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Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A. Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 2021; 21:72. [PMID: 33593301 PMCID: PMC7885467 DOI: 10.1186/s12876-021-01651-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).
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Affiliation(s)
- Chengcheng Christine Zhang
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Lukas Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Reynolds JV, Donlon N, Elliott JA, Donohoe C, Ravi N, Kuppusamy MK, Low DE. Comparison of Esophagectomy outcomes between a National Center, a National Audit Collaborative, and an International database using the Esophageal Complications Consensus Group (ECCG) standardized definitions. Dis Esophagus 2021; 34:5863448. [PMID: 32591791 DOI: 10.1093/dote/doaa060] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/19/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Abstract
The ECCG developed a standardized platform for reporting operative complications, with consensus definitions. The Dutch Upper Gastrointestinal Cancer Audit (DUCA) published a national comparison against these benchmarks. This study compares ECCG data from the Irish National Center (INC) with both published benchmark studies. All patients undergoing multimodal therapy or surgery with curative intent from 2014 to 2018 inclusive were studied, with data recorded prospectively and entered onto a secure online database (Esodata.org). 219 patients (mean age 67; 77% male) underwent open resection, 66.6% via transthoracic en bloc resection. 30-day and 90-day mortality were 0.0 and 0.9%,nrespectively. Anastomotic leak rate was 5.4%, pneumonia 18.2%, respiratory failure 10%, ARDS 2.7%, atrial dysrhythmia 22.8%, recurrent nerve injury 3%, and delirium in 5% of patients. Compared with both ECCG and DUCA, where MIE constituted 47 and 86% of surgical approaches, respectively, overall complications were similar, as were severity of complications; however, anastomotic leak rate was several-fold less, and mortality was significantly lower (P < 0.001). In this consecutive series and comparative audit with benchmark averages from the ECCG and DUCA publications, a low mortality and anastomotic leak rate were the key differential findings. Although not risk stratified, the severity of complications from this 'open' series is consistent with series containing large numbers of total or hybrid MIE, highlighting a need to adhere to these strictly defined definitions in further prospective research and randomized studies.
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Affiliation(s)
- John V Reynolds
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Noel Donlon
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Jessie A Elliott
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Claire Donohoe
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
| | - Narayanasamy Ravi
- National Esophageal and Gastric Cancer Center, St James's Hospital and Trinity College, Dublin, Ireland
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Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus 2021; 34:doaa039. [PMID: 32476017 PMCID: PMC7801633 DOI: 10.1093/dote/doaa039] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.
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Affiliation(s)
- M Fabbi
- Fondazione IRCCS Cà Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - E R C Hagens
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Eichelmann AK, Ismail S, Merten J, Slepecka P, Palmes D, Laukötter MG, Pascher A, Mardin WA. Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy. J Gastrointest Surg 2021; 25:2447-2454. [PMID: 33629233 PMCID: PMC8523444 DOI: 10.1007/s11605-021-04955-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/01/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL. METHODS All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging. RESULTS 42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28). CONCLUSION Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies.
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Affiliation(s)
- Ann-Kathrin Eichelmann
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Sarah Ismail
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Jennifer Merten
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Patrycja Slepecka
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Daniel Palmes
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Mike G. Laukötter
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Andreas Pascher
- Department of General, Visceral and Transplant Surgery, University Hospital of Muenster, Albert-Schweitzer-Campus 1, W1, 48149 Muenster, Germany
| | - Wolf Arif Mardin
- Department of Medical Controlling, University Hospital of Muenster, Nils-Stensen-Str. 8, 48149 Muenster, Germany
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Plat VD, Bootsma BT, Straatman J, van den Bergh J, van Waesberghe JHTM, Luttikhold J, Luyer MDP, van der Peet DL, Daams F. The clinical suspicion of a leaking intrathoracic esophagogastric anastomosis: the role of CT imaging. J Thorac Dis 2020; 12:7182-7192. [PMID: 33447407 PMCID: PMC7797855 DOI: 10.21037/jtd-20-954] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background CT imaging is the primary diagnostic approach to assess the integrity of the intrathoracic anastomosis following Ivor Lewis esophagectomy. In the postoperative setting interpretation of CT findings, such as air and fluid collections, may be challenging. Establishment of a scoring system that incorporates CT findings to diagnose anastomotic leakage could assist radiologists and surgeons in the postoperative phase. Methods Consecutive patients who underwent a CT scan for a clinical suspicion of postoperative anastomotic leakage following Ivor Lewis esophagectomy between 2010 and 2016 in two medical centers were retrospectively included. Scans were excluded when oral contrast was not (correctly) administered. Acquired images were randomized and independently assessed by two experienced gastrointestinal radiologists, blinded for clinical information. For this study anastomotic leakage was defined as a visible defect during endoscopy or thoracotomy. Results A total of 80 patients had 101 CT scans, resulting in 32 scans with a confirmed anastomotic leak (25 patients). After multivariable backward stepwise logistic regression, a practical 5-point scoring system was developed, which included the following CT findings: presence of extraluminal oral contrast, air collection at the anastomotic site, fluid collection at the anastomotic site, pneumothorax and loculated pleural effusion. Patients with a score of ≥3 were considered at high risk for anastomotic leakage (positive predictive value: 83.3%), patients with scores <3 were considered at low risk for anastomotic leakage (negative predictive value: 84.4%). The scoring system showed a superior diagnostic performance compared to the original CT report and blinded interpretation of two radiologists. Conclusions Our CT-based practical scoring system enables a standardized approach in CT assessment and could facilitate early recognition of anastomotic leakage in patients after Ivor Lewis esophagectomy.
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Affiliation(s)
- Victor D Plat
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Boukje T Bootsma
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Janneke van den Bergh
- Department of Radiology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Joanna Luttikhold
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Micha D P Luyer
- Department of Gastrointestinal Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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Rubicondo C, Lovece A, Pinelli D, Indriolo A, Lucianetti A, Colledan M. Endoluminal vacuum-assisted closure (E-Vac) therapy for postoperative esophageal fistula: successful case series and literature review. World J Surg Oncol 2020; 18:301. [PMID: 33189152 PMCID: PMC7666449 DOI: 10.1186/s12957-020-02073-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/28/2020] [Indexed: 12/05/2022] Open
Abstract
Background Treatment of esophageal perforations and postoperative anastomotic leaks of the upper gastrointestinal tract remains a challenge. Endoluminal vacuum-assisted closure (E-Vac) therapy has positively contributed, in recent years, to the management of upper gastrointestinal tract perforations by using the same principle of vacuum-assisted closure therapy of external wounds. The aim is to provide continuous wound drainage and to promote tissue granulation, decreasing the needed time to heal with a high rate of leakage closure. Cases presentation A series of two different cases with clinical and radiological diagnosis of esophageal fistulas, recorded from 2018 to 2019 period at our institution, is presented. The first one is a case of anastomotic leak after esophagectomy for cancer complicated by pleuro-mediastinal abscess, while the second one is a leak of an esophageal suture, few days after resection of a bronchogenic cyst perforated into the esophageal lumen. Both cases were successfully treated with E-Vac therapy. Conclusion Our experience shows the usefulness of E-Vac therapy in the management of anastomotic and non-anastomotic esophageal fistulas. Further research is needed to better define its indications, to compare it to traditional treatments and to evaluate its long-term efficacy.
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Affiliation(s)
| | - Andrea Lovece
- General Surgery I, ASST Papa Giovanni XXIII, Piazza OMS, 1, 24127, Bergamo, Italy
| | | | - Amedeo Indriolo
- Department of Gastroenterology and Endoscopy, ASST Papa Giovanni XXIII, Bergamo, Italy
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Cai M, Weng Y, Wang Z, Zhu J, You Q. Prevention of Esophageal-Stomach Anastomosis Leakage After Esophagectomy—an Analysis of 1243 Patients. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02100-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rasihashemi SZ, Ramouz A, Beheshtirouy S, Amini H. Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study. BMC Gastroenterol 2020; 20:250. [PMID: 32736599 PMCID: PMC7393709 DOI: 10.1186/s12876-020-01393-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023] Open
Abstract
Background Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients. Methods This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation. Results Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02). Conclusion Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.
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Affiliation(s)
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg, Germany
| | - Samad Beheshtirouy
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Amini
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Department of General Surgery, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
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Guo XF, Zhang SG. Tubular anastomosis with full-thickness discontinuous tension-reduction suture can reduce incidence of cervical anastomotic fistula after surgery for esophageal cancer. Shijie Huaren Xiaohua Zazhi 2020; 28:637-642. [DOI: 10.11569/wcjd.v28.i14.637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anastomotic fistula is the most common serious complication after operation for esophageal cancer. This study retrospectively analyzed the clinical data of patients undergoing radical resection of esophageal carcinoma at our department, identified the relevant risk factors for anastomotic fistula, and investigated the effects of tubular anastomosis with full-thickness discontinuous tension-reduction suture for the prevention of anastomotic fistula.
AIM To analyze the risk factors affecting the occurrence of cervical anastomotic fistula after surgery of esophageal cancer, and to explore the safety and effectiveness of tubular anastomosis with full-thickness discontinuous tension-reduction suture on anastomotic fistula.
METHODS The clinical data of 544 patients with esophageal squamous cell carcinoma undergoing radical surgery from May 2014 to December 2018 at the Department of Thoracic Surgery, Anyang Tumor Hospital were retrospectively analyzed, and possible factors related to the occurrence of cervical anastomotic fistula were identified. Single-factor and multi-factor Logistic regression analyses were performed to determine the independent risk factors for the occurrence of cervical anastomotic fistula.
RESULTS The patient's age, diabetes history, duration of operation (> 300 min), and full-thickness discontinuous suture after tubular anastomosis were independent risk factors for the occurrence of postoperative anastomotic fistula. Among them, tubular anastomosis with full-thickness discontinuous tension-reduction suture was beneficial to reduce the incidence of postoperative cervical anastomotic fistula (6.1% vs 13.1%, P < 0.05).
CONCLUSION It is safe and effective to prevent cervical anastomotic fistula by using tubular anastomosis with full-thickness discontinuous tension-reduction suture.
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Affiliation(s)
- Xiao-Feng Guo
- Department of Thoracic Surgery, Anyang Tumor Hospital, Anyang 455000, Henan Province, China
| | - Shu-Guang Zhang
- Department of Thoracic Surgery, the First Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
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Xu QL, Li H, Zhu YJ, Xu G. The treatments and postoperative complications of esophageal cancer: a review. J Cardiothorac Surg 2020; 15:163. [PMID: 32631428 PMCID: PMC7336460 DOI: 10.1186/s13019-020-01202-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/22/2020] [Indexed: 12/24/2022] Open
Abstract
Abstract Esophageal cancer is still one of the most common cancers in the world. We review the appropriate treatments at different stages of esophageal cancer and also analyze the advantages and disadvantages of these treatments. The prognosis and recovery of different treatment regimens are further discussed. In particular, post-operative complications are the major causes of high mortality derived from the esophageal cancer. Therefore, we particularly discuss the main complications resulting in high mortality after surgery of esophageal cancer, and summarize their risk factors and treatment options. Background As the common cancer, the complications of esophageal cancer after surgery have been not obtained systematic treatment strategy, focusing on treatment regimens based on the different stages of esophageal cancers. Methods and overview This paper systematically summarizes the appropriate treatment strategies for different stages of esophageal cancers, and their advantages and disadvantages. We particularly focus on the postoperative survival rate of patients and postoperative complications, and discuss the causes of high mortality risk factors after surgery. The risk factors of death and corresponding treatment methods are further summarized in this study. Conclusion Postoperative complications is the main cause responsible for the hard cure of esophageal cancers. The existing literatures indicate that postoperative anastomotic fistula is one of the most important complications leading to death, while it has not received much attention yet. We suggest that anastomotic fistula should be detected and dealt with early by summarizing these literatures. It is, therefore, necessary to develop a set of methods to predict or check anastomotic fistula in advance.
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Affiliation(s)
- Qi-Liang Xu
- Department of Cardiothoracic Surgery, Heze Municipal Hospital, Heze, 274031, Shandong, China
| | - Hua Li
- Department of Information, Heze Municipal Hospital, Heze, 274031, Shandong, China
| | - Ye-Jing Zhu
- Department of Clinical Pharmacy, Heze Municipal Hospital, Heze, 274031, Shandong, China
| | - Geng Xu
- Department of Cardiothoracic Surgery, Heze Municipal Hospital, Heze, 274031, Shandong, China.
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Ahmadinejad M, Soltanian A, Maghsoudi LH. Risk factors and therapeutic measures for postoperative complications associated with esophagectomy. Ann Med Surg (Lond) 2020; 55:167-173. [PMID: 32489659 PMCID: PMC7262474 DOI: 10.1016/j.amsu.2020.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023] Open
Abstract
Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.
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Affiliation(s)
- Mojtaba Ahmadinejad
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Ali Soltanian
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Leila Haji Maghsoudi
- Department of General Surgery, Faculty of Medicine, Alborz University of Medical Sciences, Karaj, Iran
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Mixed Type Histology as a Predictive Factor for Esophagojejunostomy Leak in Advanced Gastric Cancer. Cancers (Basel) 2020; 12:cancers12061701. [PMID: 32604802 PMCID: PMC7352589 DOI: 10.3390/cancers12061701] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/25/2020] [Indexed: 12/12/2022] Open
Abstract
Since esophagojejunostomy leak (EJL) after gastrectomy is a potentially fatal complication and may impact the survival of patients with advanced gastric cancer (GC), it is important to establish risk factors for the EJL and to prevent this surgical complication. The aim of this study was analysis of predictors for the postoperative clinically apparent EJL. All patients operated for advanced GC between October 2016 and December 2019 were analyzed from a prospectively maintained database. The evaluation of the EJL and postoperative complications according to the demographic and clinical (categorized) variables was performed with odds ratio test (multivariate analysis was performed with the use of logistic regression method). Among the 114 patients included in the study, 71.1% received neoadjuvant chemotherapy and 19.3% underwent gastrectomy followed by the hyperthermic intraperitoneal chemotherapy (HIPEC). Postoperative EJL was found in 4.6% patients. The risk of EJL was significantly higher for mixed-type GC (OR = 12.45, 95% CI: 1.03-150.10; p = 0.0472). The risk of other postoperative complications was significantly higher in patients undergoing HIPEC (OR = 3.88, 95% CI: 1.40-10.80, p = 0.0094). The number of lymph nodes removed (>38) was characterized by 80% sensitivity and 79.6% specificity in predicting EJL (AUC = 0.80, 95% CI: 0.72-0.87; p < 0.0001). Mixed histological type of GC is a tumor-related risk factor for the EJL. HIPEC was confirmed to be a risk factor for postoperative complications after gastrectomy.
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Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study). Trials 2020; 21:448. [PMID: 32487210 PMCID: PMC7265255 DOI: 10.1186/s13063-020-04366-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality. Methods/design The NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient’s health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled. Discussion The two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF. Trial registration ClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.
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65
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Huang C, Yao H, Huang Q, Lu H, Xu M, Wu J. A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy. BMC Surg 2020; 20:64. [PMID: 32252738 PMCID: PMC7137293 DOI: 10.1186/s12893-020-00726-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 03/25/2020] [Indexed: 01/25/2023] Open
Abstract
Background Anastomotic leakage is a dangerous postoperative complication of oesophageal surgery. The present study aimed to develop a simple and practical scoring system to predict the risk of anastomotic leakage after oesophageal resection. Methods A consecutive series of 330 patients who underwent oesophageal cancer surgery from January 2016 to January 2018 at the Shanghai Chest Hospital were included to develop a prediction model. Anastomotic leakage was evaluated using oesophagography, computed tomography, or flexible endoscopy. Least absolute shrinkage and selection operator regression based on a generalized linear model was used to select variables for the anastomotic leakage risk model while avoiding overfitting. Multivariable logistic regression analysis was applied to build forest plots and a prediction model. The concordance index or the area under the curve was used to judge the discrimination, and calibration plots verified the consistency. Internal validation of the model was conducted, and the clinical usefulness and threshold screening of the model were evaluated by decision curve analysis. Results The factors included in the predictive nomogram included Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia. The model displayed a discrimination performance with a concordance index of 0.690 (95% confidence interval: 0.620–0.760) and good calibration. A concordance index value of 0.664 was maintained during the internal validation. The calibration curve showed good agreement between the actual observations and the predicted results. Conclusion The present prediction model, which requires only seven variables and includes Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia, may be useful for predicting anastomotic leakage in patients after oesophagectomy.
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Affiliation(s)
- Chengya Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Haixia Yao
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Qi Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Huijie Lu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Meiying Xu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Jingxiang Wu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.
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Famiglietti A, Lazar JF, Henderson H, Hamm M, Malouf S, Margolis M, Watson TJ, Khaitan PG. Management of anastomotic leaks after esophagectomy and gastric pull-up. J Thorac Dis 2020; 12:1022-1030. [PMID: 32274171 PMCID: PMC7139088 DOI: 10.21037/jtd.2020.01.15] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient’s clinical status and the surgeon’s preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.
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Affiliation(s)
- Amber Famiglietti
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - John F. Lazar
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Hayley Henderson
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Margaret Hamm
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Stefanie Malouf
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Marc Margolis
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Thomas J. Watson
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Puja Gaur Khaitan
- Department of Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
- Division of Thoracic and Esophageal Surgery, Georgetown University School of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Zuo J, Zhao M, Fan Z, Liu B, Wang Y, Li Y, Lv P, Xing L, Zhang X, Shen H. MicroRNA-153-3p regulates cell proliferation and cisplatin resistance via Nrf-2 in esophageal squamous cell carcinoma. Thorac Cancer 2020; 11:738-747. [PMID: 32012470 PMCID: PMC7049518 DOI: 10.1111/1759-7714.13326] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background Our recent studies have indicated that miR‐153‐3p is downregulated in the esophageal squamous cell carcinoma (ESCC) cell lines and tissues. Upregulation of miR‐153‐3p was found to inhibit migration and invasion of ESCC cells. However, whether miR‐153‐3p regulates the cisplatin sensitivity in ESCC cells remains unclear. In this study, we explored whether and how miR‐153‐3p regulates the proliferation and confers cisplatin resistance in ESCC by targeting the Nrf‐2 protein. Methods Eca109 cell line was transfected with microRNA‐153‐3p mimics or Nrf‐2siRNA and cell proliferation and cisplatin resistance were studied. A dual‐luciferase reporter assay was performed on Eca109 cells cotransfected with the wild‐type/mutant 3′UTR sequences of Nrf‐2 and control or microRNA‐153‐3p mimics. We determined the correlation between microRNA‐153‐3p and Nrf‐2 expression in human ESCC samples and explored the effect of Nrf‐2 in the overall survival rate of ESCC patients. Results MiR‐153‐3p significantly suppressed cell proliferation and increased the sensitivity of Eca‐109 cells to cisplatin. MiR‐153‐3p showed a negative correlation with Nrf‐2 in human esophageal carcinoma tissues. MiR‐153‐3p suppressed the expression of Nrf‐2 via binding to its 3′‐UTR region. Furthermore, inhibition of Nrf‐2 also decreased cell proliferation and increased the sensitivity of Eca109 cells to cisplatin. High expression of Nrf‐2 in human ESCC samples was associated with poor overall survival of ESCC patients. Conclusion MiR‐153‐3p inhibits cell proliferation and confers cisplatin resistance by downregulating Nrf‐2 expression in Eca‐109 cells. Thus, miR‐153‐3p/Nrf‐2 may play an important role in conferring cisplatin resistance in ESCC. Nrf‐2 appears to be a promising therapeutic target for ESCC.
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Affiliation(s)
- Jing Zuo
- Department of Pathology, The Second Hospital, Hebei Medical University, Shijiazhuang, China.,Department of Oncology, The Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Mei Zhao
- Lab of Pathology, Hebei Medical University, Shijiazhuang, China
| | - Zhisong Fan
- Department of Oncology, The Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Bowei Liu
- Department of Pathology, The Second Hospital, Hebei Medical University, Shijiazhuang, China
| | - Yudong Wang
- Department of Oncology, The Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Yuehong Li
- Department of Pathology, The Second Hospital, Hebei Medical University, Shijiazhuang, China
| | - Ping Lv
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, China
| | - Lingxiao Xing
- Lab of Pathology, Hebei Medical University, Shijiazhuang, China
| | - Xianghong Zhang
- Department of Pathology, The Second Hospital, Hebei Medical University, Shijiazhuang, China.,Lab of Pathology, Hebei Medical University, Shijiazhuang, China
| | - Haitao Shen
- Lab of Pathology, Hebei Medical University, Shijiazhuang, China
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Evans RPT, Singh P, Nepogodiev D, Bundred J, Kamarajah S, Jefferies B, Siaw-Acheampong K, Wanigasooriya K, McKay S, Mohamed I, Whitehouse T, Alderson D, Gossage J, van Hillegersberg R, Vohra RS, Griffiths EA. Study protocol for a multicenter prospective cohort study on esophagogastric anastomoses and anastomotic leak (the Oesophago-Gastric Anastomosis Audit/OGAA). Dis Esophagus 2020; 33:5393317. [PMID: 30888419 DOI: 10.1093/dote/doz007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/25/2019] [Accepted: 02/05/2019] [Indexed: 12/11/2022]
Abstract
Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2-3% as compared to 17-35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien-Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings.
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Affiliation(s)
| | - P Singh
- West Midlands Research Collaborative.,Department of Upper GI Surgery, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham
| | - D Nepogodiev
- West Midlands Research Collaborative.,Academic Department of Surgery
| | - J Bundred
- West Midlands Research Collaborative
| | | | | | | | | | - S McKay
- West Midlands Research Collaborative
| | - I Mohamed
- West Midlands Research Collaborative
| | | | | | - J Gossage
- Department of Upper GI Surgery, St Thomas' Hospital, Guys and St. Thomas' Foundation Trust, London
| | | | - R S Vohra
- Queen's Medical Centre Nottingham University Hospitals, Nottingham, UK
| | - E A Griffiths
- Academic Department of Surgery.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham
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Rodrigues-Pinto E, Repici A, Donatelli G, Macedo G, Devière J, van Hooft JE, Campos JM, Galvao Neto M, Silva M, Eisendrath P, Kumbhari V, Khashab MA. International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks. Endosc Int Open 2019; 7:E1671-E1682. [PMID: 31788551 PMCID: PMC6877414 DOI: 10.1055/a-1005-6632] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 08/05/2019] [Indexed: 12/19/2022] Open
Abstract
Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.
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Affiliation(s)
- Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal,Corresponding author Eduardo Rodrigues-Pinto, MD Gastroenterology DepartmentCentro Hospitalar São JoãoPorto. Al. Prof. Hernâni Monteiro 4200 – 319PortoPortugal+351 22 551 3601
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Rozzano, Milan; Humanitas University, Rozzano, Milan, Italy
| | - Gianfranco Donatelli
- Department of Gastroenterology and Hepatology, Hôpital Privé des Peupliers Paris, France
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Jacques Devière
- Department of Gastroenterology Hepatopancreatology, and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Manoel Galvao Neto
- Herbert Wertheim College of Medicine at Florida International University, Department of Surgery, Miami, Florida, United States
| | - Marco Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Pierre Eisendrath
- Department of Gastroenterology & Hepatology, CHU Saint Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Vivek Kumbhari
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
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de Mooij CM, Maassen van den Brink M, Merry A, Tweed T, Stoot J. Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery. J Clin Med 2019; 8:E2005. [PMID: 31744186 PMCID: PMC6912692 DOI: 10.3390/jcm8112005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.
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Affiliation(s)
- Cornelius Maarten de Mooij
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Martijn Maassen van den Brink
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Audrey Merry
- Department of Epidemiology, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands;
| | - Thais Tweed
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Jan Stoot
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
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Barchi LC, Ramos MFKP, Pereira MA, Dias AR, Ribeiro-Júnior U, Zilberstein B, Cecconello I. Esophagojejunal anastomotic fistula: a major issue after radical total gastrectomy. Updates Surg 2019; 71:429-438. [PMID: 31161587 DOI: 10.1007/s13304-019-00659-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 05/27/2019] [Indexed: 02/05/2023]
Abstract
Gastric cancer surgery has evolved considerably over the past years, with substantial improvement on outcomes. Meanwhile, esophagojejunal anastomotic fistula (EJF) continues to impair postoperative results. This study aimed to assess EJF regarding its incidence, risk factors, management and the impact on overall survival. We retrospectively analyzed 258 consecutive patients who underwent total or completion gastrectomy for GC from 2009 and 2017. Clinicopathological characteristics analysis was performed comparing patients who developed EJF with patients with other clinical or surgical complications, as well as patients without any postoperative complications. Fifteen (5.8%) patients had EJF and 81 (31.4%) had other complications (including other surgical fistulas). The median time of EJF diagnosis was on the eighth postoperative day (range 3-76). Completion gastrectomy (p = 0.048) and longer hospital stay (p < 0.001) were associated with the occurrence of EJF. The surgical mortality of patients with EJF was higher than in non-EJF patients (26.7% vs. 4.5%; p < 0.001). Nine patients were treated conservatively and six required surgery. The mortality rate of EJF was 11.1% and 50% in patients who underwent conservative and surgical treatment, respectively. Patients with other complications and patients with EJF had worse survival compared to patients without any complication (p = 0.004 and p = 0.013, respectively). Completion gastrectomy is the main risk factor for EJF occurrence. Still, EJF is associated with high postoperative mortality, longer hospital stay and has a negative impact on long-term survival.
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Affiliation(s)
- Leandro Cardoso Barchi
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil.
| | | | - Marina Alessandra Pereira
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - André Roncon Dias
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ulysses Ribeiro-Júnior
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Bruno Zilberstein
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
| | - Ivan Cecconello
- Cancer Institute (ICESP), Hospital das Clínicas, University of São Paulo Medical School, Av Dr Arnaldo 251, São Paulo, SP, 01249000, Brazil
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De Pasqual CA, Weindelmayer J, Laiti S, La Mendola R, Bencivenga M, Alberti L, Giacopuzzi S, de Manzoni G. Perianastomotic drainage in Ivor-Lewis esophagectomy, does habit affect utility? An 11-year single-center experience. Updates Surg 2019; 72:47-53. [DOI: 10.1007/s13304-019-00674-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/05/2019] [Indexed: 01/10/2023]
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73
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Li SS, Costantino CL, Mullen JT. Morbidity and Mortality of Total Gastrectomy: a Comprehensive Analysis of 90-Day Outcomes. J Gastrointest Surg 2019; 23:1340-1348. [PMID: 31062268 DOI: 10.1007/s11605-019-04228-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total gastrectomy (TG) is a complex procedure that carries a high risk of morbidity and mortality and in which patients may experience post-operative sequelae well past the standard 30-day follow-up period. Large studies from high-volume centers with detailed 90-day follow-up data are needed to provide benchmarks for high-quality care for this complex procedure. METHODS Single-institution, retrospective review of a comprehensive gastric cancer database of 148 patients undergoing curative intent TG from 2000 to 2017. Clinicopathologic and treatment factors were analyzed for their impact on 90-day outcomes. RESULTS The median age of the cohort was 66 years, and 61% were male. Neoadjuvant chemotherapy and radiation therapy were delivered to 32% and 11% of patients, respectively. Open and laparoscopic TG were performed in 93% (n = 137) and 7% (n = 11) of patients, respectively. Extended lymphadenectomy, pancreatectomy, and splenectomy were performed in 37%, 4.7%, and 19% of patients, respectively. The 30- and 90-day mortality rates were 2.0% and 3.4%, respectively. At least one 90-day complication was experienced by 43.9% (n = 65) of patients, and 14% (n = 21) experienced a Clavien-Dindo grade 3 or 4 complication. Anastomotic leak occurred in 5.4% (n = 8) of patients, half of which required an invasive intervention. Median length of stay was 8 days. The readmission rate was 22%, and most readmissions were due to dehydration and/or nutritional compromise. CONCLUSIONS This study defines 30- and 90-day post-operative outcomes after total gastrectomy in a high-volume center. These outcomes data are critical to the improvement of the informed consent process and as benchmarks for future quality improvement initiatives.
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Affiliation(s)
- Selena S Li
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Christina L Costantino
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - John T Mullen
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, YAW-7926, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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Plum PS, Herbold T, Berlth F, Christ H, Alakus H, Bludau M, Chang DH, Bruns CJ, Hölscher AH, Chon SH. Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy. World J Surg 2019; 43:862-869. [PMID: 30377723 DOI: 10.1007/s00268-018-4832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. METHODS Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. RESULTS Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. CONCLUSIONS The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
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Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - De-Hua Chang
- Institute of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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75
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Min YW, Kim T, Lee H, Min BH, Kim HK, Choi YS, Lee JH, Rhee PL, Kim JJ, Zo JI, Shim YM. Endoscopic vacuum therapy for postoperative esophageal leak. BMC Surg 2019; 19:37. [PMID: 30975210 PMCID: PMC6458610 DOI: 10.1186/s12893-019-0497-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 03/27/2019] [Indexed: 02/07/2023] Open
Abstract
Background Anastomotic leak is the most common and serious complication following esophagectomy. Endoscopic vacuum-assisted closure (EVAC) is a promising method for treating anastomotic leak. We aimed to evaluate the efficacy of EVAC and to identify factors associated with longer treatment duration for esophageal anastomotic leak following esophagectomy for cancer. Methods We retrospectively analyzed 20 esophageal cancer patients who had undergone EVAC for anastomotic leak after esophagectomy. The efficacy and success rates were evaluated and factors associated with longer treatment duration (≥ 21 days) were identified. Results All 20 patients were male. Of these, 10 (50.0%) received neoadjuvant treatment and 6 (30.0%) had one or more comorbidities. The median size of fistula opening was 1.75 cm. During a median of 14.5 days of EVAC treatment, a median of 5 interventions were performed. Treatment success was achieved in 19 patients (95.0%). Neoadjuvant treatment was significantly associated with longer EVAC treatment. There was a non-significant trend toward the need for longer treatment duration for a larger fistula opening size. Conclusions EVAC treatment is a good non-surgical option for anastomotic leak following esophagectomy. Long duration of treatment is associated with neoadjuvant treatment and a large leakage opening.
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Affiliation(s)
- Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taewan Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Poong-Lyul Rhee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae J Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea.
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, South Korea
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76
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Verstegen MHP, Bouwense SAW, van Workum F, Ten Broek R, Siersema PD, Rovers M, Rosman C. Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer: a systematic review. World J Emerg Surg 2019; 14:17. [PMID: 30988695 PMCID: PMC6449949 DOI: 10.1186/s13017-019-0235-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/14/2019] [Indexed: 01/28/2023] Open
Abstract
Background Anastomotic leakage (0-30%) after esophagectomy is a severe complication and is associated with considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy have the best clinical outcome, based on the currently available literature. Methods A systematic literature search was performed in Medline, Embase, and Web of Science until April 2017. All studies reporting on the specific treatment of cervical or intrathoracic anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Results Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Mortality rates of intrathoracic anastomotic leakages in the treatment groups were as follows: conservative (14%), endoscopic stent (8%), endoscopic drainage (8%), endoscopic vacuum-assisted closure system (0%), and surgery treatment group (50%). Mortality rates of cervical anastomotic leakages in the treatment groups were as follows: conservative (8%), endoscopic stent (29%), and endoscopic dilatation (0%). Discussion Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting a specific treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. In the absence of robust evidence-based treatment guidelines, we suggest customized treatment depending on sequelae of the leak and clinical condition of the patient. PrDepartment of Surgery, Radboudumc, P.O.B. 9101/618 NLactical advices are provided. Trial registration Registration number PROSPERO: CRD42016032374.
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Affiliation(s)
- Moniek H P Verstegen
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Stefan A W Bouwense
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Frans van Workum
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Richard Ten Broek
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Peter D Siersema
- 2Gastroenterology and Hepatology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Maroeska Rovers
- 3Operating Rooms and Health Evidence, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Camiel Rosman
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Abstract
Anastomotic leakage (AL) is one of the most critical and detrimental complications in esophageal surgery. Early diagnosis and timely therapeutic action are necessary if patients are to avoid AL-related problems. However, there is no gold standard or consensus for early diagnosis. In this review, we focus on summarizing the definition and types of AL and modalities for early diagnosis of AL after esophagectomy.
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Affiliation(s)
- Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, The Catholic University of Korea, College of Medicine, Suwon, Republic of Korea
| | - Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
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Schizas D, Kosmopoulos M, Giannopoulos S, Giannopoulos S, Kokkinidis DG, Karampetsou N, Papanastasiou CA, Rouvelas I, Liakakos T. Meta-analysis of risk factors and complications associated with atrial fibrillation after oesophagectomy. Br J Surg 2019; 106:534-547. [DOI: 10.1002/bjs.11128] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 12/11/2018] [Accepted: 01/08/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Oesophagectomy is associated with high morbidity and mortality rates. New-onset atrial fibrillation (AF) is a frequent complication following oesophagectomy. Several studies have explored whether new-onset AF is associated with adverse events after oesophagectomy.
Methods
This review was performed according to PRISMA guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 25 November 2018. A meta-analysis was conducted with the use of random-effects modelling. The I2 statistic was used to assess for heterogeneity.
Results
In total, 53 studies including 9087 patients were eligible for analysis. The overall incidence of postoperative AF was 16·5 per cent. Coronary artery disease and hypertension were associated with AF, whereas diabetes, smoking and chronic obstructive pulmonary disease were not. Patients with AF had a significantly higher risk of overall postoperative adverse events than those without fibrillation (odds ratio (OR) 5·50, 95 per cent c.i. 3·51 to 8·30), including 30-day mortality (OR 2·49, 1·70 to 3·64), anastomotic leak (OR 2·65, 1·53 to 4·59) and pneumonia (OR 3·42, 2·39 to 4·90).
Conclusion
Postoperative AF is frequently observed in patients undergoing oesophagectomy for cancer. It is associated with an increased risk of death and postoperative complications.
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Affiliation(s)
- D Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - M Kosmopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | | | - S Giannopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - D G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - N Karampetsou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - C A Papanastasiou
- Division of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology and Department of Upper Abdominal Diseases, Karolinska Institutet, Stockholm, Sweden
| | - T Liakakos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Rodrigues-Pinto E, Morais R, Macedo G, Khashab MA. Choosing the Appropriate Endoscopic Armamentarium for Treatment of Anastomotic Leaks. Am J Gastroenterol 2019; 114:367-371. [PMID: 30413816 DOI: 10.1038/s41395-018-0412-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Rui Morais
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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80
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Shao CY, Liu KC, Li CL, Cong ZZ, Hu LW, Luo J, Diao YF, Xu Y, Ji SG, Qiang Y, Shen Y. C-reactive protein to albumin ratio is a key indicator in a predictive model for anastomosis leakage after esophagectomy: Application of classification and regression tree analysis. Thorac Cancer 2019; 10:728-737. [PMID: 30734487 PMCID: PMC6449232 DOI: 10.1111/1759-7714.12990] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/06/2019] [Accepted: 01/06/2019] [Indexed: 12/14/2022] Open
Abstract
Background Anastomotic leakage (AL), a serious complication after esophagectomy, might impair patient quality of life, prolong hospital stay, and even lead to surgery‐related death. The aim of this study was to show a novel decision model based on classification and regression tree (CART) analysis for the prediction of postoperative AL among patients who have undergone esophagectomy. Methods A total of 450 patients (training set: 356; test set: 94) with perioperative information were included. A decision tree model was established to identify the predictors of AL in the training set, which was validated in the test set. A receiver operating characteristic curve was also created to illustrate the diagnostic ability of the decision model. Results A total of 12.2% (55/450) of the 450 patients suffered AL, which was diagnosed at median postoperative day 7 (range: 6–16). The decision tree model, containing surgical duration, postoperative lymphocyte count, and postoperative C‐reactive protein to albumin ratio, was established by CART analysis. Among the three variables, the postoperative C‐reactive protein to albumin ratio was identified as the most important indicator in the CART model with normalized importance of 100%. According to the results validated in the test set, the sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of the prediction model were 80%, 98.8%, 88.9%, 97.6%, and 96.8%, respectively. Moreover, the area under the receiver operating characteristic curve was 0.95. Conclusion The decision model based on CART analysis presented good performance for predicting AL, and might allow the early identification of patients at high risk.
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Affiliation(s)
- Chen-Ye Shao
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Kai-Chao Liu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chu-Ling Li
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li-Wen Hu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Sai-Guang Ji
- Department of Cardiothoracic Surgery, Jingling Hospital, Bengbu Medical College, Anhui, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, Jingling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
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Giulini L, Dubecz A, Solymosi N, Tank J, Renz M, Thumfart L, Stein HJ. Prognostic Value of Chest-Tube Amylase Versus C-Reactive Protein as Screening Tool for Detection of Early Anastomotic Leaks After Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2019; 29:192-197. [DOI: 10.1089/lap.2018.0656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Norbert Solymosi
- Center for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marcus Renz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Lucas Thumfart
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Hubert J. Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Fumagalli U, Baiocchi GL, Celotti A, Parise P, Cossu A, Bonavina L, Bernardi D, de Manzoni G, Weindelmayer J, Verlato G, Santi S, Pallabazzer G, Portolani N, Degiuli M, Reddavid R, de Pascale S. Incidence and treatment of mediastinal leakage after esophagectomy: Insights from the multicenter study on mediastinal leaks. World J Gastroenterol 2019; 25:356-366. [PMID: 30686903 PMCID: PMC6343094 DOI: 10.3748/wjg.v25.i3.356] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 01/04/2019] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mediastinal leakage (ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has been difficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.
AIM To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group (ECCG).
METHODS Seven Italian surgical centers (five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies (n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017. Anastomotic MLs were defined according to the classification recently proposed by the ECCG.
RESULTS Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8% (95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy (HE), respectively, and doubled (20%) after totally minimally invasive esophagectomy (TMIE) (P = 0.016). No other predictive factors were found. The 30- and 90-d overall mortality rates were 1.4% and 3.2%, respectively; the 30- and 90-d leak-related mortality rates were 5.1% and 10.2%, respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%, respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases. Endoscopic treatment had the lowest mortality rate (6.9%). Removal of the gastric tube with stoma formation was necessary in 8 (13.6%) cases.
CONCLUSION The incidence of ML after esophagectomy was high mainly in the TMIE group. However, the general and specific (leak-related) mortality rates were low. Early treatment (surgical or endoscopic) of severe leaks is mandatory to limit related mortality.
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Affiliation(s)
- Uberto Fumagalli
- Department of Digestive Surgery, IEO European Institute of Oncology IRCCS, Milano 20141, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Studies, Surgical Clinic, University of Brescia, Brescia 25123, Italy
| | - Andrea Celotti
- General Surgery 2, ASST Spedali Civili di Brescia, Brescia 25123, Italy
| | - Paolo Parise
- Department of Gastrointestinal Surgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milano 20132, Italy
| | - Andrea Cossu
- Department of Gastrointestinal Surgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milano 20132, Italy
| | - Luigi Bonavina
- Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milano 20122, Italy
| | - Daniele Bernardi
- Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milano 20122, Italy
| | - Giovanni de Manzoni
- General and Upper GI Surgery Division, University of Verona, Verona 37134, Italy
| | - Jacopo Weindelmayer
- General and Upper GI Surgery Division, University of Verona, Verona 37134, Italy
| | - Giuseppe Verlato
- Department of Diagnostics and Public Health, University of Verona, Verona 37134, Italy
| | - Stefano Santi
- Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa 56124, Italy
| | - Giovanni Pallabazzer
- Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa 56124, Italy
| | - Nazario Portolani
- Department of Clinical and Experimental Studies, Surgical Clinic, University of Brescia, Brescia 25123, Italy
| | - Maurizio Degiuli
- University of Turin, Department of Oncology, Surgical Oncology and Digestive Surgery, San Luigi University Hospital, Orbassano 10043, Italy
| | - Rossella Reddavid
- University of Turin, Department of Oncology, Surgical Oncology and Digestive Surgery, San Luigi University Hospital, Orbassano 10043, Italy
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83
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Rausa E, Asti E, Aiolfi A, Bianco F, Bonitta G, Bonavina L. Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis. Dis Esophagus 2018; 31:5043493. [PMID: 29939229 DOI: 10.1093/dote/doy060] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/05/2018] [Indexed: 12/11/2022]
Abstract
Esophageal leaks remain a life-threatening postoperative complication of esophagectomy. Currently, self-expanding metal stents (SEMS) represent the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) has emerged and shown promising results in these patients. We conducted an electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) looking for studies comparing EVT and SEMS for the treatment of esophageal leak and/or perforation. Four studies including 163 patients matched the inclusion criteria. Esophageal leak closure rate is significantly higher with EVT than SEMS [pooled odds ratio 5.51 (95% CI 2.11-14.88; P < 0.001)]. Additionally, EVT has a shorter treatment duration [pooled mean difference -9.0 days (95% CI 16.6-1.4; P = 0.021)], lower major complication (P = 0.011), and in-hospital mortality (P = 0.002) rate compared to SEMS. EVT for esophageal leak is feasible and safe. It has the potential to become the new gold standard in the endoscopic treatment of esophageal leaks and perforations. However, further comparative studies with SEMS are needed to strengthen the current evidence.
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Affiliation(s)
- E Rausa
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - E Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - A Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - F Bianco
- Department of General Surgery, ASST - Bergamo Est Ospedale Bolognini Seriate, Bergamo, Italy
| | - G Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - L Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
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84
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Makuuchi R, Irino T, Tanizawa Y, Bando E, Kawamura T, Terashima M. Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer. Surg Today 2018; 49:187-196. [PMID: 30317492 DOI: 10.1007/s00595-018-1726-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 09/27/2018] [Indexed: 02/07/2023]
Abstract
Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.
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Affiliation(s)
- Rie Makuuchi
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Tomoyuki Irino
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Yutaka Tanizawa
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Etsuro Bando
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Taiichi Kawamura
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan
| | - Masanori Terashima
- Division of Gastric Surgery, Shizuoka Cancer Center, 1007, Shimonagakubo, Nagaizumi-Cho, Sunto-Gun, Shizuoka, 411-8777, Japan.
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85
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Grimminger PP, Goense L, Gockel I, Bergeat D, Bertheuil N, Chandramohan SM, Chen KN, Chon SH, Denis C, Goh KL, Gronnier C, Liu JF, Meunier B, Nafteux P, Pirchi ED, Schiesser M, Thieme R, Wu A, Wu PC, Buttar N, Chang AC. Diagnosis, assessment, and management of surgical complications following esophagectomy. Ann N Y Acad Sci 2018; 1434:254-273. [PMID: 29984413 DOI: 10.1111/nyas.13920] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/13/2018] [Accepted: 06/05/2018] [Indexed: 12/15/2022]
Abstract
Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.
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Affiliation(s)
- Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Damien Bergeat
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital, Rennes, France
| | | | - Ke-Neng Chen
- Department of Thoracic Surgery I, Beijing University Cancer Hospital, Beijing, China
| | - Seung-Hon Chon
- Department of General, Visceral and Tumor Surgery, University Hospital of Cologne, Cologne, Germany
| | - Collet Denis
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Khean-Lee Goh
- Combined Endoscopy Unit, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Caroline Gronnier
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Jun-Feng Liu
- Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Bernard Meunier
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Phillippe Nafteux
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Enrique D Pirchi
- Department of Surgery, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Aaron Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Peter C Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Chang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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86
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Impact of Surgeon Self-evaluation and Positive Deviance on Postoperative Adverse Events After Non-cardiac Thoracic Surgery. J Healthc Qual 2018; 40:e62-e70. [DOI: 10.1097/jhq.0000000000000130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wang ZQ, Jiang YQ, Xu W, Cai HR, Zhang Z, Yin Z, Zhang Q. A novel technique for cervical gastro-oesophageal anastomosis during minimally invasive oesophagectomy. Int J Surg 2018; 53:221-229. [PMID: 29609046 DOI: 10.1016/j.ijsu.2018.03.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 03/22/2018] [Accepted: 03/24/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Anastomotic leakage, fibrous stricture and gastro-oesophageal reflux are three major complications of gastro-oesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to traditional side-to-side anastomosis (SS) and end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux. METHODS A total of 390 patients with thoracic oesophageal cancer underwent minimally invasive oesophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. A detailed description of the surgical procedure is provided, and the major postoperative complications, including postoperative leakage, stricture and reflux, were compared using a three-armed controlled study. RESULTS The anastomotic method was an independent risk factor for anastomotic leakage, as well as stricture and reflux. The rate of anastomotic leakage of the NA group (1.0%) was significantly lower than that in the SS group (8.8%, P = 0.025) and in the CS group (8.5%, P = 0.001). The rate of anastomotic stricture in the NA group was not significantly different than that in the SS group (1.5% vs. 2.9%, P = 0.368) but was significantly lower than that in the CS group (1.5% vs. 18.9%, P < 0.001). The incidence of gastro-oesophageal reflux in the NA group was significantly lower than that in the SS group and the CS group (5.7% vs. 23.5% and 18.3%, P = 0.003 and 0.001, respectively). CONCLUSION Jiang's anastomosis technique remarkably reduces the incidence of gastro-oesophageal anastomotic leakage, stricture and reflux, and it is a safe and effective technique for minimally invasive oesophagectomy.
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Affiliation(s)
- Zhi-Qiang Wang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
| | - Yue-Quan Jiang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China.
| | - Wei Xu
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
| | - Hua-Rong Cai
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
| | - Zhi Zhang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
| | - Zhe Yin
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
| | - Qi Zhang
- Department of Thoracic Surgery, Chongqing University Cancer Hospital & Chongqing Cancer Institute & Chongqing Cancer Hospital, Chongqing 400030, China
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Abstract
OPINION STATEMENT PURPOSE OF REVIEW: Esophageal stents are used in clinical practice for endoscopic treatment of a wide variety of esophageal diseases and conditions. This review provides key principles and a literature update on the utility and limitations of esophageal stenting in clinical practice. RECENT FINDINGS Indications for esophageal stenting can be subdivided into two groups. The first group consists of patients with malignant or benign dysphagia, in which an esophageal stent restores luminal patency. In the past years, temporary stent placement has increasingly been used in the therapeutic management of refractory benign esophageal strictures. When endoscopic repeated bougie dilation and other endoscopic treatment modalities have failed, an esophageal stent could be considered. Based on the literature, a fully covered self-expandable metal stent may be the preferred choice for the treatment of both malignant and benign dysphagia. The second group consists of patients with leakage from the esophageal lumen into the surrounding tissue. Esophageal leakage can be subdivided into three forms, benign esophageal perforations (iatrogenic and spontaneous), anastomotic leakage after reconstructive esophageal surgery, and fistula. In a carefully selected group of patients, a covered esophageal stent may be used for sealing off the leakage, thereby preventing further contamination of the tissue surrounding the defect. The past few years, several validated prediction tools have been developed that may assist clinicians in the selection of patients eligible for esophageal stent placement. Based on retrospective studies and expert opinion, a partially or fully covered self-expandable metal stent may have a role in treatment of esophageal leakage. Research do date supports the utilization of esophageal stents for the treatment of malignant or benign dysphagia and esophageal leakage.
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Affiliation(s)
- Bram D Vermeulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands.
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein-Zuid 8 (route 455), 6500, HB, Nijmegen, the Netherlands
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89
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Biebl M, Andreou A, Chopra S, Denecke C, Pratschke J. Upper Gastrointestinal Surgery: Robotic Surgery versus Laparoscopic Procedures for Esophageal Malignancy. Visc Med 2018; 34:10-15. [PMID: 29594164 DOI: 10.1159/000487011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background The evolution of minimally invasive surgery (MIS) also extends to the field of esophageal surgery and has brought forth the development of several approaches of minimally invasive esophagectomy (MIE). Hybrid and total minimally invasive operative techniques have proven beneficial compared to open surgery and are currently evaluated against robotic-assisted minimally invasive esophagectomy (RAMIE). We aim to review the current literature regarding the position of MIE versus RAMIE. Methods A systematic review of the relevant literature on minimally invasive esophageal surgery for cancer is presented. A PubMed search was carried out for the period of 1992-2018 with the following search terms: 'esophageal cancer', 'minimally invasive surgery', 'resection', 'transhiatal', 'transthoracic', 'MIE', 'hybrid', 'robotic resection', 'RAMIE', 'RATE'. Results Hybrid and total minimally invasive operative techniques have proven beneficial, especially with regard to pulmonary complications, compared to open surgery. Oncologic outcomes appear equivalent between open and minimally invasive techniques. Currently, the position of RAMIE is being evaluated against other minimally invasive techniques. Conclusion All minimally invasive techniques confer the expected reduction in perioperative morbidity compared to open surgery. However, MIS is still evolving with regard to specific technical challenges, especially anastomotic techniques.
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Affiliation(s)
- Matthias Biebl
- Department of Surgery, Campus Klinikum Virchow and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Andreas Andreou
- Department of Surgery, Campus Klinikum Virchow and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Sascha Chopra
- Department of Surgery, Campus Klinikum Virchow and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian Denecke
- Department of Surgery, Campus Klinikum Virchow and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Johann Pratschke
- Department of Surgery, Campus Klinikum Virchow and Campus Charité Mitte, Charité - University Medicine Berlin, Berlin, Germany
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90
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Yu LL, He ZF, Liu QF, Dai N, Si JM, Ye B, Zhou JC. Two-tube method for treatment of spontaneous esophageal rupture and concomitant mediastinal infection. J Int Med Res 2018; 46:1528-1536. [PMID: 29376459 PMCID: PMC6091846 DOI: 10.1177/0300060517752995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective Spontaneous esophageal rupture (SER) is a rare but life-threatening condition with high mortality. The prognosis of patients with SER treated with surgical intervention or the traditional “three-tube” method is controversial. Thus, the aim of this study was to evaluate the clinical efficacy, feasibility, and safety of a new “two-tube” method involving a trans-fistula drainage tube and a three-lumen jejunal feeding tube for the treatment of SER without concomitant pleural rupture. Methods From January 2007 to June 2016, patients with SER and managed with the “two-tube” method or other methods were retrospectively analyzed. Data collected included initial presentation, procedure time, duration of treatment, numbers of patients with eventual healing of leaks, and complications. Results The average procedure time for the “two-tube” method was 22.1 ± 5.5 minutes. In comparison with the control method, the “two-tube” method had a similar diagnosis time (3.6 ± 1.4 vs. 3.4 ± 1.4 days) but a significantly higher successful closure rate (94.4% vs. 63.6%) and shorter treatment time (38.2 ± 5.6 vs. 53.6 ± 16.9 days). No complications associated with performance of the “two-tube” method occurred. Conclusion The “two-tube” method is an effective and safe approach for patients with SER.
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Affiliation(s)
- Liang-Liang Yu
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zheng-Fu He
- 2 Department of Thoracic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qi-Fang Liu
- 3 Department of Endoscopy Center, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ning Dai
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jian-Min Si
- 1 Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bei Ye
- 4 Taizhou Vocational College of Science and Technology, Taizhou, Zhejiang, China
| | - Jian-Cang Zhou
- 5 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Zhou P, Zhang R, Wang Y, Xu D, Zhang L, Qin J, Su G, Feng Y, Chen H, You S, Rui W, Liu H, Chen S, Chen H, Wang Y. Cepharanthine hydrochloride reverses the mdr1 (P-glycoprotein)-mediated esophageal squamous cell carcinoma cell cisplatin resistance through JNK and p53 signals. Oncotarget 2017; 8:111144-111160. [PMID: 29340044 PMCID: PMC5762312 DOI: 10.18632/oncotarget.22676] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/07/2017] [Indexed: 11/25/2022] Open
Abstract
Esophageal squamous cell carcinoma (ESCC) is an aggressive malignancy that is often resistant to therapy. Nowadays, chemotherapy is still one of the main methods for the treatment of ESCC. However, the multidrug resistance (MDR)-mediated chemotherapy resistance is one of the leading causes of death. Exploring agents able to reverse MDR, which thereby increase the sensitivity with clinical first-line chemotherapy drugs, could significantly improve cancer treatment. Cepharanthine hydrochloride (CEH) has the ability to reverse the MDR in ESCC and the mechanism involved have not been reported. The aim of the study was to investigate the potential of CEH to sensitize chemotherapeutic drugs in ESCC and explore the underlying mechanisms by in vitro and in vivo studies. Our data demonstrated that CEH significantly inhibited ESCC cell proliferation in a dose-dependent manner, induced G2/M phase cell cycle arrest and apoptosis, and increased the sensitivity of cell lines resistant to cisplatin (cDDP). Mechanistically, CEH inhibited ESCC cell growth and induced apoptosis through activation of c-Jun, thereby inhibiting the expression of P-gp, and enhancing p21 expression via activation of the p53 signaling pathway. In this study, we observed that growth of xenograft tumors derived from ESCC cell lines in nude mice was also significantly inhibited by combination therapy. To our knowledge, we demonstrate for the first time that CEH is a potentially effective MDR reversal agent for ESCC, based on downregulation of the mRNA expression of MDR1 and P-gp. Together, these results reveal emphasize CEH putative role as a resistance reversal agent for ESCC.
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Affiliation(s)
- Pengjun Zhou
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
- Department of Pathogen Biology and Immunology, School of Basic Course, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
| | - Rong Zhang
- State Key Laboratory of Oncology in South China and Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, Guangdong, P. R. China
| | - Ying Wang
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
| | - Dandan Xu
- Guangdong Food and Drug Vocational College, Guangzhou 510520, Guangdong, P. R. China
| | - Li Zhang
- Guangzhou Institute of Pediatrics, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou 510623, Guangdong, P. R. China
| | - Jinhong Qin
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
| | - Guifeng Su
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
| | - Yue Feng
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
| | - Hongce Chen
- Department of Pathogen Biology and Immunology, School of Basic Course, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
| | - Siyuan You
- Department of Pathogen Biology and Immunology, School of Basic Course, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
| | - Wen Rui
- Department of Pathogen Biology and Immunology, School of Basic Course, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
| | - Huizhong Liu
- Department of Hepatobiliary Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an 710032, Shanxi, P. R. China
| | - Suhong Chen
- Guangdong Food and Drug Vocational College, Guangzhou 510520, Guangdong, P. R. China
| | - Hongyuan Chen
- Department of Pathogen Biology and Immunology, School of Basic Course, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
- Guangdong Provincial Engineering Center of Topical Precise Drug Delivery System, Guangdong Pharmaceutical University, Guangzhou 510006, Guangdong, P. R. China
| | - Yifei Wang
- Guangzhou Jinan Biomedicine Research and Development Center, Guangdong Provincial Key Laboratory of Bioengineering Medicine, College of Life Science and Technology, Jinan University, Guangzhou 510632, Guangdong, P. R. China
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Madan R, Laur O, Crudup B, Peavy L, Carter BW. Imaging of iatrogenic oesophageal injuries using optimized CT oesophageal leak protocol: pearls and pitfalls. Br J Radiol 2017; 91:20170629. [PMID: 29166132 DOI: 10.1259/bjr.20170629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Iatrogenic injury to the oesophagus is a serious complication which is increasingly seen in clinical practice secondary to expansion and greater acceptability of surgical and endoscopic oesophageal procedures. Morbidity and mortality following such injury is high. This is mostly due to an inflammatory response to gastric contents in the mediastinum, and the negative intrathoracic pressures that may further draw out oesophageal contents into the mediastinum leading to mediastinitis. Subsequently, pulmonary complications such as pneumonia or abscess may ensue leading to rapid clinical deterioration. Optimized and timely cross-sectional imaging evaluation is necessary for early and aggressive management of these complications. The goal of this review is to make the radiologist aware of the importance of early and accurate identification of postoperative oesophageal injury using optimized CT imaging protocols and use of oral contrast. Specifically, it is critical to differentiate benign post-operative findings, such as herniated viscus or redundant anastomosis, from clinically significant postoperative complications as this helps guide appropriate management. Advantages and drawbacks of other diagnostic methods, such as contrast oesophagogram, are also discussed.
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Affiliation(s)
- Rachna Madan
- 1 Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School , Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA
| | - Olga Laur
- 1 Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School , Brigham and Women's Hospital, Harvard Medical School , Boston, MA , USA
| | - Breland Crudup
- 2 Department of Medicine, University of Mississippi Medical Center (UMMC) , Jackson, MS , USA
| | - Latia Peavy
- 3 Department of Medical Sciences, Mississippi College , Mississippi College , Clinton, MS , USA
| | - Brett W Carter
- 4 Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center , University of Texas MD Anderson Cancer Center , Houston, TX , USA
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93
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Zhang S, Huang W, Liu X, Li J. Pilot study on preventing anastomotic leakage in stapled gastroesophageal anastomosis. Thorac Cancer 2017; 9:142-145. [PMID: 29130643 PMCID: PMC5754289 DOI: 10.1111/1759-7714.12552] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 01/15/2023] Open
Abstract
Background This study explored how to improve the surgical technique to reduce or avoid anastomotic leakage. Methods From January 2012 to December 2016, 101 consecutive patients with cancer of the esophagus or gastroesophageal junction underwent stapled gastroesophageal anastomosis. The procedure included creating a tube‐type stomach, fixing an inserted anvil, inspecting mucosa‐to‐mucosa alignment in the lumen under direct vision after firing the stapler, and, if found, manually repairing a rupture of the mucous membrane of the anastomosis. Results A rupture of the mucous membrane of the anastomosis was found in four out of the 101 patients and manually repaired. No postsurgical anastomotic leakage occurred. All patients recovered well and the average postoperative stay was 10.4 days. There was no mortality within 30 days after surgery. Conclusion It is critical to inspect the integrality of the luminal mucous membrane of the anastomosis under direct vision in order to prevent anastomotic leakage in surgical resection of esophageal and gastroesophageal junction malignancies.
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Affiliation(s)
- Shijie Zhang
- Department of Thoracic Surgery, Peking University First Hospital, Beijing, China
| | - Weiming Huang
- Department of Thoracic Surgery, Peking University First Hospital, Beijing, China
| | - Xiangzheng Liu
- Department of Thoracic Surgery, Peking University First Hospital, Beijing, China
| | - Jian Li
- Department of Thoracic Surgery, Peking University First Hospital, Beijing, China
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94
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Are Thoracotomy and/or Intrathoracic Anastomosis Still Predictors of Postoperative Mortality After Esophageal Cancer Surgery?: A Nationwide Study. Ann Surg 2017; 266:854-862. [PMID: 28742697 DOI: 10.1097/sla.0000000000002401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Intrathoracic (vs cervical) anastomosis and a thoracotomy (vs absence) have previously been associated with increasing postoperative mortality (POM). Recent improvements in surgical practices and perioperative management may have changed these dogmas. OBJECTIVES The aim of this study was to evaluate the impact of performing intrathoracic anastomosis and/or thoracotomy on POM after esophageal cancer surgery in recent years. METHODS All consecutive patients who underwent esophageal cancer surgery with reconstruction between 2010 and 2012 in France were included (n = 3286). Patients with a thoracoscopic approach were excluded (n = 4). We compared 30-day POM between patients having received intrathoracic (vs cervical) anastomosis and between those having received a thoracotomy or not. Multivariate analyses and propensity score matching were used to adjust for confounding factors. RESULTS Patients had either cervical (n = 548) or intrathoracic (n = 2738) anastomosis. Thirty-day POM was higher after cervical anastomosis (8.8% vs 4.9%, P < 0.001). Having received a thoracotomy (n = 3061) was associated with a decreased risk of 30-day POM (5.3% vs 9.3%, P = 0.011). After adjustment for confounding factors, cervical anastomosis was associated with 30-day POM [odds ratio (OR) 1.71; 95% confidence interval (CI) 1.05-2.77); P = 0.032], whereas performing a thoracotomy was not associated with 30-day POM (OR 0.97; 95% CI 0.51-1.84; P = 0.926). CONCLUSIONS Nowadays, intrathoracic anastomosis provides a lower 30-day POM rate compared to cervical anastomosis, and performing a thoracotomy is not associated with POM. Systematic anastomosis neck placement or thoracotomy avoidance is not a relevant argument anymore to decrease POM.
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95
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Park JK, Kim JJ, Moon SW. C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis. J Thorac Dis 2017; 9:3693-3702. [PMID: 29268376 DOI: 10.21037/jtd.2017.08.125] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background Anastomotic leak is one of most significant causes of mortality after esophagectomy. Therefore, it is clinically valuable to detect anastomotic leak early after esophagectomy in esophageal cancer. The purpose of this study is to investigate the associations between routine postoperative laboratory findings and anastomotic leak and to analyze the laboratory findings to find out an independent predictive marker for anastomotic leak. In addition, this study compares cases treated with neoadjuvant therapy (NT) and those without (non-NT). Methods We retrospectively assessed the medical records of 201 consecutive cases that met this study's criteria from January 2009 to December 2016. All patients underwent curative and complete esophagectomy for intra-thoracic esophageal cancer. We compiled and analyzed routine laboratory findings from the day before surgery to the eighth postoperative day on a daily basis. Routine laboratory tests consisted of 26 separate tests, including complete blood cell counts, blood chemistries, as well as erythrocyte sedimentation rate and C-reactive protein (CRP). Barium esophagogram with chest computed tomography (CT) was performed on the seventh postoperative day to evaluate the presence of an anastomotic leak. Results A total of 45 of 201 patients underwent NT. Anastomotic leaks were found in 23 (11.4%) of 201 patients (8 patients in NT and 15 patients in non-NT). White blood cell (WBC) from the second postoperative day (P=0.031, P=0.006, P=0.007, P=0.007, P=0.041, and P=0.003, respectively) and CRP from the third postoperative day (P=0.012, P<0.001, P=0.014, P<0.001, P=0.001, and P=0.006, respectively) were associated with anastomotic leak in non-NT; however, only CRP on the third, fifth, sixth, and seventh postoperative days (P=0.041, P=0.037, P=0.002, and P=0.003, respectively) was associated with anastomotic leak in NT. The CRP level on the third postoperative day was a significant independent predictive marker of anastomotic leak (P=0.041, odd ratio (OR) 1.056, 95% confidential interval (CI): 1.002-1.113) and had a significant diagnostic cutoff value for the development of anastomotic leak (non-NT: cutoff value 17.12 mg/dL, sensitivity 69.2%, specificity 78.1%, P<0.001, area 0.822; NT: cutoff value 16.42 mg/dL, sensitivity 80.0%, specificity 70.0%, P=0.042, area 0.7104). Conclusions There were divergent laboratory findings reflective of anastomotic leak between patients who underwent NT and those who did not. The CRP level on the third postoperative day had a significant cutoff value for early detection of anastomotic leak after esophagectomy in both NT and non-NT groups.
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Affiliation(s)
- Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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96
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Huang J, Zhou Y, Wang C, Yuan W, Zhang Z, Chen B, Zhang X. Logistic regression analysis of the risk factors of anastomotic fistula after radical resection of esophageal-cardiac cancer. Thorac Cancer 2017; 8:666-671. [PMID: 28940985 PMCID: PMC5668517 DOI: 10.1111/1759-7714.12509] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 08/13/2017] [Accepted: 08/13/2017] [Indexed: 12/25/2022] Open
Abstract
Background This study was conducted to investigate the risk factors of anastomotic fistula after the radical resection of esophageal‐cardiac cancer. Methods Five hundred and forty‐four esophageal‐cardiac cancer patients who underwent surgery and had complete clinical data were included in the study. Fifty patients diagnosed with postoperative anastomotic fistula were considered the case group and the remaining 494 subjects who did not develop postoperative anastomotic fistula were considered the control. The potential risk factors for anastomotic fistula, such as age, gender, diabetes history, smoking history, were collected and compared between the groups. Statistically significant variables were substituted into logistic regression to further evaluate the independent risk factors for postoperative anastomotic fistulas in esophageal‐cardiac cancer. Results The incidence of anastomotic fistulas was 9.2% (50/544). Logistic regression analysis revealed that female gender (P < 0.05), laparoscopic surgery (P < 0.05), decreased postoperative albumin (P < 0.05), and postoperative renal dysfunction (P < 0.05) were independent risk factors for anastomotic fistulas in patients who received surgery for esophageal‐cardiac cancer. Of the 50 anastomotic fistulas, 16 cases were small fistulas, which were only discovered by conventional imaging examination and not presenting clinical symptoms. All of the anastomotic fistulas occurred within seven days after surgery. Five of the patients with anastomotic fistulas underwent a second surgery and three died. Conclusion Female patients with esophageal‐cardiac cancer treated with endoscopic surgery and suffering from postoperative hypoproteinemia and renal dysfunction were susceptible to postoperative anastomotic fistula.
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Affiliation(s)
- Jinxi Huang
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Zhou
- Department of Anesthesiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Chenghu Wang
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Weiwei Yuan
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhandong Zhang
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Beibei Chen
- Depatment of Oncology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiefu Zhang
- Department of General Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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97
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Gong W, Li J. Combat with esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer: A critical review of the literature. Int J Surg 2017; 47:18-24. [PMID: 28935529 DOI: 10.1016/j.ijsu.2017.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/14/2017] [Accepted: 09/10/2017] [Indexed: 02/06/2023]
Abstract
Esophagojejunal anastomotic leakage (EJAL) is considered to be one of the most serious complications after total gastrectomy (TG), despite improvements in surgical instruments and technique. The occurrence of EJAL would cause poorer quality of life, prolonged hospital stay, and increased surgery-related costs and mortality. Although there is ever-increasing knowledge about EJAL, the optimal management is controversial. In the present review, we aim to demonstrate the effective management by focus on the possible risk factors, potentially useful preventive strategies, and several kinds of treatments in esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer.
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Affiliation(s)
- Wenbin Gong
- School of Medicine, Southeast University, Nanjing, China.
| | - Junsheng Li
- Department of General Surgery, Affiliated Zhongda Hospital, Nanjing, China
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98
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Hummel R, Bausch D. Anastomotic Leakage after Upper Gastrointestinal Surgery: Surgical Treatment. Visc Med 2017; 33:207-211. [PMID: 28785569 DOI: 10.1159/000470884] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anastomotic leakage after upper gastrointestinal surgery is associated with major morbidity and mortality. In recent years, there was a major paradigm shift in the management of leakage after upper gastrointestinal surgery from surgical towards conservative and endoscopic treatment approaches as first-line treatment options. METHODS We conducted a PubMed literature search using combinations of the keywords 'leakage', 'complication', 'esophagectomy', 'gastrectomy', and 'pancreatectomy' to identify relevant publications. RESULTS Surgical re-intervention after esophagectomy, gastrectomy, or pancreatectomy is still indicated in selected patients, depending on the severity of symptoms, the condition of the patient, and failure of initiated treatment. Furthermore, surgical revision after esophagectomy and gastrectomy is indicated for early leakage and depends on the extent of anastomotic disruption and the condition of tissue. CONCLUSION Surgical re-intervention still plays a crucial role in the management of leakage after upper gastrointestinal surgery, especially in critically ill patients and after failure of conservative or endoscopic treatment.
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Affiliation(s)
- Richard Hummel
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Dirk Bausch
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Abstract
OPINION STATEMENT Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.
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100
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Peng F, Hu D, Lin X, Chen G, Liang B, Zhang H, Dong X, Lin J, Zheng X, Niu W. Analysis of Preoperative Metabolic Risk Factors Affecting the Prognosis of Patients with Esophageal Squamous Cell Carcinoma: The Fujian Prospective Investigation of Cancer (FIESTA) Study. EBioMedicine 2017; 16:115-123. [PMID: 28163045 PMCID: PMC5474505 DOI: 10.1016/j.ebiom.2017.01.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 01/14/2017] [Accepted: 01/25/2017] [Indexed: 01/15/2023] Open
Abstract
Some metabolic factors have been shown to be associated with an increased risk of esophageal cancer; however the association with its prognosis is rarely reported. Here, we assessed the prediction of preoperative metabolic syndrome and its single components for esophageal cancer mortality by analyzing a subset of data from the ongoing Fujian prospective investigation of cancer (FIESTA) study. Between 2000 and 2010, patients who underwent three-field lymphadenectomy were eligible for inclusion. Blood/tissue specimens, demographic and clinicopathologic data were collected at baseline. Metabolic syndrome is defined by the criteria proposed by Chinese Diabetes Society. In this study, analysis was restricted to esophageal squamous cell carcinoma (ESCC) due to the limited number of other histological types. The median follow-up in 2396 ESCC patients (males/females: 1822/574) was 38.2months (range, 0.5-180months). The multivariate-adjusted hazard ratio (HR) of metabolic syndrome for ESCC mortality was statistically significant in males (HR, 95% confidence interval, P: 1.45, 1.14-1.83, 0.002), but not in females (1.46, 0.92-2.31, 0.107). For single metabolic components, the multivariate-adjusted HRs were significant for hyperglycemia (1.98, 1.68-2.33, <0.001) and dyslipidemia (1.41, 1.20-1.65, <0.001) in males and for hyperglycemia (1.76, 1.23-2.51, <0.001) in females, independent of clinicopathologic characteristics and obesity. In tree-structured survival analysis, the top splitting factor in both genders was tumor-node-metastasis stage, followed by regional lymph node metastasis. Taken together, our findings demonstrate that preoperative metabolic syndrome was a significant independent predictor of ESCC mortality in males, and this effect was largely mediated by glyeolipid metabolism disorder.
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Affiliation(s)
- Feng Peng
- Department of Cardiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Dan Hu
- Department of Pathology, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xiandong Lin
- Department of Pathology, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Gang Chen
- Department of Pathology, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Binying Liang
- Department of Medical Record, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Hejun Zhang
- Department of Pathology, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Xiaoqun Dong
- Department of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jinxiu Lin
- Department of Cardiology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China.
| | - Xiongwei Zheng
- Department of Pathology, Fujian Provincial Cancer Hospital, The Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China.
| | - Wenquan Niu
- State Key Laboratory of Medical Genomics, Rui Jin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China..
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