Rural-Urban Differences in Esophagectomy for Cancer

Background: Patients who are socioeconomically disadvantaged or in rural areas may not pursue surgery at high-volume centers, where outcomes are better for some complex procedures. The objective of this study was to determine and compare rural and urban patient differences and outcomes after undergoing esophagectomy for cancer. Study Design: An analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS) database was performed, capturing adult patients with esophageal cancer who underwent esophagectomy. Patients were stratified into rural or urban groups by the National Center for Health Statistics Urban-Rural Classification Scheme. Demographics, hospital variables, and outcomes were compared. Results: A total of 2,877 patients undergoing esophagectomy for esophageal cancer were captured by the database, with 228 (7.92%) rural and 2,575 (89.50%) urban patients. The rural and urban groups had no difference in age, race, insurance status, and many common comorbidities. Major outcomes of mortality and length of stay were similar for both rural and urban patients (3.95% versus 4.27%, p=0.815) and (15.75±13.22 versus 15.55±14.91 days, p=0.828), respectively. There was a trend for rural patients to be more likely to discharge home (35.96% versus 29.79%, OR 0.667 [95%CI 0.479-0.929]; p=0.0167). Conclusions: This retrospective administrative database study indicates that rural and urban patients receive equivalent postoperative care after undergoing esophagectomy. The findings are reassuring as there does not appear to be a disparity in major outcomes depending on the location of residence, but further studies are necessary to assure equitable treatment for rural patients.

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

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/m2 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.

676 NECESSITY OF EXTENDED LOWER PARATRACHEAL LYMPH NODE RESECTION DURING ESOPHAGECTOMY FOR CANCER

Objective To evaluate the impact of lower paratracheal lymph node resection on oncological radicality and complication rate during esophagectomy for cancer. Backround The ideal extend of lymphadenectomy (LAD) in esophageal surgery is debated. Until today, there has been no proof for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy. Methods Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. Retrospectively, we identified 200 patients operated in our center for esophageal cancer from January 2017—December 2019. Histopathologically, 143 patients suffered from adenocarcinoma, 53 patients from squamous cell carcinoma, two patients from neuroendocrine carcinoma, and one from melanoma of the esophagus. Patients with and without lower paratracheal LAD were compared to patients regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival. Results 103 of 200 patients received lower paratracheal lymph node resection. On average, six lymph nodes were resected in the paratracheal region with histopathological cancer positivity in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma, none of the AC or SCC patients were positive. There was no significant difference between both groups regarding age, gender, BMI, or comorbidity. Harvesting of lower paratracheal lymph nodes was associated with less postoperative overall complications (p-value 0,029). Regarding overall survival and recurrence rate no difference could be detected between both groups (p-value 0,168, respectively 0,371). Conclusion The resection of lower paratracheal lymph nodes during esophagectomy seems not mandatory for distal squamous cell carcinoma or adenocarcinoma of the esophagus. It may be necessary in NEC, Melanoma of the esophagus or on demand if suspicious LN are detected in the CT scan. No increase of morbidity was caused by paratracheal dissection.

490 COLONIC INTERPOSITION FOR ESOPHAGEAL REPLACEMENT AFTER ESOPHAGECTOMY FOR CANCER—A SINGLE CENTER EXPERIENCE

The standard esophageal replacement after esophagectomy for cancer treatment is a gastric conduit, as it is a simpler technique than the other options available, requiring only one anastomosis. However, when the stomach is not available, a left- or right colon graft interposition can be performed. The purpose of this study was to review our experience with colon interposition following esophagectomy for cancer and assess the surgical outcomes. Methods The clinical data and surgical outcomes form patients who underwent esophagectomy with colon interposition for cancer treatment, in a single institution, between January 1990 and December 2017. The results were compared with cases with gastric reconstruction. Results From January 1990 and December 2017, 25 cases of transhiatal esophagectomy with colon interposition were identified. In the same period, 97 cases of transhiatal esophagectomy with gastric pull-up were also performed. The patient’s clinical data and surgical outcomes are presented in Table 1. The indication for performing a colon interposition was positive distal margin in 87% of cases, gastric conduit ischemia in 8,7% and prior gastric surgery in 4,3%. The most common pull-up route was the posterior mediastinum (87%). Conclusion Our results are in line with the literature and demonstrate that colon interposition after esophagectomy is feasible and, despite having a significant morbimortality, appears to be a valuable alternative for the challenging situation where the stomach is not available.

734 PL11.06 PROGNOSTIC FACTORS FOR MORTALITY IN PATIENTS WITH ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY FOR CANCER (TENTACLE—ESOPHAGUS STUDY)

Anastomotic leakage (AL) is a common and potentially life-threatening complication after esophagectomy. In patients with AL it is largely unknown which patient parameters and leakage characteristics are associated with leak severity and mortality. We aimed to identify prognostic factors for mortality in patients with anastomotic leakage after esophagectomy. Methods The TENTACLE—Esophagus study is an international retrospective cohort study, in which 1451 patients with AL after esophagectomy between 2011 and 2019 were included in 71 centers from 20 countries. Potential prognostic factors were selected from literature and a hypothetical association with mortality. Confounders of (individual) prognostic factors were identified using a directed acyclic graph approach to minimize bias. Primary outcome was 90-day mortality. Logistic regression analysis was performed to estimate crude and adjusted odds ratios (AOR) and 95% confidence intervals (95%CI). The study protocol is accessible at www.tentaclestudy.com. Results Overall 90-day mortality rate was 11.6%. Leakage characteristics with the largest prognostic effect on mortality were gastric conduit ischemia/necrosis (AOR 2.23, 95%CI 1.43-3.49), defect circumference ≥ 25% (AOR 2.10, 95%CI 1.32-3.36) and intrathoracic fluid collections (drained AOR 1.98, 95%CI 1.05-3.75; undrained AOR 2.43, 95%CI 1.57-3.75). Patient parameters with the largest prognostic effect were ASA-score ≥ 3 (AOR 4.18, 95%CI 1.67-10.51), ECOG-score ≥ 2 (AOR 2.83, 95%CI 1.56-5.14) and respiratory failure (AOR 3.89, 95%CI 2.67-5.66), hemodynamic failure (AOR 3.09, 95%CI 1.96-4.88) or renal failure (AOR 4.08, 95%CI 2.20-7.59) at time of AL diagnosis. Conclusion Defect circumference, intrathoracic fluid collections, gastric conduit condition and several patient parameters were identified as prognostic factors for mortality in patients with AL. Adjusting for these prognostic factors may reduce confounding bias in future studies assessing efficacy of AL treatments. The identified prognostic factors contribute to the understanding of the severity of anastomotic leakage after esophagectomy and may be used to recognize the severity of an anastomotic leak in individual patients.

309 ASSOCIATION BETWEEN CERVICAL ANASTOMOSIS METHODS AND ANASTOMOSIS STRICTURE AFTER ESOPHAGECTOMY FOR CANCER

Esophagectomy with three-field lymph node dissection is the most important part of advanced esophageal cancer therapy, especially for squamous cell carcinoma (SCC) patients. After esophagectomy, cervical anastomosis with gastric tube is required. However, some patients suffer anastomotic stenosis and require endoscopic balloon dilations. In this study, we investigated the relationship between cervical anastomosis methods and anastomosis stricture after esophagectomy for cancer patients. Methods Patients with esophageal cancer undergoing radical esophagectomy with cervical anastomosis were identified from the prospectively maintained database at our institution. From 2013 to 2019, 28 patients received esophagectomy with cervical lymph node dissection in our institution. Association between anastomotic methods, linear stapler vs circular stapler, and other factors (patient characteristics, surgical complications including anastomotic stenosis, and length of postoperative stay) were analyzed. Results Their average age was 63.3 years. Males and SCC cases predominated. Thirteen patients (46%) received cervical anastomosis with the circular stapler (Group C), and 11 patients (39%) received treatment with the linear stapler (Group L). None of the following variables were significant different between the two methods: preoperative chemotherapy (53.8% in group C vs. 45.5% in group L; p = 0.58), length of hospital stay (25.8 vs. 20.7 days; p = 0.15), pulmonary complications (16.7% vs. 0.0%; p = 0.36), and anastomotic leakage (33.3% vs. 9.1%; p = 0.24). However, the rate of anastomotic stenosis without malignancies was significantly higher in group C patients (66.7% vs. 0%, p < 0.01). Conclusion Cervical anastomosis with the linear stapler may be safer and associated with a lower stenosis rate than with the circular stapler. In future, cervical anastomosis with linear stapler after mediastinoscopic esophagectomy would be better for not only esophageal SCC patients but also esophagogastric junction adenocarcinoma patients with pulmonary complications.

729 RELATION OF POSTOPERATIVE MORBIDITY WITH QUALITY OF LIFE FOLLOWING ESOPHAGEAL SURGERY FOR CANCER: A EUROPEAN MULTICENTER STUDY

Despite improvements in perioperative esophageal cancer care, severe postoperative complications occur in 17.2% of the patients. Postoperative complications are associated with reduced health-related quality of life (HR-QoL), and severe complications may have a profound negative effect on the HR-QoL.The aim of this study was to investigate the relation between postoperative morbidity and reported HR-QoL in patients following esophagectomy for cancer. Methods Disease-free patients at least one year following esophagectomy for cancer in one of the participating LASER study centers between 2010 and 2016 were included. Patients completed the LASER, EORTC-QLQ-C30 and QLQ-OG25 questionnaires at least one year following surgery. The primary outcome was the relation between reported HR-QoL and occurrence of postoperative complications and to compare the HR-QoL in the study population with the reference values of the general population. Subgroup analysis was performed in patients with ‘no’ or ‘minor’ (Clavien-Dindo grade I-IIIa) and ‘severe’ (Clavien-Dindo grade ≥ IIIb) complications, using univariable and multivariable logistic regression analysis. Results Among 645 included patients, 283 patients with ‘no’, 207 patients with ‘minor’ and 155 patients with ‘severe’ postoperative complications were included. The mean age of the patients was 64 years (SD 9), with a mean time since surgery of 4.4 years (SD 1.7). Neither significant or clinically relevant differences were found in the HR-QoL scores between patients with and without complications, nor were differences observed in subgroup analysis for severity of postoperative complications. Compared to the general population, patients reported worse HR-QoL in all domains except ‘Global Health’ and ‘Emotional Functioning’, and more symptomatology in all symptom domains except ‘Pain'. Conclusion HR-QoL between patients at a median of 4.4 years after esophagectomy for cancer did not differ. Differences were neither significant nor clinically relevant and furthermore, no differences were observed in subgroup analysis for severity of postoperative complications according to Clavien-Dindo.