TY - JOUR
AU - Sihvo,, Eero
AB - SUMMARY Population-based studies examining whether preoperative esophageal stenting influences the short-term outcomes after esophagectomy for esophageal cancer are lacking. This nationwide cohort combining data from Finland and Sweden was conducted to cover this gap. Patients with locally advanced esophageal cancer (T ≥ 3 and/or N ≥ 1, M0) who underwent esophagectomy between 2007 and 2014 were identified from nationwide registries in Finland and Sweden. The study exposure was preoperative stenting. The primary outcomes were 30- and 90-day mortality. Secondary outcomes were length of hospital stay and 30- and 90-day readmission rates. Multivariable Cox and linear regression analyses provided hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, comorbidity, tumor histology, year of surgery, and country. Of all 1029 participating patients who underwent surgery for locally advanced esophageal cancer, 127 (12.3%) had an esophageal stent inserted preoperatively. The absolute 30-day mortality rates were higher in stented patients (3.9%) than in those without a stent (1.6%), but the HR was not statistically significantly increased (HR 2.42; 95% CI 0.85–6.92). Similarly, the absolute 90-day mortality rates were increased after preoperative stenting (11.8%) compared to no stenting (7.0%), but again the HR was not statistically significantly increased (HR 1.68; 95% CI 0.95–2.98). Preoperative stenting did not influence length of hospital stay or readmission rates. The possibly increased short-term mortality after preoperative stenting in patients who undergo esophagectomy for esophageal cancer indicated in this study suggests a cautious approach to preoperative stenting until future research or meta-analyses provide a more definite answer. INTRODUCTION Esophageal cancer is the sixth leading cause of cancer-related death worldwide.1 Surgery offers the best chance for cure.2 Patients with esophageal cancer commonly present with dysphagia and weight loss with malnutrition due to an obstructing tumor.3 Malnutrition is associated with an increased risk of postoperative complications and reoperations and a decreased chance of long-term survival.4,5 Oral nutrition can be secured with esophageal stenting before surgery, especially in patients selected for neoadjuvant therapy.6,7 There are also other options for securing nutrition, such as a nasogastric tube, feeding jejunostomy, and gastrostomy.8,–10 Neoadjuvant therapy is recommended for all locally advanced esophageal cancers,2,11 and stenting can be used as a bridge to surgery during neoadjuvant therapy. However, stent-related adverse events are common,12,13 and the impact of esophageal stenting on short-term outcomes has been questioned.2,14 In a matched cohort study with 38 stented patients from high-volume European centers, stented patients had more serious complications (Clavien–Dindo ≥ 3a) and increased risk estimates for in-hospital mortality, although not statistically significant.14 There is a need for larger studies assessing the short-term outcomes associated with preoperative esophageal stenting in patients who undergo surgery for esophageal cancer. The aim of this study was to assess short-term outcomes, especially the 30- and 90-day mortality, comparing esophageal cancer patients with or without esophageal stenting prior to resectional surgery in a large cohort study from Finland and Sweden. METHODS Design All patients who underwent esophagectomy for cancer of the esophagus in Finland or Sweden during the study period from January 1, 2007, to October 2, 2014, were considered for this population-based cohort study. The final cohort was restricted to patients with a confirmed locally advanced esophageal cancer (T ≥ 3 and/or N ≥ 1, M0) from Finland and Sweden. The National Institute for Health and Welfare of Finland (permissions no: THL/143/5.05.00/2015 and THL/1349/5.05.00/2015), Statistics Finland (TK53-1410-15), and the Regional Ethical Review Board in Stockholm, Sweden (DNR-2015/1916-31/1 and 2016/584-32), approved the study. Data collection All residents in both countries have unique personal identity codes, which allows for a complete identification of patients from hospital records, administrative databases, and national health data registries and makes linkages of individuals’ data between these databases reliable. In this study, patients who underwent esophagectomy for locally advanced esophageal cancer between January 1, 2007, and October 2, 2014, were identified from the Care Register for Healthcare in Finland and the Cancer Registry and Patient Registry in Sweden. All patients were followed up until 90 days postsurgery or death. The follow-up ended on December 31, 2014. Mortality data were linked for each patient individually from Statistics Finland and from the Swedish Cause of Death Registry. The Charlson comorbidity index was calculated from the diagnoses in the registries during the study period, according to a well-validated algorithm,15 and excluding upper gastrointestinal cancer. Information on age, sex, and tumor histology was also acquired from the registries. Standard surgical procedures for esophageal cancer in Finland and Sweden during the study period were either Ivor Lewis esophagectomy with intrathoracal anastomosis (in the majority of patients) or the McKeown procedure with cervical anastomosis.16,17 The used registries have nationwide coverage and reporting to the registries is compulsory in Finland and Sweden. The coverage of the Finnish Hospital Discharge Registry and the Swedish Patient Registry is high and is encouraged both by the legislative obligation of reporting every inpatient treatment period and all outpatient contacts and by the hospital funding linked to this registration. The data recorded in these registers are reliable in both Finland18 and Sweden.19 The Finnish Cancer Registry has a nationwide overall coverage of over 99%,20 and the Swedish Cancer Registry has at least 98% nationwide coverage for esophageal cancer.21 Statistical analysis Kaplan–Meier survival curves were calculated according to the life table method to visualize the crude all-cause mortality and readmission rates within 90 days of surgery. Multivariable Cox regression was used for calculating hazard ratios (HRs) with 95% confidence intervals (CIs) of mortality and readmissions, whereas linear regression was used in analyses of length of hospital stay (logarithmically transformed and standardized due to skewness). The patient group without a preoperative esophageal stent was used as the reference group in all analyses. The regression models were adjusted for six potential confounding factors: age (continuous variable), sex (male or female), comorbidity (Charlson comorbidity score 0, 1, or ≥2), tumor histology (adenocarcinoma or squamous cell carcinoma), year of surgery (continuous), and country (Finland or Sweden). Patients who died during hospital admission for esophagectomy were censored from the length of hospital stay analysis. Patients who died within the first 30 days of surgery were censored from the analysis of 30-day readmissions, and patients who died during 90 days were censored from the 90-day readmissions analysis. All statistical analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). RESULTS Patients In all, 1614 patients underwent esophagectomy for esophageal cancer in Finland (n = 565) or Sweden (n = 1049) during the study period. Of these, 1029 (63.8%) had confirmed locally advanced disease and were thus selected for this study (Finland n = 338, Sweden n = 691). Among these participants, the mean age at surgery was 64.6 years (median 65.0, range 21–87), 53% had Charlson comorbidity score 0, and 75% had adenocarcinoma tumor histology (Table 1). There were no major differences in the distribution of age, sex, comorbidity, tumor histology, or calendar year of surgery between patients with (Finland n = 49, Sweden n = 78) and without (Finland n = 289, Sweden n = 613) a preoperative esophageal stent (Table 1). Table 1 Characteristics of 1029 patients having undergone surgery for locally advanced esophageal cancer with and without preoperative stent in Finland or Sweden in 2007–2014 . All operations . No preoperative stent . With preoperative stent . Variable . Patients (%) n = 1029 . Patients (%) n = 902 . Patients (%) n = 127 . Mean age (standard deviation) 64.6 (9.5) 64.6 (9.6) 64.2 (8.1) Sex  Male 825 (80) 720 (80) 105 (83)  Female 204 (20) 182 (20) 22 (17) Charlson comorbidity score  0 543 (53) 480 (53) 63 (50)  1 169 (16) 151 (17) 18 (14)  ≥2 317 (31) 271 (30) 46 (36) Tumor histology†  Adenocarcinoma 770 (75) 680 (75) 90 (71)  Squamous cell carcinoma 237 (23) 201 (22) 36 (28) Minimally invasive esophagectomy‡ 151 (15) 128 (14) 23 (18) Year of surgery  2007 125 (12) 114 (13) 11 (9)  2008 117 (11) 109 (12) 8 (6)  2009 123 (12) 109 (12) 14 (11)  2010 136 (13) 110 (12) 26 (20)  2011 149 (14) 129 (14) 20 (16)  2012 129 (13) 110 (12) 19 (15)  2013 151 (15) 137 (15) 14 (11)  2014§ 99 (10) 84 (9) 15 (12) 30-day mortality 19 (1.8) 14 (1.6) 5 (3.9) 90-day mortality 78 (7.6) 63 (7.0) 15 (11.8) Median hospital stay (days, interquartile range) 16 (11) 16 (11) 15 (12) Readmissions within 30 days¶ 117 (11.6) 101 (11.4) 16 (13.1) Readmissions within 90 days†† 313 (32.9) 275 (32.8) 38 (33.9) . All operations . No preoperative stent . With preoperative stent . Variable . Patients (%) n = 1029 . Patients (%) n = 902 . Patients (%) n = 127 . Mean age (standard deviation) 64.6 (9.5) 64.6 (9.6) 64.2 (8.1) Sex  Male 825 (80) 720 (80) 105 (83)  Female 204 (20) 182 (20) 22 (17) Charlson comorbidity score  0 543 (53) 480 (53) 63 (50)  1 169 (16) 151 (17) 18 (14)  ≥2 317 (31) 271 (30) 46 (36) Tumor histology†  Adenocarcinoma 770 (75) 680 (75) 90 (71)  Squamous cell carcinoma 237 (23) 201 (22) 36 (28) Minimally invasive esophagectomy‡ 151 (15) 128 (14) 23 (18) Year of surgery  2007 125 (12) 114 (13) 11 (9)  2008 117 (11) 109 (12) 8 (6)  2009 123 (12) 109 (12) 14 (11)  2010 136 (13) 110 (12) 26 (20)  2011 149 (14) 129 (14) 20 (16)  2012 129 (13) 110 (12) 19 (15)  2013 151 (15) 137 (15) 14 (11)  2014§ 99 (10) 84 (9) 15 (12) 30-day mortality 19 (1.8) 14 (1.6) 5 (3.9) 90-day mortality 78 (7.6) 63 (7.0) 15 (11.8) Median hospital stay (days, interquartile range) 16 (11) 16 (11) 15 (12) Readmissions within 30 days¶ 117 (11.6) 101 (11.4) 16 (13.1) Readmissions within 90 days†† 313 (32.9) 275 (32.8) 38 (33.9) †In a total of 22 cases no specific histology of the cancer was reported, or histology could not be determined (undefined carcinoma). ‡Including hybrid procedures. §Included operations from 1 January, 2014, to 2 October, 2014. ¶Death within the first 30 days after surgery was accounted for (censoring). ††Death within the first 90 days after surgery was accounted for (censoring). Open in new tab Table 1 Characteristics of 1029 patients having undergone surgery for locally advanced esophageal cancer with and without preoperative stent in Finland or Sweden in 2007–2014 . All operations . No preoperative stent . With preoperative stent . Variable . Patients (%) n = 1029 . Patients (%) n = 902 . Patients (%) n = 127 . Mean age (standard deviation) 64.6 (9.5) 64.6 (9.6) 64.2 (8.1) Sex  Male 825 (80) 720 (80) 105 (83)  Female 204 (20) 182 (20) 22 (17) Charlson comorbidity score  0 543 (53) 480 (53) 63 (50)  1 169 (16) 151 (17) 18 (14)  ≥2 317 (31) 271 (30) 46 (36) Tumor histology†  Adenocarcinoma 770 (75) 680 (75) 90 (71)  Squamous cell carcinoma 237 (23) 201 (22) 36 (28) Minimally invasive esophagectomy‡ 151 (15) 128 (14) 23 (18) Year of surgery  2007 125 (12) 114 (13) 11 (9)  2008 117 (11) 109 (12) 8 (6)  2009 123 (12) 109 (12) 14 (11)  2010 136 (13) 110 (12) 26 (20)  2011 149 (14) 129 (14) 20 (16)  2012 129 (13) 110 (12) 19 (15)  2013 151 (15) 137 (15) 14 (11)  2014§ 99 (10) 84 (9) 15 (12) 30-day mortality 19 (1.8) 14 (1.6) 5 (3.9) 90-day mortality 78 (7.6) 63 (7.0) 15 (11.8) Median hospital stay (days, interquartile range) 16 (11) 16 (11) 15 (12) Readmissions within 30 days¶ 117 (11.6) 101 (11.4) 16 (13.1) Readmissions within 90 days†† 313 (32.9) 275 (32.8) 38 (33.9) . All operations . No preoperative stent . With preoperative stent . Variable . Patients (%) n = 1029 . Patients (%) n = 902 . Patients (%) n = 127 . Mean age (standard deviation) 64.6 (9.5) 64.6 (9.6) 64.2 (8.1) Sex  Male 825 (80) 720 (80) 105 (83)  Female 204 (20) 182 (20) 22 (17) Charlson comorbidity score  0 543 (53) 480 (53) 63 (50)  1 169 (16) 151 (17) 18 (14)  ≥2 317 (31) 271 (30) 46 (36) Tumor histology†  Adenocarcinoma 770 (75) 680 (75) 90 (71)  Squamous cell carcinoma 237 (23) 201 (22) 36 (28) Minimally invasive esophagectomy‡ 151 (15) 128 (14) 23 (18) Year of surgery  2007 125 (12) 114 (13) 11 (9)  2008 117 (11) 109 (12) 8 (6)  2009 123 (12) 109 (12) 14 (11)  2010 136 (13) 110 (12) 26 (20)  2011 149 (14) 129 (14) 20 (16)  2012 129 (13) 110 (12) 19 (15)  2013 151 (15) 137 (15) 14 (11)  2014§ 99 (10) 84 (9) 15 (12) 30-day mortality 19 (1.8) 14 (1.6) 5 (3.9) 90-day mortality 78 (7.6) 63 (7.0) 15 (11.8) Median hospital stay (days, interquartile range) 16 (11) 16 (11) 15 (12) Readmissions within 30 days¶ 117 (11.6) 101 (11.4) 16 (13.1) Readmissions within 90 days†† 313 (32.9) 275 (32.8) 38 (33.9) †In a total of 22 cases no specific histology of the cancer was reported, or histology could not be determined (undefined carcinoma). ‡Including hybrid procedures. §Included operations from 1 January, 2014, to 2 October, 2014. ¶Death within the first 30 days after surgery was accounted for (censoring). ††Death within the first 90 days after surgery was accounted for (censoring). Open in new tab 30-day mortality The absolute 30-day mortality rate was 3.9% in patients with a preoperative stent, and 1.6% in those without (Fig. 1, Table 1). The adjusted HR of 30-day mortality was not statistically significantly increased (HR 2.42; 95% CI 0.85–6.92) (Table 2). Fig. 1 Open in new tabDownload slide (a) Kaplan–Meier curves of 90-day mortality of patients who underwent esophagectomy for locally advanced esophageal cancer stratified by preoperative esophageal stent. (b) Broken y-axis from 0.80 to 1.00. Fig. 1 Open in new tabDownload slide (a) Kaplan–Meier curves of 90-day mortality of patients who underwent esophagectomy for locally advanced esophageal cancer stratified by preoperative esophageal stent. (b) Broken y-axis from 0.80 to 1.00. Table 2 Hazard ratios (HRs) with 95% confidence intervals (CIs) of short-term mortality comparing patients with locally advanced esophageal cancer with and without a preoperative stent in Finland and Sweden in 2007–2014 . Patient number . No preoperative stent HR (95% CI) . With preoperative stent HR (95% CI) . 30-day mortality  Crude 1029 1 (reference) 2.56 (0.92–7.10)  Adjusted† 1029 1 (reference) 2.42 (0.85–6.92) 90-day mortality  Crude 1029 1 (reference) 1.74 (0.99–3.05)  Adjusted† 1029 1 (reference) 1.68 (0.95–2.98) . Patient number . No preoperative stent HR (95% CI) . With preoperative stent HR (95% CI) . 30-day mortality  Crude 1029 1 (reference) 2.56 (0.92–7.10)  Adjusted† 1029 1 (reference) 2.42 (0.85–6.92) 90-day mortality  Crude 1029 1 (reference) 1.74 (0.99–3.05)  Adjusted† 1029 1 (reference) 1.68 (0.95–2.98) †Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. Open in new tab Table 2 Hazard ratios (HRs) with 95% confidence intervals (CIs) of short-term mortality comparing patients with locally advanced esophageal cancer with and without a preoperative stent in Finland and Sweden in 2007–2014 . Patient number . No preoperative stent HR (95% CI) . With preoperative stent HR (95% CI) . 30-day mortality  Crude 1029 1 (reference) 2.56 (0.92–7.10)  Adjusted† 1029 1 (reference) 2.42 (0.85–6.92) 90-day mortality  Crude 1029 1 (reference) 1.74 (0.99–3.05)  Adjusted† 1029 1 (reference) 1.68 (0.95–2.98) . Patient number . No preoperative stent HR (95% CI) . With preoperative stent HR (95% CI) . 30-day mortality  Crude 1029 1 (reference) 2.56 (0.92–7.10)  Adjusted† 1029 1 (reference) 2.42 (0.85–6.92) 90-day mortality  Crude 1029 1 (reference) 1.74 (0.99–3.05)  Adjusted† 1029 1 (reference) 1.68 (0.95–2.98) †Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. Open in new tab 90-day mortality The absolute 90-day mortality rate was 11.8% in patients with a preoperative stent, and 7.0% in patients without (Fig. 1, Table 1). The adjusted HR of 90-day mortality was not statistically significantly increased (HR 1.68; 95% CI 0.95–2.98) (Table 2). Hospital stay The median length of hospital stay after esophagectomy was 15 days in patients with a preoperative esophageal stent, and 16 days in those without (Table 1), and the adjusted linear regression analysis showed no difference (Table 3). Table 3 β coefficient with standard error (SE) and P-values for comparison of length of hospital stay between patients undergoing esophagectomy for locally advanced esophageal cancer with and without preoperative stenting . Patient Number . No preoperative stent β (SE) . With preoperative stent β (SE) . P-value . Hospital stay†  Crude 992 1 (reference) −0.03 (0.10) 0.797  Adjusted‡ 992 1 (reference) 0.01 (0.10) 0.925 . Patient Number . No preoperative stent β (SE) . With preoperative stent β (SE) . P-value . Hospital stay†  Crude 992 1 (reference) −0.03 (0.10) 0.797  Adjusted‡ 992 1 (reference) 0.01 (0.10) 0.925 †Patients who died during hospital admission for esophagectomy were censored from the analysis. ‡Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. Open in new tab Table 3 β coefficient with standard error (SE) and P-values for comparison of length of hospital stay between patients undergoing esophagectomy for locally advanced esophageal cancer with and without preoperative stenting . Patient Number . No preoperative stent β (SE) . With preoperative stent β (SE) . P-value . Hospital stay†  Crude 992 1 (reference) −0.03 (0.10) 0.797  Adjusted‡ 992 1 (reference) 0.01 (0.10) 0.925 . Patient Number . No preoperative stent β (SE) . With preoperative stent β (SE) . P-value . Hospital stay†  Crude 992 1 (reference) −0.03 (0.10) 0.797  Adjusted‡ 992 1 (reference) 0.01 (0.10) 0.925 †Patients who died during hospital admission for esophagectomy were censored from the analysis. ‡Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. Open in new tab Readmission after surgery The readmission rate within the first 30 postoperative days was 13.1% in stented patients and 11.4% in patients without a stent. The corresponding readmission rates within 90 days of surgery were 33.9% and 32.8%, respectively (Table 1). There were no differences in adjusted HRs between the groups (Table 4). Table 4 Hazard ratios with 95% confidence intervals of readmissions comparing patients operated for locally advanced esophageal cancer with or without preoperative stenting within 30 and 90 days of surgery . Patient number . No preoperative stent HR (95% CI) . Preoperative stent HR (95% CI) . 30-day readmissions†  Crude 1010 1 (reference) 1.16 (0.68–1.96)  Adjusted‡ 1010 1 (reference) 1.12 (0.66–1.91) 90-day readmissions§  Crude 951 1 (reference) 1.03 (0.73–1.45)  Adjusted‡ 951 1 (reference) 1.02 (0.73–1.44) . Patient number . No preoperative stent HR (95% CI) . Preoperative stent HR (95% CI) . 30-day readmissions†  Crude 1010 1 (reference) 1.16 (0.68–1.96)  Adjusted‡ 1010 1 (reference) 1.12 (0.66–1.91) 90-day readmissions§  Crude 951 1 (reference) 1.03 (0.73–1.45)  Adjusted‡ 951 1 (reference) 1.02 (0.73–1.44) †Patients who died during the first 30 days after surgery were censored from the analysis. ‡Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. §Patients who died during the first 90 days after surgery were censored from the analysis. Open in new tab Table 4 Hazard ratios with 95% confidence intervals of readmissions comparing patients operated for locally advanced esophageal cancer with or without preoperative stenting within 30 and 90 days of surgery . Patient number . No preoperative stent HR (95% CI) . Preoperative stent HR (95% CI) . 30-day readmissions†  Crude 1010 1 (reference) 1.16 (0.68–1.96)  Adjusted‡ 1010 1 (reference) 1.12 (0.66–1.91) 90-day readmissions§  Crude 951 1 (reference) 1.03 (0.73–1.45)  Adjusted‡ 951 1 (reference) 1.02 (0.73–1.44) . Patient number . No preoperative stent HR (95% CI) . Preoperative stent HR (95% CI) . 30-day readmissions†  Crude 1010 1 (reference) 1.16 (0.68–1.96)  Adjusted‡ 1010 1 (reference) 1.12 (0.66–1.91) 90-day readmissions§  Crude 951 1 (reference) 1.03 (0.73–1.45)  Adjusted‡ 951 1 (reference) 1.02 (0.73–1.44) †Patients who died during the first 30 days after surgery were censored from the analysis. ‡Adjustment for age, sex, Charlson comorbidity index, histological type, year of surgery, and country. §Patients who died during the first 90 days after surgery were censored from the analysis. Open in new tab DISCUSSION This study suggests that preoperative esophageal stenting might be associated with an increased 30- and 90-day postoperative mortality after esophagectomy for locally advanced esophageal cancer, although the increased point estimates were not statistically significant. The population-based design with nationwide data from two Nordic countries and complete follow-up are the main strengths of this study. Yet, because observational studies are prone to confounding, a large randomized clinical trial would have been preferable. Confounding was taken into account, however, by adjusting for several potential confounding factors. Some potential confounders were not available in the study, e.g., use of neoadjuvant therapy, specific tumor stage, and weight changes. To reduce the influence of neoadjuvant therapy and tumor stage, the study was restricted to patients with locally advanced esophageal cancer (where neoadjuvant therapy is generally used) and only assessed short-term mortality (which is less influenced by tumor stage).22,23 Malnutrition may lead to increased short-term mortality and it is likely that the stented group had more dysphagia and weight loss compared to the group without stenting. This might explain the higher frequencies of short-term mortality indicated in this study. The inability to provide specific data regarding complications is another limitation. However, hospital length and readmission rates are proxies for complications and these were similarly distributed in the comparison groups.24 Finally, even with nationwide data from two countries and a larger sample size than in previous studies, the number of patients with a preoperative esophageal stent was still relatively low, resulting in a limited statistical power. However, the findings might be useful for future meta-analyses on the topic. Only a few studies have examined short-term outcomes in esophageal cancer patients with a preoperative stent. One Danish single-center study including 273 patients with locally advanced esophageal cancer not receiving neoadjuvant therapy reported no difference in postoperative complications or 30-day mortality rates in patients with (1/63, 1.6%) and without (5/210, 2.4%) a stent.25 A French study comparing 38 patients with and 152 without stenting found a higher number of Clavien–Dindo ≥ 3a complications (45% vs 27%) and a nonsignificant trend toward increased in-hospital mortality (13.2% vs 8.6%) in stented patients.14 This mortality difference of 4.6% in the French study is similar to the 90-day mortality difference of 4.8% (11.8% vs 7.0%) in this study. Also, the observed higher frequencies of the 90-day mortality compared to the 30-day rates after esophagectomy in this study are in line with the previous literature,26,27 as well as the length of hospital stay and readmission rates.28,29 Similar length of stay and readmission rates indicate that the rate of nonfatal complications is comparable in patients with and without a stent. Some factors may explain the possibly increased short-term mortality in stented esophageal cancer patients. Traditionally used metallic stents exert a high radial force.30 This force, during neoadjuvant therapy, might cause stent penetration, leading to such serious complications as esophageal perforation, mediastinitis, aortic wall erosion, and tracheo-esophageal fistulation.13 Stent penetration may also lead to less severe complications, i.e. local inflammation with scar formation and fibrosis with loss of normal anatomical planes. This could lead to difficulties during surgery and a lower rate of radical (R0) esophageal cancer resections in stented patients.14 Based on a low level of evidence, ESMO guidelines still suggest alternative routes of feeding instead of esophageal stenting in the neoadjuvant setting.2 The results of this study support these guidelines. The optimal route of nutritional support during neoadjuvant therapy is uncertain.8 Yet, preoperative stenting is often used, but whether the results of stenting could be improved by optimizing the diameter, length, or type of stent is unknown. Alternatives to stenting include nasogastric or nasojejunal feeding tubes, gastrostomy, and jejunostomy. Because preoperative nutrition is essential also in postoperative recovery, a robust solution to improve the nutritional status needs to be resolved.4 The results of this study together with previous evidence highlight that alternative routes of feeding instead of esophageal stenting should be considered.2,13,14 The feasibility of feeding jejunostomy and gastrostomy during neoadjuvant treatment has been reported,9,10 but future studies should aim for direct comparison between different enteral feeding strategies in patients with nutritional problems or dysphagia before or during neoadjuvant therapy for esophageal cancer. In conclusion, this population-based study from Finland and Sweden suggests that 30- and 90-day mortality might be increased when preoperative stenting is used in patients with locally advanced esophageal cancer, although the increased point risk estimates were not statistically significant. The results may be used in future meta-analyses. Acknowledgments This study was supported by Finnish State Research Funding (OH), the Instrumentarium Science Foundation (OH), the Sigrid Juselius Foundation (JHK), the Orion Research Foundation (JHK), the Swedish Research Council (JL) and the Swedish Cancer Society (JL), the Finnish Cardiac Society (VK), and the Finnish Cultural Foundation (VK). Conflicts of interest: The authors declare no conflicts of interest. References 1 Global Burden of Disease Cancer Collaboration , Fitzmaurice C Allen C , Barber R M et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study . JAMA Oncol 2017 ; 3 : 524 – 48 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Lordick F Mariette C Haustermans K Obermannova R Arnold D ESMO Guidelines Committee ,. Oesophageal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up . Ann Oncol 2016 ; 27 : v50 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Mariette C Piessen G Triboulet J P . Therapeutic strategies in oesophageal carcinoma: Role of surgery and other modalities . Lancet Oncol 2007 ; 8 : 545 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Mariette C De Botton M L Piessen G . Surgery in esophageal and gastric cancer patients: what is the role for nutrition support in your daily practice? Ann Surg Oncol 2012 ; 19 : 2128 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Yoshida N Harada K Baba Y et al. Preoperative controlling nutritional status (CONUT) is useful to estimate the prognosis after esophagectomy for esophageal cancer . Langenbecks Arch Surg 2017 ; 402 : 333 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Langer F B Schoppmann S F Prager G et al. Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy . Ann Surg Oncol 2010 ; 17 : 470 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Brown R E Abbas A E Ellis S et al. A prospective phase II evaluation of esophageal stenting for neoadjuvant therapy for esophageal cancer: optimal performance and surgical safety . J Am Coll Surg 2011 ; 212 : 582 – 8 ; discussion 588-9 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Huddy J R Huddy F M S Markar S R Tucker O . Nutritional optimization during neoadjuvant therapy prior to surgical resection of esophageal cancer — a narrative review . Dis Esophagus 2018 ; 31 : 1 – 11 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Manfredelli S Delhorme J B Venkatasamy A et al. Could a feeding jejunostomy be integrated into a standardized preoperative management of oeso-gastric junction adenocarcinoma? Ann Surg Oncol 2017 ; 24 : 3324 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Tessier W Piessen G Briez N Boschetto A Sergent G Mariette C . Percutaneous radiological gastrostomy in esophageal cancer patients: A feasible and safe access for nutritional support during multimodal therapy . Surg Endosc 2013 ; 27 : 633 – 41 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Sjoquist K M Burmeister B H Smithers B M et al. Survival after neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal carcinoma: an updated meta-analysis . Lancet Oncol 2011 ; 12 : 681 – 92 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Spaander M C Baron T H Siersema P D et al. Esophageal stenting for benign and malignant disease: European society of gastrointestinal endoscopy (ESGE) clinical guideline . Endoscopy 2016 ; 48 : 939 – 48 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Jones C M Griffiths E A . Should oesophageal stents be used before neo-adjuvant therapy to treat dysphagia in patients awaiting oesophagectomy? Best evidence topic (BET) . Int J Surg 2014 ; 12 : 1172 – 80 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Mariette C Gronnier C Duhamel A et al. Self-expanding covered metallic stent as a bridge to surgery in esophageal cancer: impact on oncologic outcomes . J Am Coll Surg 2015 ; 220 : 287 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Quan H Sundararajan V Halfon P et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data . Med Care 2005 ; 43 : 1130 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Kauppi J Rasanen J Sihvo E Huuhtanen R Nelskyla K Salo J . Open versus minimally invasive esophagectomy: clinical outcomes for locally advanced esophageal adenocarcinoma . Surg Endosc 2015 ; 29 : 2614 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Lagergren K Derogar M . Validation of oesophageal cancer surgery data in the Swedish patient registry . Acta Oncol (Madr) 2012 ; 51 : 65 – 8 . Google Scholar Crossref Search ADS WorldCat 18 Sund R . Quality of the Finnish hospital discharge register: a systematic review . Scand J Public Health 2012 ; 40 : 505 – 15 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Ludvigsson J F Andersson E Ekbom A et al. External review and validation of the Swedish national inpatient register . BMC Public Health 2011 ; 11 : 450 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Korhonen P Malila N Pukkala E Teppo L Albanes D Virtamo J . The Finnish cancer registry as follow-up source of a large trial cohort–accuracy and delay . Acta Oncol (Madr) 2002 ; 41 : 381 – 8 . Google Scholar Crossref Search ADS WorldCat 21 Lindblad M Ye W Lindgren A Lagergren J . Disparities in the classification of esophageal and cardia adenocarcinomas and their influence on reported incidence rates . Ann Surg 2006 ; 243 : 479 – 85 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Talsma A K Lingsma H F Steyerberg E W Wijnhoven B P Van Lanschot J J . The 30-day versus in-hospital and 90-day mortality after esophagectomy as indicators for quality of care . Ann Surg 2014 ; 260 : 267 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Rouvelas I Zeng W Lindblad M Viklund P Ye W Lagergren J . Survival after surgery for oesophageal cancer: a population-based study . Lancet Oncol 2005 ; 6 : 864 – 70 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Kassin M T Owen R M Perez S D et al. Risk factors for 30-day hospital readmission among general surgery patients . J Am Coll Surg 2012 ; 215 : 322 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Kjaer D W Nassar M Jensen L S Svendsen L B Mortensen F V . A bridging stent to surgery in patients with esophageal and gastroesophageal junction cancer has a dramatic negative impact on patient survival: a retrospective cohort study through data acquired from a prospectively maintained national database . Dis Esophagus 2017 ; 30 : 1 – 7 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 26 In H Palis B E Merkow R P et al. Doubling of 30-day mortality by 90 days after esophagectomy: a critical measure of outcomes for quality improvement . Ann Surg 2016 ; 263 : 286 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Rutegard M Lagergren P Johar A Lagergren J . Time shift in early postoperative mortality after oesophagectomy for cancer . Ann Surg Oncol 2015 ; 22 : 3144 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Mamidanna R Bottle A Aylin P Faiz O Hanna G B . Short-term outcomes following open versus minimally invasive esophagectomy for cancer in England: a population-based national study . Ann Surg 2012 ; 255 : 197 – 203 . Google Scholar Crossref Search ADS PubMed WorldCat 29 Yerokun B A Sun Z Jeffrey Yang C F et al. Minimally invasive versus open esophagectomy for esophageal cancer: a population-based analysis . Ann Thorac Surg 2016 ; 102 : 416 – 23 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Hirdes M M Vleggaar F P de Beule M Siersema P D . In vitro evaluation of the radial and axial force of self-expanding esophageal stents . Endoscopy 2013 ; 45 : 997 – 1005 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Preoperative esophageal stenting and short-term outcomes of surgery for esophageal cancer in a population-based study from Finland and Sweden
JF - Diseases of the Esophagus
DO - 10.1093/dote/doz005
DA - 2019-12-30
UR - https://www.deepdyve.com/lp/oxford-university-press/preoperative-esophageal-stenting-and-short-term-outcomes-of-surgery-oyc4Lu3Mdo
VL - 32
IS - 11
DP - DeepDyve
ER -