.04, P = .039). Preoperative malnutrition, synchronous gastrectomy, and upper and middle tumor locations were independent risk factors for postoperative complications. Reducing the incidence of postoperative complications may contribute to improved long-term outcomes.

Clinical practice guidelines for esophagogastric junction cancer (EGJ GLs) were published in 2023. In order to evaluate how EGJ GLs have been adopted into clinical practice worldwide and to identify any outstanding clinical questions to be addressed in the next edition, this survey was conducted. An electronic questionnaire was developed. The questionnaire comprised 16 questions designed to assess the adoption of the guideline. Responses were collected online. The survey was conducted by the EGJ working group of International Gastric Cancer Association (IGCA) following approval from the guideline committee of The International Society for Diseases of the Esophagus (ISDE). As results, we received 344 valid and complete responses. 55% of respondents were from East Asia followed by Europe, Central/South America, and Central/West Asia. 80% of respondents recognized and followed the guidelines to some extent. There was still diversity in the extent of lymphadenectomy for EGJ cancers with an esophageal invasion of 2-4 cm. Although white light imaging (WLE) alone was recommended in the EGJ GLs, both WLE and image enhanced endoscopy were used in 86% of respondents. The perioperative treatment was shown to be highly diverse worldwide. While 50% of respondents provided perioperative chemotherapy, preoperative chemotherapy without adjuvant treatment and upfront surgery were still the first treatment option in 15% of respondents. In conclusion, the current survey conducted by IGCA and ISDE identified the current standard and remaining issues of EGJ cancers.

During surgery for thoracic esophageal cancer, the resected esophagus remains in the thoracic cavity, allowing fluid to leak from the specimen. If this fluid contains cancer cells, they may spread throughout the cavity. However, the presence and prognostic impact of free cancer cells in leaked fluid from the esophagus (LF-E) remain unclear. We conducted a prospective cohort study of 96 patients with thoracic esophageal cancer who underwent radical subtotal esophagectomy. After the thoracic procedure, the esophagus was placed in a bag and removed following the abdominal and cervical procedures. Fluid collected from the bag, combined with saline used to rinse the specimen, was defined as LF-E and examined cytologically. We evaluated the clinicopathological characteristics and prognosis of LF-E-positive (LF-E [+]) patients. LF-E (+) was observed in 5 of 96 patients (5.2%), all of whom had pT3 or higher squamous cell carcinoma with nodal metastasis and vascular invasion. Among the 44 patients with pT3-4a disease, those in the LF-E (+) group had significantly poorer regression-free survival (RFS) (P < 0.001) and overall survival (OS) (P < 0.001) than those in the LF-E-negative group. Multivariate Cox regression analysis identified LF-E positivity as an independent prognostic factor for RFS (hazard ratio [HR]: 4.57, 95% confidence interval [CI]: 1.21-16.2, P = 0.026) and OS (HR: 11.9, 95% CI: 2.04-69.1, P = 0.008). The presence of free cancer cells in LF-E indicated a poor prognosis in patients with pT3 or higher esophageal cancer. LF-E positivity may serve as a new prognostic biomarker.

Current recommendations for the clinical staging of patients undergoing resection for early esophago-gastric (OG) cancer are variable and the value of staging investigations is unclear. The aim of this study was to assess current practice for staging early OG cancers across the UK, and the accuracy of staging with reference to nodal disease at surgery. Data for surgical patients was extracted from the CONGRESS database, a large UK-based multicenter dataset for patients with T1N0 OG cancer between 2015 and 2022. Logistic regression analysis was performed to assess the association of different staging investigations on subsequent nodal upstaging. Cox regression analysis was used to analyze for impact on overall survival (OS). In total, 497 patients from 28 centers were included, 13.1% of which underwent N upstaging from clinical to pathological staging. The rate of unexpected LNM was 12.7% in patients who underwent a CT pre-treatment, compared to 18.2% in patients with no staging investigations. Patients that underwent no staging investigations were also more likely to have unexpected nodal metastases at surgery (OR 6.66 [95%CI 1.34-33.24], P = 0.021). The addition of PET-CT, EUS and staging laparoscopy had no significant impact on N upstaging (P = 0.062, 0.053, and 0.690, respectively). No combination of staging modality had a significant impact on OS. Current guidelines are variable in their recommendation of pre-operative staging investigations for early OG cancer. This study suggests CT plays an important role in the staging of this population. Other staging modalities could be considered selectively, rather than routinely, to preserve resources and accelerate treatment pathways.