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Worrell SG, Gupta S, Alvarado CE, Sarode A, Luo X, Towe CW, Linden PA. Morbidity After Esophagectomy Is Higher for Benign Than Malignant Disease. Ann Thorac Surg 2023; 115:363-369. [PMID: 36126720 DOI: 10.1016/j.athoracsur.2022.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 08/15/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications. METHODS A retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts. RESULTS Of 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62). CONCLUSIONS Esophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.
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Affiliation(s)
- Stephanie G Worrell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, Tucson, Arizona.
| | - Shreya Gupta
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Anuja Sarode
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Xun Luo
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals/Case Western Reserve University, Cleveland, Ohio
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Carrera Ceron RE, Oelschlager BK. Management of Recurrent Paraesophageal Hernia. J Laparoendosc Adv Surg Tech A 2022; 32:1148-1155. [PMID: 36161967 DOI: 10.1089/lap.2022.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Recurrent paraesophageal hernias (rPEH) represent a clinical and surgical challenge. Even with a relatively high incidence, most of them are minimally symptomatic, and the need for reoperation is low. For those patients who are candidates for surgery, laparoscopic revision is a feasible and safe technique although there are other treatment options available. Methods: This article provides an overview of the definition, mechanisms of recurrence, epidemiology, clinical presentation, and indications for treatment of rPEH, as well as an overview of the surgical management options and a description of the technical principles of the repair and/or resection. Results: Surgeons should consider multiple factors when deciding the appropriate treatment of patients with rPEH, and all of them require a complete and comprehensive evaluation. The surgical options need to be individualized and include a redo PEH repair and revisional fundoplication, a partial or total gastrectomy with Roux-en-Y reconstruction, or an esophagectomy. There are key steps during the surgical repair that contribute to a successful operation and also auxiliary techniques that can improve postoperative outcomes. After laparoscopic redo most patients have improvement of their symptoms and an acceptable rate of perioperative complications when they are performed by experienced foregut surgeons. In obese patients with rPEH, bariatric surgery can be the best treatment option. Conclusions: Laparoscopic reoperative management should be considered in symptomatic patients who are not controlled with maximal nonoperative therapy, after a thorough work-up and appropriate counseling. In cases with multiple hernia repairs, it is important to consider alternative operations.
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Medina B, Molena D. Reflux, Barrett's Esophagus, and Esophageal Adenocarcinoma After Bariatric Surgery. FOREGUT (THOUSAND OAKS, CALIF.) 2021; 1:393-400. [PMID: 38646141 PMCID: PMC11031263 DOI: 10.1177/26345161211068367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
We present the case of a patient who developed esophageal adenocarcinoma after a previous laparoscopic sleeve gastrectomy. Bariatric surgery has emerged as the most effective treatment option for weight loss and obesity-related diseases; however, sleeve gastrectomy promotes gastroesophageal reflux and leads to Barrett's esophagus in a substantial portion of patients. The natural history of Barrett's esophagus in these patients is unknown, and active surveillance is recommended until the incidence of dysplasia and adenocarcinoma in this population is clarified. Management options for these patients include conversion to Roux-en-Y gastric bypass. Although esophagectomy in patients who have previously undergone sleeve gastrectomy may require an alternative conduit, the remnant stomach can be used in carefully selected patients. Here, we review the different weight loss procedures, their effect on gastroesophageal reflux disease and Barrett's esophagus, and the treatment options for patients with esophageal cancer after sleeve gastrectomy. We report the use of preoperative coil embolization as a means of vascular preconditioning before successful use of a gastric conduit.
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Pather K, Ghannam AD, Hacker S, Guerrier C, Mobley EM, Esma R, Awad ZT. Reoperative Surgery After Minimally Invasive Ivor Lewis Esophagectomy. Surg Laparosc Endosc Percutan Tech 2021; 32:60-65. [PMID: 34516475 PMCID: PMC8814731 DOI: 10.1097/sle.0000000000000996] [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: 06/07/2021] [Accepted: 08/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study is to identify factors influencing reoperations following minimally invasive Ivor Lewis esophagectomy and associated mortality and hospital costs. MATERIALS AND METHODS Between 2013 and 2018, 125 patients were retrospectively analyzed. Outcomes included reoperations, mortality, and hospital costs. Multivariable logistic regression analyses determined factors associated with reoperations. RESULTS In-hospital reoperations (n=10) were associated with in-hospital mortality (n=3, P<0.01), higher hospital costs (P<0.01), and longer hospital stay (P<0.01). Conversely, reoperations after discharge were not associated with mortality. By multivariable analysis, baseline cardiovascular (P=0.02) and chronic kidney disease (P=0.01) were associated with reoperations. However, anastomotic leaks were not associated with reoperations nor mortality. CONCLUSION The majority of reoperations occur within 30 days often during index hospitalization. Reoperations were associated with increased in-hospital mortality and hospital costs. Notably, anastomotic leaks did not influence reoperations nor mortality. Efforts to optimize patient baseline comorbidities should be emphasized to minimize reoperations following minimally invasive Ivor Lewis esophagectomy.
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Affiliation(s)
- Keouna Pather
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Alexander D. Ghannam
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Shoshana Hacker
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Christina Guerrier
- Center for Data Solutions, University of Florida College of Medicine, Jacksonville, FL
| | - Erin M. Mobley
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
| | - Rhemar Esma
- University of Florida Health, Jacksonville, FL
| | - Ziad T. Awad
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL
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Abstract
A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.
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Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA.
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Wilshire CL, Louie BE, Shultz D, Jutric Z, Farivar AS, Aye RW. Clinical Outcomes of Reoperation for Failed Antireflux Operations. Ann Thorac Surg 2016; 101:1290-6. [DOI: 10.1016/j.athoracsur.2015.10.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 09/16/2015] [Accepted: 10/09/2015] [Indexed: 11/17/2022]
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Johnson CS, Louie BE, Wille A, Dunst CM, Worrell SG, DeMeester SR, Reynolds J, Dixon J, Lipham JC, Lada M, Peters JH, Watson TJ, Farivar AS, Aye RW. The Durability of Endoscopic Therapy for Treatment of Barrett's Metaplasia, Dysplasia, and Mucosal Cancer After Nissen Fundoplication. J Gastrointest Surg 2015; 19:799-805. [PMID: 25740341 DOI: 10.1007/s11605-015-2783-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/18/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) ± endoscopic resection (EMR) is an established treatment strategy for neoplastic Barrett's and intramucosal cancer. Most patients are managed with proton pump inhibitors. The incidence of recurrent Barrett's metaplasia, dysplasia, or cancer after complete eradication is up to 43 % using this strategy. We hypothesize the addition of fundoplication should result in a lower recurrence rates after complete eradication. METHODS Multi-institutional retrospective review of patients undergoing endotherapy followed by Nissen fundoplication RESULTS A total of 49 patients underwent RFA ± EMR followed by Nissen fundoplication. Complete remission of intestinal metaplasia (CR-IM) was achieved in 26 (53 %) patients, complete remission of dysplasia (CR-D) in 16 (33 %) patients, and 7 (14 %) had persistent neoplastic Barrett's. After fundoplication, 18/26 (70 %) remained in CR-IM. An additional 10/16 CR-D achieved CR-IM and 4/7 with persistent dysplasia achieved CR-IM. One patient progressed to LGD while no patient developed HGD or cancer. CONCLUSION Endoscopic therapy for Barrett's dysplasia and/or intramucosal cancer followed by fundoplication results in similar durability of CR-IM to patients being managed with PPIs alone after endoscopic therapy. However, fundoplication may be superior in preventing further progression of disease and the development of cancer. Fundoplication is an important strategy to achieve and maintain CR-IM, and facilitate eradication of persistent dysplasia.
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Affiliation(s)
- Corey S Johnson
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, Suite 900, 1101 Madison Street, Seattle, WA, 98105, USA
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Roux-en-Y Near Esophagojejunostomy for Failed Antireflux Operations: Outcomes in More Than 100 Patients. Ann Thorac Surg 2014; 98:1905-11; discussion 1911-3. [DOI: 10.1016/j.athoracsur.2014.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 07/07/2014] [Accepted: 07/07/2014] [Indexed: 12/12/2022]
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Neoangiogenesis. Assessment in Esophageal Adenocarcinomas. Indian J Surg 2014; 77:971-6. [PMID: 27011493 DOI: 10.1007/s12262-014-1091-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/23/2014] [Indexed: 12/18/2022] Open
Abstract
Esophageal cancer has always been subject of research for various studies. According to some authors, esophageal cancer represents the 10th leading cause of cancer in the world with a 5-year survival of 10 %. In terms of anatomopathological form of the esophageal neoplasia, the literature mainly describes two major pathological types: adenocarcinoma and esophageal squamous cell carcinoma. Lately there has been an increased incidence of esophageal adenocarcinoma. The aim of the present work was to study neoangiogenesis in esophageal adenocarcinomas. The study was conducted on 40 cases diagnosed and surgically treated. Subsequently, fragment processing was performed using various immunohistochemical staining and marking with CD34 and p53 antigen. Later, quantitative measurements were performed, and images were taken using a microscope imaging system. In the end of the procedures, the professional program PRODIT 5.2. was applied. The study of the vascular system in the esophageal epithelial tumors revealed an axis consisting of three elements which have a mutual induction process: inflammatory infiltrate-neoangiogenesis-fibrosis, with significant differences between the three degrees of differentiation. A significant increase in tumor micro vascular density was present together with the increasing of the histological grading, with an inverse correlation with the degree of differentiation and directly proportional to the risk of malignancy.
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Madenci AL, Reames BN, Chang AC, Lin J, Orringer MB, Reddy RM. Factors Associated with Rapid Progression to Esophagectomy for Benign Disease. J Am Coll Surg 2013; 217:889-95. [DOI: 10.1016/j.jamcollsurg.2013.07.384] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/30/2013] [Accepted: 07/09/2013] [Indexed: 11/29/2022]
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Triadafilopoulos G, Lombard CM, Jobe BA. "War and Peace" with Barrett's esophagus. Dig Dis Sci 2011; 56:988-92. [PMID: 21161381 DOI: 10.1007/s10620-010-1490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Reoperative laparoscopic paraesophageal herniorrhaphy can produce excellent outcomes. Surg Endosc 2010; 25:1458-65. [DOI: 10.1007/s00464-010-1414-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 08/07/2010] [Indexed: 10/18/2022]
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