A Standardized Anesthetic and Surgical Clinical Pathway for Esophageal Resection

Porteous, Grete H.; Neal, Joseph M.; Slee, April; Schmidt, Henner; Low, Donald E.

doi:10.1097/aap.0000000000000197

Cited by 43 publications

(25 citation statements)

References 38 publications

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“…Esophagectomy with lymph node dissection is a complex surgery and is associated with moderate postoperative mortality and morbidity. 20,22,26–28 Therefore, the potential survival benefit of surgery is counterbalanced by its surgical risk. In Taiwan, almost half of patients (n = 2848, 45.9%) with locoregional ESCC received definitive CRT during the period 2008 to 2012.…”

Section: Discussionmentioning

confidence: 99%

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

Chen

Hung

et al. 2016

Medicine

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The optimal treatment modality for locoregional esophageal squamous-cell carcinoma (ESCC) is still undetermined. This study investigated the treatment modalities affecting survival of patients with ESCC in Taiwan.Data on 6202 patients who underwent treatment for locoregional esophageal squamous-cell carcinoma during 2008 to 2012 in Taiwan were collected from the Taiwan Cancer Registry. Patients were stratified by clinical stage. The major treatment approaches included definitive chemoradiotherapy, preoperative chemoradiation followed by esophagectomy, esophagectomy followed by adjuvant therapy, and esophagectomy alone. The impact of different treatment modalities on overall survival was analyzed.The majority of patients had stage III disease (n = 4091; 65.96%), followed by stage II (n = 1582, 25.51%) and stage I cancer (n = 529, 8.53%). The 3-year overall survival rates were 60.65% for patients with stage I disease, 36.21% for those with stage II cancer, and 21.39% for patients with stage III carcinoma. Surgery alone was associated with significantly better overall survival than the other treatment modalities for patients with stage I disease (P = 0.029) and was associated with significantly worse overall survival for patients with stage III cancer (P < 0.001). There was no survival risk difference among the different treatment methods for patients with clinical stage II disease.Multimodality treatment is recommended for patients with stage II–III esophageal squamous-cell carcinoma. Patients with clinical stage I disease can be treated with esophagectomy without preoperative therapy.

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Section: Discussionmentioning

confidence: 99%

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

Chen

Hung

et al. 2016

Medicine

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“…Furthermore, besides improving the success of preoperative thoracic epidural blocks, EWA and fluoroscopy/ epidurogram also provide diagnostic versatility, as they can be used in the recovery room to manage nonfunctioning epidural catheters. 94,95 Interestingly, adjunctive NS can also be used to confirm correct placement of epidural catheters. 96 Although it seems to provide high sensitivity and specificity, 97 further investigation is required to compare conventional and NS-confirmed LOR.…”

Section: Solutionsmentioning

confidence: 99%

Beyond Ultrasound Guidance for Regional Anesthesiology

Tran

Boezaart

Neal

2017

Regional Anesthesia and Pain Medicine

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Despite its popularity, ultrasound (US)-guided regional anesthesiology is associated with significant limitations. The latter can be attributed to either the US machine (ie, decreased ability to insonate deep neural structures, as well as the thoracic spine) or the operator. Shortcomings associated with the operator can be explained by errors in perception (ie, ambiguous criteria for needle/catheter tip-to-nerve proximity and subparaneural local anesthetic injection) or interpretation. Perhaps the greatest confusion afflicting US-guided regional anesthesiology originates from an intellectual misconception pertaining to its application. Increasingly, authors are using US to identify interfascial planes where local anesthetic can be injected thereby "discovering" new truncal blocks. Often these novel blocks suffer from a lack of proper randomized, comparative validation.Fortunately, solutions have been proposed to remedy many shortcomings associated with US guidance. The inability of US to reliably insonate deep neural structures can be circumvented with adjunctive neurostimulation. Fluoroscopy and waveform analysis have been proven to increase the success rate of thoracic epidural blocks. For continuous nerve blocks, combined US-neurostimulation may provide an objective end point (ie, an evoked motor response) for neural proximity and subparaneural positioning of the catheter tip. Finally, the solution to the plethora of nonvalidated US-guided blocks is both elegant and simple. New nerve blocks should answer a specific clinical need, and their first descriptions should take the form of an adequately powered, observer-blinded, randomized comparison against the established standard of care or, at the very least, a large case series (eg, a Brief Technical Report).

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“…Oesophageal cancer resection is associated with extremely high perioperative morbidity and mortality [ 36 ]. Neoadjuvant chemoradiation not only is now the gold standard therapy but has not been shown to increase postoperative morbidity or mortality [ 37 , 38 ].…”

Section: Current Rates Of Operative Morbidity and Mortalitymentioning

confidence: 99%

“…Factors known to increase operative risk include locally advanced disease, diabetes, dyspnoea, peripheral vascular disease and previous cerebrovascular accident, international normalised ratio, and wound contamination at the time of surgery [ 40 ]. While recent advances have been made with the introduction of standardised anaesthesia and surgical clinical pathways, lowering the incidence of complications remains a significant challenge [ 36 , 41 ]. Adverse events are decreasing in relation to the treatment of many medical conditions; however their incidence with respect to surgery continues to increase [ 42 ].…”

Section: Current Rates Of Operative Morbidity and Mortalitymentioning

confidence: 99%

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

O’Sullivan

Hurley

2015

Gastroenterology Research and Practice

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Despite significant improvement over recent decades, oesophageal cancer survival rates remain poor. Neoadjuvant chemoradiotherapy followed by oesophageal resection is mainstay of therapy for resectable oesophageal tumours. Operative morbidity and mortality associated with oesophagectomy remain high and complications arise in up to 60% of patients. Management strategies have moved towards definitive chemoradiotherapy for a number of tumour sites (head and neck, cervical, and rectal) particularly for squamous pathology. We undertook to perform a review of the current status of morbidity and mortality associated with oesophagectomy, grading systems determining pathologic response, and data from clinical trials managing patients with definitive chemoradiotherapy to inform a discussion on the topic.

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A Standardized Anesthetic and Surgical Clinical Pathway for Esophageal Resection

Abstract: We present a detailed anesthetic and surgical perioperative pathway for esophageal resection, along with evidence of improved or stable patient outcomes despite an increase in comorbidity burden and increasingly advanced tumor stage.

Cited by 43 publications

References 38 publications

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

Impact of Treatment Modalities on Survival of Patients With Locoregional Esophageal Squamous-Cell Carcinoma in Taiwan

Beyond Ultrasound Guidance for Regional Anesthesiology

Understanding Complete Pathologic Response in Oesophageal Cancer: Implications for Management and Survival

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