1
|
N V, Varshney VK, B S, Soni S, Varshney P, Agarwal L. Impact of nasogastric tube exclusion after minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study in India. JOURNAL OF MINIMALLY INVASIVE SURGERY 2024; 27:23-32. [PMID: 38494183 PMCID: PMC10961234 DOI: 10.7602/jmis.2024.27.1.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/01/2024] [Accepted: 02/19/2024] [Indexed: 03/20/2024]
Abstract
Purpose This study examines the impacts of omitting nasogastric tube (NGT) placement following cervical esophagogastric anastomosis (CEGA) in Enhanced Recovery After Surgery (ERAS) protocols, comparing outcomes to those from early NGT removal. Methods In a retrospective cohort of esophagectomy patients treated for esophageal cancer, participants were divided into two groups: group 1 had the NGT inserted post-CEGA and removed by postoperative day 3, while group 2 underwent the procedure without NGT placement. We primarily investigated anastomotic leak rates, also analyzing hospital stay duration, pulmonary complications, and NGT reinsertion. Results Among 50 esophageal squamous cell carcinoma patients, 30 in group I were compared with 20 in group II. The baseline demographic and tumor characteristics were similar between both groups. The overall incidence of anastomotic leak was 14.0%, comparable in both groups (16.7% vs. 10.0%, p = 0.63). The postoperative hospital stay was significantly shorter in the no NGT group (median of 7 days vs. 6 days, p = 0.03) with similar major morbidity (Clavien-Dindo grade ≥IIIa; 13.3% vs. 5.0%, p = 0.63). There was no 30-day mortality, and one patient in each group had reinsertion of NGT for conduit dilatation. Conclusion The exclusion of an NGT across CEGA after esophagectomy did not influence the anastomotic leak rate with comparable complications and a shorter hospital stay.
Collapse
Affiliation(s)
- Vignesh N
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Selvakumar B
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Subhash Soni
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Peeyush Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Lokesh Agarwal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| |
Collapse
|
2
|
Impact of Nasogastric Decompression on Gastric Tube Size After McKeown Minimally Invasive Esophagectomy: a Retrospective Controlled Cohort Study. J Gastrointest Surg 2022; 26:2585-2587. [PMID: 35819665 DOI: 10.1007/s11605-022-05406-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 06/25/2022] [Indexed: 01/31/2023]
|
3
|
Nevo Y, Arjah S, Katz A, Ramírez García Luna JL, Spicer J, Cools-Lartigue J, Mueller C, Feldman L, Ferri L. ERAS 2.0: Continued Refinement of an Established Enhanced Recovery Protocol for Esophagectomy. Ann Surg Oncol 2021; 28:4850-4858. [PMID: 33774774 DOI: 10.1245/s10434-021-09854-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND We have previously demonstrated that implementing an enhanced recovery protocol (ERP) improved outcomes after esophagectomy. We sought to examine if, after a decade of an established ERP, further improvements in postoperative outcomes could be made after continually optimizing and revising the pathway. METHODS Patients undergoing esophagectomy for cancer from January 2019 to January 2020 were compared with our early-experience group within the initial ERP (June 2010-May 2011) and pre-ERP traditional care (June 2009-May 2010). The original ERP was initiated on June 2010 and underwent several revisions from 2014 to 2018, incorporating the following, amongst other elements: shorten the planned length of stay from 7 to 6 days, elimination of nasogastric tubes, use of soft closed-suction chest drains, and increased application of minimally invasive esophagectomy (MIE). Thirty-day outcomes (complications, length of stay, readmission) were compared for patients undergoing esophagectomy during the initial and most recent ERPs. RESULTS Overall, 175 patients were identified; 47 underwent esophagectomy before ERP implementation (traditional care), 59 patients underwent esophagectomy after implementation of the original ERP, and 69 patients underwent esophagectomy after the most recent ERP (ERP 2.0). The groups were similar with respect to age, sex, and diagnosis. There were three times more MIEs in the ERP 2.0 group with a shorter median length of stay (7 [6-9] vs. 8 [7-17] vs. 10 [9-17]; p < 0.001) without impacting postoperative morbidity or readmission rate. CONCLUSION Continued evaluation of institutional outcomes after esophagectomy should be performed to identify target areas for optimization and revision of established enhanced recovery protocols. ERPs are dynamic processes that can be further refined to yield greater improvements in outcomes.
Collapse
Affiliation(s)
- Yehonatan Nevo
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada.
| | - Sarah Arjah
- Faculty of Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Amit Katz
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
| | | | - Jonathan Spicer
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
| | | | - Carmen Mueller
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Liane Feldman
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic Surgery, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
4
|
Abstract
Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.
Collapse
Affiliation(s)
- Ammara A Watkins
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA.
| |
Collapse
|
5
|
Nasogastric tube utilization after esophagectomy: an unnecessary gesture? Cir Esp 2020; 98:598-604. [PMID: 32505557 DOI: 10.1016/j.ciresp.2020.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 04/14/2020] [Accepted: 04/26/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Nasogastric decompressive tube utilization has been accepted as one of the basic perioperative care measures after esophageal resection surgery. However, with the development of multimodal rehabilitation programs and without clear evidence to support their use, the systematic indication of this measure may be controversial. MATERIAL AND METHODS Retrospective, descriptive and comparative study of patients who had undergone Ivor-Lewis esophagectomy in our center -from January 2015 to December 2018- with placement (Group S), or without placement (Group N) of a decompressive tube in gastroplasty during postoperative period. Epidemiological variables and differences between groups in post-surgical morbidity and mortality, hospital stay, onset of oral tolerance and the need for nasogastric tube placement were evaluated. RESULTS A total of 43 patients were included in this study, with a median age of 61 years, being 86% male. 46.5% were hypertensive, 25.5% had lung disease and 16.3% had diabetes mellitus. The median length of hospital stay was 9 days in group S versus 11.5 days in group N, with no differences in the onset of oral tolerance. Anastomotic dehiscence rate was 5% and 0% respectively. The overall mortality was 2.3% in the first 90 days, without differences between the groups. Placement of nasogastric tube during postoperative period was required only in 1 patient (4.3%) of the group N. CONCLUSIONS Non-use of nasogastric tube during postoperative period of an Ivor-Lewis esophagectomy is a safe measure, as it is not associated with a higher rate of complications or hospital stay. This fact may be able to improve patients' comfort and postoperative recovery.
Collapse
|
6
|
Hayashi M, Kawakubo H, Shoji Y, Mayanagi S, Nakamura R, Suda K, Wada N, Takeuchi H, Kitagawa Y. Analysis of the Effect of Early Versus Conventional Nasogastric Tube Removal on Postoperative Complications After Transthoracic Esophagectomy: A Single-Center, Randomized Controlled Trial. World J Surg 2019; 43:580-589. [PMID: 30353406 DOI: 10.1007/s00268-018-4825-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although esophagectomy is the only curative option for esophageal cancer, the associated invasiveness is high. Nasogastric (NG) tube use may prevent complications; however, its utility remains unclear, and the decompression period depends on the doctor. This study aimed to reveal the effect of conventional versus early NG tube removal on postoperative complications after esophagectomy. METHODS This single-center prospective randomized controlled clinical trial enrolled patients aged 20-80 years with histologically proven primary esophageal squamous cell carcinoma. Eighty patients admitted for transthoracic first-stage esophagectomy reconstructed with gastric conduit were randomly assigned (1:1) to the conventional and early NG tube removal groups. In the conventional NG tube removal group, the tube was removed on postoperative day (POD) 7; in the other, it was removed on POD 1. The occurrence rate of major complications, length of postoperative hospital stay, and NG tube reinsertion rate were compared between the groups. RESULTS The incidence of postoperative major complications such as pneumonia, anastomotic leakage, recurrent nerve palsy and gastrointestinal bleeding, and the NG tube reinsertion rate was not different between the groups. However, recurrent nerve palsy was more commonly observed in the conventional removal group; this difference was not significant. In terms of postoperative pneumonia, tumor location and field of lymph node dissection were significant risk factors. CONCLUSION Although early NG tube removal did not reduce the rate of postoperative pneumonia, it could be performed safely. Hence, the NG tube can be removed earlier than conventional methods.
Collapse
Affiliation(s)
- Masato Hayashi
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Yoshiaki Shoji
- Department of Surgery, Cancer Institute Hospital, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Syuhei Mayanagi
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Rieko Nakamura
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Koichi Suda
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Norihito Wada
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroya Takeuchi
- Department of Surgery, School of Medicine, Hamamatsu University, 1-20-1 Handayama, Higashi-ku, Hamamatsu-shi, Shizuoka Prefecture, 431-3192, Japan
| | - Yuko Kitagawa
- Department of Surgery, School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| |
Collapse
|
7
|
Zhang R, Zhang L. Feasibility of complete nasogastric tube omission in esophagectomy patients. J Thorac Dis 2019; 11:S819-S823. [PMID: 31080664 DOI: 10.21037/jtd.2018.11.98] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Routine nasogastric tube (NGT) placement is a common practice in esophagectomy patients. However, its continued application has been controversial in recent years. In this review, we will discuss the potential risks and benefits, including anastomosis leak, pneumonia, NGT reinsertion, patients' discomfort and hospital length of stay, to evaluate the feasibility of complete NGT omission in esophagectomy patients.
Collapse
Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China
| |
Collapse
|
8
|
Abstract
Delayed gastric conduit emptying (DGE) is a common complication after esophagectomy. Currently, pyloric interventions are the major prevention and treatment for DGE. In this review, we attempt to evaluate the clinical effect and safety of different pyloric interventions in esophagectomy patients. Moreover, other important management of DGE, including size of esophageal substitute, erythromycin and nasogastric tube (NGT) will also be discussed.
Collapse
Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China
| |
Collapse
|
9
|
Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
10
|
Kingma BF, Steenhagen E, Ruurda JP, van Hillegersberg R. Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction. J Surg Oncol 2017; 116:623-629. [PMID: 28968919 DOI: 10.1002/jso.24827] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/09/2017] [Indexed: 12/18/2022]
Abstract
Enhanced Recovery After Surgery (ERAS) aims to accelerate recovery by a set of multimodality management strategies. For esophagectomy, several nutritional elements of ERAS can be safely introduced and are advised in routine practice, including preadmission counseling to screen and treat for potential malnutrition, shortened preoperative fasting, and carbohydrate loading. However, the timing of oral intake and the use of routine nasogastric decompression remain matter of debate after esophagectomy. Furthermore, more research is needed on future developments such as perioperative immunonutrition.
Collapse
Affiliation(s)
- B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Elles Steenhagen
- Department of Dietetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | |
Collapse
|
11
|
An Update on Randomized Clinical Trials in Gastric Cancer. Surg Oncol Clin N Am 2017; 26:621-645. [PMID: 28923222 DOI: 10.1016/j.soc.2017.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The optimal treatment of esophageal cancer is still being defined. The timing of surgical management and the application of chemotherapy and radiation in the neoadjuvant and adjuvant settings have been studied in several prospective, randomized, controlled trials. This article outlines some of the historical as well as updated research that has been published regarding the management of esophageal cancer.
Collapse
|
12
|
Weijs TJ, Kumagai K, Berkelmans GHK, Nieuwenhuijzen GAP, Nilsson M, Luyer MDP. Nasogastric decompression following esophagectomy: a systematic literature review and meta-analysis. Dis Esophagus 2017; 30:1-8. [PMID: 27627872 DOI: 10.1111/dote.12530] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Routine use of nasogastric tubes for gastric decompression has been abolished in nearly all types of gastro-intestinal surgery after introduction of enhanced recovery after surgery programs. However, in esophagectomy the routine use of nasogastric decompression is still a matter of debate. To determine the effects of routine nasogastric decompression following esophagectomy compared with early or peroperative removal of the nasogastric tube on pulmonary complications, anastomotic leakage, mortality, and postoperative recovery. A systematic literature review and meta-analysis of studies comparing early or peroperative versus late removal of nasogastric tubes. A total of seven comparative studies were included (n = 608). In two randomized trials, and one retrospective cohort study, peroperative removal of the nasogastric tube was compared with routine nasogastric decompression. In one randomized trial early removal of the nasogastric tube (on postoperative day 2) was compared with removal of the nasogastric tube on the 6th-10th postoperative day. In the remaining three trials a fast-track protocol without a nasogastric tube was compared with conventional care with a nasogastric tube during the first postoperative days. Peroperative or early removal of the nasogastric tube did not result in a significantly different rate of anastomotic leakage, pulmonary complications or mortality in individual studies, nor in the meta-analysis. In the meta-analysis, hospital stay was significantly shorter with peroperative or early removal of the nasogastric tube when all studies were included, but not when the meta-analysis was limited to randomized trials. This systematic review did not find a difference in adverse outcomes between nasogastric decompression or no nasogastric decompression following esophagectomy.
Collapse
Affiliation(s)
- Teus J Weijs
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| | - Koshi Kumagai
- Division of Surgery, CLINTEC, Karolinska Institutet, and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | | | | | - Magnus Nilsson
- Division of Surgery, CLINTEC, Karolinska Institutet, and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital Eindhoven, The Netherlands
| |
Collapse
|
13
|
Abstract
ERAS programs are based on a combination of perioperative measures with a proven efficacy, that combined with each other lead to an enhanced recovery after surgery through a synergistic pathway. Such programs help to decrease postoperative morbidity and to reduce length of hospital stay. Beside immunonutrition, carbohydrate loading until 2 hours before surgery and early postoperative oral feeding are safe and allows enhanced recovery after surgery.
Collapse
Affiliation(s)
- C Mariette
- Department of Gastrointestinal and General Surgery, Lille Regional University Hospital.
| |
Collapse
|
14
|
Abstract
The paradigm for postoperative care for thoracic surgical patients in the United States has shifted with efforts to reduce hospital length of stay and improve quality of life. The increasing usage of minimally invasive techniques in thoracic surgery has been an important part of this. In this review we will examine our standard practices as well as the evidence behind both general contemporary postoperative care principles and those specific to certain operations.
Collapse
Affiliation(s)
- Benjamin Wei
- Division of Cardiothoracic Surgery, University of Alabama-Birmingham Medical Center, Birmingham, AL, USA
| | - Robert J Cerfolio
- Division of Cardiothoracic Surgery, University of Alabama-Birmingham Medical Center, Birmingham, AL, USA
| |
Collapse
|
15
|
Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg 2014; 259:413-31. [PMID: 24253135 DOI: 10.1097/sla.0000000000000349] [Citation(s) in RCA: 175] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines. BACKGROUND ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy. METHODS We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated. RESULTS Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery. CONCLUSIONS ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.
Collapse
|
16
|
Weijs TJ, Ruurda JP, Nieuwenhuijzen GAP, van Hillegersberg R, Luyer MDP. Strategies to reduce pulmonary complications after esophagectomy. World J Gastroenterol 2013; 19:6509-6514. [PMID: 24151374 PMCID: PMC3801361 DOI: 10.3748/wjg.v19.i39.6509] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 08/23/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy, the surgical removal of all or part of the esophagus, is a surgical procedure that is associated with high morbidity and mortality. Pulmonary complications are an especially important postoperative problem. Therefore, many perioperative strategies to prevent pulmonary complications after esophagectomy have been investigated and introduced in daily clinical practice. Here, we review these strategies, including improvement of patient performance and technical advances such as minimally invasive surgery that have been implemented in recent years. Furthermore, interventions such as methylprednisolone, neutrophil elastase inhibitor and epidural analgesia, which have been shown to reduce pulmonary complications, are discussed. Benefits of the commonly applied routine nasogastric decompression, delay of oral intake and prophylactic mechanical ventilation are unclear, and many of these strategies are also evaluated here. Finally, we will discuss recent insights and new developments aimed to improve pulmonary outcomes after esophagectomy.
Collapse
|
17
|
|
18
|
Puri V, Hu Y, Guthrie T, Crabtree TD, Kreisel D, Krupnick AS, Patterson GA, Meyers BF. Retrograde Jejunogastric Decompression After Esophagectomy Is Superior to Nasogastric Drainage. Ann Thorac Surg 2011; 92:499-503. [DOI: 10.1016/j.athoracsur.2011.03.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/17/2022]
|
19
|
Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
Collapse
Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Abstract
PURPOSE OF REVIEW The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery. RECENT FINDINGS An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended. SUMMARY The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.
Collapse
|
22
|
Grotenhuis BA, Wijnhoven BPL, Grüne F, van Bommel J, Tilanus HW, van Lanschot JJB. Preoperative risk assessment and prevention of complications in patients with esophageal cancer. J Surg Oncol 2010; 101:270-8. [PMID: 20082349 DOI: 10.1002/jso.21471] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this review the preoperative risk assessment and prevention of complications in patients undergoing esophagectomy for cancer is discussed. Age, pulmonary and cardiovascular condition, nutritional status, and neoadjuvant chemo(radio)therapy are known predictive factors. None of these factors is a valid exclusion criterion for esophagectomy, but may help in careful patient selection. Both anesthetists and surgeons play an important role in intraoperative risk reduction by means of appropriate fluid management and application of optimal surgical techniques.
Collapse
|
23
|
Abstract
The treatment of esophageal cancer with curative intent remains highly controversial, with advocates of surgery alone, chemoradiotherapy alone, surgery with adjuvant therapy (including neoadjuvant and postoperative), and trimodality therapy each contributing prospective randomized controlled trials (PRCTs) to the body of scientific publications between 2000 and 2008. Any improvements in survival have been small in absolute percentage terms, and as such PRCTs published over the last decade have met the same primary obstacle encountered by the studies from the two prior decades, namely lack of power to detect small differences in outcome. Variations in staging methods, surgical technique, radiotherapy technique, and chemotherapy regime have in turn been the subject of PRCTs over the last nine years. In many cases primary end points have not been survival but rather rates of complication or response. As well as giving an overview of PRCTs, this article collates the level Ia evidence published to date.
Collapse
Affiliation(s)
- Stephen A Barnett
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
| | | |
Collapse
|
24
|
Ryu J, Nam BH, Jung YS. Clinical outcomes comparing parenteral and nasogastric tube nutrition after laryngeal and pharyngeal cancer surgery. Dysphagia 2009; 24:378-86. [PMID: 19255706 DOI: 10.1007/s00455-009-9213-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 01/20/2009] [Indexed: 11/30/2022]
Abstract
Nasogastric tube-assisted enteral feeding and parenteral feeding are utilized for nutritional support after major surgery. Although these nutritional supports have been compared before, there have been no comparative trials following surgery for laryngeal and pharyngeal cancer. In this study, 81 patients were randomized to total parenteral nutrition (TPN) or nasogastric tube nutrition (NGTN) after laryngopharyngeal cancer surgery. The two groups were well-matched demographically and clinically. Clinical outcomes such as time of commencement of oral feeding and hospital stay and complications such as fistula were similar in both groups. One case in the TPN group had catheter-related sepsis, whereas aspiration pneumonia occurred in four cases (9.8%) in the NGTN group. The daily cost of NGTN was $11.81 cheaper than that of TPN. Subjective symptoms of nasal and pharyngeal discomfort and scores on subjective swallowing were more severe in the NGTN group within the first postoperative week but became similar thereafter. Although there was no difference in objective postoperative outcomes between both groups, these results imply that each method had particular advantages and disadvantages. Nutritional support after laryngopharyngeal cancer surgery should be determined after full consideration of each patient's conditions and surgical details along with economics.
Collapse
Affiliation(s)
- Junsun Ryu
- Head and Neck Oncology Clinic, Department of Otolaryngology, National Cancer Center, Goyang, Gyeonggi-do, Korea
| | | | | |
Collapse
|
25
|
Schuchert MJ, Pettiford BL, Landreneau JP, Waxman J, Kilic A, Santos RS, Kent MS, El-Sherif A, Abbas G, Luketich JD, Landreneau RJ. Transcervical gastric tube drainage facilitates patient mobility and reduces the risk of pulmonary complications after esophagectomy. J Gastrointest Surg 2008; 12:1479-84. [PMID: 18560944 DOI: 10.1007/s11605-008-0541-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Accepted: 04/14/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Standard nasogastric decompression following esophagectomy is associated with reduced patient comfort and mobility and impaired hypopharyngeal function--predisposing the patient to sinusitis, pharyngitis, and the risk of aspiration. In this study, we evaluate the results of the transcervical gastric tube drainage in the setting of esophagectomy. METHODS Transcervical gastric tube decompression was performed on 145 consecutive patients undergoing open esophagectomy between 2003 and 2007. Postoperative outcome variables include morbidity, mortality, esophagostomy duration, and length of stay. RESULTS There were 107 males and 38 females (median age = 66; range = 37-87). Perioperative mortality was 2.8%. Major complications included five anastomotic leaks (3.4%), ten pneumonias (6.9%), two myocardial infarctions (1.4%), and the need for reoperation in four patients (bleeding, dehiscence). Median duration of transcervical drainage was 8 days. No tubes were dislodged prematurely. There were no bleeding complications. Four patients developed cellulitis near the cervical gastric tube site and were treated successfully with antibiotics and/or tube removal. CONCLUSIONS Transcervical gastric decompression can be performed safely with minimal complication risk. Inadvertent tube removal was not encountered in this series. The use of this technique may help to promote accelerated patient mobilization, greater patient comfort, and a durable means of gastric decompression.
Collapse
Affiliation(s)
- Matthew J Schuchert
- Division of Thoracic and Foregut Surgery, Heart, Lung and Esophageal Surgery Institute, UPMC Health System, Shadyside Medical Building-Suite 715, 5200 Centre Avenue, Pittsburgh, PA 15232, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
BACKGROUND Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program. OBJECTIVE To assess, synthesize, and discuss implementation of "fast-track" recovery programs. DATA SOURCES Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work. DATA SYNTHESIS Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology. CONCLUSION Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.
Collapse
|
27
|
D’Journo XB, Michelet P, Avaro JP, Trousse D, Giudicelli R, Fuentes P, Doddoli C, Thomas P. Complications respiratoires de l’œsophagectomie pour cancer. Rev Mal Respir 2008; 25:683-94. [DOI: 10.1016/s0761-8425(08)73798-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
28
|
Lunardi AC, Resende JM, Cerri OM, Carvalho CRFD. Efeito da continuidade da fisioterapia respiratória até a alta hospitalar na incidência de complicações pulmonares após esofagectomia por câncer. FISIOTERAPIA E PESQUISA 2008. [DOI: 10.1590/s1809-29502008000100012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O presente estudo avaliou os efeitos na incidência de complicações pulmonares do cuidado contínuo de fisioterapia respiratória no pós-operatório de esofagectomia, até a alta hospitalar. Examinaram-se retrospectivamente 40 prontuários de pacientes de esofagectomia consecutivos (nenhuma exclusão), que foram divididos em dois grupos: um dos que receberam fisioterapia respiratória apenas na unidade de tratamento intensivo (gUTI, n=20) e outro dos que a receberam até a alta hospitalar (gALTA, n=20). Foram coletadas informações referentes ao pré, intra e pós-operatório. Os resultados mostram que gUTI e gALTA, respectivamente, apresentaram-se similares (média±dp) quanto a idade (55,5±9,9 e 57,1±10,8 anos), IMC (22,5±3,3 e 18±4 kg/m²), tempo de cirurgia (400±103,8 e 408,5±142 min), tempo de anestesia (498,3±107,3 e 516±148,9 min) e número de atendimentos de fisioterapia na UTI (9,6±14,9 e 8,3±7,6). Apesar de o gALTA apresentar história de tabagismo superior (35,7±17,6 vs 26,1±18,4 maços-ano, p<0,05), houve menos 20% de complicações respiratórias após esofagectomia nesse grupo quando comparado ao gUTI (10% vs 30%, p<0,05): incidência 75% menor de derrame pleural e 50% menos broncopneumonia. Além disso, o gALTA teve permanência menor de dreno pleural no hemitórax direito (menos 4,5 dias, p<0,05). Estes achados sugerem que os cuidados de fisioterapia respiratória até a alta hospitalar podem reduzir a incidência de complicações pulmonares após esofagectomia por câncer.
Collapse
|
29
|
Page RD, Shackcloth MJ. Gastric outlet obstruction and respiratory complications after esophagectomy. Eur J Cardiothorac Surg 2007; 32:552. [PMID: 17596955 DOI: 10.1016/j.ejcts.2007.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Revised: 05/10/2007] [Accepted: 05/16/2007] [Indexed: 10/23/2022] Open
|
30
|
Abstract
PURPOSE OF REVIEW To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy. RECENT FINDINGS Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery. SUMMARY Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.
Collapse
|
31
|
Abstract
PURPOSE OF REVIEW To examine the available documentation addressing the introduction of early food after major upper gastrointestinal surgery. RECENT FINDINGS No high-quality trials, recent or old, have addressed this topic. A few attempts have been identified. Information is extracted from papers discussing other topics of postoperative care in this field. Generally, nasogastric tubes and nil-by-mouth prevail in the early postoperative period. SUMMARY The reluctance to allow early food at will is not evidence based, but neither is the safety of an alternative regimen. Early food at will should probably be allowed after hepatic resections, gastric resections, and total gastrectomies and maybe also after pancreaticoduodenectomies. Resections of the esophagus remain the most challenging issue. The need is urgent for high-powered and high-quality randomized controlled clinical trials.
Collapse
Affiliation(s)
- Kristoffer Lassen
- Department of Digestive Surgery, University Hospital Northern Norway, Tromsø, Norway.
| | | |
Collapse
|