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DEMOGRAPHIC DETAILS* These details are to be used locally and kept secure, they are not required to be submitted via REDCAPName _________________________ Date of Surgery __________________DoB_______/_____/_______ d/m/y Hospital No _________________ Age (years)Height (centimetres) __________Weight (kilograms) __________________Male Female Smoking HistoryNever Current Ex-smoker for less than 6 weeks Ex-smoker for more than 6 weeks Unknown COMORBIDITYASA GradePlease note ASA5 (moribund) or emergency oesophagectomy patients are excluded from this study1 - A normal healthy patient 2 - A patient with mild systemic disease 3 - A patient with severe systemic disease 4 - A patient with severe systemic disease that is a constant threat to life Eastern Cooperative Oncology Group (ECOG)/WHO/Zubrod Score0 - Fully active, able to carry on all pre-disease performance without restriction. 1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. 2 - Capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours. 3 - Capable of only limited self-care; confined to bed or chair more than 50% of waking hours. 4 - Completely disabled; cannot carry on any self-care; totally confined to bed or chair. Charlson Comorbidity IndexPlease choose all that applyMyocardial infarction Congestive heart failure Peripheral vascular disease (includes aortic aneurysm >= 6 cm) Cerebrovascular disease: CVA with mild or no residual weakness or TIA Dementia Chronic pulmonary disease Connective tissue disease Peptic ulcer disease Mild liver disease (without portal hypertension, includes chronic hepatitis) Diabetes without end-organ damage (excludes diet-controlled alone) Hemiplegia Moderate or severe renal disease Diabetes with end-organ damage (retinopathy, neuropathy, nephropathy, or brittle diabetes) Tumour without metastasis (exclude if > 5 y from diagnosis) Leukaemia (acute or chronic) Lymphoma Moderate or severe liver disease Metastatic solid tumour AIDS (not just HIV positive) Albumin ______________g/L Albumin ________________mmol/LHaemoglobin ____________g/LSerum Creatinine μmol/L ________Serum Creatinine (mg/dL) ___________MALIGNANCY DETAILSTumour TypeAdenocarcinoma Squamous Cell Carcinoma Other - Please specify Specify other:_____________________Location of tumourUpper thoracic - approx. 20-25cm Middle thoracic - approx. 25-30cm Distal thoracic - approx. 30cm-greater than 5cm proximal to the anatomical squamocolumnar junction or Z-line Siewert 1 - between 5 and 1 cm proximal to the anatomical squamocolumnar junction or Z-line Siewert 2 - between 1 cm proximal and 2 cm distal to the anatomical Z-line Siewert 3 - between 2 and 5 cm distal to the anatomical Z-line Pre-op T Stage (as per Tumour Node Metastases (TNM) 7th edition)TX - Primary tumour cannot be assessed T0 - No evidence of primary tumour Tis - High-grade dysplasia T1a - Tumour invades lamina propria or muscularis mucosae T1b - Tumour invades submucosa T2 - Tumour invades muscularis propria T3 - Tumour invades adventitia T4a - Resectable tumour invading pleura, pericardium, or diaphragm T4b -Unresectable tumour invading other adjacent structures, such as aorta, vertebral body, trachea, etc. Pre-op N stage (as per TNM 7th edition)NX - Regional lymph node(s) cannot be assessed N0 - No regional lymph node metastasis N1 - Metastasis in 1-2 regional lymph nodes N2 - Metastasis in 3-6 regional lymph nodes N3 - Metastasis in seven or more regional lymph nodes Pre-op M stage (as per TNM 7th edition)M0 - No distant metastasis M1 - Distant metastasis Neo-adjuvant therapyNone Chemotherapy alone Radiotherapy alone Chemoradiotherapy Chemotherapy regimenCF - Cisplatin, 5FU ECF - Epirubicin, Cisplatin, 5FU ECX - Epirubicin, Cisplatin, Capecitabine EOX - Epirubicin, Oxaliplatin, Capecitabine FLOT - 5FU, Oxaliplatin, Leucoverin, Docetaxel MIC - Mitomycin, Ifosfamide, Cisplatin CROSS - Carboplatin, Paclitaxel Other - Please specify Total number of cycles of neo-adjuvant chemotherapy - Intended to be given ___________cyclesTotal number of cycles of neo-adjuvant chemotherapy - Completed___________cyclesTotal neo-adjuvant radiotherapy dose (Total Gy)___________GyGastric fundus included in radiotherapy fieldYes No Pre-operative nutritional supportNone Oral supplements Enteral nutrition support via NG - Nasogastric Tube Enteral nutrition support via NJ - Nasojejunal Tube Enteral nutrition support via PEG - Percutaneous Endoscopic Gastrostomy Enteral nutrition support via Jejunostomy PN - Parenteral Nutrition Pre-operative gastric ischaemic pre-conditioning performed.Yes No OPERATIVE DATA COLLECTIONTraining OperationYes No Trainee performed abdominal phaseYes No Trainee performed chest dissectionYes No Trainee performed neck dissectionYes No Not applicable (not done) Trainee performed anastomosisYes No Not applicable (not done) Abdominal phaseOpen Laparoscopic Laparoscopic converted to open Robotic Robotic converted to laparoscopic Robotic converted to open Thoracic phaseOpen-right chest Open-left chest Open-Thoracoabdominal Thoracoscopic Thoracoscopic converted to open Transhiatal Robotic Robotic converted to thoracoscopic Robotic converted to open LymphadenectomyAbdominal only Abdominal and chest (two field) Abdominal, chest and neck (three field) Gastric tubeWhole stomach Wide gastric tube more than 5cm Thin gastric tube less than 5cm ANASTOMOSISAnastomosis techniqueHandsewn Circular stapled Linear stapled and sutured (Orringer style) No anastomosis Anastomotic configurationEnd to end End to side Side to side Site of AnastomosisNeck Chest above Azygous Chest at Azygous Chest below Azygous Anastomosis not performed Linear stapler deviceEndopath (Ethicon) GIA (Covidien) NTLC (Ethicon) TA (Covidien) TCT (Ethicon) TL (Covidien) TLC (Ethicon) TX (Ethicon) Other - please specify Handsewn techniqueSingle layer interrupted Single layer continuous Double layer interrupted Double layer continuous Circular staplerCDH (Ethicon) CEEA (Covidien) ECS (Ethicon) EEA (Covidien) SDH (Ethicon) OrViL (Covidien) Other Circular stapler- specify type_______________________________________ free textCircular stapler- Head diameter21 22 23 24 25 26 27 28 29 30 31 32 33 34 Size in millimetersAnastomosis covered in omentumYes No Anastomosis buried in the pleuraYes No Anastomosis checked intra-operatively for integrityNot performed Nasogastric tube air leak test Intra-operative endoscopy Methylene blue/ other dye Indigocyanine green (ICG) assessment Other - please specify Nutritional feeding accessNone Feeding Jejunostomy Nasojejunal tube Pyloric proceduresNot performed Pyloromyotomy Pyloroplasty Botox Dilatation INTRA-OPERATIVE COMPLICATIONSIntra-operative complicationMajor vessel injury Unable to perform anastomosis Unplanned splenectomy Enteric injury Airway injury Non-viable gastric conduit Gastric conduit unable to reach planned anastomosis site ANAESTHETIC RECORDSingle lung ventilation Yes No Mechanism of single lung ventilation Double lumen ET tube Bronchial blocker Duration of single lung ventilation (minutes) ___________________Intra-operative vasopressor support requiredNot given Intermittent boluses Intravenous infusion vasopressors include: adrenaline/epinephrinie, noradrenaline/norepinephrine, vasopressin, dopamine, dobutamine, phenylephrineTotal volume of crystalloids given intra-op ________________ mlsTotal volume of colloids given intra-op ________________ mlsIntra-operative blood transfusion - Yes No Number of units of packed red cells (blood) transfused. _______Post-operative blood transfusion - Yes No Number of units of packed red cells (blood) transfused. _______Analgesia techniquesEpidural Thoracic paravertebral block Spinal/ intra-thecal morphine Patient controlled analgesia (PCA) Ketamine Abdominal pain catheter Lactate immediately post-op ____________________mmol/LWas the patient extubated the same day as resectional surgeryYes No POST OPERATIVE COMPLICATIONS (Low, Donald E., et al. "International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy Complications Consensus Group (ECCG)." Annals of surgery 262.2 (2015): 286-294.)Was assessment of the anastomosis performed in the post operative period? Yes - as routine assessment Yes - clinical suspicion of leak No What day post operatively was the anastomosis assessed FIRST assessed______________ days post opPlease specify number of day post-operativelyWhat assessment of the anastomosis was performed Endoscopy Plain film contrast swallow CT contrast swallow Other - please specify __________________Final Anastomotic Leak Grade No leak Type 1 leak Type 2 leak Type 3 leak For example, if initially managed with a stent but then went on to have surgery, this would be a Type 3 leak.Final Conduit Necrosis Grade No necrosis Type 1 necrosis Type 2 necrosis Type 3 necrosis For example if initially managed with non-surgical therapy but then went on to have surgery, this would be a Type 3 conduit necrosis.What post operative day was an anastomotic leak identified?__________________days post opPlease enter post-operative day i.e. 5 if fifth day post-operationWhat post operative day was a conduit necrosis identified?__________________days post opPlease enter post-operative day i.e. 5 if fifth day post-operationPost operative day primary leak/conduit necrosis management initiated__________________days post opPlease enter post-operative day i.e. 5 if fifth day post-operationPRIMARY TREATMENT STRATEGY OF LEAK/CONDUIT NECROSISPrimary treatment of Leak/conduit necrosis: Operative?Yes No Operative technique - ApproachMinimal access chest Minimal access abdomen Minimal access converted to open chest Minimal access converted to open abdomen Open chest Open abdomen Open neck Operative technique - ProcedureWashout only no resection or repair Drainage - T-tube or foley catheter in defect Repair of anastomosis, no resection Repair of anastomosis, no resection, with muscle flap Resection of anastomosis and refashioning Disconnection and cervical oesophagostomy Conservative Management StrategyNil by mouth Antibiotics Antifungals Parenteral Nutrition Enteral Nutrition (e.g.NG/NJ/Feeding Jejunostomy) Please tick all that applyRadiological drain?Yes No Number of radiologically sited drains at initial intervention ___________________ Please specify number of inserted drainsWas an Oesophageal stent used to treat an anastomotic leak? Yes No Oesophageal stent typeCovered plastic Covered metal Covered biodegradable Other Complication of oesophageal stentNo complication Failed placement Displacement Erosion Failure to occlude leak Other Total number of stent placements____________________ Please specify numberEndoVac/Endosponge placed Yes No Total number of EndoVac/EndoSponge changes____________________Please specify numberOther Endoscopic Methods of Leak ManagementHaemostatic Clips Fibrin Glue Over The Scope Clips (OTSCs) Was a second strategy of leak/necrosis management used?Yes No SECONDARY TREATMENT STRATEGYNumber of post-operative days secondary leak management strategy instigated____________________ days post opPlease specify numberSecondary treatment strategy of Leak/ Conduitnecrosis: Operative?Yes No Operative technique - ApproachMinimal access chest Minimal access abdomen Minimal access converted to open chest Minimal access converted to open abdomen Open chest Open abdomen Open neckOperative technique - ProcedureWashout only no resection or repair Drainage - T-tube or foley catheter in defect Repair of anastomosis, no resection Repair of anastomosis, no resection, with muscle flap Resection of anastomosis and refashioning Disconnection and cervical oesophagostomy Radiological drain? Yes No Number of radiological drains sited_______________________ Please specify numberOesophageal stent placedYes No Oesophageal stentCovered plastic Covered metal Covered biodegradable Other Complication of oesophageal stentNo complication Failed placement Displacement Erosion Failure to occlude leak Other Total number of stent placements____________________ (Including initial stent and any subsequent restenting)EndoVac/ Endosponge placed Yes No Total number of Endovac/ EndoSponge changes____________________ Other Endoscopic Methods of Leak ManagementHaemostatic Clips Fibrin Glue Over The Scope Clips (OTSCs) Was a tertiary strategy of leak/necrosis management used?Yes no TERTIARY TREATMENT STRATEGYNumber of post-operative days tertiary leak management strategy instigated_________________ days post opPlease specify number of daysOperative technique - ApproachMinimal access chest Minimal access abdomen Minimal access converted to open chest Minimal access converted to open abdomen Open chest Open abdomen Open neck Operative technique - ProcedureWashout only no resection or repair Drainage - T-tube or foley catheter in defect Repair of anastomosis, no resection Repair of anastomosis, no resection, with muscle flap Resection of anastomosis and refashioning Disconnection and cervical oesophagostomy Radiological drain placedYes No Number of radiological drains sited_______________________ Oesophageal stent placedYes No Complication of oesophageal stentNo complication Failed placement Displacement Erosion Failure to occlude leak Other Total number of stent placements____________________(Including initial stent and any subsequent restenting)EndoVac / Endosponge placedYes No Total number of Endovac/ EndoSponge changes____________________Other Endoscopic Methods of Leak ManagementHaemostatic Clips Fibrin Glue Over The Scope Clips (OTSCs) Please choose any that applyWas a further management strategy of leak/conduit necrosis used?Yes No Please describe this further leak/conduit necrosis management strategy.____________________ _______________________________________________________________________________________OTHER COMPLICATIONSChyle Leak GradeNo chyle leak Type 1: Treatment-enteric dietary modifications Type 2: Treatment-total parenteral nutrition Type 3: Treatment-interventional or surgical therapy Type A - < than 1 Litre in 24 hours Type B - > than 1 Litre in 24 hours Vocal Cord Injury/PalsyDe?ned as: Vocal cord dysfunction post-resection. Con?rmation and assessment should be by direct examinationNo vocal cord injury Type 1: Transient injury requiring no therapy. Dietary modi?cation allowed Type 2: Injury requiring elective surgical procedure, for example, thyroplasty or medialization procedure Type 3: Injury requiring acute surgical intervention (due to aspiration or respiratory issues), for example, thyroplasty or medialization procedure Type A – Unilateral Type B – Bilateral Gastrointestinal complicationNone Ileus de?ned as small bowel dysfunction preventing or delaying enteral feeding Small bowel obstruction Feeding J-tube complication Pyloromyotomy/pyloroplasty complication Clostridium dif?cile Infection Gastrointestinal bleeding requiring intervention or transfusion Delayed conduit emptying requiring intervention or delaying discharge or requiring maintenance of NG drainage >7d postoperatively Pancreatitis Liver dysfunction Respiratory complicationNone Pneumonia Pleural effusion requiring additional drainage procedure Pneumothorax requiring treatment Atelectasis mucous plugging requiring bronchoscopy Respiratory failure requiring reintubation Acute respiratory distress syndrome (Berlin De?nition) Acute aspiration Tracheobronchial injury Chest tube maintenance for air leak for >10 d postoperatively Tracheostomy Cardiac complicationNone Cardiac arrest requiring CPR Myocardial infarction (De?nition: World Health Organization) Dysrhythmia atrial requiring treatment Dysrhythmia ventricular requiring treatment Congestive heart failure requiring treatment Pericarditis requiring treatment Wound/Diaphragmatic complicationNone Thoracic wound dehiscence Acute abdominal wall dehiscence/hernia Acute diaphragmatic hernia Infectious complicationNone Wound infection requiring opening wound or antibiotics Central IV line infection requiring removal or antibiotics Intrathoracic/intra-abdominal abscess Generalised sepsis Other infections requiring antibiotics Urological & Renal complicationNone Acute renal insuf?ciency (de?ned as doubling of baseline creatinine) Acute renal failure requiring dialysis Urinary tract infection Urinary retention requiring reinsertion of urinary catheter, delaying discharge, or discharge with urinary catheter Thromboembolic complicationNone DVT PE Stroke (CVA - Cerebrovascular accident) Peripheral thrombophlebitis Return to theatre for ANY surgical procedure under a GA?Yes No Complication not specified___________________________________________________________________________________________________________Final T Stage (as per TNM 7th edition)TX - Primary tumour cannot be assessed T0 - No evidence of primary tumour Tis - High-grade dysplasia T1a - Tumour invades lamina propria or muscularis mucosae T1b - Tumour invades submucosa T2 - Tumour invades muscularis propria T3 - Tumour invades adventitia T4a - Resectable tumour invading pleura, pericardium, or diaphragm T4b - Unresectable tumour invading other adjacent structures, such as aorta, vertebral body, trachea, etc. Total number of lymph nodes examined__________________ Number of lymph nodes with metastases__________________ Final M stage (TNM 7th)M0 - No distant metastasis M1 - Distant metastasis Proximal resection margin involved (< 1mm)Yes No Distal resection margin involved (< 1mm)Yes No Circumferential (radial) resection margin involved (< 1mm)Yes No Overall Clavien-Dindo Complication Classification(at time of discharge)Grade I - Any deviation from the normal postoperative course* Grade II - Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood transfusions and total parenteral nutrition are also included. Grade IIIa - Requiring surgical, endoscopic or radiological intervention NOT under GA Grade IIIb - Requiring surgical, endoscopic or radiological intervention UNDER GA Grade IVa - Life-threatening complicationrequiring ICU-management: SINGLE organ dysfunction Grade IVb - Life-threatening complication requiring ICU-management: MULTI organ dysfunction. Grade V - Death of a patient *Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgetics, diuretics and electrolytes and physiotherapy. Grade I also includes wound infections opened at the bedside.Total length of stay on ITU & HDU (non "ward based care) _________________ daysPlease specify number of daysWas the patient eating and drinking on discharge Yes No Total length of hospital stay (days)_________________ daysPlease specify number of daysDischarge destination Home Other Medical Facility e.g. secondary hospital, rehabilitation center, nursing facility Not applicable - Not discharged RE-ADMISSION TO HOSPITAL WITHIN 30 DAYSNumber of days after discharge the patient was re-admitted_________________ post op daysLocation of re-admission Primary Hospital Secondary Hospital Cause for readmission_________________ free text90-day mortalityYes No How many days post-operatively did the patient die? _______Location of deathIn hospital death Out of hospital death ................
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