Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications
Persistent moderate-to-severe symptoms after minimally invasive esophagectomy (MIE) remain poorly characterized. While patient-reported outcomes (PROs) are increasingly recognized as important endpoints in surgical oncology, the prevalence, risk factors, optimal intervention timing, and prognostic impact of persistent postoperative symptom burden in esophageal squamous cell carcinoma (ESCC) patients have not been systematically evaluated. Understanding these factors is essential for developing evidence-based, timely symptom management strategies to improve postoperative recovery and quality of life.
We retrospectively analyzed 345 ESCC patients who underwent MIE at a single tertiary center. Symptoms were assessed using the MDASI, EORTC QLQ-C30, and QLQ-OES18 at baseline through 6 months postoperatively. Persistent moderate-to-severe symptoms at postoperative month 3 were defined by composite criteria (meeting any one): MDASI ≥3 core symptoms scoring ≥4; QLQ-C30 ≥2 functional domains below 66.7; or OES18 ≥2 symptom domains above 33.3. Independent risk factors were identified by multivariable logistic regression. Symptom trajectory analysis identified the critical divergence timepoint. Kaplan–Meier analysis, log-rank tests, multivariable Cox regression, and propensity score matching (1:1, 81 pairs) evaluated associations between symptom persistence and overall survival (OS) and disease-free survival (DFS).
At postoperative month 3, 89 patients (25.8%) met criteria for persistent moderate-to-severe symptoms. Independent risk factors were anastomotic leak (OR=7.92, P<0.001), adjuvant therapy (OR=3.05, P<0.001), and smoking history (OR=2.58, P=0.029); male sex was protective (OR=0.34, P=0.013). Predictive model AUC was 0.734. Symptom trajectories diverged at postoperative day 14. Five-year OS (63.5% vs 66.1%, HR=1.16, P=0.478) and DFS (72.9% vs 73.8%, HR=0.87, P=0.554) showed no significant differences. After propensity score matching (81 pairs), OS remained non-significant (HR=0.94, P=0.796), while DFS favored the persistent group (HR=0.55, P=0.029), potentially mediated by higher adjuvant therapy exposure.
Approximately one-quarter of post-MIE ESCC patients experience persistent moderate-to-severe symptoms at 3 months, primarily driven by anastomotic leak and adjuvant therapy. Symptom persistence does not adversely affect overall survival; its association with improved DFS likely reflects the tumor-control benefit of adjuvant therapy. Postoperative day 14 represents the critical symptom trajectory divergence point, providing an optimal window for initiating targeted PRO-based intervention.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications
Postoperative complications following oesophagectomy occur in 25–60% of patients, yet traditional patient-reported outcome (PRO) assessment relies on standardised questionnaires with limited reliability, particularly among elderly patients with low health literacy. We aimed to develop and externally validate a multimodal artificial intelligence (AI) system that automates PRO assessment from natural patient conversations and provides early warning of major postoperative complications.
We conducted a prospective observational study at a tertiary cancer center, enrolling consecutive patients undergoing esophagectomy.The development cohort (Centre 1, n=196) and the temporally independent external validation cohort (Centre 2, n=103) were recruited sequentially. Using the validated Patient Symptom Assessment for Oesophageal Cancer (PSA-ESO) instrument, we collected trimodal recordings (video, audio, text) at up to 25 timepoints per patient, yielding 6,813 evaluable assessments. We fine-tuned the Qwen2.5-Omni-7B multimodal large language model with LoRA adaptation for two tasks: automated PRO symptom grading (Task A) and Temporal Transformer-based early warning of Clavien-Dindo grade II or higher complications (Task B). In a prospective implementation substudy (n=62), we evaluated the clinical impact of real-time alerts on time-to-intervention.
In the external validation cohort, the trimodal PRO assessment achieved a weighted kappa of 0.801 (95% CI 0.73–0.87) and ICC of 0.858 against expert consensus, significantly outperforming audio-text bimodal (kappa 0.754, p<0.0001) and text-only (kappa 0.689, p<0.0001) configurations. The early warning model achieved an AUROC of 0.873 (95% CI 0.82–0.93) with a mean detection lead time of 28.7 hours before clinical diagnosis. The system detected 76.1% of symptom under-reporting cases. In the implementation substudy, real-time alerts reduced median time-to-intervention from 14.2 hours to 6.8 hours (p=0.003) and were associated with shorter ICU stays (3.1 vs 5.4 days, p=0.028).
An end-to-end multimodal AI system can accurately automate PRO assessment from natural patient conversations and provide clinically meaningful early warning for postoperative complications, with external validation confirming generalisability across cohorts. This conversation-based approach represents a paradigm shift from questionnaire-based PRO evaluation in surgical oncology, with particular relevance for populations with limited health literacy.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
Esophageal Cancer: Surgical Treatment of Esophageal Cancer – long term outcomes
Esophageal cancer remains a significant global health burden. While surgical and oncologic factors influencing survival after esophagectomy are well studied, the potential impact of surgical timing and medical staff burnout on long-term outcomes remains underexplored. This study investigates whether the month of esophagectomy and esophageal surgery personnel burnout affect survival in esophageal squamous cell carcinoma (ESCC).
A retrospective cohort of ESCC patients who underwent esophagectomy between January 2010 and December 2017 was analyzed from a single-center esophageal cancer case management database. Patients were stratified into twelve monthly subgroups based on the month of surgery. Survival outcomes were assessed using Kaplan–Meier analysis, Cox proportional hazards regression, and restricted mean survival time (RMST). Propensity score matching (PSM) was employed to adjust for confounding variables including age, sex, tumor stage, and neoadjuvant therapy. Additionally, a cross-sectional survey was conducted from 2024 to 2025 to evaluate burnout levels among 409 esophageal surgery professionals using the Maslach Burnout Inventory–Human Services Survey (MBI-HSS), with monthly stratification to examine the temporal relationship between staff burnout patterns and surgical outcomes.
Among 2,758 ESCC patients who underwent esophagectomy, those operated in February had the poorest survival, with a median survival time (MST) of 34.17 months compared to 45.23 months for non-February surgeries (HR: 0.833, 95% CI: 0.677–1.025, P=0.084). The 3- and 5-year overall survival rates were lower for February (47% and 36%) versus other months (56% and 45%). Conversely, April and June surgeries yielded superior outcomes (MST: 61.44 and 63.60 months, respectively). Burnout survey data (n=409) revealed a striking inverse pattern: February showed mild burnout (EE: 16.69, DP: 5.63), coinciding with the Chinese New Year holiday period, whereas non-February months demonstrated severe burnout (EE: 30.95, DP: 13.51). This paradoxical finding suggests that lower burnout alone does not predict better outcomes; rather, February’s reduced surgical volume and case complexity may be contributory factors.
Surgical timing, particularly esophagectomy performed in February, is associated with inferior long-term survival in ESCC patients. The concurrent low burnout levels during this period suggest that reduced surgical volume and altered case selection during the holiday season, rather than staff fatigue, may underlie this disparity. These findings highlight the importance of considering temporal factors in esophagectomy scheduling and warrant further multicenter validation.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
Esophageal Cancer: Surgical Treatment of Esophageal Cancer
Preoperative risk stratification for esophagectomy complications relies on clinical prediction models; however, their discriminative performance in multi-institutional settings remains poorly defined. We hypothesized that standard preoperative variables would demonstrate limited predictive validity across heterogeneous surgical cohorts.
We analyzed 2,490 patients undergoing esophagectomy across four institutions in Asia (total n=2,490; individual center n range 75–1,012). Four outcomes were studied: recurrent laryngeal nerve palsy (RLNP), anastomotic leak (AL), pulmonary complications (PC), and vocal cord palsy (VCP). Logistic regression models with bootstrap-validated odds ratios (1,000 iterations) were evaluated by 5-fold cross-validated AUC. SHAP (SHapley Additive exPlanations) via Gradient Boosting Machines quantified variable importance. Decision curve analysis (DCA) assessed net clinical benefit across threshold probabilities 2–70%. Association between tumor location and each complication was assessed using chi-squared tests.
All prediction models demonstrated poor-to-fair discrimination: RLNP AUC 0.533, AL AUC 0.586, PC AUC 0.676, and VCP AUC 0.556. Tumor location was the only statistically significant categorical predictor of RLNP—upper/cervical location was associated with higher RLNP incidence compared to middle thoracic tumors (39.1% vs. 28.0%; OR 1.22, 95%CI 1.05–1.42; p=0.009). No significant association was observed between tumor location and AL, PC, or VCP. DCA demonstrated negligible clinical net benefit for RLNP and AL models; only the PC model provided modest benefit (max net benefit gain +0.057) at threshold probabilities of 5–20%. SHAP analysis identified FEV1%, PNI score, and BMI as the highest-importance variables for RLNP prediction, with tumor location ranking sixth—indicating that location contributes a statistically real but clinically modest signal.
Standard preoperative variables are insufficient for individualized risk stratification of RLNP, anastomotic leak, or vocal cord palsy after esophagectomy. Statistical significance (p=0.009 for location–RLNP association) does not translate to clinically meaningful predictive power (AUC 0.533). Tumor location should be incorporated into RLNP preoperative counseling. Improved prediction will require prospective integration of real-time intraoperative data. Pulmonary complication risk approaches clinically actionable prediction (AUC 0.676) and may guide respiratory prehabilitation targeting.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
A multimodal early warning system integrating PROs, laboratory trajectories, and large language model-extracted clinical text features to enable real-time, automated complication surveillance substantially outperforms single-modality approaches for detecting postoperative complications after esophagectomy.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
Postoperative CRP trajectory patterns are significantly associated with complication severity after esophagectomy, and the High-Persistent trajectory identifies a high-risk subgroup, and the D3/D1 ratio enables early risk stratification by POD 3.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations
The natural product compounds CNP0456830 and CNP0467494 exhibited the lowest binding free energies for both EGFR and PIK3CA, identifying them as the most promising dual-target inhibitors.
Si-miao Lu, Yi Zhu, Yong-tao Han et al.· Diseases of the esophagus· 0 citations