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Kjaer DW, Liao D, Ingemann Petersen T, Katballe N, Bendixen M, Drewes AM, Krogh K. EndoFLIP evaluation of the pylorus during minimal invasive Ivor-Levis esophagectomy. Scand J Gastroenterol 2024:1-7. [PMID: 39189721 DOI: 10.1080/00365521.2024.2396483] [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] [Received: 02/05/2024] [Revised: 08/11/2024] [Accepted: 08/20/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND/AIMS During esophagectomy for malignancy, the anterior and posterior branches of the vagus nerve are transected in order to achieve surgical radicality. This leads to loss of central nervous system-control of the pylorus which may lead to delayed gastric emptying. We aimed to investigate the feasibility of the EndoFLIP technique for assessment of pyloric biomechanical properties in patients undergoing esophagectomy. METHODS A feasibility study in six patients undergoing surgery was conducted. EndoFLIP measurements were carried out preoperative (Pre-op), after surgical resection (Post-op) and following prophylactic balloon dilatation of the pylorus (Post-dil). By measuring the cross-sectional area and pressure of the pylorus the pyloric compliance and the incremental pressure-strain elastic modulus (Ep) were calculated. RESULTS Placing the catheter in the pyloric region was successfully achieved in all six patients. No complications were observed. Resection of the esophagus increased the incremental pyloric elastic modulus (Ep) from 0.59 ± 0.18 kPa to 0.99 ± 0.34 kPa (p = 0.03). After dilatation, the Ep was reduced to 0.53 ± 0.23 kPa (p = 0.04), which was close to Pre-op (p = 0.62). The pyloric compliance showed a similar pattern as that found for Ep. CONCLUSION The EndoFLIP system holds promise for assessment of biomechanics of the pyloric region in patients undergoing esophagectomy for cancer.
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Affiliation(s)
| | - Donghua Liao
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Niels Katballe
- Department of Thoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Bendixen
- Department of Thoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn Mohr Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Csontos A, Németh D, Szakó L, Berke G, Sindler DL, Berki D, Papp C, Hegyi P, Vereczkei A, Papp A. Intraoperative pyloric drainage is unnecessary during esophagectomies: a meta-analysis and systematic review of randomized controlled trials. Pathol Oncol Res 2024; 30:1611823. [PMID: 39165646 PMCID: PMC11333203 DOI: 10.3389/pore.2024.1611823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 07/19/2024] [Indexed: 08/22/2024]
Abstract
Objective: The topic of this meta-analysis is the comparison of gastric conduit esophageal reconstructions with or without pyloroplasty. Background: Surgical procedures, especially minimal invasive esophagectomy (MIE) can be a curative treatment in the early stages of esophageal cancer. Previously, intraoperative pyloroplasty was routinely performed, but nowadays it became debated again in the light of minimally invasive esophagectomy. Methods: A comprehensive search was performed in multiple databases to identify randomized controlled trials investigating the topic. Two independent authors performed the selection based on predefined criteria. Statistical analysis was performed to assess any significant difference, then the bias and quality of the data were estimated. Results: Nine relevant RCTs consisting of 529 patients with esophageal cancer were identified. No significance was found in mortality [odds ratio (OR): 0.85; p = 0.642], anastomosis leakage (OR: 0.57; p = 0.254), respiratory morbidity (OR: 0.51; p = 0.214) and vomiting (OR: 0.74; p = 0.520), however the results about gastric emptying time (GET) were controversial (weighted mean difference (WMD): -67.71; p = 0.009, OR: 2.75; p = 0.072). Significant heterogeneity was not detected except for GET. Trial sequential analyses (TSA) show that a certain conclusion would require more data except in the binary variables of GET. Conclusion: We conclude that the pyloric drainage procedure is not routinely necessary, but further well-designed studies would be needed, especially in Europe.
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Affiliation(s)
- Armand Csontos
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dávid Németh
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Lajos Szakó
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- János Szentágothai Research Centre, Medical School, University of Pécs, Pécs, Hungary
- Department of Emergency Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gergő Berke
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dóra Lili Sindler
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - Dávid Berki
- First Department of Surgery, Military Hospital Medical Centre, Hungarian Defense Forces, Budapest, Hungary
| | - Csenge Papp
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- First Department of Medicine, Medical School, University of Szeged, Szeged, Hungary
- Hungary Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - András Vereczkei
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - András Papp
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
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Hultcrantz J, Klevebro F, Lindblad M, Brismar TB, Coy DL, Low DE, Andersson M. Improved radiologic diagnosis of delayed gastric conduit emptying (DGCE) after esophagectomy using a functional upper gastrointestinal contrast study. Acta Radiol 2024; 65:329-333. [PMID: 38111253 DOI: 10.1177/02841851231217990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND With increasing incidence of esophageal cancer, a growing number of patients are at risk of developing delayed gastric conduit emptying (DGCE) in the early postoperative phase after esophagectomy. This condition is of great postoperative concern due to its association with adverse outcomes. PURPOSE To give a narrative review of the literature concerning radiological diagnosis of DGCE after esophagectomy and a proposal for an improved, functional protocol with objective measurements. MATERIAL AND METHODS The protocol was designed at Virginia Mason Medical Center in Seattle and is based on the Timed Barium Esophagogram (TBE) concept, which has been adapted to assess the passage of contrast from the gastric conduit into the duodenum. RESULTS The literature review showed a general lack of standardization and scientific evidence behind the use of radiology to assess DGCE. We found that our proposed standardized upper gastrointestinal (UGI) contrast study considers both the time aspect in DGCE and provides morphologic information of the gastric conduit. This radiological protocol was tested on 112 patients in a trial performed at two high-volume centers for esophageal surgery and included an UGI contrast study 2-3 days postoperatively. The study demonstrated that this UGI contrast study can be included in the standardized clinical pathway after esophagectomy. CONCLUSION This new, proposed UGI contrast study has the potential to diagnose early postoperative DGCE in a standardized manner and to improve overall patient outcomes after esophagectomy.
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Affiliation(s)
- Jens Hultcrantz
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Centre for Upper Gastrointestinal Diseases, Division of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Torkel B Brismar
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - David L Coy
- Department of Radiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Mats Andersson
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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Tankel J, Patel D, Nevo Y, Najmeh S, Spicer J, Mulder D, Mueller C, Ferri L, Cools-Lartigue J. Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy. Ann Surg Oncol 2023; 30:8182-8191. [PMID: 37436604 DOI: 10.1245/s10434-023-13733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/17/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL). METHODS From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL. RESULTS Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001). CONCLUSION While the type of reconstruction did not affect QoL, it did affect the postoperative course.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Devangi Patel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Yenonatan Nevo
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - David Mulder
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Horváth ÖP, Pavlovics G, Cseke L, Vereczkei A, Papp A. Dysphagia After Esophageal Replacement and Its Treatment. Dysphagia 2023; 38:1323-1332. [PMID: 36719515 PMCID: PMC10471736 DOI: 10.1007/s00455-023-10557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.
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Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary.
| | - Gábor Pavlovics
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - László Cseke
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Papp
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
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Bolger JC, Lau H, Yeung JC, Darling GE. Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients. Dis Esophagus 2023; 36:6694033. [PMID: 36073933 DOI: 10.1093/dote/doac061] [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] [Received: 03/10/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 12/11/2022]
Abstract
Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65 years, P = 0.6), pathological stage (P = 0.10) or ASA status (P = 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P = 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P = 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.
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Affiliation(s)
- Jarlath C Bolger
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Harry Lau
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada
| | - Jonathan C Yeung
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:823-835. [PMID: 36650418 DOI: 10.1007/s11605-022-05573-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy. METHODS PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality. RESULTS There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I2 = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I2 = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I2 = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I2 = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I2 = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I2 = 0%) between the pyloric drainage and no intervention groups. CONCLUSIONS Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.
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Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:3287-3295. [PMID: 36163378 DOI: 10.1007/s00423-022-02685-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure. METHODS A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention. RESULTS Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29). CONCLUSION Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.
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Endoscopic Intrapyloric Botulinum Toxin Injection with Pyloric Balloon Dilation for Symptoms of Delayed Gastric Emptying after Distal Esophagectomy for Esophageal Cancer: A 10-Year Experience. Cancers (Basel) 2022; 14:cancers14235743. [PMID: 36497224 PMCID: PMC9737592 DOI: 10.3390/cancers14235743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Patients with esophageal cancer undergoing esophagectomy have an improved survival over time, however adverse events associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related complication which can decreased quality of life by causing debilitating gastrointestinal symptoms and malnutrition. The aim of our study was to evaluate the effect of endoscopic intrapyloric botulinum (BT) injection in combination with pyloric balloon dilation in patients with DGE following distal esophagectomy at our tertiary cancer center. Patients with a prior history of distal esophagectomy who had also undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study. One hundred units of BT were injected endoscopically into the pylorus in four quadrants using an injection needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12−20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed. A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. The patients underwent the procedures at a median of 22 months (range, 1−108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times (>2). Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. Eighteen patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) showed no improvement, whereas in two (10%) patients responses were not available. In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex, possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results.
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10
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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11
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Comparative Study of Pyloromyotomy and H-M Pyloroplasty in Proximal Gastrectomy for Adenocarcinoma of Esophageal-Gastric Junction. J Gastrointest Surg 2022; 26:1585-1595. [PMID: 35585422 DOI: 10.1007/s11605-022-05347-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The incidence of adenocarcinoma of esophageal-gastric junction (AEJ) has been increasing in recent years. Esophagogastrostomy after proximal gastrectomy (PG-EG) is the most commonly used surgical method for this disease which causes a constant spasm of the pyloric sphincter by cutting the vagus nerve around the esophagus, so H-M pyloroplasty (Heineke-Mikulicz pyloroplasty) is often operated after PG-EG to prevent delayed gastric emptying. However, H-M pyloroplasty destroys anti-reflux structure of pylorus and leads to serious bile reflux. The present study was designed to compare pyloromyotomy and H-M pyloroplasty in proximal subtotal gastrectomy through clinical studies and animal experiments. METHODS We retrospectively evaluated the outcomes of 73 AEJ patients (39 underwent PG-EG with an H-M pyloroplasty and 34 underwent PG-EG with a pyloromyotomy) between January 2016 and August 2020, and perioperative variables were compared. In the animal experiment, 48 rats were randomly divided into four groups (n = 12): vagotomy group (V group), H-M pyloroplasty group (HM group), pyloromyotomy group (PM group), and control group (O group). Gastric emptying and bile reflux were evaluated in each group. RESULTS In the retrospective clinic study, pyloromyotomy and H-M pyloroplasty could all prevent delayed gastric emptying effectively, and the incidence of bile reflux found by electronic gastroscopy in the PM group was significantly lower than that in the HM group (HM, 14/39; PM, 4/34; P = 0.028). In the animal experiment, there was no significant between-group difference of gastric emptying rate (%) in the HM group and PM group (HM, 70.6 ± 16; PM, 72.3 ± 12; P = 0.68) while the gastric emptying rate (%) was significantly lower in the V group than in the HM, PM, and control group (P values were 0.037, 0.021, and 0.001 respectively). The gastric mucosa bile acid concentration was significantly higher in the HM group than other group (P values were all less than 0.001). CONCLUSIONS The pyloromyotomy could prevent delayed gastric emptying effectively after PG-EG for types II and III AEJ and reduce bile reflux compared to Heineke-Mikulicz pyloroplasty.
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Nienhüser H, Heger P, Crnovrsanin N, Schaible A, Sisic L, Fuchs HF, Berlth F, Grimminger PP, Nickel F, Billeter AT, Probst P, Müller-Stich BP, Schmidt T. Mechanical stretching and chemical pyloroplasty to prevent delayed gastric emptying after esophageal cancer resection-a meta-analysis and review of the literature. Dis Esophagus 2022; 35:6530222. [PMID: 35178557 DOI: 10.1093/dote/doac007] [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] [Received: 10/26/2021] [Revised: 01/09/2022] [Accepted: 01/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) occurs in up to 40% of patients after esophageal resection and prolongs recovery and hospital stay. Surgically pyloroplasty does not effectively prevent DGE. Recently published methods include injection of botulinum toxin (botox) in the pylorus and mechanical interventions as preoperative endoscopic dilatation of the pylorus. The aim of this study was to investigate the efficacy of those methods with respect to the newly published Consensus definition of DGE. METHODS A systematic literature search using CENTRAL, Medline, and Web of Science was performed to identify studies that described pre- or intraoperative botox injection or mechanical stretching methods of the pylorus in patients undergoing esophageal resection. Frequency of DGE, anastomotic leakage rates, and length of hospital stay were analyzed. Outcome data were pooled as odd's ratio (OR) or mean difference using a random-effects model. Risk of bias was assessed using the Robins-I tool for non-randomized trials. RESULTS Out of 391 articles seven retrospective studies described patients that underwent preventive botulinum toxin injection and four studies described preventive mechanical stretching of the pylorus. DGE was not affected by injection of botox (OR 0.87, 95% confidence interval [CI] 0.37-2.03, P = 0.75), whereas mechanical stretching resulted in significant reduction of DGE (OR 0.26, 95% CI 0.14-0.5, P < 0.0001). CONCLUSION Mechanical stretching of the pylorus, but not injection of botox reduces DGE after esophageal cancer resection. A newly developed consensus definition should be used before the conduction of a large-scale randomized-controlled trial.
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Affiliation(s)
- Henrik Nienhüser
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Heger
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nerma Crnovrsanin
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Leila Sisic
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans F Fuchs
- Department of General, Visceral-, Tumor and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Felix Nickel
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Department of General, Visceral-, Tumor and Transplant Surgery, University Hospital Cologne, Cologne, Germany
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Yano M, Sugimura K, Miyata H, Motoori M, Tanaka K, Omori T, Ohue M, Sakon M. Response to Comment on "Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy" by Dr Prakash et al. Ann Surg 2022; 276:e68-e69. [PMID: 33278170 DOI: 10.1097/sla.0000000000004659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Masahiko Yano
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keijiro Sugimura
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka Prefectural General Medical Center, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological surgery, Osaka University Graduate school of Medicine, suita, Japan
| | - Takeshi Omori
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masato Sakon
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
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14
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Sleeve Gastrectomy with Pyloroplasty in Wistar Rats: Assessment of Gastric Emptying, Intestinal Transit, and Possible Duodenogastric Alkaline Reflux. Obes Surg 2022; 32:2611-2617. [PMID: 35715612 DOI: 10.1007/s11695-022-06151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 06/07/2022] [Accepted: 06/07/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Studies indicate sleeve gastrectomy (SG) as a factor of aggravation or even emergence of symptoms of gastroesophageal reflux disease. Accelerated gastric emptying is described as a mitigating factor. SG may be potentiated by adding a pyloroplasty, although with the potential risk of resulting in duodenogastric alkaline reflux. The objective was to standardize sleeve gastrectomy with pyloroplasty in rats, analyze the complementation in terms of mortality and weight evolution, and conduct assessments on gastric emptying, intestinal transit, and genesis of possible duodenogastric reflux. METHODS Ninety-three male Wistar rats were divided into a pilot study (standardization of the surgical technique and the scintigraphic study), and the main study. They were then subdivided into the SHAM group, the sleeve gastrectomy (SG) group, and the sleeve gastrectomy with pyloroplasty (SGP) group. After 3 months, the animals were submitted to two scintigraphic experiments and histological analysis of gastric biopsies. RESULTS The surgical groups (SG and SGP) lost initially more weight than the SHAM group, and the gastric emptying and intestinal transit in the first were more accelerated. However, no difference was found between the SG and SGP groups. Scintigraphic and histological analyses did not reveal statistical differences among the SG and SGP groups regarding gastroesophageal and duodenogastric refluxes. CONCLUSIONS Pyloroplasty did not affect weight reduction or increase duodenogastric reflux, after three postoperative months in this animal model of sleeve gastrectomy.
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15
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Garbarino GM, van Berge Henegouwen MI, Gisbertz SS, Eshuis WJ. Today's Mistakes and Tomorrow's Wisdom in the Surgical Treatment of Barrett's Adenocarcinoma. Visc Med 2022; 38:203-211. [PMID: 35814974 PMCID: PMC9210033 DOI: 10.1159/000524928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/02/2022] [Indexed: 09/17/2023] Open
Abstract
Background Barrett's esophagus is a premalignant condition caused by longstanding gastroesophageal reflux disease and may progress to low-grade dysplasia, high-grade dysplasia (HGD), and finally esophageal adenocarcinoma. Summary Barrett's adenocarcinoma can be treated either by endoscopic or surgical resection, depending on the clinical staging. Endoscopic resection is a safe and adequate treatment option for HGD, mucosal tumors, and low-risk submucosal tumors. Its role in the treatment of high-risk submucosal tumors and the role of organ-preserving sentinel node navigated surgery are still under investigation. Esophagectomy with neoadjuvant chemoradiation or perioperative chemotherapy is considered the standard of care for locally advanced Barrett's adenocarcinoma. Regarding operative technique, there is no proven superiority of one technique over another, although a minimally invasive transthoracic technique seems most commonly applied nowadays. In this review, state-of-the-art evidence and future expectations are presented regarding indications for resection, neoadjuvant or perioperative therapy, type of surgery, and postoperative follow-up for Barrett's adenocarcinoma. Key Messages In Barrett's adenocarcinoma, endoscopic resection is the standard treatment option for low-risk mucosal and submucosal tumors. For high-risk submucosal tumors, endoscopic submucosal dissection with close surveillance and sentinel node navigated surgery are currently being studied. For locally advanced cancer, a multimodal therapy including esophagectomy is the standard of care. Nowadays, in high-volume centers, a minimally invasive transthoracic esophagectomy with an intrathoracic anastomosis is the most common procedure for Barrett's adenocarcinoma.
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Affiliation(s)
- Giovanni Maria Garbarino
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Medical Surgical Science and Translational Medicine, Sapienza University of Rome, Sant'Andrea Hospital, Rome, Italy
| | - Mark Ivo van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne Sarah Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse Jelle Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
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16
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Double tract-like gastric tube reconstruction decreases the incidences of delayed gastric emptying and bile reflux after esophagectomy: results of a pilot study of an experimental technique. Langenbecks Arch Surg 2022; 407:1431-1439. [DOI: 10.1007/s00423-022-02461-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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17
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Babic B, Schiffmann LM, Fuchs HF, Mueller DT, Schmidt T, Mallmann C, Mielke L, Frebel A, Schiller P, Bludau M, Chon SH, Schroeder W, Bruns CJ. There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy. Surg Endosc 2022; 36:6777-6783. [PMID: 34981236 PMCID: PMC9402722 DOI: 10.1007/s00464-021-08962-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/12/2021] [Indexed: 10/29/2022]
Abstract
INTRODUCTION Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. PATIENTS AND METHODS 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. RESULTS 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. CONCLUSION Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.
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Affiliation(s)
- Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Lars Mortimer Schiffmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Dolores Thea Mueller
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Christoph Mallmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Laura Mielke
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Antonia Frebel
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Petra Schiller
- Faculty of Medicine, Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Wolfgang Schroeder
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Carr RA, Harrington C, Stella C, Glauner D, Kenny E, Russo LM, Garrity MJ, Bains MS, Sihag S, Jones DR, Molena D. Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer. Cancer Med 2021; 11:592-601. [PMID: 34935304 PMCID: PMC8817095 DOI: 10.1002/cam4.4360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 11/11/2022] Open
Abstract
Background Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients. Methods We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded. Results Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups. Conclusions Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.
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Affiliation(s)
- Rebecca A Carr
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caitlin Harrington
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christina Stella
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Diana Glauner
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Erin Kenny
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lianne M Russo
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan J Garrity
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Comment on "a Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy". Ann Surg 2021; 274:e853. [PMID: 33278162 DOI: 10.1097/sla.0000000000004662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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BUßMEYER F, Kneifel F, Eichelmann AK, Palmes D, Hummel R, Lindner K. Effects of therapy modifications during the last decade on the outcome of patients undergoing esophagectomy for esophageal cancer. Minerva Surg 2021; 76:235-244. [PMID: 33855371 DOI: 10.23736/s2724-5691.21.08393-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND During the last decade, numerous therapeutic regimes were assessed to improve the outcome of patients with esophageal carcinoma. We analyzed the impact of therapy alterations, including the establishment of a standardized clinical pathway and the introduction of an interdisciplinary tumor conference on the outcome of patients undergoing esophagectomy because of esophageal cancer. METHODS Three hundred one patients were included (204 adenocarcinoma and 97 squamous cell carcinoma) who underwent an esophagectomy between 2006 and 2015. Patients were divided into 3 groups: interval A (2006-2008), interval B (2009-2011) and interval C (2012-2015) and evaluated separately focusing on therapy management and patients' outcome. RESULTS Over the time periods, the incidence of tumor entity of adenocarcinoma increased from 61% to 76.2% (P=0.059). Patients with an initial tumor stage uT1 increased significantly from 4% to 15.9% over the intervals (P=0.002), while positive nodal involvement remained comparable (P=0.237). Patients in the later interval suffered from greater physical impairments preoperatively, represented by a significantly increased American Society Anesthesiologists (ASA) score (P=0.023) and a reduced Karnofsky Index (P<0.001). The tumor conference was accompanied by an increasing implementation of neoadjuvant therapy (27.1% vs. 42.2%, P=0.097). After establishing the clinical pathway 30-day mortality decreased (P=0.67). Grad III anastomotic leakage decreased significantly from 6.5% to 2% (P=0.01). However, gastrointestinal (P=0.007), pulmonary complications (P<0.001) including pneumonia (P<0.001) increased. Over the past ten years both overall survival and relapse-free survival prolonged (P=0.056 and P=0.063, respectively). CONCLUSIONS Patients' collective suffering from esophageal cancer has changed over the last decade. Continuous further developments of the therapy regimes are needed to meet the requirements of reducing perioperative mortality and extending survival time.
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Affiliation(s)
- Florian BUßMEYER
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Felicia Kneifel
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Ann-Kathrin Eichelmann
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Daniel Palmes
- Department of General and Visceral Surgery, Muenster University Hospital, Muenster, Germany
| | - Richard Hummel
- Department of Surgery, Campus Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany
| | - Kirsten Lindner
- Department of Surgery, Campus Lübeck, University Hospital of Schleswig-Holstein, Lübeck, Germany -
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21
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Response to Comment on "Randomized Comparison of Gastric Tube Reconstruction with and without Duodenal Diversion Plus Roux-en-Y Anastomosis after Esophagectomy" by Dr Ahmed et al. Ann Surg 2020; 274:e853-e854. [PMID: 33278171 DOI: 10.1097/sla.0000000000004660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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De Pasqual CA, Weindelmayer J, Gobbi L, Alberti L, Veltri A, Giacopuzzi S, de Manzoni G. Effect of Pyloroplasty on Gastric Conduit Emptying and Patients' Quality of Life After Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2020; 31:692-697. [PMID: 32898448 DOI: 10.1089/lap.2020.0595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Delayed gastric emptying (DGE) is a common complication after esophagectomy with gastric tube reconstruction. It is still unclear whether a pyloric drainage procedure might reduce the risk of DGE. Methods: We identified in our database all patients subjected to Ivor Lewis esophagectomy after neoadjuvant chemoradiotherapy in the period 2000-2012. In the period 2000-2009, we performed a routine pyloroplasty (pyloroplasty group, PP group, 15 patients), after 2009 we did not perform any type of pyloric drainage procedure (nonpyloroplasty group, NPP group, 11 patients). We compared the groups with subjective questionnaires to assess the perceived quality of life (QoL) (QLQ-C30 and OES-18) and with objective test to study the gastric tube emptying (timed barium swallow test, scintigraphy, 24 hours' pH-metry). Results: No difference was observed in questionnaires QLC-C30 and OES-18 scores: 73% of patients in PP group and 63% in NPP group scored their overall QoL as good to excellent (QLC-C30). We did not report difference in timed barium swallow test results and in scintigraphy results. Twenty-four-hour pH-metry results showed in PP group a nonsignificant higher number of acid reflux episodes (NPP group 23.2 ± 9.5 versus PP group 41.3 ± 10.7, P = .29) and a longer time with pH <4 (NPP group 0.89% ± 1.6% versus PP group 3.1% ± 2.1%, P = .24). Conclusions: In our series, pyloroplasty was not associated with improved long-term QoL nor with better gastric conduit emptying. Further studies are needed to confirm these findings.
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Affiliation(s)
- Carlo Alberto De Pasqual
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Jacopo Weindelmayer
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Laura Gobbi
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Luca Alberti
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Alessandro Veltri
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Simone Giacopuzzi
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Giovanni de Manzoni
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
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Yano M, Sugimura K, Miyata H, Motoori M, Tanaka K, Omori T, Ohue M, Sakon M. Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy. Ann Surg 2020; 272:48-54. [PMID: 31415003 DOI: 10.1097/sla.0000000000003557] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This prospective randomized phase-II trial examined whether gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis(RY) minimized gastroduodenal reflux and delayed gastric emptying compared with standard gastric reconstruction. SUMMARY BACKGROUND DATA There is no established standard surgical procedure to prevent both gastroduodenal reflux and delayed gastric emptying simultaneously. METHODS Sixty patients with thoracic esophageal cancer scheduled to undergo esophagectomy with retrosternal gastric tube reconstruction were randomly allocated to standard gastric reconstruction (non-RY, n = 31) or gastric reconstruction with duodenal diversion plus RY (n = 29) groups. Primary endpoint was quality of life assessed by DAUGS-32 score 1 year after surgery. Secondary endpoints were the extent of postoperative duodenal juice reflux into the gastric tube, postoperative morbidity, endoscopic findings, body weight changes, and nutritional status. RESULTS Preoperative clinicopathological characteristics and postoperative morbidity did not differ significantly between groups. However, operation time and blood loss volume were significantly higher in the RY group. Pancreatic amylase concentrations in the gastric conduit on postoperative days 2, 3, and 7 were higher in the non-RY group. Postoperative endoscopic examination showed residual gastric content in 7 of 17 patients in the non-RY group but in none in the RY group (P = 0.012). Quality of life was significantly favorable in the RY group with regard to reflux symptoms and food passage dysfunction. Postoperative body weight changes, serum albumin levels, and peripheral blood lymphocyte counts were not significantly different between groups. CONCLUSION Gastric reconstruction with duodenal diversion plus RY is effective in improving both gastroduodenal reflux and delayed gastric emptying.
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Affiliation(s)
- Masahiko Yano
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keijiro Sugimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masato Sakon
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
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24
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Kim D. The Optimal Pyloric Procedure: A Collective Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:233-241. [PMID: 32793458 PMCID: PMC7409877 DOI: 10.5090/kjtcs.2020.53.4.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 01/04/2023]
Abstract
Vagal damage and subsequent pyloric denervation inevitably occur during esophagectomy, potentially leading to delayed gastric emptying (DGE). The choice of an optimal pyloric procedure to overcome DGE is important, as such procedures can lead to prolonged surgery, shortening of the conduit, disruption of the blood supply, and gastric dumping/bile reflux. This study investigated various pyloric methods and analyzed comparative studies in order to determine the optimal pyloric procedure. Surgical procedures for the pylorus include pyloromyotomy, pyloroplasty, or digital fracture. Botulinum toxin injection, endoscopic balloon dilatation, and erythromycin are non-surgical procedures. The scope, technique, and effects of these procedures are changing due to advances in minimally invasive surgery and postoperative interventions. Some comparative studies have shown that pyloric procedures are helpful for DGE, while others have argued that it is difficult to reach an objective conclusion because of the variety of definitions of DGE and evaluation methods. In conclusion, recent advances in interventional technology and minimally invasive surgery have led to questions regarding the practice of pyloric procedures. However, many clinicians still perform them and they are at least somewhat effective. To provide guidance on the optimal pyloric procedure, DGE should first be defined clearly, and a large-scale study with an objective evaluation method will then be required.
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Affiliation(s)
- Dohun Kim
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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25
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Yang HC, Choi JH, Kim MS, Lee JM. Delayed Gastric Emptying after Esophagectomy: Management and Prevention. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:226-232. [PMID: 32793457 PMCID: PMC7409889 DOI: 10.5090/kjtcs.2020.53.4.226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022]
Abstract
The quality of life associated with eating is becoming an increasingly significant problem for patients who undergo esophagectomy as a result of the improved survival rate after esophageal cancer surgery. Delayed gastric emptying (DGE) is a common complication after esophagectomy. Although several strategies have been proposed for the management and prevention of DGE, no clear consensus exists. The purpose of this review is to present a brief overview of DGE and to help clinicians choose the most appropriate treatment through an analysis of DGE by cause. Furthermore, we would like to suggest some tips to prevent DGE based on our experience.
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Affiliation(s)
- Hee Chul Yang
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jin Ho Choi
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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26
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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.
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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.
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27
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Nevins EJ, Rao R, Nicholson J, Murphy KD, Moore A, Smart HL, Stephens N, Grocock C, Kaul A, Gunasekera RT, Hartley MN, Howes NR. Endoscopic Botulinum toxin as a treatment for delayed gastric emptying following oesophagogastrectomy. Ann R Coll Surg Engl 2020; 102:693-696. [PMID: 32538118 DOI: 10.1308/rcsann.2020.0136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION The incidence of delayed gastric emptying (DGE) following oesophagogastrectomy with gastric conduit reconstruction is reported to be between 1.7% and 50%. This variation is due to differing practices of intraoperative pylorus drainage procedures, which increase the risk of postoperative biliary reflux and dumping syndrome, resulting in significant morbidity. The aim of our study was to establish rates of DGE in people undergoing oesophagogastrectomy without routine intraoperative drainage procedures, and to evaluate outcomes of postoperative endoscopically administered Botulinum toxin into the pylorus (EBP) for people with DGE resistant to systemic pharmacological treatment. METHODS All patients undergoing oesophagogastrectomy between 1 January 2016 and 31 March 2018 at our unit were included. No intraoperative pyloric drainage procedures were performed, and DGE resistant to systemic pharmacotherapy was managed with EBP. RESULTS Ninety-seven patients were included. Postoperatively, 29 patients (30%) were diagnosed with DGE resistant to pharmacotherapy. Of these, 16 (16.5%) were diagnosed within 30 days of surgery. The median pre-procedure nasogastric tube aspirate was 780ml; following EBP, this fell to 125ml (p<0.001). Median delay from surgery to EBP in this cohort was 13 days (IQR 7-16 days). Six patients required a second course of EBP, with 100% successful resolution of DGE before discharge. There were no procedural complications. CONCLUSIONS This is the largest series of patients without routine intraoperative drainage procedures. Only 30% of patients developed DGE resistant to pharmacotherapy, which was managed safely with EBP in the postoperative period, thus minimising the risk of biliary reflux in people who would otherwise be at risk following prophylactic pylorus drainage procedures.
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Affiliation(s)
- E J Nevins
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R Rao
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - J Nicholson
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - K D Murphy
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Moore
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - H L Smart
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N Stephens
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - C Grocock
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - A Kaul
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - R T Gunasekera
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - M N Hartley
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - N R Howes
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
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28
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Hasan IS, Mahajan N, Viehman J, Allen MS, Cassivi SD, Lee MK, Nichols FC, Pierson K, Reisenauer JS, Shen RK, Wigle DA, Blackmon SH. Predictors of Patient-Reported Reflux After Esophagectomy. Ann Thorac Surg 2020; 110:1160-1166. [PMID: 32454018 DOI: 10.1016/j.athoracsur.2020.03.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. METHODS A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). RESULTS Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. CONCLUSIONS The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.
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Affiliation(s)
- Irsa S Hasan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita Mahajan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jason Viehman
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Mark S Allen
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Stephen D Cassivi
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minji K Lee
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karlyn Pierson
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Janani S Reisenauer
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert K Shen
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
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29
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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.
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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
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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30
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Hadzijusufovic E, Tagkalos E, Neumann H, Babic B, Heinrich S, Lang H, Grimminger PP. Preoperative endoscopic pyloric balloon dilatation decreases the rate of delayed gastric emptying after Ivor-Lewis esophagectomy. Dis Esophagus 2019; 32:5223194. [PMID: 30508077 DOI: 10.1093/dote/doy097] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/26/2018] [Accepted: 09/12/2018] [Indexed: 12/11/2022]
Abstract
Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p = 0.014), respectively. DGE-related complications such as anastomotic leaks (p = 0.466), pulmonary complications (p = 0.466) and longer median hospital stay (p = 0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.
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Affiliation(s)
- E Hadzijusufovic
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - E Tagkalos
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - H Neumann
- Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - B Babic
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - S Heinrich
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - H Lang
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - P P Grimminger
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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Abstract
With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.
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Affiliation(s)
- Magnus Konradsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
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32
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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.
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Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, 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
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33
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Nobel T, Tan KS, Barbetta A, Adusumilli P, Bains M, Bott M, Jones D, Molena D. Does pyloric drainage have a role in the era of minimally invasive esophagectomy? Surg Endosc 2018; 33:3218-3227. [PMID: 30535543 DOI: 10.1007/s00464-018-06607-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pyloric drainage during minimally invasive esophagectomy (MIE) may be more technically challenging than with an open approach. Alternatives to classic surgical drainage have increased in popularity; however, data are lacking to demonstrate whether one technique is superior in MIE. The purpose of this study was to compare post-operative outcomes after MIE between different pyloric drainage methods. METHODS We performed a retrospective review of a prospectively maintained database of patients undergoing MIE at a single academic institution. Patients were divided into three groups for analysis: no drainage, intrapyloric Botulinum Toxin injection, and surgical drainage (pyloroplasty or pyloromyotomy). The primary outcome was any complication within 90 days of surgery; secondary outcomes included reported symptoms and need for pyloric dilation at 6 and 12 months post-operatively. Comparisons among groups were conducted using the Kruskal Wallis and Chi Square tests. RESULTS There were 283 MIE performed between 2011 and 2017; of these, 126 (45%) had drainage (53 Botulinum injection and 73 surgical). No significant difference in the rate of post-operative complications, pneumonia, or anastomotic leak was observed between groups. At 6 and 12 months, patients that received Botulinum injection and surgical drainage had significantly more symptoms than no drainage (p < 0.0001) and higher need for pyloric dilation at 6 months (p = 0.007). CONCLUSIONS Pyloric drainage was not significantly associated with lower post-operative complications or long-term symptoms. While Botulinum injection appears safe post-operatively, it was associated with increased morbidity long-term. Pyloric drainage in MIE may be unnecessary.
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Affiliation(s)
- Tamar Nobel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Kay See Tan
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arianna Barbetta
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manjit Bains
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew Bott
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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34
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Boshier PR, Adam ME, Doran S, Muthuswamy K, Hanna GB. Effects of intraoperative pyloric stretch procedure on outcomes after esophagectomy. Dis Esophagus 2018; 31:5018658. [PMID: 29846516 DOI: 10.1093/dote/doy038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Various methods have been described to aid pyloric drainage in patients undergoing esophagectomy with gastric reconstruction. These techniques are intended to prevent delayed gastric empting following esophagectomy that can be associated with early morbidity and long-term functional complaints. The current study aims to review the safety and efficacy of a pyloric stretch procedure performed at the time of esophagectomy. To achieve this, a retrospective review of 100 consecutive patients undergoing esophagectomy during the period 2011-2016 was performed. Until May 2013, no patients received intraoperative pyloric intervention. After May 2013, all patients (N = 50) underwent intraoperative pyloric stretch procedure that involved bidirectional mechanical dilatation of the pylorus. Postoperative outcomes including result of routine oral contrast swallow and early morbidity were evaluated. Intraoperative pyloric stretching was performed safely and without local complications in all patients. Delayed gastric emptying was observed significantly less frequently in patients who received intraoperative pyloric stretching (48% vs. 22%, P = 0.006). No significant differences were observed in postoperative outcomes. When considering all patients as a single cohort, the presence of delayed gastric emptying was associated with significantly higher rates of postoperative pneumonia (71% vs. 45%, P = 0.010), cardiac complications (57% vs. 25%, P = 0.001) as well as longer hospital say (12 vs. 15 days, P < 0.001) and delay to free oral fluid intake (7 vs. 9 days, < 0.001). Binary logistic regression identified age and postoperative delayed gastric emptying as independent risk factors for postoperative pneumonia. In conclusion, this study has demonstrated the safety and efficacy an intraoperative pyloric stretch procedure for the prevention of delayed gastric emptying following esophagectomy.
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Affiliation(s)
- P R Boshier
- Department of Surgery and Cancer, Imperial College London, UK
| | - M E Adam
- Department of Surgery and Cancer, Imperial College London, UK
| | - S Doran
- Department of Surgery and Cancer, Imperial College London, UK
| | - K Muthuswamy
- Department of Surgery and Cancer, Imperial College London, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College London, UK
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35
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Usui H, Fukaya M, Itatsu K, Miyata K, Miyahara R, Funasaka K, Nagino M. The Impact of the Location of Esophagogastrostomy on Acid and Duodenogastroesophageal Reflux After Transthoracic Esophagectomy with Gastric Tube Reconstruction and Intrathoracic Esophagogastrostomy. World J Surg 2018; 42:599-605. [PMID: 28808755 DOI: 10.1007/s00268-017-4186-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of the location of esophagogastrostomy on acid and duodenogastroesophageal reflux (DGER) in patients undergoing gastric tube reconstruction and intrathoracic esophagogastrostomy. METHODS Thirty patients receiving transthoracic esophagectomy without cervical lymph node dissection and gastric tube reconstruction by intrathoracic anastomosis were enrolled. All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy one year after surgery. Patients were divided into three groups according to esophagogastrostomy location: group A (n = 9), above the top of the aortic arch; group B (n = 15), between the top and bottom of the aortic arch; and group C (n = 6), below the bottom of the aortic arch. The relations among the esophagogastrostomy location, 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were investigated. RESULTS No acid reflux into the remnant esophagus was observed in group A, whereas it was observed in three of 15 patients (20%) in group B and in two of six patients (33%) in group C (P = 0.139). No DGER was found in group A, whereas DGER was observed in eight (53%) patients in group B and all patients in group C (P < 0.001). Reflux esophagitis was observed in one patient (11%) in group A, five patients (33%) in group B, and all patients in group C (P = 0.002). CONCLUSION In gastric tube reconstruction via intrathoracic anastomosis, esophagogastrostomy should be performed above the top of the aortic arch to prevent postoperative DGER and reduce the incidence of reflux esophagitis.
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Affiliation(s)
- Hiroaki Usui
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Masahide Fukaya
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Keita Itatsu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Ryoji Miyahara
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Kohei Funasaka
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-Ku, Nagoya, 466-8550, Japan
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36
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Marchese S, Qureshi YA, Hafiz SP, Dawas K, Turner P, Mughal MM, Mohammadi B. Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study. J Gastrointest Surg 2018; 22:1319-1324. [PMID: 29667092 DOI: 10.1007/s11605-018-3759-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus. METHODS A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment. RESULTS Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively). CONCLUSION We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.
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Affiliation(s)
- Salvatore Marchese
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Yassar A Qureshi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Shazia P Hafiz
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Khaled Dawas
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Paul Turner
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - M Muntzer Mughal
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Borzoueh Mohammadi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK.
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Nakahara Y, Yamasaki M, Miyazaki Y, Tanaka K, Makino T, Takahashi T, Kurokawa Y, Nakajima K, Takiguchi S, Mori M, Doki Y. Reflux after esophagectomy with gastric conduit reconstruction in the posterior mediastinum for esophageal cancer: original questionnaire and EORTC QLQ-C30 survey. Dis Esophagus 2018; 31:4956131. [PMID: 29617733 DOI: 10.1093/dote/doy001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 12/11/2022]
Abstract
Reflux following an esophagectomy with gastric conduit reconstruction in the posterior mediastinum is a clinically significant problem. In this study, we investigated the frequency and impact of reflux on the quality of life (QOL) among 158 patients who underwent an esophagectomy for esophageal cancer using an original questionnaire and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Version 3.0 (EORTC QLQ-C30). Reflux frequency was assessed using the original questionnaire. The number of patients who complained of reflux every day, two or three times a week, once a week, or less than once a week was 16 (10.1%), 21 (13.3%), 26 (16.5%), and 60 (38.0%), respectively. Out of 35 patients (22.2%) reported no reflux symptoms. Patients were divided into two groups: those with reflux ≥ once/week (63 patients) and those with low frequency of symptoms (95 patients). Time elapsed following surgery was the only factor to influence reflux frequency. Reflux frequency decreased within two years of surgery; however, the frequency plateaued after more than two years. QOL was assessed using the EORTC QLQ-C30. The ≥ once/week reflux group had a significantly lower global health status score than the low-frequency reflux group (59.6 ± 24.2 vs. 70.8 ± 20.7; P = 0.007). In addition, the ≥ once/week reflux group had a significantly lower social functioning score than the low-frequency reflux group (81.6 ± 24.1 vs. 88.4 ± 19.8; P = 0.035). Regarding symptoms, the ≥ once/week reflux group had significantly higher scores for fatigue, nausea, and vomiting, dyspnea and insomnia compared to the low-frequency reflux group (fatigue: 42.4 ± 21.9 vs. 28.9 ± 18.4, P < 0.001; nausea and vomiting: 17.3 ± 17.1 vs. 4.9 ± 10.6, P < 0. 001; dyspnea: 29.2 ± 26.0 vs. 21.7 ± 26.8, P = 0.043; insomnia: 22.2 ± 31.1 vs. 10.5 ± 21.7, P = 0.015). Thus, reflux after an esophagectomy was associated with a lower QOL.
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Affiliation(s)
- Y Nakahara
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita.,Department of Surgery, Kinki Central Hospital, Itami, Japan
| | - M Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Y Miyazaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - K Tanaka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - T Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - T Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Y Kurokawa
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - K Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - S Takiguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - M Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
| | - Y Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita
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Fritz S, Feilhauer K, Schaudt A, Killguss H, Esianu E, Hennig R, Köninger J. Pylorus drainage procedures in thoracoabdominal esophagectomy - a single-center experience and review of the literature. BMC Surg 2018; 18:13. [PMID: 29490701 PMCID: PMC5831596 DOI: 10.1186/s12893-018-0347-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 02/19/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Pylorotomy and pyloroplasty in thoracoabdominal esophagectomy are routinely performed in many high-volume centers to prevent delayed gastric emptying (DGE) due to truncal vagotomy. Currently, controversy remains regarding the need for these practices. The present study aimed to determine the value and role of pyloric drainage procedures in esophagectomy with gastric replacement. METHODS A retrospective review of prospectively collected data was performed for all consecutive patients who underwent thoracoabdominal resection of the esophagus between January 2009 and December 2016 at the Katharinenhospital in Stuttgart, Germany. Clinicopathologic features and surgical outcomes were evaluated with a focus on postoperative nutrition and gastric emptying. RESULTS The study group included 170 patients who underwent thoracoabdominal esophageal resection with a gastric conduit using the Ivor Lewis approach. The median age of the patients was 64 years. Most patients were male (81%), and most suffered from adenocarcinoma of the esophagus (75%). The median hospital stay was 20 days, and the 30-day hospital death rate was 2.9%. According to the department standard, pylorotomy, pyloroplasty, or other pyloric drainage procedures were not performed in any of the patients. Overall, 28/170 patients showed clinical signs of DGE (16.5%). CONCLUSIONS In the literature, the rate of DGE after thoracoabdominal esophagectomy is reported to be approximately 15%, even with the use of pyloric drainage procedures. This rate is comparable to that reported in the present series in which no pyloric drainage procedures were performed. Therefore, we believe that pyloric drainage procedures may be unwarranted in thoracoabdominal esophagectomy. However, future randomized trials are needed to ultimately confirm this supposition.
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Affiliation(s)
- Stefan Fritz
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
| | - Katharina Feilhauer
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - André Schaudt
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Hansjörg Killguss
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Eduard Esianu
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - René Hennig
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Jörg Köninger
- Department of General, Visceral, Thoracic and Transplantation Surgery, Katharinenhospital Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
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Gastric Outlet Obstruction After Esophagectomy: Retrospective Analysis of the Effectiveness and Safety of Postoperative Endoscopic Pyloric Dilatation. World J Surg 2017; 40:2405-11. [PMID: 27216809 DOI: 10.1007/s00268-016-3575-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS Delayed gastric emptying after esophagectomy with gastric replacement can pose a significant postoperative problem, often leading to aspiration and pneumonia. The present study analyzes retrospectively the effectiveness of endoscopic pyloric dilatation for post-surgical gastric outlet obstruction. METHODS Between March 2006 and March 2010, 403 patients underwent a transthoracic en-bloc esophagectomy and reconstruction with a gastric tube and intrathoracic esophagogastrostomy. In patients with postoperative symptoms of an outlet dysfunction and the confirmation by endoscopy, pyloric dilatations were performed without preference with either 20- or 30-mm balloons. RESULTS A total of 89 balloon dilatations of the pylorus after esophagectomy were performed in 60 (15.6 %) patients. In 21 (35 %) patients, a second dilatation of the pylorus was performed. 55 (61.8 %) dilatations were performed with a 30-mm balloon and 34 (38.2 %) with a 20-mm balloon. The total redilatation rate for the 30-mm balloon was 20 % (n = 11) and 52.9 % (n = 18) for the 20-mm balloon (p < 0.001). All dilatations were performed without any complications. CONCLUSIONS Pylorus spasm contributes to delayed gastric emptying leading to postoperative complications after esophagectomy. Endoscopic pyloric dilatation after esophagectomy is a safe procedure for treatment of gastric outlet obstruction. The use of a 30-mm balloon has the same safety profile but a 2.5 lower redilatation rate compared to the 20-mm balloon. Thus, the use of 20-mm balloons has been abandoned in our clinic.
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Giugliano DN, Berger AC, Meidl H, Pucci MJ, Rosato EL, Keith SW, Evans NR, Palazzo F. Do intraoperative pyloric interventions predict the need for postoperative endoscopic interventions after minimally invasive esophagectomy? Dis Esophagus 2017; 30:1-8. [PMID: 28375478 DOI: 10.1093/dote/dow034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 12/11/2022]
Abstract
Intraoperative pyloric procedures are often performed during esophagectomies to reduce the rates of gastric conduit dysfunction. They include pyloroplasty (PP), pyloromyotomy (PM), and pylorus botulinum toxin type-A injections (BI). Despite these procedures, patients frequently warrant further endoscopic interventions. The aim of this study is to compare intraoperative pyloric procedures and the rates of postoperative endoscopic interventions following minimally invasive esophagectomy (MIE). We identified patients who underwent MIE for esophageal carcinoma and grouped them as 'None' (no intervention), 'PP', 'PM', or 'BI' based on intraoperative pyloric procedure type. The rates of endoscopic interventions for the first six postoperative months were compared. To adjust for variability due to MIE type, the rates of >1 interventions were compared using a zero-inflated Poisson regression analysis. Significance was established at P < 0.05. There were 146 patients who underwent an MIE for esophageal cancer from 2008 to 2015; 77.4% were three-hole MIE, and 22.6% were Ivor- Lewis MIE. BI was most frequent in Ivor-Lewis patients (63.5%), while PP was most frequent (46.9%) in three-hole patients. Postoperative endoscopic interventions occurred in 38 patients (26.0%). The BI group had the highest percentage of patients requiring a postoperative intervention (n = 13, 31.7%). After adjusting for higher rates of interventions in three-hole MIE patients, the BI and None groups had the lowest rates of >1 postoperative interventions. Our data did not show superiority of any pyloric intervention in preventing endoscopic interventions. The patients who received BI to the pylorus demonstrated a trend toward a greater likelihood of having a postoperative intervention. However when adjusted for type of MIE, the BI and None groups had lower rates of subsequent multiple interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.
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Affiliation(s)
| | | | | | | | | | - S W Keith
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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41
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Risk factors for delayed gastric emptying after esophagectomy. Langenbecks Arch Surg 2017; 402:547-554. [PMID: 28324171 DOI: 10.1007/s00423-017-1576-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy with gastric tube reconstruction. Little is known about risk factors that can predict this debilitating complication. METHODS Patients who underwent elective esophagectomy from 2008 to 2016 in a single center were retrospectively reviewed. Diagnosis of DGE was based on clinical, radiological, and endoscopic findings. Uni- and multivariate analyses were performed to identify patient-, tumor-, and procedure-related factors that increase the risk of DGE. RESULTS One hundred eighty-two patients were included. Incidence of DGE was 39.0%. Overall, 27 (14.8%) needed an endoscopic intervention. Patients in the DGE group had a longer hospital stay (p < 0.01). No differences were found for the 30-day (p = 1.0) and hospital mortality (p = 1.0). On univariate analyses, a significant influence on DGE was demonstrated for pre-existing pulmonary comorbidity (p = 0.04), an anastomotic leak (p < 0.01), and postoperative pulmonary complications (pneumonia: p = 0.02, pleural empyema: p < 0.01, and adult respiratory distress syndrome: p = 0.03). Furthermore, there was a non-significant trend toward an increased risk for DGE for the following variable: female gender (p = 0.09) and longer operative time (p = 0.09). On multivariate analysis, only female gender (p = 0.03) and anastomotic leak (p = 0.01) were significantly associated with an increased risk for DGE. CONCLUSIONS DGE is a frequent complication following esophagectomy that can successfully be managed with conservative or endoscopic measures. DGE did not increase mortality but was associated with increased morbidity and prolonged hospitalization. We identified risk factors that increase the incidence of DGE. However, this has to be confirmed in future studies with standardized definition of DGE.
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Zhang L, Hou SC, Miao JB, Lee H. Risk factors for delayed gastric emptying in patients undergoing esophagectomy without pyloric drainage. J Surg Res 2017; 213:46-50. [PMID: 28601331 DOI: 10.1016/j.jss.2017.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 01/18/2017] [Accepted: 02/14/2017] [Indexed: 01/23/2023]
Abstract
BACKGROUND The incidence of delayed gastric emptying (DGE) after esophagectomy is 10%-50%, which can interfere with postoperative recovery in the short-term and result in poor quality of life in the long term. Pyloric drainage is routinely performed to prevent DGE, but its role is highly controversial. The aim of this study was to report the rate of DGE after esophagectomy without pyloric drainage and to investigate its risk factors and the potential effect on recovery. MATERIALS AND METHODS Between January 2010 and January 2015, we analyzed 285 consecutive patients who received an esophagectomy without pyloric drainage. Possible correlations between the incidence of DGE and its potential risk factors were examined in univariate and multivariate analyses, respectively. The outcomes of DGE were reviewed with a follow-up of 3 mo. RESULTS The overall rate of DGE after esophagectomy was 18.2% (52/285). Among perioperative factors, gastric size (gastric tube versus the whole stomach) was the only significant factor affecting the incidence of DGE in the univariate analysis. The patients who received a whole stomach as an esophageal substitute were more likely to develop DGE than were patients with a gastric tube (13.2% versus 22.4%; P = 0.05). No independent risk factor for DGE was found in the multivariate analysis. The incidence of major postoperative complications, including anastomotic leak, respiratory complications, and cardiac complications, was also not significantly different between both groups, with or without DGE. Within 3 mo of follow-up, most patients could effectively manage their DGE through medication (39/52) or endoscopic pyloric dilation (12/52), with only one patient requiring surgical intervention. CONCLUSIONS In our study, the overall incidence of DGE is about 20% for patients undergoing esophagectomy without pyloric drainage. Compared with prior findings, this does not result in a significantly increased incidence of DGE. In patients with symptoms of DGE after esophagectomy, prokinetic agents and endoscopic balloon dilation of the pylorus can be effective, as indicated by the high success rate and lack of significant complications.
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Affiliation(s)
- Lei Zhang
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Sheng-Cai Hou
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jin-Bai Miao
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hui Lee
- Department of Thoracic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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Stewart CL, Wilson L, Hamm A, Bartsch C, Boniface M, Gleisner A, Mitchell JD, Weyant MJ, Meguid R, Gajdos C, Edil BH, McCarter M. Is Chemical Pyloroplasty Necessary for Minimally Invasive Esophagectomy? Ann Surg Oncol 2017; 24:1414-1418. [PMID: 28058546 DOI: 10.1245/s10434-016-5742-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients. METHODS The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student's t test, χ 2 analysis, and Mann-Whitney U test where appropriate. RESULTS The study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p > 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention. CONCLUSIONS In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Lauren Wilson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aidan Hamm
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christan Bartsch
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Boniface
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael J Weyant
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Abstract
Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.
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Affiliation(s)
- A Beham
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - S Dango
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - B M Ghadimi
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
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Schaible A, Schwan K, Bruckner T, Plaschke K, Büchler MW, Weigand M, Sauer P, Bopp C, Knebel P. Acupuncture to improve tolerance of diagnostic esophagogastroduodenoscopy in patients without systemic sedation: results of a single-center, double-blinded, randomized controlled trial (DRKS00000164). Trials 2016; 17:350. [PMID: 27455961 PMCID: PMC4960815 DOI: 10.1186/s13063-016-1468-0] [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: 01/21/2016] [Accepted: 07/04/2016] [Indexed: 01/27/2023] Open
Abstract
Background Sedation prior to esophagogastroduodenoscopy is widespread and increases patient comfort. However, it demands additional trained personnel, accounts for up to 40 % of total endoscopy costs and impedes rapid hospital discharge. Most patients lose at least one day of work. 98 % of all serious adverse events occurring during esophagogastroduodenoscopy are ascribed to sedation. Acupuncture is reported to be effective as a supportive intervention for gastrointestinal endoscopy, similar to conventional premedication. We investigated whether acupuncture during elective diagnostic esophagogastroduodenoscopy could increase the comfort of patients refusing systemic sedation. Methods We performed a single-center, double-blinded, placebo-controlled superiority trial to compare the success rates of elective diagnostic esophagogastroduodenoscopies using real and placebo acupuncture. All patients aged 18 years or older scheduled for elective, diagnostic esophagogastroduodenoscopy who refused systemic sedation were eligible; 354 patients were randomized. The primary endpoint measure was the rate of successful esophagogastroduodenoscopies. The intervention was real or placebo acupuncture before and during esophagogastroduodenoscopy. Successful esophagogastroduodenoscopy was based on a composite score of patient satisfaction with the procedure on a Likert scale as well as quality of examination, as assessed by the examiner. Results From February 2010 to July 2012, 678 patients were screened; 354 were included in the study. Baseline characteristics of the two groups showed a similar distribution in all but one parameter: more current smokers were allocated to the placebo group. The intention-to-treat analysis included 177 randomized patients in each group. Endoscopy could successfully be performed in 130 patients (73.5 %) in the real acupuncture group and 129 patients (72.9 %) in the placebo group. Willingness to repeat the procedure under the same conditions was 86.9 % in the real acupuncture group and 87.6 % in the placebo acupuncture group. Conclusions Esophagogastroduodenoscopy without sedation is safe and can successfully be performed in two-thirds of patients. Patients planned for elective esophagogastroduodenoscopy without sedation do not benefit from acupuncture of the Sinarteria respondens (Rs) 24 Chengjiang middle line, Pericard (Pc) 6 Neiguan bilateral, or Dickdarm (IC) 4 Hegu bilateral, according to traditional Chinese medicine meridian theory. Trial registration DRKS00000164. Registered on 10 December 2009.
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Affiliation(s)
- Anja Schaible
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - Katja Schwan
- Department of Anaesthesiology, GRN-Hospital, Eberbach, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Konstanze Plaschke
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - Markus Weigand
- Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, University of Heidelberg, Heidelberg, Germany
| | - Christian Bopp
- Department of Anaesthesiology, GRN-Hospital, Schwetzingen, Germany
| | - Phillip Knebel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, INF 110, 69120, Heidelberg, Germany.
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Mohajeri G, Tabatabaei SA, Hashemi SM, Hemmati H. Comparison of pyloromyotomy, pyloric buginage, and intact pylorus on gastric drainage in gastric pull-up surgery after esophagectomy. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:33. [PMID: 27904579 PMCID: PMC5122219 DOI: 10.4103/1735-1995.181993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/08/2015] [Accepted: 03/08/2016] [Indexed: 11/24/2022]
Abstract
Background: There are controversies regarding the usefulness of the pyloric drainage methods after esophagectomy as well as differences among various pyloric drainage techniques. Therefore, we compared the outcome of pyloromyotomy, pylorus buginage, and no intervention methods on gastric emptying among patients undergone esophagectomy. Materials and Methods: In this randomized clinical trial, patients with diagnosed esophageal cancer or any other benign lesions candidate for esophagectomy were selected. They randomized in three groups with three different approaches for gastric pull-up esophageal surgery including esophagectomy with pyloromyotomy, esophagectomy without intervention, and esophagectomy with pylorus buginage. The outcomes of procedures regarding gastric emptying time and delayed gastric emptying were compared. Results: Thirty patients were allocated in three groups. Gastric emptying time was not significantly different in the three groups (P > 0.05). Frequency of delayed gastric emptying, complications and barium leakage were not different in three studied groups (P > 0.05). Conclusion: Gastric emptying time and delayed gastric emptying were not different between common pyloric drainage methods after esophagectomy and esophagectomy without drainage.
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Affiliation(s)
- Gholamreza Mohajeri
- Department of Thoracic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Seyed Mozafar Hashemi
- Department of Thoracic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hamidreza Hemmati
- Department of Thoracic Surgery, Isfahan University of Medical Sciences, Isfahan, Iran
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Mungo B, Lidor AO, Stem M, Molena D. Early experience and lessons learned in a new minimally invasive esophagectomy program. Surg Endosc 2015; 30:1692-8. [PMID: 26123339 DOI: 10.1007/s00464-015-4343-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/17/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) is gaining increasing popularity in the treatment of esophageal cancer. In fact, while surgical and oncologic outcomes are not inferior to those achieved through a traditional open approach, patients undergoing MIE benefit from shorter length of stay, lesser pain and prompter recovery. This technique is, however, highly challenging, and the development of a MIE program, even in the setting of a tertiary center, requires time and progressive honing of surgical skills. METHODS We use a minimally invasive Ivor Lewis approach. The abdominal phase of the procedure includes complete celiac lymphadenectomy and tubularization of the stomach, which will constitute the neo-esophagus. The video-assisted thoracoscopic surgery portion of the operation takes place in left lateral decubitus and allows for optimal thoracic lymphadenectomy and anastomosis. RESULTS From October 2011 to January 2015, we treated 52 patients with the above-described procedure. The evolution of our anastomotic technique included a first group of circular stapled anastomosis with Orvil™ and 3.5-mm EEA™ (n = 16 patients), subsequently abandoned in favor of a linear anastomosis (n = 12), before going back to the Orvil™ coupled with 4.8-mm EEA™ (n = 22) in more recent times. There were also an additional two anastomoses that did not fall under any of these categories. We experienced two postoperative deaths. The overall leak rate was 14%, but fell down to 4% in the last group. Median LOS was 9 days. Lymph node retrieval was adequate throughout the whole series. CONCLUSIONS Developing a MIE program requires a significant learning curve before the results plateau. Only once a technique of choice is refined and mastered, the advantages granted by MIE become apparent.
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Affiliation(s)
- Benedetto Mungo
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock 240, Baltimore, MD, 21287, USA
| | - Anne O Lidor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Miloslawa Stem
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniela Molena
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Blalock 240, Baltimore, MD, 21287, USA.
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Bugiantella W, Rondelli F, Mariani L, Mariani E. Laparoscopic circular stapled longitudinal extramucosal pyloroplasty: an alternative technique for pyloric disruption. Interact Cardiovasc Thorac Surg 2015; 21:143-6. [PMID: 25977132 DOI: 10.1093/icvts/ivv116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Accepted: 04/08/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Oesophagectomy with gastric pull-up is the most common surgical procedure for oesophageal cancer. Pyloroplasty may be performed to facilitate stomach emptying, but its role is still controversial. When laparoscopic mobilization of the stomach is performed, conventional extramucosal pyloroplasty may be difficult to carry out; therefore, we describe a new technique for mechanical pyloric disruption. METHODS We conceived the laparoscopic longitudinal extramucosal partial section of the anterior pyloric wall using a circular stapler. We performed it in 6 patients undergoing oesophagectomy for cancer, with the laparoscopic abdominal step before thoracotomy. RESULTS The procedure was easy and safe and without intraoperative complications in all patients. Postoperative video-oesophagogram showed regular anastomosis and graft emptying. CONCLUSIONS Our preliminary experience has led us to conclude that circular stapler longitudinal extramucosal pyloroplasty is an easy, safe and quick procedure that can be performed in laparoscopic surgery. Moreover, it seems to ensure a regular emptying of the graft as standard pyloroplasty does.
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Affiliation(s)
- Walter Bugiantella
- General Surgery, 'San Giovanni Battista Hospital', Foligno, Italy PhD School in Biotechnologies, University of Perugia, Perugia, Italy
| | - Fabio Rondelli
- General Surgery, 'San Giovanni Battista Hospital', Foligno, Italy Department of Surgical and Biomedical Sciences, University of Perugia, Perugia, Italy
| | - Lorenzo Mariani
- General Surgery, 'San Giovanni Battista Hospital', Foligno, Italy
| | - Enrico Mariani
- General Surgery, 'San Giovanni Battista Hospital', Foligno, Italy
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Abstract
Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.
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Affiliation(s)
- Adam Carney
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, City Campus, Hucknall Road, Nottingham NG5 1PB, UK.
| | - Matt Dickinson
- Department of Anaesthesia, Perioperative Medicine and Pain, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7XX, UK
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Dunn LJ, Shenfine J, Griffin SM. Columnar metaplasia in the esophageal remnant after esophagectomy: a systematic review. Dis Esophagus 2015; 28:32-41. [PMID: 24224923 DOI: 10.1111/dote.12129] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's metaplasia is a well-recognized risk factor for esophageal adenocarcinoma. It is believed to develop in response to the injurious effects of gastroesophageal reflux. Following subtotal esophagectomy and reconstruction with a gastric conduit, many patients experience profound reflux into the remnant esophagus. Barrett's-like epithelium has been described in these patients, and they have been identified as a potential human model in which to study the early events in the development of metaplasia. This phenomenon also raises clinical concerns about the long-term fate of the esophageal remnant following surgery and the potential for further malignant change. This systematic review summarizes the literature on the prevalence and timing of Barrett's metaplasia occurring after esophagectomy, reviews the evidence regarding risk factors and malignant progression in such patients, and considers the implications for clinical practice.
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Affiliation(s)
- L J Dunn
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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