[Intrathoracic anastomotic leakage following esophageal and cardial resection : Definition and validation of a new severity grading classification]

Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

Introduction

Anastomotic leakage after esophagectomy with gastric-pullup is the most feared postoperative complication associated with high morbidity and mortality rates. Management of anastomotic leakage underwent an evolution in the last decade from surgical and conservative to an endoscopic management. However, to date there is no clear consensus on management and if endoluminal vacuum therapy (EVT) is the most superior therapy.

Material and methods

Between 2012 and 2022 all patients that underwent Ivor-Lewis esophagectomy for an underlying malignancy were included in this study. Patients that developed an anastomotic leakage and received endoscopic vacuum therapy were further analysed.

Results

A total of 17 patients were treated with EVT following AL after esophagectomy. The median duration of EVT was 23 days with a median number of 5,5 vacuum sponge changes per patient. EVT-systems were placed 12 times intraluminal and 5 times extraluminal. Successful closure of the defect was achieved in 14 patients.

Conclusion

Endoscopic vacuum therapy can be successfully applied in the treatment of anastomotic leakage after esophagectomy even in septic patients with an extraluminal cavity. Event-related complications are present but rare.

Endoskopisches Komplikationsmanagement am oberen und unteren Gastrointestinaltrakt

Even when wide-ranging measures for avoidance of complications by improved techniques, training and many other activities are undertaken, postoperative and postinterventional complications still represent a daily problem in clinical medicine. The outcome of the patient is not uncommonly decided by the management of the complications. The failure to rescue or to control complications is increasingly recognized as being decisive for the success of treatment. This article therefore provides a current overview of the endoscopic management of complications of the upper and lower gastrointestinal tract. It describes when endoscopy can be used to detect or exclude a complication. The most important principles of treatment including the indications, limits of performance and technique are presented.

Comparison of Two Endoscopic Therapeutic Interventions as Primary Treatment for Anastomotic Leakages after Total Gastrectomy

Simple Summary

An esophagojejunal anastomotic leak after oncological gastrectomy is a life-threatening complication. Endoscopic treatment offers the possibility of minimally invasive diagnosis and immediate effective therapy in one session. A retrospective, single-center analysis of two different endoscopic strategies as first-line treatment options was performed.

Abstract

Introduction: An esophagojejunal anastomotic leak following an oncological gastrectomy is a life-threatening complication, and its management is challenging. A stent application and endoscopic negative pressure therapy are possible therapeutic options. A clinical comparison of these strategies has been missing until now. Methods: A retrospective analysis of 14 consecutive patients endoscopically treated for an anastomotic leak after a gastrectomy between June 2014 and December 2019 was performed. Results: The mean time of the diagnosis of the leakage was 7.14 days after surgery. Five patients were selected for a covered stent, and nine patients received endoscopic negative pressure therapy. In the stent group, the mean number of endoscopies was 2.4, the mean duration of therapy was 26 days, and the mean time of hospitalization was 30 days. In patients treated with endoscopic negative pressure therapy, the mean number of endoscopies was 6.0, the mean days of therapy duration was 14.78, and the mean days of hospitalization was 38.11. Treatment was successful in all patients in the stent-based therapy group and in eight of nine patients in the negative pressure therapy group. Discussion: Good clinical results in preserving the anastomosis and providing sepsis control was achieved in all patients. Stent therapy resulted in anastomosis healing with a lower number of endoscopies, a shorter time of hospitalization, and rapid oral nutrition.

Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer

Simple Summary

Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments.

Abstract

Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.

Continuous negative pressure irrigation with double cannula through the anterior sacral space for treatment of anastomotic fistula after anus-preserving laparoscopic radical resection for ultra-low rectal cancer in elderly patients

BACKGROUND

Ultra-low rectal cancer refers to rectal cancer where the lower edge of the tumor is less than 5 cm from the dentate line. It is mostly caused by genetics, diet, chronic inflammation of the large intestine, and many other factors. Surgery is the main method of treatment for rectal cancer. Although surgery can effectively control the deterioration of the disease and remove the diseased tissue, postoperative complications such as anastomotic leakage often occur, which is not conducive to the prognosis and even threatens the life and health of patients. The prevention and treatment of anastomotic leakage in elderly patients after surgery are a clinical focus and difficulty.

AIM

To evaluate the effect of continuous negative pressure irrigation with double cannula through the anterior sacral space in the treatment of anastomotic fistula after anus-preserving laparoscopic radical resection for ultra-low rectal cancer in elderly patients (over 60 years old).

METHODS

One hundred and eighteen elderly patients with anastomotic fistula after laparoscopic radical resection for ultra-low rectal cancer from November 2018 to October 2020 were selected and classified into either a control group or an experimental group according to the order of admission. The control group (59 cases) underwent single-chamber drainageed, and the experimental group (59 cases) received continuous negative pressure irrigation with double cannula through the presacral space. The efficacy, time to recovery of various indications, postoperative function, and inflammatory factors were compared between the two groups.

RESULTS

The total effective rate in the experimental group (98.31%) was significantly higher than that of the control group (84.75%), and the time to extubation, time to recovery of normal body temperature, healing time, time to disappearance of lower abdominal pain, and hospital stay were significantly shorter than those of the control group (P < 0.05). The visual analogue assessment scale score of the experimental group was significantly lower than that of the control group after 2 wk of treatment, and the granulation growth grade and EORTC quality of life measurement scale score were significantly higher than those of the control group (P < 0.05). After 2 wk of treatment, white blood cell count, erythrocyte sedimentation rate, C-reactive protein, and procalcitonin were significantly lower, and vascular endothelial growth factor level was significantly higher in the experimental group than in the control group (P < 0.05).

CONCLUSION

Double cannula continuous negative pressure flushing through the presacral space is effective in the treatment of anastomotic fistula after anus-preserving laparoscopic radical resection for ultra-low rectal cancer in elderly patients, and it can quickly relieve clinical symptoms, promote the growth of fresh granulation, inhibit the release of inflammatory factors, and improve life quality.

Classification and evaluation of anastomotic leaks after esophageal surgery—a tertiary university experience

Background

Anastomotic insufficiency of the esophagus is the most feared complication of surgeons, leading to high postoperative morbidity and mortality. However, there is no internationally accepted guideline for its classification and treatment algorithm. Therefore, the aim of this study was to analyze the detection of anastomotic leaks as well as to discuss and validate the classification proposed by the Surgical Working Group on Endoscopy and Ultrasound in late 2018.

Methods

All patients undergoing surgery for malignancy of the esophagogastric junction between 2013 and 2020 were analyzed. Out of these patients, those diagnosed with an anastomotic insufficiency were extracted and classified according to the classification proposed by the Surgical Working Group on Endoscopy and Ultrasound. Continuous variables were expressed as medians, categorical variables were compared using Fisher’s exact test or chi-square test.

Results

From 2013 to 2020, all 23 patients (10.84%) who developed an anastomotic leak after esophageal surgery were included in this study. The study revealed a significant increase in median hospital stay, median intensive care unit stay, and overall mortality rate (p = 0.028) with increased classification type.

Conclusion

The results of this study showed that the classification proposed by the Surgical Working Group on Endoscopy and Ultrasound can be validated and that there is a clear differentiation between the subtypes. Standardized diagnosis and management improve the overall outcome of patients.

Main novel aspects

This article gives an introduction to classifying anastomotic insufficiencies according to the classification proposed by the Surgical Working Group on Endoscopy and Ultrasound.

Results of the classification can be validated, with a clear differentiation of postoperative outcome between subtypes.