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Kit OI, Kolesnikov EN, Katsieva TB, Kozhushko MA, Myagkov RE, Sanamyants SV, Snezhko AV, Trifanov VS. [Short-term outcomes of surgical treatment of gastroesophageal junction cancer]. Khirurgiia (Mosk) 2019:17-21. [PMID: 31464269 DOI: 10.17116/hirurgia201908117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To confirm simplicity, safety and efficacy of stapling devices for gastroesophageal anastomosis (including those formed in mediastinum) in the treatment of gastroesophageal junction cancer. MATERIAL AND METHODS There were 147 patients with cardioesophageal cancer. Tumors Siewert type II and III were predominant (44.2 and 40.3%, respectively). Simultaneous procedures were performed in 30.6% of cases. RESULTS Postoperative complication rate was 42.2%. Pneumonia was the most common. Postoperative mortality was 2.7%.
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Affiliation(s)
- O I Kit
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - E N Kolesnikov
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - T B Katsieva
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - M A Kozhushko
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - R E Myagkov
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - S V Sanamyants
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - A V Snezhko
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
| | - V S Trifanov
- Rostov Research Institute for Oncology, Rostov-on-Don, Russia
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Abstract
A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.
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Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA.
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Minimally Invasive and Robotic Esophagectomy: A Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 13:391-403. [PMID: 30543576 DOI: 10.1097/imi.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
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54
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Zhang R, Zhang L. Feasibility of complete nasogastric tube omission in esophagectomy patients. J Thorac Dis 2019; 11:S819-S823. [PMID: 31080664 DOI: 10.21037/jtd.2018.11.98] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Routine nasogastric tube (NGT) placement is a common practice in esophagectomy patients. However, its continued application has been controversial in recent years. In this review, we will discuss the potential risks and benefits, including anastomosis leak, pneumonia, NGT reinsertion, patients' discomfort and hospital length of stay, to evaluate the feasibility of complete NGT omission in esophagectomy patients.
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Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China
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The Impact of Circular Stapler Size on the Incidence of Cervical Anastomotic Stricture After Esophagectomy. World J Surg 2019; 43:1746-1755. [DOI: 10.1007/s00268-019-04938-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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56
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Chikhladze S, Kupreishvili S, Korsake K, Sick O, Fink J, Seifert G, Läßle C, Nenova G, Höppner J, Glatz T, Fichtner-Feigl S, Marjanovic G. Recurring Anastomotic Leak-A Prospective Clinicopathological Investigation of a Distinct Disease Pattern. J Surg Res 2019; 239:201-207. [PMID: 30851519 DOI: 10.1016/j.jss.2019.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/14/2019] [Accepted: 02/06/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Intestinal anastomotic insufficiency (AI) is a common problem in visceral surgery associated with overexpression of matrix metalloproteinases (MMPs). In some patients it occurs more than once. The etiology of recurring anastomotic insufficiency (RAI) is not understood yet and should be addressed as an independent disease entity. MATERIALS AND METHODS Thirty nine consecutive patients with AI were treated at our university center and were included in this prospective study. Clinical data were evaluated by correlative statistical analysis to identify independent risk factors for RAI. Patients were divided in two groups: 18 patients had a single operative revision until restoration (group SAI), and 21 patients had two or more revisions (group RAI). Anastomotic tissue samples as well as untouched bowel wall were collected during reoperations for analysis of MMPs and tissue inhibitor of metalloproteinases (TIMP2). Clinical data were correlated with pathological observations. RESULTS Significant differences of clinical and molecular pathological data were found between the two groups. Transfusion of red blood cells until the first reoperation and alcohol abuse led to RAI and were the only independent risk factors for RAI in multivariate analysis. Overexpression of MMP-8, -9, and -13 in anastomotic tissue correlated with the administration of red blood cells during initial operation. Reduced expression of TIMP2 was frequent in nearly all patients without differences throughout the subgroups. CONCLUSIONS RAI seems to have an independent disease pattern. Transfusion of blood products is not only a known risk factor for AI but seems to significantly disturb the anastomotic healing process leading to RAI.
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Affiliation(s)
- Sophia Chikhladze
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany.
| | - Shota Kupreishvili
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Kristina Korsake
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Olivia Sick
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Jodok Fink
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Gabriel Seifert
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Claudia Läßle
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Gergana Nenova
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Jens Höppner
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Torben Glatz
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
| | - Goran Marjanovic
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Center for Surgery, Freiburg, Germany
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Finley RJ. Commentary: Severe anastomotic leaks after esophagectomy need early operative intervention. J Thorac Cardiovasc Surg 2019; 157:2094-2095. [PMID: 30638622 DOI: 10.1016/j.jtcvs.2018.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Richard J Finley
- Division of Thoracic Surgery, Department of Surgery, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada.
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Sugimura K, Miyata H, Matsunaga T, Asukai K, Yanagimoto Y, Takahashi Y, Tomokuni A, Yamamoto K, Hirofumi A, Nishimura J, Motoori M, Wada H, Takahashi H, Yasui M, Omori T, Ohue M, Yano M. Comparison of the modified Collard and hand-sewn anastomosis for cervical esophagogastric anastomosis after esophagectomy in esophageal cancer patients: A propensity score-matched analysis. Ann Gastroenterol Surg 2019; 3:104-113. [PMID: 30697615 PMCID: PMC6345657 DOI: 10.1002/ags3.12220] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Several studies have reported that modified Collard anastomosis is useful for cervical anastomosis after esophagectomy for thoracic esophageal cancer. However, no large-scale study has confirmed the efficacy of the modified Collard anastomosis. METHODS Between 2008 and 2016, 398 consecutive esophageal cancer patients who underwent esophagectomy and cervical anastomosis were enrolled in this study. Patients with a short remnant cervical esophagus were excluded. We investigated the utility of the modified Collard anastomosis by comparing the results of postoperative complications using a propensity score-matched analysis between the hand-sewn method (HS) and the modified Collard anastomosis (MC) for esophagogastric anastomosis of the neck after esophagectomy in thoracic esophageal cancer patients. RESULTS Of the 398 patients, 127 were included in the MC group and 127 were included in the HS group after propensity score matching. Clinical characteristics did not differ between the two groups. Frequency of anastomotic leakage tended to be lower in the MC group than in the HS group (3% vs. 7%, P = 0.127). Frequency of anastomotic stenosis was significantly lower in the MC group than in the HS group (13% vs. 59%, P < 0.001). Multivariate logic analysis showed that anastomotic technique (HS) and performance status were independent factors associated with anastomotic stenosis (odds ratio, 12.24 and 2.52; P-value <0.001 and 0.047, respectively). CONCLUSION In cervical esophagogastric anastomosis after esophagectomy, the modified Collard anastomosis is more suitable than hand-sewn anastomosis in terms of reducing the frequency of anastomotic stenosis.
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Affiliation(s)
- Keijiro Sugimura
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Tomoyuki Matsunaga
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | | | - Yusuke Takahashi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Akira Tomokuni
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kazuyoshi Yamamoto
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Akita Hirofumi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Junichi Nishimura
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masaaki Motoori
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Wada
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayoshi Yasui
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Takeshi Omori
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayuki Ohue
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masahiko Yano
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
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Agzarian J, Visscher SL, Knight AW, Allen MS, Cassivi SD, Nichols FC, Shen KR, Wigle D, Blackmon SH. The cost burden of clinically significant esophageal anastomotic leaks-a steep price to pay. J Thorac Cardiovasc Surg 2018; 157:2086-2092. [PMID: 30558876 DOI: 10.1016/j.jtcvs.2018.10.137] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 10/08/2018] [Accepted: 10/14/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of this retrospective cohort study was to evaluate resource consumption of clinically significant esophageal anastomotic leaks. METHODS Between September 1, 2008, to December 31, 2014, a prospectively maintained database was queried to identify patients with grade III to IV anastomotic leaks after esophagectomy for esophageal cancer. Inflation-adjusted standardized costs were applied to billed services related to leak diagnosis and treatment, from time of leak detection to resumption of oral diet. A matched analysis was used to compare average expenditures in patients without vs. those with an anastomotic leak. RESULTS Of 448 patients undergoing esophagectomy after neoadjuvant treatment, 399 patients met inclusion criteria. Twenty-four grade III to IV anastomotic leaks were identified (6% leak rate). Five transhiatal esophagectomies accounted for 20.8% of cases, whereas 9 Ivor Lewis and 10 McKeown esophagectomies accounted for 37.5% and 41.7%, respectively. The median time required to treat an anastomotic leak was 73 days (range 14-701). The additional median standardized cost per leak was $68,296 (mean $119,822). Matched analysis demonstrated that mean treatment costs were 2.6 times greater for patients with an anastomotic leak. This was primarily attributed to prolonged hospitalization, with post-leak detection length of stay ranging from 7 to 73 days. The largest contributors to cost for all patients were intensive care stay (30%), hospital room (17%), pharmacy (16%), and surgical intervention (13%). CONCLUSIONS Grade III to IV esophageal anastomotic leaks more than double the cost of an esophagectomy and have a significant cost burden. Focus should be placed on preventative measures to avoid leaks at the time of the index operation.
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Affiliation(s)
- John Agzarian
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester.
| | - Sue L Visscher
- Mayo Clinic, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minn
| | - Ariel W Knight
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - Mark S Allen
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - Stephen D Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - Francis C Nichols
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - K Robert Shen
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - Dennis Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
| | - Shanda H Blackmon
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester
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Shridhar R, Takahashi C, Huston J, Doepker MP, Meredith KL. Anastomotic leak and neoadjuvant chemoradiotherapy in esophageal cancer. J Gastrointest Oncol 2018; 9:894-902. [PMID: 30505592 DOI: 10.21037/jgo.2018.04.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Anastomotic leaks (AL) cause significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (UFS) and NCR patients. Methods An esophagectomy database was queried for UFS and NCR patients treated between 1996 and 2015. Predictors of AL rate were identified using univariate and multivariate (MVA) analysis and propensity score matching (PSM). Results We identified 820 patients (UFS, 288; NCR, 532). Overall AL rate was 5.4%. Decreased AL rate was observed in NCR patients on MVA (8.0% vs. 4.1%; P=0.02) but no difference was seen after PSM (7.7% vs. 4.2%; P=0.14). MVA of factors associated with decreased AL in UFS patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic. Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM. MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. Conclusions There is no difference in the AL rate between UFS and NCR patients. Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.
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Affiliation(s)
- Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA
| | | | - Jamie Huston
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Matthew P Doepker
- Department of Surgery, University of South Carolina, Columbia, SC, USA
| | - Kenneth L Meredith
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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Liu YJ, Fan J, He HH, Zhu SS, Chen QL, Cao RH. Anastomotic leakage after intrathoracic versus cervical oesophagogastric anastomosis for oesophageal carcinoma in Chinese population: a retrospective cohort study. BMJ Open 2018; 8:e021025. [PMID: 30181184 PMCID: PMC6129039 DOI: 10.1136/bmjopen-2017-021025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the characteristics and predictors for anastomotic leakage after oesophagectomy for oesophageal carcinoma from the perspective of anastomotic level. DESIGN Retrospective cohort study. SETTINGS A single tertiary medical centre in China. PARTICIPANTS From January 2010 to December 2016, all patients with oesophageal cancer of the distal oesophagus or gastro-oesophageal junction undergoing elective oesophagectomy with a curative intent for oesophageal carcinoma with intrathoracic oesophagogastric anastomosis (IOA) versus cervical oesophagogastric anastomosis (COA) were included. We investigated anastomotic level and perioperative confounding factors as potential risk factors for postoperative leakage by univariate and multivariate logistic regression. PRIMARY OUTCOME MEASURES The primary outcome was the odds of anastomotic leakage by different confounding factors. Secondary outcome was the association of IOA versus COA with other postoperative outcomes. RESULTS Of 458 patients included, 126 underwent cervical anastomosis and 332 underwent intrathoracic anastomosis. Anastomotic leakage developed in 55 patients (12.0%), with no statistical differences between COA and IOA (16.6% vs 10.2%; p=0.058). Multivariable analysis identified active diabetes mellitus (OR 2.001, p=0.047), surgical procedure (open: reference; minimally invasive: OR 1.770, p=0.049) and anastomotic method (semimechanical: reference; stapled: OR 1.821; handsewn: OR 2.271, p=0.048) rather than anastomotic level (IOA: reference; COA: OR 1.622, p=0.110) were independent predictors of leakage. CONCLUSIONS Surgical and anastomotic techniques rather than the level of anastomotic site were independent predictors of postoperative anastomotic leakage in patients undergoing oesophageal cancer surgery.
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Affiliation(s)
- Yin-jiang Liu
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Jun Fan
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huang-he He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shu-sheng Zhu
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Qiu-lan Chen
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Rong-hua Cao
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
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Speicher JE, Gunn TM, Rossi NP, Iannettoni MD. Delay in Oral Feeding is Associated With a Decrease in Anastomotic Leak Following Transhiatal Esophagectomy. Semin Thorac Cardiovasc Surg 2018; 30:476-484. [PMID: 30189260 DOI: 10.1053/j.semtcvs.2018.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 08/27/2018] [Indexed: 02/08/2023]
Abstract
The cervical anastomotic leak is a major complication of transhiatal esophagectomy and results in chronic strictures in up to half of patients. A change in postoperative protocol to delaying initiation of oral intake was made with the goal of reducing anastomotic leak rate and associated sequelae. A postoperative protocol change was applied to all patients undergoing elective transhiatal esophagectomy. Rate of anastomotic leak and anastomotic stricture, defined as defect in the esophagogastric anastomosis and narrowing of the anastomosis, respectively, were compared between pre- and post-change groups. Between 2004 and 2013, 203 patients underwent transhiatal esophagectomy with cervical anastomosis. Historically, oral intake was resumed on postoperative day 3, and during the course of the study, a change was made to the protocol to delay oral intake until 15 days postoperatively. Eighty-three patients were in the early oral feeding group (postoperative day 3), and 120 were in the delayed oral intake group (postoperative day 15). There was a statistically significant decrease in the rate of anastomotic leak from 14.5% to 4.2% between the early and delayed intake groups, respectively (P = 0.0089). There was also a trend (P = 0.05) towards a lower rate of anastomotic stricture in all patients in the delayed intake group (15.8%) compared with those in the early feeding group (27.7%). By increasing the time to postoperative oral feeding, we have noted an associated improvement in both immediate and long-term outcomes of elective transhiatal esophagectomy patients.
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Affiliation(s)
- James E Speicher
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina.
| | - Tyler M Gunn
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky
| | - Nicholas P Rossi
- Division of Cardiothoracic Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Mark D Iannettoni
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina
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Kesler KA, Ramchandani NK, Jalal SI, Stokes SM, Mankins MR, Ceppa D, Birdas TJ, Vardas PN, Rieger KM. Outcomes of a novel intrathoracic esophagogastric anastomotic technique. J Thorac Cardiovasc Surg 2018; 156:1739-1745.e1. [PMID: 30033105 DOI: 10.1016/j.jtcvs.2018.05.088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel "side-to-side: staple line-on-staple line" (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide-diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institution's initial 6-year experience. METHODS An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications. RESULTS There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end-stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P = .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge. CONCLUSIONS We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.
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Affiliation(s)
- Kenneth A Kesler
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind.
| | - Neal K Ramchandani
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Shadia I Jalal
- Medical Oncology Division, Department of Medicine, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Samatha M Stokes
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Mark R Mankins
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - DuyKhanh Ceppa
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Thomas J Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Panos N Vardas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Karen M Rieger
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
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Kumar T, Krishanappa R, Pai E, Sringeri R, Singh TB, Swain J, Kondapavuluri S, Pandey M. Completely Linear Stapled Versus Handsewn Cervical Esophagogastric Anastomosis After Esophagectomy. Indian J Surg 2018; 80:134-139. [PMID: 29915479 DOI: 10.1007/s12262-018-1732-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 01/22/2018] [Indexed: 01/17/2023] Open
Abstract
Very limited data is present which compares completely linear stapled to handsewn cervical esophagogastric anastomosis. Primary objective was to determine whether linearly stapled (LS) anastomosis has lower clinically apparent leaks, when compared to handsewn anastomosis (HS). Secondary objectives were morbidity, mortality, overall leak and stricture rates, and presence of a symptomatic cervical stricture. This is a comparative study of 77 patients who underwent LS (n = 29) and HS (n = 48) cervical anastomosis. Anastomotic leak was found to be 19.4% (15/77). In the HS group, 27.08% (13/48) and in the LS group, 6.89% (2/29), respectively, leaked (p = 0.03), relative risk (RR)-3.93 (95% CI 1.21-15.25). 32.5% (23/77) patients remained admitted for more than 14 days. 52.1% (25/48) patients in the HS group were discharged within 14 days of surgery; whereas; 93.1% (27/29) were discharged in LS group (p = 0.001), RR-6.95 (95% CI 2.13-25.94). Overall, 90-day mortality was 7.8% (6/77). In the HS group, 8.3% (4/48) patients died while in the LS group, 6.8% (2/29) patients died (p = 0.82), RR-1.21(95% CI 0.27-5.53). In the HS group, 6.25% (3/48) patients were diagnosed with stricture compared to 6.8% (2/29) patients in the LS group (p = 0.9), RR-0.91 (95% CI 0.19-4.44). Overall stricture rate was 6.4% (5/77). Cervical anastomosis done with linear staplers has less leak rates compared to handsewn anastomosis.
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Affiliation(s)
- Tarun Kumar
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Ravi Krishanappa
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - Esha Pai
- 3Department Of Surgical Oncology, Tata Memorial Hospital, E Borges Road, Parel, Mumbai, 400012 India
| | - Raxith Sringeri
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - T B Singh
- 4Department of Biostatistics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Jyoti Swain
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
| | - Sindhuri Kondapavuluri
- 2Department of Surgical Oncology, JSS Medical College, Mysore Bangalore Road, Bannimantap, Mysuru, 570015 India
| | - Manoj Pandey
- 1Department of Surgical Oncology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, 221005 India
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Ishibashi Y, Fukunaga T, Mikami S, Oka S, Kanda S, Yube Y, Kohira Y, Enomoto T, Otsubo T. Triple-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis. Esophagus 2018; 15:88-94. [PMID: 29892931 PMCID: PMC5884892 DOI: 10.1007/s10388-017-0599-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far. METHODS The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap. RESULTS The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680-320 min). The intraoperative blood loss volume was 104.4 mL (range 240-30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II. CONCLUSIONS TRIQ can be performed easily and safely, and good short-term outcome can be expected.
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Affiliation(s)
- Yuji Ishibashi
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Tetsu Fukunaga
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Shinya Mikami
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shinichi Oka
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Satoshi Kanda
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Yukinori Yube
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Yoshinori Kohira
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Takeharu Enomoto
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
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Rostas JW, Graffree BD, Scoggins CR, McMasters KM, Martin RCG. Long-term outcomes after hand-sewn versus circular-stapled (25 and 29 mm) anastomotic technique after esophagogastrectomy for esophageal cancer. J Surg Oncol 2017; 117:469-472. [PMID: 29044576 DOI: 10.1002/jso.24865] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/05/2017] [Indexed: 01/17/2023]
Abstract
BACKGROUND Anastomotic stricture following esophagogastrectomy (EG) can lead to significant dysphagia, necessitating interventions such as endoscopic dilatation. These post-operative complications gain importance with the increased survival rate of patients after EG. This study aimed to assess the outcomes of both circular-stapled (CS: 25 and 29 mm) and hand-sewn (HS) anastomoses after EG. METHODS We reviewed prospectively accrued data from December 2004 to December 2014 identifying all patients undergoing EG for esophageal cancer. Immediate post-operative and long-term complications were noted. Primary outcome measures included anastomotic leak and stricture, dysphagia, and subsequent. RESULTS A total of 142 patients were identified for analysis. The method used for reconstruction was noted: CS-EEA-25 mm (n = 30), CS-EEA-29 mm (n = 30), and HS (n = 82). Demographics, tumor pathology, and tumor locations were similar in each group. All groups experienced similar rates of anastomotic leak, stricture, and dysphagia. Furthermore, post-operative dilations for symptomatic dysphagia were required in 3 (10%), 4 (13%), and 9 (11%) patients, P = 0.91. CONCLUSION In this cohort, the method of anastomotic construction had no bearing on the rate of complications after EG for the treatment of esophageal cancer. Furthermore, long-term need for dilations for symptomatic dysphagia was equal among all groups.
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Affiliation(s)
- Jack W Rostas
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | | | - Charles R Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky
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Endoscopy after esophagectomy: Safety demonstrated in a porcine model. J Thorac Cardiovasc Surg 2017; 154:1152-1158. [DOI: 10.1016/j.jtcvs.2016.12.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/26/2016] [Accepted: 12/17/2016] [Indexed: 12/19/2022]
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Culetto A, Gonzalez JM, Vanbiervliet G, da Garcia PM, Tellechea JI, Garnier E, Berdah S, Barthet M. Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid "Lewis Santy". Endosc Int Open 2017; 5:E455-E462. [PMID: 28573178 PMCID: PMC5451277 DOI: 10.1055/s-0043-106577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 02/10/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Esophagogastric anastomosis (EGA) has a high risk of leakage. Based upon our experience in endoscopic gastrojejunal anastomosis using LAS, the aim of this study was to verify the technical feasibility and the safety of performing an EGA using a hybrid approach (endoscopic and surgical). MATERIALS AND METHODS A pilot prospective study was performed on 8 survival pigs. The procedure was carried out in 2 stages: (i) surgical step consisting of an esogastrectomy by laparotomy with separated suture of the esophagus and stomach; (ii) endoscopic esophagogastric anastomosis using the LAS. The first 2 pigs allowed for the setting of the 2 steps procedure, and 6 were included in the study for assessing the efficacy and safety of the procedure with a 3-week survival course. The primary endpoint was morbidity and mortality. RESULTS All procedures were successfull. The mean operative time was 98 minutes, with a mean endoscopic time of 46 minutes. Three early deaths occurred within the first weeks, unrelated to the LAS anastomosis. At 3 weeks, endoscopic assessment followed by necropsy demonstrated the right position and the endoscopic removability of the stent with good patency of the esophagogastric anastomosis, without leakage of the endoscopic suture. Pathological examination confirmed the patency of the anastomosis with fusion of mucosal and muscle layers. CONCLUSION Endoscopic esophagogastric anastomosis with LAS is feasible and reproducible, without anastomotic leakage. It could be a new alternative to perform safe anastomoses, as part of a hybrid approach (surgical and endoscopic).
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Affiliation(s)
- Adrian Culetto
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France,Corresponding author Adrian Culetto, MD Department of GastroenterologyPublic Assistance Hospitals of MarseilleNorth Hospital, Marseille, France
| | - Jean-Michel Gonzalez
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France
| | - Geoffroy Vanbiervliet
- Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France,Department of Endoscopy, University Hospital of Nice, Nice, France
| | - Pablo Mira da Garcia
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France
| | - Juan Ignacio Tellechea
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France
| | | | - Stephane Berdah
- Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France,Department of Digestive Surgery, Public Assistance Hospitals of Marseille, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Aix-Marseille University, CERC, Faculty of Medecin, Marseille, France
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Dolan JP, McLaren PJ, Diggs BS, Schipper PH, Tieu BH, Sheppard BC, Gilbert EW, Conroy MA, Hunter JG. Evolution in the Treatment of Esophageal Disease at a Single Academic Institution: 2004-2013. J Laparoendosc Adv Surg Tech A 2017; 27:915-923. [PMID: 28486000 DOI: 10.1089/lap.2017.0069] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of benign and malignant esophageal disease has changed rapidly over the past decade. The aim of this study was to analyze evolution in surgical management of esophageal disease at a single academic medical center during this period. MATERIALS AND METHODS We reviewed a retrospective cohort of patients who underwent esophagectomy between 2004 and 2013. Patient, institutional, treatment, and outcomes variables were reviewed. RESULTS 317 patients were analyzed. Median age was 63.5 years; 80% were male. Average inhospital mortality rate was 3.8%. Operative indications changed significantly from 2004 to 2013, with more operations performed for invasive malignancy (77% vs. 95%) and fewer for high-grade dysplasia (12% vs. 3%, P = .008). In 2004, Ivor Lewis esophagectomy was the most common surgical technique, but the three-field technique was the operation of choice in 2013. A minimally invasive approach was used in 19% of cases in 2004 and 100% of cases in 2013 (P < .001). Anastomotic leak ranged from 0% to 21% with no significant difference over the study period (P = .18). Median lymph node harvest increased from seven to 18 nodes from 2004 to 2013 (P = .001). Hospital length of stay decreased from 15 to 8 days (P = .001). In 2013, 79% of patients were discharged to home, compared to 73% in 2004 (P = .04). DISCUSSION Over the last decade, our treatment of esophageal disease has evolved from a predominantly open Ivor Lewis to a minimally invasive three-field approach. Operations for malignancy have also increased dramatically. Postoperative complications and mortality were not significantly changed, but were consistently low during the latter years of the study.
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Affiliation(s)
- James P Dolan
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Patrick J McLaren
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Brian S Diggs
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Paul H Schipper
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brandon H Tieu
- 2 Division of Cardiothoracic Surgery, Section of General Thoracic Surgery, Department of Surgery, Oregon Health & Science University , Portland, Oregon
| | - Brett C Sheppard
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Erin W Gilbert
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - Molly A Conroy
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
| | - John G Hunter
- 1 Division of Gastrointestinal & General Surgery, Department of Surgery, the Knight Cancer Institute, Oregon Health & Science University , Portland, Oregon
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Hayata K, Nakamori M, Nakamura M, Ojima T, Iwahashi M, Katsuda M, Tsuji T, Kato T, Kitadani J, Takeuchi A, Tabata H, Yamaue H. Circular stapling versus triangulating stapling for the cervical esophagogastric anastomosis after esophagectomy in patients with thoracic esophageal cancer: A prospective, randomized, controlled trial. Surgery 2017; 162:131-138. [PMID: 28318550 DOI: 10.1016/j.surg.2017.01.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 01/26/2023]
Abstract
BACKGROUND Several studies have reported that the triangulating stapling method decreases the incidence of anastomotic stricture after esophagectomy, but no randomized, controlled trial has confirmed the efficacy of the triangulating stapling method for cervical esophagogastrostomy. We compared triangulating stapling and circular stapling for cervical esophagogastric anastomosis regarding the decrease in anastomotic stricture after esophagectomy for thoracic esophageal cancer. METHODS Between August 2010 and April 2014, 100 patients enrolled in this randomized, controlled trial at the Wakayama Medical University Hospital were allocated randomly to either the circular stapling group (n = 49) or the triangulating stapling group (n = 51). The primary end point was the incidence of anastomotic stricture within 12 months postoperatively. This randomized, controlled trial was registered with the University Hospital Medical Information Network Clinical Trial Registry (UMIN000004848). RESULTS There were no differences between the circular stapling and triangulating stapling groups in terms of clinical data. The amount of time required for esophagogastric anastomosis was slightly greater for the triangulating stapling group (22 minutes) than for the circular stapling group (18 minutes) (P = .028). Anastomotic stricture occurred in 8 patients (17%) in the circular stapling group and 9 patients (19%) in the triangulating stapling group (P = .935). The rate of anastomotic leakage was 11% for the circular stapling group and 2% for the triangulating stapling group (P = .073). CONCLUSION The triangulating stapling method for cervical anastomosis for thoracic esophageal cancer does not decrease the incidence of anastomotic stricture compared with the circular stapling method within 12 postoperative months but may affect the rate of anastomotic leakage.
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Affiliation(s)
- Keiji Hayata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Mikihito Nakamori
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Masaki Nakamura
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Makoto Iwahashi
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Toshiaki Tsuji
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Tomoya Kato
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Jyunya Kitadani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Akihiro Takeuchi
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hirotaka Tabata
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, Wakayama, Japan.
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Mahajan A, Desai S, Sable NP, Thakur MH. Status of barium studies in the present era of oncology: Are they a history? Indian J Med Paediatr Oncol 2017; 37:223-226. [PMID: 28144086 PMCID: PMC5234156 DOI: 10.4103/0971-5851.195740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
With the advent of the modern imaging technologies, the present era of oncology is seeing steady decline in requests for barium studies due to the many reasons. It is prudent to mention here, that, barium examinations cannot be made obsolete! Our aim to preserve the age old technique of barium studies not only to keep it going on but also for the betterment and appropriate management of the patient. Our goal is not to “save” barium studies simply to keep this technology alive, per se, but rather to preserve barium radiology for the quality in patient care.
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Affiliation(s)
- Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Subash Desai
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nilesh Pandurang Sable
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Meenakshi Haresh Thakur
- Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
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Huang C, Xu X, Zhuang B, Chen W, Xu X, Wang C, Lin S. A comparison of cervical delta-shaped anastomosis and circular stapled anastomosis after esophagectomy. World J Surg Oncol 2017; 15:31. [PMID: 28103879 PMCID: PMC5244570 DOI: 10.1186/s12957-017-1097-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 01/12/2017] [Indexed: 01/24/2023] Open
Abstract
Background The delta-shaped anastomosis has been reported to reduce anastomotic complications for a decade. However, little has been written comparing this technique with the circular stapler technique. The objective of this retrospective study was to assess the safety and efficacy of cervical delta-shaped anastomosis after esophagectomy. Methods Medical records of patients with esophageal squamous cell carcinoma who underwent McKeown (three-incision) esophagectomy between September 2013 and June 2015 were reviewed. Either circular stapled anastomosis (CSA) or delta-shaped anastomosis (DSA) was performed at the cervical stage. The clinical characteristics and short-term outcome were retrospectively assessed to identify the differences between the two groups. Results A total of 81 patients were included in this study. The clinical characteristics were similar between the two groups. Cervical anastomotic leakage occurred in 3 (7.7%) of 39 patients in the DSA group and in 8 (19%) of 42 patients in the CSA group (P = 0.197). The average anastomotic orifice width was 16.1 ± 4.9 mm and 11.7 ± 2.2 mm, respectively (P < 0.001). The incidence of anastomotic stenosis was 2.6% (1/39) and 23.5% (10/42) in the DSA and CSA groups, respectively (P = 0.007). There was no significant difference in surgical duration, blood loss, pulmonary complication, postoperative mortality, time of hospitalisation and time of ICU stay between the two groups. Conclusions Delta-shaped anastomosis may be an effective alternative method for gastroesophageal anastomosis after esophagectomy, with lower incidence of leakage and stenosis.
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Affiliation(s)
- Chen Huang
- Department of Thoracic Surgery, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, No. 134 East St, Fuzhou, 350001, Fujian, China
| | - Xunhai Xu
- Department of Thoracic Surgery, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, No. 134 East St, Fuzhou, 350001, Fujian, China
| | - Binbin Zhuang
- Department of Thoracic Surgery, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, No. 134 East St, Fuzhou, 350001, Fujian, China
| | - Wenshu Chen
- Department of Thoracic Surgery, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, No. 134 East St, Fuzhou, 350001, Fujian, China
| | - Xunyu Xu
- Department of Thoracic Surgery, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, No. 134 East St, Fuzhou, 350001, Fujian, China.
| | - Chao Wang
- Gastrointestinal Endoscopy Center, Fujian Provincial Hospital, Fuzhou, 35001, China
| | - Shengmei Lin
- Department of Radiology, Fujian Provincial Hospital, Fuzhou, 350001, China
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Wiesel O, Whang B, Cohen D, Fisichella PM. Minimally Invasive Esophagectomy for Adenocarcinomas of the Gastroesophageal Junction and Distal Esophagus: Notes on Technique. J Laparoendosc Adv Surg Tech A 2016; 27:162-169. [PMID: 27858584 DOI: 10.1089/lap.2016.0430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
In the last three decades, with the advancement of laparoscopic and thoracoscopic surgery, minimally invasive approaches for benign and malignant diseases of the esophagus have been developed and more experience is starting to accumulate across the world. Minimally invasive esophagectomy (MIE) has demonstrated acceptable lymph node retrieval, good postoperative outcomes, and low mortality. In this article, we review our preferred technique of MIE for adenocarcinomas of the gastroesophageal junction and distal esophagus.
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Affiliation(s)
- Ory Wiesel
- 1 Division of Thoracic Surgery, Brigham and Women's Hospital , Veterans Health Administration, Boston Healthcare System, Boston, Massachusetts
| | - Brian Whang
- 1 Division of Thoracic Surgery, Brigham and Women's Hospital , Veterans Health Administration, Boston Healthcare System, Boston, Massachusetts
| | - Daniel Cohen
- 1 Division of Thoracic Surgery, Brigham and Women's Hospital , Veterans Health Administration, Boston Healthcare System, Boston, Massachusetts
| | - P Marco Fisichella
- 2 Department of Surgery, Brigham and Women's Hospital , Veterans Health Administration, Boston Healthcare System, Boston, Massachusetts
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Endoscopic dilation of benign esophageal anastomotic strictures over 16 mm has a longer lasting effect. Surg Endosc 2016; 31:1871-1881. [PMID: 27585471 PMCID: PMC5346152 DOI: 10.1007/s00464-016-5187-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/13/2016] [Indexed: 12/26/2022]
Abstract
Background The optimal target of endoscopic dilation of postsurgical esophageal strictures is unknown. Our aim was to compare the dilation-free period of patients who underwent dilation up to 16 mm with patients who were dilated up to 17 or 18 mm. Methods We retrospectively analyzed adult patients who received bougie/balloon dilation for a benign anastomotic stricture after esophagectomy. An anastomotic stricture was defined as dysphagia in combination with a luminal diameter of ≤13 mm at endoscopy. We analyzed the dilation-free period using Kaplan–Meier and multivariable Cox regression analysis. Results Eighty-eight patients were dilated up to a maximum diameter of 16 mm and 91 patients to a diameter >16 mm. The stricture recurrence rate was 79.5 % in the 16 mm group and 68.1 % in the >16 mm group (p = 0.083). The overall dilation-free period had a median of 41.5 (range 8–3233) days and 92 (range 17–1745) days, respectively (p < 0.001). For patients who developed a stricture recurrence, the median dilation-free period was 28 (range 8–487) days and 63 (range 17–1013) days, respectively (p = 0.001). Cox regression analysis showed a reduced risk of stricture recurrence for patients who were dilated up to >16 mm: crude hazard ratio (HR) 0.57 (95 % confidence interval (CI) 0.41–0.81) and adjusted HR 0.48 (95 % CI 0.33–0.70). Conclusions Endoscopic dilation over 16 mm resulted in a significant prolongation of the dilation-free period in comparison with dilation up to 16 mm in patients with benign anastomotic strictures after esophagectomy. Electronic supplementary material The online version of this article (doi:10.1007/s00464-016-5187-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard J Battafarano
- Division of Thoracic Surgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Blalock 240, Baltimore, MD 21287, USA.
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Ryan CE, Paniccia A, Meguid RA, McCarter MD. Transthoracic Anastomotic Leak After Esophagectomy: Current Trends. Ann Surg Oncol 2016; 24:281-290. [PMID: 27406098 DOI: 10.1245/s10434-016-5417-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Leaks from intrathoracic esophagogastric anastomosis are thought to be associated with higher rates of morbidity and mortality than leaks from cervical anastomosis. We challenge this assumption and hypothesize that there is no significant difference in mortality based on the location of the esophagogastric anastomosis. METHODS A systematic literature search was conducted using PubMed and Embase databases on all studies published from January 2000 to June 2015, comparing transthoracic (TTE) and transhiatal (THE) esophagectomies. Studies using jejunal or colonic interposition were excluded. Outcomes analyzed were leak rate, leak-associated mortality, overall 30-day mortality, and overall morbidity. Meta-analyses were performed using Mantel-Haenszel statistical analyses on studies reporting leak rates of both approaches. Nominal data are presented as frequency and interquartile range (IQR); measures of the association between treatments and outcomes are presented as odds ratio (OR) with 95 % confidence interval. RESULTS Twenty-one studies (3 randomized controlled trials) were analyzed comprising of 7167 patients (54 % TTE). TTE approach yields a lower anastomotic leak rate (9.8 %; IQR 6.0-12.2 %) than THE (12 %; IQR 11.6-22.1 %; OR 0.56 [0.34-0.92]), without any significant difference in leak associated mortality (7.1 % TTE vs. 4.6 % THE: OR 1.83 [0.39-8.52]). There was no difference in overall 30-day mortality (3.9 % TTE vs. 4.3 % THE; OR 0.86 [0.66-1.13]) and morbidity (59.0 % TTE vs. 66.6 % THE; OR 0.76 [0.37-1.59]). DISCUSSION Based on meta-analysis, TTE is associated with a lower leak rate and does not result in higher morbidity or mortality than THE. The previously assumed higher rate of transthoracic anastomotic leak-associated mortality is overstated, thus supporting surgeon discretion and other factors to influence the choice of thoracic versus cervical anastomosis.
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Affiliation(s)
- Carrie E Ryan
- University of South Florida Morsani College of Medicine, Tampa, FL, USA.
| | - Alessandro Paniccia
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, CO, USA
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Dua KS, Hogan WJ, Aadam AA, Gasparri M. In-vivo oesophageal regeneration in a human being by use of a non-biological scaffold and extracellular matrix. Lancet 2016; 388:55-61. [PMID: 27068836 DOI: 10.1016/s0140-6736(15)01036-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Tissue-engineered extracellular matrix populated with autologous pluripotent cells can result in de-novo organogenesis, but the technique is complex, not widely available, and has not yet been used to repair large oesophageal defects in human beings. We aimed to use readily available stents and extracellular matrix to regenerate the oesophagus in vivo in a human being to re-establish swallowing function. METHODS In a patient aged 24 years, we endoscopically placed a readily available, fully covered, self-expanding, metal stent (diameter 18 mm, length 120 mm) to bridge a 5 cm full-thickness oesophageal segment destroyed by a mediastinal abscess and leading to direct communication between the hypopharynx and the mediastinum. A commercially available extracellular matrix was used to cover the stent and was sprayed with autologous platelet-rich plasma adhesive gel. The sternocleidomastoid muscle was placed over the matrix. After 4 weeks, stent removal was needed due to stent migration, and was replaced with three stents telescopically aligned to improve anchoring. The stents were removed after 3·5 years and the oesophagus was assessed by endoscopy, biopsy, endoscopic ultrasonography, and high-resolution impedance manometry. FINDINGS After stent removal we saw full-thickness regeneration of the oesophagus with stratified squamous epithelium, a normal five-layer wall, and peristaltic motility with bolus transit. 4 years after stent removal, the patient was eating a normal diet and maintaining a steady weight. INTERPRETATION Maintenance of the structural morphology of the oesophagus with off-the-shelf non-biological scaffold and stimulation of regeneration with commercially available extracellular matrix led to de-novo structural and functional regeneration of the oesophagus. FUNDING None.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Walter J Hogan
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abdul A Aadam
- Division of Gastroenterology and Hepatology, Northwestern University, Evanston, IL, USA
| | - Mario Gasparri
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, Dolmans ACP, Kouwenhoven EA, Rosman C, Ruurda JP, van Workum F, van Det MJ, Silva Corten LC, van Hillegersberg R, Luyer MDP. Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial. Ann Thorac Surg 2016; 102:1141-8. [PMID: 27324526 DOI: 10.1016/j.athoracsur.2016.04.067] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/01/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy. METHODS A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7. RESULTS The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake. CONCLUSIONS Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.
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Affiliation(s)
- Teus J Weijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | | | | | - Camiel Rosman
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital, Almelo, the Netherlands
| | | | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Baker EH, Hill JS, Reames MK, Symanowski J, Hurley SC, Salo JC. Drain amylase aids detection of anastomotic leak after esophagectomy. J Gastrointest Oncol 2016; 7:181-8. [PMID: 27034784 DOI: 10.3978/j.issn.2078-6891.2015.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak. METHODS The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated. RESULTS Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak. CONCLUSIONS Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.
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Affiliation(s)
- Erin H Baker
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Joshua S Hill
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Mark K Reames
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - James Symanowski
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Susie C Hurley
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
| | - Jonathan C Salo
- 1 Department of Surgery, 2 Division of Surgical Oncology, Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Charlotte, NC 28203, USA ; 3 Department of Surgery, Sanger Heart and Vascular Institute, Charlotte, NC 28203, USA ; 4 Department of Cancer Biostatistics, Levine Cancer Institute, 5 Levine Cancer Institute, Carolinas Medical Center, Charlotte Levine Cancer Institute, NC 28204, USA
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80
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Irino T, Tsai JA, Ericson J, Nilsson M, Lundell L, Rouvelas I. Thoracoscopic side-to-side esophagogastrostomy by use of linear stapler-a simplified technique facilitating a minimally invasive Ivor-Lewis operation. Langenbecks Arch Surg 2016; 401:315-22. [PMID: 26960591 DOI: 10.1007/s00423-016-1396-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 03/01/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Minimally invasive esophagectomy (MIE) has been met with increased interest for the surgical treatment of esophageal cancer. One critical obstacle for the implementation of MIE has been the intrathoracic anastomosis. In this study, we describe a technique of thoracoscopic intrathoracic anastomosis using a linear stapler in prone position and present the short-term outcomes of this procedure. METHODS This prospective pilot study included 46 consecutive patients with a cancer either of the gastroesophageal junction (GEJ) or the distal esophagus who underwent either total MIE or thoracoscopic-assisted esophagectomy followed by intrathoracic stapled side-to-side anastomosis. The short-term outcomes including postoperative complications were recorded and analyzed. RESULTS This pilot study included 41 males (89 %) and 5 females (11 %) with a mean age of 65.7 years. The majority had adenocarcinoma (93 %). Before surgery, 4 patients (8.7 %) had an incomplete endoscopic submucosal resection, 5 patients (11 %) received chemotherapy alone, and 33 patients (71 %) had chemoradiotherapy. Mean operation time was 408 minutes. Postoperative complications classified as Clavien-Dindo Grade IIIa or more severe occurred in 7 patients (15 %), of whom 4 patients (8.7 %) developed anastomotic leakages without any need for intensive care. Another 2 patients (4.3 %) required intensive care due to aspiration pneumonia and acute renal failure. No in-hospital mortality was registered. Only one patient (2.2 %) with anastomotic leakage developed postoperative anastomotic stenosis requiring balloon dilatation. CONCLUSIONS The intrathoracic stapled side-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.
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Affiliation(s)
- Tomoyuki Irino
- Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden
| | - Jon A Tsai
- Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden.,Division of Surgery, CLINTEC, Karolinska Institute, Huddinge, 141 86, Stockholm, Sweden
| | - Jessica Ericson
- Department of Clinical Nutrition and Dietetics, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden
| | - Magnus Nilsson
- Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden.,Division of Surgery, CLINTEC, Karolinska Institute, Huddinge, 141 86, Stockholm, Sweden
| | - Lars Lundell
- Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden.,Division of Surgery, CLINTEC, Karolinska Institute, Huddinge, 141 86, Stockholm, Sweden
| | - Ioannis Rouvelas
- Center for Digestive Diseases, Karolinska University Hospital, Huddinge, 141 86, Stockholm, Sweden. .,Division of Surgery, CLINTEC, Karolinska Institute, Huddinge, 141 86, Stockholm, Sweden.
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81
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Burke LMB, Bashir MR, Gardner CS, Parsee AA, Marin D, Vermess D, Bhattacharya SD, Thacker JK, Jaffe TA. Image-guided percutaneous drainage vs. surgical repair of gastrointestinal anastomotic leaks: is there a difference in hospital course or hospitalization cost? ACTA ACUST UNITED AC 2016; 40:1279-84. [PMID: 25294007 DOI: 10.1007/s00261-014-0265-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To identify differences in hospital course and hospitalization cost when comparing image-guided percutaneous drainage with surgical repair for gastrointestinal anastomotic leaks. MATERIALS AND METHODS A retrospective IRB-approved search using key words "leak" and/or "anastomotic" was performed on all adult CT reports from 2002 to 2011. CT examinations were reviewed for evidence of a postoperative gastrointestinal leak and assigned a confidence score of 1-5 (1 = no leak, 5 = definite leak). Patients with an average confidence score <4 were excluded. Type of surgery, patient data, method of leak management, number of hospital admissions, length of hospital stay, discharge disposition, number of CT examinations, number of drains, and hospitalization costs were collected. RESULTS One hundred thirty-nine patients had radiographic evidence of a gastrointestinal anastomotic leak (esophageal, gastric, small bowel or colonic). Nine patients were excluded due to low confidence scores. Twenty-seven patients underwent surgical repair (Group A) and 103 were managed entirely with percutaneous image-guided drainage (Group B). There was no significant difference in patient demographics or number of hospital admissions. Patients in Group A had longer median hospital stays compared to Group B (48 vs. 32 days, p = 0.007). The median total hospitalization cost for Group A was more than twice that for Group B ($99,995 vs. $47,838, p = 0.001). Differences in hospital disposition, number of CT examinations, number of drains, and time between original surgery and first CT examination were statistically significant. CONCLUSION Gastrointestinal anastomotic leaks managed by percutaneous drainage are associated with lower hospital cost and shorter hospital stays compared with surgical management.
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Affiliation(s)
- Lauren M B Burke
- Department of Radiology, Duke University Medical Center, Durham, NC, 27710, USA,
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Zhai C, Liu Y, Li W, Xu T, Yang G, Lu H, Hu D. A comparison of short-term outcomes between Ivor-Lewis and McKeown minimally invasive esophagectomy. J Thorac Dis 2016; 7:2352-8. [PMID: 26793358 DOI: 10.3978/j.issn.2072-1439.2015.12.15] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Only few comparative studies have been reported on the outcomes of minimally invasive esophagectomy (MIE) with intrathoracic anastomosis (MIE Ivor-Lewis) and MIE with cervical anastomosis (MIE McKeown) for patients with mid and lower esophageal cancer. The objective of this study is to compare the safety, feasibility, and short-term outcomes between two groups. METHODS Clinical and surgical data of patients with esophageal cancer who underwent either MIE Ivor-Lewis or MIE McKeown between January 2013 and October 2014 were retrospectively analyzed. Demographic characteristics, pathological data, operative procedures, and perioperative outcomes and survival in patients were compared between both groups. RESULTS Of the 72 patients included in this retrospective analysis, 32 underwent MIE Ivor-Lewis and 40 underwent MIE McKeown. Demographics, pathologic data, inpatient mortality, and surgical morbidity in both cohorts were almost identical. A significant difference was observed in Pulmonary complication (18.8% vs. 42.5%, P=0.032), Anastomotic leakage (9.4% vs. 30%, P=0.032), Anastomotic stenosis (12.5% vs. 35%, P=0.028), recurrent laryngeal nerve (RLN) injury (6.3% vs. 22.5%, P=0.034) between MIE Ivor-Lewis and MIE McKeown groups; however, no difference in operative time (312.6±82.0 vs. 339.4±80.0, P=0.249), blood loss (246.3±82.4 vs. 272.9±136.3, P=0.443), lymph nodes harvested (19.3±8.1 vs. 20.2±7.2, P=0.655) and 90-day mortality (3.1% vs. 5%, P=0.692) was observed between two groups. CONCLUSIONS The procedure of MIE Ivor-Lewis for esophageal cancer possesses advantages in perioperative outcomes and less complications compared with MIE McKeown.
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Affiliation(s)
- Chunbo Zhai
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Yongjing Liu
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Wei Li
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Tongzhen Xu
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Guotao Yang
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Hengxiao Lu
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
| | - Dehong Hu
- 1 Department of Thoracic Surgery, Qilu Hospital, Shandong University, Jinan 250012, China ; 2 Department of Thoracic Surgery, Weifang people's Hospital, Weifang 261041, China ; 3 Department of Cardiothoracic Surgery, 105th Hospital of PLA, Hefei 230031, China
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83
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Tapias LF, Mathisen DJ, Wright CD, Wain JC, Gaissert HA, Muniappan A, Lanuti M, Donahue DM, Morse CR. Outcomes With Open and Minimally Invasive Ivor Lewis Esophagectomy After Neoadjuvant Therapy. Ann Thorac Surg 2015; 101:1097-103. [PMID: 26652140 DOI: 10.1016/j.athoracsur.2015.09.062] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 07/21/2015] [Accepted: 09/21/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neoadjuvant therapy is integral in the treatment of locally advanced esophageal cancer. Despite increasing acceptance of minimally invasive approaches to esophagectomy, there remain concerns about the safety and oncologic soundness after neoadjuvant therapy. We examined outcomes in patients undergoing open and minimally invasive (MIE) Ivor Lewis esophagectomy after neoadjuvant therapy. METHODS This was a retrospective series of 130 consecutive patients with esophageal cancer undergoing Ivor Lewis esophagectomy with curative intention after neoadjuvant therapy at a tertiary academic center (2008 to 2012). RESULTS An open procedure was performed in 74 patients (56.9%), and 56 (43.1%) underwent MIE after neoadjuvant therapy. MIE patients had shorter median intensive care unit (p = 0.002) and hospital lengths of stay (p < 0.0001). The incidence of postoperative complications was similar (open: 54.8% vs MIE: 41.1%, p = 0.155). However, observed respiratory complications were significantly reduced after MIE (8.9%) compared with open (29.7%; p = 0.004). Anastomotic leak rates were similar (open: 1.4% vs. MIE: 0%, p = 1.00). Mortality at 30 and 90 days was comparable (open: 2.7% and 4.1% vs MIE: 0% and 1.8%, p = 0.506 and p = 0.634, respectively). Complete resection rates and the number of collected lymph nodes was similar. Overall survival rates at 5 years were similar (open: 61% vs MIE: 50%, p = 0.933). MIE was not a significant predictor of overall survival (hazard ratio, 1.07; 95% confidence interval, 0.61 to 1.87; p = 0.810). CONCLUSIONS MIE proves its safety after neoadjuvant therapy because it leads to faster progression during the early postoperative period while reducing pulmonary complications. Open and MIE approaches appear equivalent with regards to perioperative oncologic outcomes after neoadjuvant therapy. Long-term outcomes need further validation.
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Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - John C Wain
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Henning A Gaissert
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Dean M Donahue
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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84
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Harustiak T, Pazdro A, Snajdauf M, Stolz A, Lischke R. Anastomotic leak and stricture after hand-sewn versus linear-stapled intrathoracic oesophagogastric anastomosis: single-centre analysis of 415 oesophagectomies. Eur J Cardiothorac Surg 2015; 49:1650-9. [PMID: 26574497 DOI: 10.1093/ejcts/ezv395] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/06/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES There seems to be a decreased anastomotic leak rate and a late stricture formation after linear-stapled (LS) cervical oesophagogastric anastomosis compared with hand-sewn (HS) technique. The aim of our study was to compare the surgical outcomes of intrathoracic side-to-side LS and end-to-end HS anastomosis after transthoracic oesophagectomy. METHODS We conducted a retrospective review of all patients undergoing Ivor Lewis oesophagectomy with LS or HS anastomosis for neoplasia at our institution from 2005 to 2012. Anastomotic leak was radiologically and clinically graded as minor or major. End-points included overall and major leak rate, morbidity, mortality, length of hospital stay and endoscopically identified late anastomotic stricture. A propensity score-matched analysis was done to compensate for the differences in baseline characteristics between HS and LS groups. Multivariable analyses of the associations of anastomotic technique and other preoperative and pathological variables with anastomotic leak and stricture were performed. RESULTS There were 415 patients, 134 with HS and 281 with LS anastomoses. Anastomotic leak occurred in 56 patients (13.5%), significantly more after HS than LS technique (20.9 vs 10.0%; P = 0.002). Major leak rate was not significantly different (9.0 vs 5.7%; P = 0.216, respectively). Overall morbidity (54.7%), in-hospital mortality (3.9%) and length of hospital stay (median 12 days) were not affected by the anastomotic technique. A follow-up endoscopic evaluation was available in 248 patients (59.8%). An anastomotic stricture was detected in 24 patients (9.7%), significantly more after HS than LS technique (20.3 vs 6.3%; P = 0.002). The propensity score-matched analysis of 105 patient pairs confirmed a significantly decreased overall leak rate (11.4 vs 22.9%; P = 0.045) and stricture formation (7.5 vs 18.2%; P = 0.041) in LS technique compared with HS technique. The multivariable analyses found obesity and HS anastomotic technique associated with an increased overall leak rate, chronic hepatopathy and diabetes associated with major leak and HS technique, female sex and the absence of arterial hypertension associated with increased stricture formation. CONCLUSIONS Our non-randomized study showed that side-to-side LS technique is the preferred method of intrathoracic oesophagogastric anastomosis due to a decreased overall anastomotic leak rate and anastomotic stricture formation compared with HS technique.
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Affiliation(s)
- Tomas Harustiak
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alexandr Pazdro
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Martin Snajdauf
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alan Stolz
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Robert Lischke
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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85
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Kesler KA. Measuring quality of life after esophagectomy: Do we really need to go there? J Thorac Cardiovasc Surg 2015; 151:631-632. [PMID: 26412314 DOI: 10.1016/j.jtcvs.2015.08.111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Affiliation(s)
- Kenneth A Kesler
- Thoracic Division, Department of Surgery, Indiana University, Indianapolis, Ind.
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Nakata K, Nagai E, Ohuchida K, Nakamura K, Tanaka M. Outcomes of cervical end-to-side triangulating esophagogastric anastomosis with minimally invasive esophagectomy. World J Surg 2015; 39:1099-104. [PMID: 25582767 DOI: 10.1007/s00268-014-2925-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophagogastric anastomosis after esophagectomy has been performed with a variety of techniques during the past decade. However, anastomotic leakage and stricture are still important clinical problems after esophagogastric anastomosis, causing burdensome symptoms and poor quality of life. Herein, we describe a novel cervical end-to-side triangulating esophagogastric anastomoasis using linear stapler. METHODS A total of 90 patients (85 % male; mean age 63 years) with thoracic esophageal cancer who underwent cervical end-to-side esophagogastric triangular anastomosis using a linear stapler after minimally invasive esophagectomy between November 2006 and April 2013 were retrospectively reviewed. RESULTS The median operation time was 602 min (range 424-936 min). The volume of blood loss during the entire operative procedure was 127 ml (range 0-700 ml). There were no cases of anastomotic leakage in this study, although four patients (4.4 %) developed dysphagia associated with benign anastomotic stricture formation. All patients with a benign anastomotic stricture underwent balloon dilation, which resulted in improvement in their symptoms. CONCLUSIONS Considering the absence of anastomotic leakage and low rate of anastomotic stricture formation in this study, our modified triangular esophagogastric anastomosis technique appears promising and may contribute to reduced morbidity and mortality rates following esophagectomy.
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Affiliation(s)
- Kohei Nakata
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka, 812-8582, Japan,
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87
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Zhou D, Liu QX, Deng XF, Min JX, Dai JG. Comparison of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis. J Cardiothorac Surg 2015; 10:67. [PMID: 25952323 PMCID: PMC4456702 DOI: 10.1186/s13019-015-0271-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 05/01/2015] [Indexed: 12/31/2022] Open
Abstract
Objective In this meta-analysis, we conducted a pooled analysis of clinical studies comparing Linear Stapled (LS) versus Circular Stapled (CS) esophagogastric anastomosis for esophageal cancer. Methods According to the recommendations of the Cochrane Collaboration, we established a rigorous study protocol. We performed a systematic electronic search of the PubMed, Embase, Cochrane Library, Web of Science, and Chinese Biomedical databases as well as Chinese scientific journals to identify articles to include in our meta-analysis. The primary outcomes compared were anastomotic leak, anastomotic stricture and 3-month mortality. Results Five controlled trials comprising 840 patients (523 LS vs. 317 CS) were included. Primary outcomes revealed a statistically significant decrease in anastomotic strictures [risk ratio (RR): 0.26, 95 % confidence interval (CI): 0.11–0.60, P = 0.002] compared with linear stapled anastomosis. However, there were no significant differences between the two groups with respect to anastomotic leakage [risk ratio (RR): 0.80, 95 % confidence interval (CI): 0.40–1.58, P = 0.52] and 3-month mortality [risk ratio (RR): 0.94, 95 % confidence interval (CI): 0.47–1.87, P = 0.85]. Conclusion There were no statistical differences in the rate of 3-month mortality or anastomotic leakage between the two groups. However, the LS method contributed to a reduced rate of anastomotic strictures. This meta-analysis may offer some specific suggestions for esophagogastric anastomosis.
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Affiliation(s)
- Dong Zhou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Quan-Xing Liu
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Xu-Feng Deng
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Jia-Xin Min
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
| | - Ji-Gang Dai
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, 400037, China.
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88
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Deng XF, Liu QX, Zhou D, Min JX, Dai JG. Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: A meta-analysis. World J Gastroenterol 2015; 21:4757-4764. [PMID: 25914488 PMCID: PMC4402326 DOI: 10.3748/wjg.v21.i15.4757] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/30/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of hand-sewn (HS) and linearly stapled (LS) esophagogastric anastomosis for esophageal cancer.
METHODS: Before beginning this study, a rigorous protocol was established according to the recommendations of the Cochrane Collaboration. Databases and references were searched for all randomized controlled trials and comparative clinical studies that compared LS with HS esophagogastric anastomosis for esophageal cancer. The primary outcomes compared were anastomotic leak and stricture. Subgroup analyses were performed according to site of anastomosis.
RESULTS: Fifteen studies were used, comprising 3203 patients (n = 2027 LS and 1176 HS). Primary outcome analysis revealed a significant decrease in anastomotic leakage (RR = 0.51, 95%CI: 0.41-0.65; P < 0.00001) associated with LS anastomosis. A significantly reduced rate of anastomotic stricture associated with LS was also found (RR = 0.56, 95%CI: 0.49-0.64; P < 0.00001). A subgroup analysis according to the site of anastomosis revealed a significantly reduced rate of anastomotic stricture (P < 0.00001). Although there was no significant difference in the decrease in thoracic anastomotic leakage, there was a significant decrease in cervical anastomotic leakage associated with LS (P < 0.00001).
CONCLUSION: This meta-analysis indicates that the LS technique contributes to a reduced rate of leakage and stricture compared with the HS method.
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89
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Roy-Shapira A, Bapaye A, Date S, Pujari R, Dorwat S. Trans-oral anterior fundoplication: 5-year follow-up of pilot study. Surg Endosc 2015; 29:3717-21. [PMID: 25783833 PMCID: PMC4648975 DOI: 10.1007/s00464-015-4142-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/19/2015] [Indexed: 12/23/2022]
Abstract
Background
This is a report of an IRB-approved pilot study of 13 patients who received a trans-oral anterior partial fundoplication for the treatment of GERD using an ultrasound-guided, flexible surgical stapler. All patients had a history of PPI use, objective evidence of GERD, and no significant comorbidity. Under general anesthesia, a flexible stapler was passed trans-orally into the stomach and placed two or three quintuplets of titanium staples approximately 3 cm above the gastroesophageal junction. The stapler contains an ultrasonic range finder, video camera, and illuminator. Methods Primary follow-up at 6 weeks included pH metrics, GERD-HRQL scores, and PPI use. The protocol allowed annual telephone interviews for the following 5 years to collect GERD-HRQL scores, PPI use, satisfaction with the procedure, and willingness to have the procedure again. Results At 6 weeks, mean total acid exposure was significantly reduced, and 12/13 patients reduced GERD-HRQL scores by ≥50 %. Twelve of 13 patients had stopped daily GERD medications, and nine of 13 had stopped all GERD medications. Each year, 11 of the 13 patients could be reached with all 13 patients having at least 4-year follow-up. Throughout the follow-up period, GERD-HRQL scores were normal (<10) in all but one patient. All patients would agree to do the procedure again. The median satisfaction score is 8 (range 6–10) on a scale of 1–10. None reported dysphagia. At 1 year, 54 % of respondents (6/11) had eliminated PPI use, with another 27 % (3/11) taking a reduced dose. Combining respondents at 4 and 5 years to account for all patients, 54 % (7/13) had eliminated and another 23 % (3/13) reduced PPI use ≥50 %. Conclusion At 5 years, the procedure remained effective as demonstrated by the improved quality of life and changes in PPI use. The results remained stable after the second year.
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Affiliation(s)
- Aviel Roy-Shapira
- Department of Surgery A, Soroka University Medical Center and the Faculty of the Health Sciences, Ben Gurion University, Beer Sheva, Israel.
| | - Amol Bapaye
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Suhas Date
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Rajendra Pujari
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Shivangi Dorwat
- Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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90
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Raman V, MacGlaflin CE, Erkmen CP. Noninvasive Positive Pressure Ventilation Following Esophagectomy. Chest 2015; 147:356-361. [DOI: 10.1378/chest.14-0886] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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91
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Meyerson SL, Mehta CK. Managing complications II: conduit failure and conduit airway fistulas. J Thorac Dis 2014; 6 Suppl 3:S364-71. [PMID: 24876943 DOI: 10.3978/j.issn.2072-1439.2014.03.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 03/25/2014] [Indexed: 12/19/2022]
Abstract
Conduit failure and conduit airway fistula are rare complications after esophagectomy, however they can be catastrophic resulting in high mortality. Survivors can expect a prolonged hospital course with multiple interventions and an extended period of time prior to being able to resume oral nutrition. High index of suspicion can aid in early diagnosis. Conduit failure usually requires a period of proximal esophageal diversion and staged reconstruction. Conduit airway fistulas may be amenable to endoscopic repair but this has a high failure rate and many patients will require surgical repair with closure of the fistula and interposition of vascularized tissue to minimize recurrence.
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Affiliation(s)
- Shari L Meyerson
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine, Chicago IL, 60611, USA
| | - Christopher K Mehta
- Division of Thoracic Surgery, Northwestern University, Feinberg School of Medicine, Chicago IL, 60611, USA
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92
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Shen Y, Wang H, Feng M, Tan L, Wang Q. The effect of narrowed gastric conduits on anastomotic leakage following minimally invasive oesophagectomy. Interact Cardiovasc Thorac Surg 2014; 19:263-8. [PMID: 24847029 DOI: 10.1093/icvts/ivu151] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Anastomotic leakage remains a major complication following minimally invasive oesophagectomy (MIO). In this study, our objective was to determine whether a narrower gastric conduit would lead to lower incidence of anastomotic leakage following MIO. METHODS In this retrospective study, patients with oesophageal cancer undergoing MIO were assigned to receive 5-cm-wide gastric conduits (from May 2011 to February 2012, Group W) and then 3-cm-wide gastric conduits (from March 2012 to December 2012, Group N) for gastro-oesophageal anastomosis. The length of the gastric conduit and the anastomotic details were recorded during surgery. Perfusion status of the conduit was analysed before and after anastomosis using a laser Doppler perfusion monitor. Following surgery, the incidence of anastomotic leakage in the two groups was statistically compared to identify differences between the two methods of gastric formation. RESULTS There were 126 patients in Group N and 133 patients in Group W. Patient demographics and surgical observations were comparable between the two groups. In Group N, the length of gastric conduit was significantly greater than in Group W (39.1 ± 2.7 vs 35.6 ± 4.4 cm, P = 0.0021). Lower reduction of perfusion units was recorded in Group N after gastro-oesophageal anastomosis (45.7 vs 28.1%, P = 0.004). Postoperatively, a total of 34 cases (13.13%) of anastomotic leakage was observed, and the incidence of anastomotic leakage was significantly lower in Group N than in Group W (8.7 vs 17.3%, P = 0.041). CONCLUSIONS Narrow gastric tubes were longer and less interfered in perfusion, which contributed to lower incidence of anastomotic leakage following minimally invasive oesophagectomy. Further study of the long-term effects of such treatment is required to confirm the advantages of this technique.
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Affiliation(s)
- Yaxing Shen
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Wang
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mingxiang Feng
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Lijie Tan
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qun Wang
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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93
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Bolton JS, Conway WC, Abbas AE. Planned delay of oral intake after esophagectomy reduces the cervical anastomotic leak rate and hospital length of stay. J Gastrointest Surg 2014; 18:304-9. [PMID: 24002761 DOI: 10.1007/s11605-013-2322-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 08/12/2013] [Indexed: 02/07/2023]
Abstract
Cervical anastomotic leak rates are high after esophagectomy. We examined the effect of a purposeful delay in institution of oral diet after esophagectomy on the leak rate and hospital length of stay. A retrospective analysis of 120 patients submitted to esophagectomy with cervical esophagogastric anastomosis was conducted. Eighty-seven resumed diet within 7 days of surgery (early eaters), and 33 had delayed diet until a mean of 12 days after surgery (late eaters). Mean age was 62.3 years; 98 patients were male. One hundred one resections were for cancer, and 49 % of cancer patients received neoadjuvant therapy. The overall leak rate was 17.5 %, and hospital length of stay was 10.9 days. Anastomotic leak rate was 3 % for late eaters versus 23 % for early eaters (OR of 9.57, p = 0.010). Hospital length of stay was 6 days for late eaters versus 11.8 days for early eaters (p < 0.001). Anastomotic leak was significantly associated with increased length of stay (p < 0.001), adding an average of 7.6 days to hospital stay. Respiratory complications (p < 0.001) and delayed gastric emptying (p = 0.014) were also independent predictors of increased length of stay, but early eater status was not. Delayed resumption of oral diet after esophagectomy significantly reduces cervical anastomotic leak rate and avoids the increased length of stay associated with leak.
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Affiliation(s)
- John S Bolton
- Department of Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA, 70121, USA,
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94
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Shen Y, Zhong M, Wu W, Wang H, Feng M, Tan L, Wang Q. The impact of tidal volume on pulmonary complications following minimally invasive esophagectomy: a randomized and controlled study. J Thorac Cardiovasc Surg 2013; 146:1267-73; discussion 1273-4. [PMID: 23993028 DOI: 10.1016/j.jtcvs.2013.06.043] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/26/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) has been advantageous for lowering pulmonary complications compared with open approaches.(1) However, pulmonary complications remain the most common morbidity after surgical resection of esophageal cancer.(2,3) The aim of this prospective, randomized, controlled, clinical trial was designed to see whether low tidal volume (VT) could further minimize pulmonary complications after MIE. METHODS Between June 2011 and July 2012, a total of 101 patients who underwent MIE received left-lung ventilation during thoracoscopic esophagectomy. All patients received left-lung ventilation during thoracoscopic esophagectomy. Patients were randomly assigned to a low VT (5 mL/kg + 5 cm H2O positive end-expiratory pressure) preserved ventilation (PV) group (n = 53) and a conventional VT (8 mL/kg) controlled ventilation (CV) group (n = 48) in the thoracic stage. Alveolar lavage fluid was harvested from the ventilated lung at intubation and at 18 hours after surgery for analysis of interleukin (IL)-1ß, IL-6, and IL-8 levels. Clinical characteristics, including patient demographics, operation features, and changes in oxygenation index, were recorded and analyzed. Pulmonary complications were identified and statistically compared between the 2 groups. RESULTS The clinical characteristics and operation features were comparable between the 2 groups. IL-1ß, IL-6, and IL-8 expressions in preoperative alveolar lavage fluid were similar between the 2 groups. Significantly lower IL expressions were observed in the PV group than those in the CV group at 18 hours after MIE (IL-1ß, 25.42 ± 31.01 vs 94.96 ± 118.24 pg/mL; IL-6, 30.86 ± 75.78 vs 92.99 ± 72.90 pg/mL; IL-8, 258.75 ± 188.24 vs 403.95 ± 151.44 pg/mL; all P < .05). The 18-hour postoperative oxygenation index was lower in the CV group than that in the PV group (292.85 ± 28.74 vs 326.35 ± 34.43; P = .046). Pulmonary complications were observed in 18 cases of our series, occurring more frequently on the ventilation side (right, 6 cases; and left, 12 cases). All patients were cured by conservative therapy without severe sequelae. The occurrence of pulmonary complications in the PV group was lower than that in the CV group (9.43% vs 27.08%; P = .021). CONCLUSIONS Lung injury due to intraoperative single-lung ventilation may contribute to pulmonary complications after MIE. Low VT ventilation could decrease ventilation-associated lung inflammation, thus minimizing pulmonary complications after MIE. Further studies, based on a larger volume of populations, are required to confirm these findings.
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Affiliation(s)
- Yaxing Shen
- Division of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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