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Tiainen E, Wirta EV, Tyrväinen T, Kuorilehto T, Toikkanen V, Laukkarinen J, Ukkonen M. Calcifications in the descending thoracic aorta predict postoperative anastomotic leakages after esophagectomy for cancer. World J Surg 2024; 48:1209-1218. [PMID: 38470437 DOI: 10.1002/wjs.12133] [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: 12/20/2023] [Accepted: 02/09/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Anastomotic leak is one of the most feared complications of esophagectomy. Previous studies have suggested a potential link between aortic calcifications detected on routine preoperative CT scans and increased risk of anastomotic leak after esophagectomy. This study aims to investigate whether clinicians' assessment of aortic calcifications can predict the occurrence of anastomotic leaks in patients undergoing esophagectomy for cancer. METHODS A long-term follow-up was conducted on consecutive patients with esophageal cancer who underwent elective open esophagectomy at a Finnish tertiary hospital. Aortic calcifications were evaluated based on CT scans and categorized on a 0-3 scale reflecting the number of calcifications in the affected segment of the aorta. Reviewers assessing the calcifications were blinded to clinical details and postoperative outcomes. RESULTS The study included 97 patients (median age: 64 years and range: 43-78; 20% female), with a median follow-up time of 1307 (2-1540) days. Among them, 22 patients (23%) had postoperative anastomotic leak. We observed a significant association between calcifications in the descending aorta and a higher risk of anastomotic leak (p = 0.007), as well as an earlier occurrence of leak postoperatively (p = 0.013). However, there was no association between aortic calcifications and increased mortality. CONCLUSIONS Presence of calcifications in the descending aorta is independently associated with an increased risk of anastomotic leaks following esophagectomy for cancer. Identifying patients at higher risk for this complication could facilitate appropriate pre- and postoperative interventions, as well as enable earlier diagnosis and treatment to mitigate the severity of the complication.
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Affiliation(s)
- Emma Tiainen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
| | - Erkki-Ville Wirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
| | - Tuula Tyrväinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
| | - Tommi Kuorilehto
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere, Finland
| | - Vesa Toikkanen
- Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
| | - Mika Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University and Tays Cancer Center, Tampere University Hospital, Tampere, Finland
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Aiolfi A, Bona D, Bonitta G, Bonavina L. Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis. Ann Surg 2024; 279:410-418. [PMID: 37830253 DOI: 10.1097/sla.0000000000006124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
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Fernández-Moreno MC, Barrios Carvajal ME, López Mozos F, Martí Obiol R, Guijarro Rozalén J, Casula E, Ortega J. Pilot Trial on Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer: Feasibility and Impact on Anastomotic Leakage (TIGOAL-I). ANNALS OF SURGERY OPEN 2024; 5:e379. [PMID: 38883947 PMCID: PMC11175858 DOI: 10.1097/as9.0000000000000379] [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: 10/24/2023] [Accepted: 01/03/2024] [Indexed: 06/18/2024] Open
Abstract
Objective To evaluate the feasibility, safety, and effectiveness of gastric conditioning using preoperative arterial embolization (PAE) before McKeown esophagectomy at a tertiary university hospital. Background Cervical anastomotic leakage (AL) is a common complication of esophagectomy. Limited clinical evidence suggests that gastric conditioning mitigates this risk. Methods This pilot randomized clinical trial was conducted between April 2016 and October 2021 at a single-center tertiary hospital. Eligible patients with resectable malignant esophageal tumors, suitable for cervical esophagogastrostomy, were randomized into 2 groups: one receiving PAE and the other standard treatment. The primary endpoints were PAE-related complications and incidence of cervical AL. Results The study enrolled 40 eligible patients. PAE-related morbidity was 10%, with no Clavien-Dindo grade III complications. Cervical AL rates were similar between the groups (35% vs 25%, P = 0.49), even when conduit necrosis was included (35% vs 35%, P = 1). However, AL severity, including conduit necrosis, was higher in the control group according to the Clavien-Dindo ≥IIIb (5% vs 30%, P = 0.029) and Comprehensive Complication Index (20.9 vs 33.7, P = 0.01). No significant differences were found in other postoperative complications, such as pneumonia or postoperative mortality. Conclusions PAE is a feasible and safe method for gastric conditioning before McKeown minimally invasive esophagectomy and shows promise for preventing severe AL. However, further studies are required to confirm its efficacy.
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Affiliation(s)
- María-Carmen Fernández-Moreno
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - María Eugenia Barrios Carvajal
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - Fernando López Mozos
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | - Roberto Martí Obiol
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
| | | | - Elisabetta Casula
- Department of Interventional Radiology. University Clinic Hospital of Valencia, Spain
| | - Joaquín Ortega
- From the Department of Surgery, Esophagogastric Surgery Unit, Biomedical Research Institute INCLIVA, University Clinic Hospital of Valencia, Spain
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4
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Edmondson J, Hunter J, Bakis G, O’Connor A, Wood S, Qureshi AP. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. J Clin Med 2023; 12:7622. [PMID: 38137691 PMCID: PMC10743498 DOI: 10.3390/jcm12247622] [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: 10/11/2023] [Revised: 11/24/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks.
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Affiliation(s)
| | | | | | | | | | - Alia P. Qureshi
- Division of General Surgery, Oregon Health & Science University, Machall 3186, Portland, OR 97239, USA; (J.E.)
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de Groot E, Schiffmann LM, van der Veen A, Borggreve A, de Jong P, Dos Santos DP, Babic B, Fuchs H, Ruurda J, Bruns C, van Hillegersberg R, Schröder W. Laparoscopic ischemic conditioning prior esophagectomy in selected patients: the ISCON trial. Dis Esophagus 2023; 36:doad027. [PMID: 37151103 DOI: 10.1093/dote/doad027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/22/2023] [Accepted: 04/12/2023] [Indexed: 05/09/2023]
Abstract
Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14 days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12-18 days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45 minutes (range: 25-230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2 days (range: 2-4 days). Esophagectomy was completed in all patients after a median of 14 days (range: 12-28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.
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Affiliation(s)
- Eline de Groot
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Arjen van der Veen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alicia Borggreve
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim de Jong
- Department of Radiology, Division of Imaging and Oncology, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Daniel Pinto Dos Santos
- Institute of Diagnostic and Interventional Radiology, University of Cologne, Medical Faculty and University Hospital Cologne, Germany
| | - Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Hans Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Jelle Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christiane Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | | | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
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Aiolfi A, Bona D, Bonitta G, Bonavina L. Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis. Updates Surg 2023; 75:1633-1643. [PMID: 37498484 DOI: 10.1007/s13304-023-01601-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/17/2023] [Indexed: 07/28/2023]
Abstract
Ischemia at the anastomotic site is thought to be a protagonist in the development of anastomosis-related complications while different strategies to overcome this problem have been reported. Gastric ischemic conditioning (GIC) prior to esophagectomy has been described with this intent. Evaluate the effect of GIC on anastomotic complications after esophagectomy. Scopus, Web of Science, MEDLINE, and PubMed were investigated up to March 31st, 2023. We considered articles that appraised short-term outcomes after GIC vs. no GIC in patients undergoing esophagectomy. Anastomotic leak (AL), anastomotic stricture (AS), and gastric conduit necrosis (GCN) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Fourteen studies (1760 patients) were included. Of those, 732 (41.6%) underwent GIC, while 1028 (58.4%) underwent one-step esophagectomy. Compared with no GIC, GIC was related to a reduced RR for AL (R RR = 0.63; 95% CI 0.47-0.86; p < 0.01) and AS (RR = 0.51; 95% CI 0.29-0.91; p = 0.02), whereas no differences were found for GCN (RR = 0.56; 95% CI 0.19-1.61; p = 0.28). Postoperative pneumonia (RR = 1.09; p = 0.99), overall complications (RR = 0.87; p = 0.19), operative time (SMD - 0.58; p = 0.07), hospital stay (SMD 0.66; p = 0.09), and 30-day mortality (RR = 0.69; p = 0.22) were comparable. GIC prior to esophagectomy seems associated with a reduced risk for AL and AS. Further studies are necessary to identify the subset of patients who can benefit from this procedure, the optimal technique, and the timing of GIC prior to esophagectomy.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy.
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Via C. Belgioioso, 173, 20157, Milan, Italy
| | - Luigi Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Agarwal L, Dash NR, Pal S, Agarwal A, Madhusudhan KS. Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study. J Gastrointest Cancer 2023; 54:759-767. [PMID: 35965285 DOI: 10.1007/s12029-022-00856-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL. METHODS Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors. RESULTS A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL. CONCLUSION Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.
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Affiliation(s)
- Lokesh Agarwal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Ayushi Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Charalampous C, Kofopoulos-Lymperis E, Pikouli A, Lykoudis P, Pararas N, Papaconstantinou D, Nastos C, Myoteri D, Dellaportas D. Gastric conduit reconstruction after esophagectomy with right gastroepiploic artery absence: a case report. J Surg Case Rep 2023; 2023:rjad474. [PMID: 37593193 PMCID: PMC10431203 DOI: 10.1093/jscr/rjad474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023] Open
Abstract
Gastric conduit reconstruction is the standard choice after esophagectomy. Conduit's vascular supply is of primary importance mainly based on right gastroepiploic vessels. A 57-year-old male with absent right gastroepiploic artery, due to a duodenal bleeding ulcer treated with gastroduodenal artery ligation 10 years ago, was treated for gastroesophageal cancer and required esophagectomy. Surgical merits of this troublesome scenario are highlighted. Previous surgical history is highly important for patients requiring complex surgery as esophagectomy. The use of the stomach as conduit after esophagectomy is always the primary option; however vascular supply of it should not be compromised. Variations are rare and careful planning may overcome obstacles as in this case.
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Affiliation(s)
- C Charalampous
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - E Kofopoulos-Lymperis
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - A Pikouli
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - P Lykoudis
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - N Pararas
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - D Papaconstantinou
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - C Nastos
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - D Myoteri
- Pathology Department, National and Kapodistrian University of Athens, Aretaieion University Hospital, Athens, Greece
| | - D Dellaportas
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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Predictive impact of the thoracic inlet space on ICG fluorescence blood flow speed in the gastric conduit wall and anastomotic leakage after esophagectomy. Esophagus 2023; 20:81-88. [PMID: 35915195 DOI: 10.1007/s10388-022-00942-5] [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: 02/05/2022] [Accepted: 07/11/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE The thoracic inlet space might influence the blood vessel perfusion in the gastric conduit. The purpose of this study was to clarify the impacts of the thoracic inlet space on blood vessel perfusion in the gastric conduit and anastomotic leakage after esophagectomy. METHODS One hundred and forty-two esophageal cancer patients underwent esophagectomy followed by gastric conduit reconstruction via the retrosternal route. The blood flow speed in the gastric conduit was measured using indocyanine green fluorescence before and after reconstruction. Parameters at the thoracic inlet space were measured using CT. We then investigated the correlation between these two parameters and whether they could predict anastomotic leakage after esophagectomy. RESULTS Blood flow speed in the gastric conduit was slower after reconstruction than before reconstruction (P < 0.001). The incidence of anastomotic leakage (n = 23) was higher among patients with a delayed blood flow speed before reconstruction (n = 27) than among those with a non-delayed blood flow speed before reconstruction (n = 115) (P < 0.001). Among the patients with a non-delayed blood flow speed before reconstruction, the thoracic inlet area (TIA, sternum-tracheal distance × clavicle head distance) was positively correlated with the blood flow speed after reconstruction (P = 0.023) and was identified as an independent predictor of anastomotic leakage (P < 0.001). CONCLUSION A narrow TIA was associated with a delayed blood flow speed in the gastric conduit after reconstruction and was capable of predicting anastomotic leakage in the patients with a non-delayed blood flow speed before reconstruction.
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A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial. Int J Surg 2022; 106:106921. [PMID: 36116675 DOI: 10.1016/j.ijsu.2022.106921] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.
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Yang Y, Ma L. Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report. BMC Surg 2022; 22:225. [PMID: 35690775 PMCID: PMC9188175 DOI: 10.1186/s12893-022-01630-y] [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: 02/05/2022] [Accepted: 05/04/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply. CASE PRESENTATION A 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally. CONCLUSIONS Oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.
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Affiliation(s)
- Yanbo Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Sichuan, 610041, Chengdu, People's Republic of China.,Chest Oncology Institute, West China Hospital, Sichuan University, Chengdu, China.,Western China Collaborative Innovation Centre for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China
| | - Lin Ma
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Sichuan, 610041, Chengdu, People's Republic of China. .,Chest Oncology Institute, West China Hospital, Sichuan University, Chengdu, China. .,Western China Collaborative Innovation Centre for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China.
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12
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Veen AVD, Schiffmann LM, de Groot EM, Bartella I, de Jong PA, Borggreve AS, Brosens LAA, Santos DPD, Fuchs H, Ruurda JP, Bruns CJ, van Hillegersberg R, Schröder W. The ISCON-trial protocol: laparoscopic ischemic conditioning prior to esophagectomy in patients with esophageal cancer and arterial calcifications. BMC Cancer 2022; 22:144. [PMID: 35123419 PMCID: PMC8817569 DOI: 10.1186/s12885-022-09231-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 01/21/2022] [Indexed: 12/14/2022] Open
Abstract
Background Anastomotic leakage is the most important surgical complication following esophagectomy. A major cause of leakage is ischemia of the gastric tube that is used for reconstruction of the gastrointestinal tract. Generalized cardiovascular disease, expressed by calcifications of the aorta and celiac axis stenosis on a pre-operative CT scan, is associated with an increased risk of anastomotic leakage. Laparoscopic ischemic conditioning (ISCON) aims to redistribute blood flow and increase perfusion at the anastomotic site by occluding the left gastric, left gastroepiploic and short gastric arteries prior to esophagectomy. This study aims to assess the safety and feasibility of laparoscopic ISCON in selected patients with esophageal cancer and concomitant arterial calcifications. Methods In this prospective single-arm safety and feasibility trial based upon the IDEAL recommendations for surgical innovation, a total of 20 patients will be included recruited in 2 European high-volume centers for esophageal cancer surgery. Patients with resectable esophageal carcinoma (cT1-4a, N0–3, M0) with “major calcifications” of the thoracic aorta accordingly to the Uniform Calcification Score (UCS) or a stenosis of the celiac axis accordingly to the modified North American Symptomatic Carotid Endarterectomy Trial (NASCET) score on preoperative CT scan, who are planned to undergo esophagectomy are eligible for inclusion. The primary outcome variables are complications grade 2 and higher (Clavien-Dindo classification) occurring during or after laparoscopic ISCON and before esophagectomy. Secondary outcomes include intra- and postoperative complications of esophagectomy and the induction of angiogenesis by biomarkers of microcirculation and redistribution of blood flow by measurement of indocyanine green (ICG) fluorescence angiography. Discussion We hypothesize that in selected patients with impaired vascularization of the gastric tube, laparoscopic ISCON is feasible and can be safely performed 12–18 days prior to esophagectomy. Depending on the results, a randomized controlled trial will be needed to investigate whether ISCON leads to a lower percentage and less severe course of anastomotic leakage in selected patients. Trial registration Clinicaltrials.gov, NCT03896399. Registered 4 January 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09231-x.
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13
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Chen L, Zhang J, Chen D, Sang Y, Yang W. Simultaneous Vascular Reconstruction and Cervical Anastomosis in McKeown Esophagectomy. Front Surg 2021; 8:646811. [PMID: 33898507 PMCID: PMC8060638 DOI: 10.3389/fsurg.2021.646811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
A stomach was considered ineligible to be an ideal conduit conventionally if its right gastroepiploic artery (RGEA) were injured. However, both sufficient blood flow and good venous return are crucial to the success of reconstruction. And there lacks robust evidence regarding the surgical techniques of reconstructing RGEA and right gastroepiploic vein (RGEV) and performing cervical anastomosis with gastric conduit simultaneously. Herein, we summarized the key surgical techniques for simultaneous vascular reconstruction and gastric conduit anastomosis in McKeown esophagectomy.
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Affiliation(s)
- Lei Chen
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiaheng Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Donglai Chen
- Department of Thoracic Surgery, School of Medicine, Shanghai Pulmonary Hospital, Tongji University, Shanghai, China
| | - Yonghua Sang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wentao Yang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
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14
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Ma H, Song X, Li J, Zhao G. Application of mediastinal drainage tube in intrathoracic esophageal anastomotic leakage for early diagnosis and effective treatment: a retrospective study. J Cardiothorac Surg 2021; 16:52. [PMID: 33766053 PMCID: PMC7993533 DOI: 10.1186/s13019-021-01435-9] [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: 11/18/2020] [Accepted: 03/16/2021] [Indexed: 12/08/2022] Open
Abstract
Background Intrathoracic esophageal anastomotic leakage (AL) is one of the most fatal complications after esophagectomy. In this study, we placed an additional drainage tube in the esophagus bed and evaluated its effect in early diagnosis and treatment of AL. Methods From January 2010 to August 2020, 312 patients with esophageal or cardia carcinoma underwent esophageal resection with intrathoracic esophagogastric anastomosis. A total of 138 patients with only one pleural drainage tube were divided into the “Control Group” and 174 patients with a pleural drainage tube and an additional mediastinal drainage tube (MDT) were divided into the “Tube Group”. For all patients, the incidence of postoperative AL, the time to diagnosis, time to recovery, and patient outcome were analyzed. Results No significant differences were observed in the AL rate (P = 0.837) and postoperative pain between two groups. However, in the Tube Group, almost all the patients were diagnosed prior to the appearance of hyperpyrexia, which was considered as the earliest and most common symptom after AL. In the Tube Group, a significant decrease was observed in the incidence of incurable fistula, which required re-operation or variable treatments under gastroscopy when compared to the Control Group (P = 0.032). Finally, patients in the Tube Group showed reduced post AL hospital day (P = 0.015) and a lower mortality, however, when compared to the Control Group, no significant differences were observed (P = 0.188). Conclusions Placement of an MDT does not prevent AL, but it is an effective approach for earlier diagnosis of AL and facilitates fistula healing and patient recovery.
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Affiliation(s)
- Hainong Ma
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Xu Song
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China. .,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China.
| | - Jie Li
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Guofang Zhao
- Hwa Mei Hospital, University of Chinese Academy of Sciences, Ningbo, China.,Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
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15
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Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus 2021; 34:doaa039. [PMID: 32476017 PMCID: PMC7801633 DOI: 10.1093/dote/doaa039] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023]
Abstract
Anastomotic leakage is one of the most severe complications after esophagectomy and is associated with increased postoperative morbidity and mortality. Several projects ranging from small retrospective studies to large collaborations have aimed to identify potential pre- and perioperative risk factors and to improve the diagnostic processes and management. Despite the increase in available literature, many aspects of anastomotic leakage are still debated, without the existence of widely accepted guidelines. The purpose of this review is to provide a cutting edge overview of the recent literature regarding the definition and classification of anastomotic leakage, risk factors, novel diagnostic modalities, and emerging therapeutic options for treatment and prevention of anastomotic leakage following esophagectomy.
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Affiliation(s)
- M Fabbi
- Fondazione IRCCS Cà Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - E R C Hagens
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Barberio M, Felli E, Pop R, Pizzicannella M, Geny B, Lindner V, Baiocchini A, Jansen-Winkeln B, Moulla Y, Agnus V, Marescaux J, Gockel I, Diana M. A Novel Technique to Improve Anastomotic Perfusion Prior to Esophageal Surgery: Hybrid Ischemic Preconditioning of the Stomach. Preclinical Efficacy Proof in a Porcine Survival Model. Cancers (Basel) 2020; 12:cancers12102977. [PMID: 33066529 PMCID: PMC7602144 DOI: 10.3390/cancers12102977] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/12/2020] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Esophagectomy has a high rate of anastomotic complications thought to be caused by poor perfusion of the gastric graft, which is used to restore the continuity of the gastrointestinal tract. Ischemic gastric preconditioning (IGP), performed by partially destroying preoperatively the gastric vessels either by means of interventional radiology or surgically, might improve the gastric conduit perfusion. Both approaches have downsides. The timing, extent and mechanism of IGP remain unclear. A novel hybrid IGP method combining the advantages of the endovascular and surgical approach was introduced in this study. IGP improves unequivocally the mucosal and serosal blood-flow at the gastric conduit fundus by triggering new vessels formation. The proposed timing and extent of IGP were efficacious and might be easily applied to humans. This novel minimally invasive IGP technique might reduce the anastomotic leak rate of patients undergoing esophagectomy, thus improving their overall oncological outcome. Abstract Esophagectomy often presents anastomotic leaks (AL), due to tenuous perfusion of gastric conduit fundus (GCF). Hybrid (endovascular/surgical) ischemic gastric preconditioning (IGP), might improve GCF perfusion. Sixteen pigs undergoing IGP were randomized: (1) Max-IGP (n = 6): embolization of left gastric artery (LGA), right gastric artery (RGA), left gastroepiploic artery (LGEA), and laparoscopic division (LapD) of short gastric arteries (SGA); (2) Min-IGP (n = 5): LGA-embolization, SGA-LapD; (3) Sham (n = 5): angiography, laparoscopy. At day 21 gastric tubulation occurred and GCF perfusion was assessed as: (A) Serosal-tissue-oxygenation (StO2) by hyperspectral-imaging; (B) Serosal time-to-peak (TTP) by fluorescence-imaging; (C) Mucosal functional-capillary-density-area (FCD-A) index by confocal-laser-endomicroscopy. Local capillary lactates (LCL) were sampled. Neovascularization was assessed (histology/immunohistochemistry). Sham presented lower StO2 and FCD-A index (41 ± 10.6%; 0.03 ± 0.03 respectively) than min-IGP (66.2 ± 10.2%, p-value = 0.004; 0.22 ± 0.02, p-value < 0.0001 respectively) and max-IGP (63.8 ± 9.4%, p-value = 0.006; 0.2 ± 0.02, p-value < 0.0001 respectively). Sham had higher LCL (9.6 ± 4.8 mL/mol) than min-IGP (4 ± 3.1, p-value = 0.04) and max-IGP (3.4 ± 1.5, p-value = 0.02). For StO2, FCD-A, LCL, max- and min-IGP did not differ. Sham had higher TTP (24.4 ± 4.9 s) than max-IGP (10 ± 1.5 s, p-value = 0.0008) and min-IGP (14 ± 1.7 s, non-significant). Max- and min-IGP did not differ. Neovascularization was confirmed in both IGP groups. Hybrid IGP improves GCF perfusion, potentially reducing post-esophagectomy AL.
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Affiliation(s)
- Manuel Barberio
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
- Correspondence:
| | - Eric Felli
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Raoul Pop
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Margherita Pizzicannella
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Bernard Geny
- Physiology Institute, EA 3072, University of Strasbourg, 67000 Strasbourg, France;
| | - Veronique Lindner
- Department of Pathology, University Hospital of Strasbourg, 67000 Strasbourg, France;
| | - Andrea Baiocchini
- Department of Surgical Pathology, San Camillo Hospital, 00152 Rome, Italy;
| | - Boris Jansen-Winkeln
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Yusef Moulla
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Vincent Agnus
- IHU-Strasbourg, Institute of Image-Guided Surgery, 67000 Strasbourg, France; (E.F.); (R.P.); (M.P.); (V.A.)
| | - Jacques Marescaux
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, 4107 Leipzig, Germany; (B.J.-W.); (Y.M.); (I.G.)
| | - Michele Diana
- Research Institute against Digestive Cancer (IRCAD), 67000 Strasbourg, France; (J.M.); (M.D.)
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17
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Michalinos A, Antoniou SA, Ntourakis D, Schizas D, Ekmektzoglou K, Angouridis A, Johnson EO. Gastric ischemic preconditioning may reduce the incidence and severity of anastomotic leakage after οesophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5830789. [PMID: 32372088 DOI: 10.1093/dote/doaa010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/17/2020] [Accepted: 02/01/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leakage after esophagectomy is a severe and life-threatening complication. Gastric ischemic preconditioning is a strategy for the improvement of anastomotic healing. Aim of this systematic review and meta-analysis is to investigate the impact of gastric ischemic preconditioning on postoperative morbidity. A systematic literature search was performed to identify studies comparing patients undergoing gastric ischemic preconditioning before esophagectomy with nonpreconditioned patients. Meta-analysis was conducted for the overall incidence of anastomotic leakage, severe anastomotic leakage, anastomotic stricture, postoperative morbidity, and mortality. Mantel-Haenszel odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed concerning preconditioning technique, the interval between preconditioning and surgery and the extent of preconditioning. Fifteen cohort studies were identified. Gastric preconditioning was associated with reduced overall incidence of anastomotic leakage (OR 0.73; 95% CI, 0.53-1.0; P = 0.050) and severe anastomotic leakage (OR 0.27; 95% CI, 0.14-0.50; P < 0.010), but not with anastomotic stricture (OR 1.18; 95% CI 0.38 to 3.66; P = 0.780), major postoperative morbidity (OR 1.03; 95% CI 0.45 to 2.36; P = 0.940) or mortality (OR 0.69; 95% CI 0.39 to 1,23; P = 0.210). Subgroup analyses did not identify any differences between embolization and ligation while increasing the interval between preconditioning and esophagectomy as well as the extent of preconditioning might be beneficial. Gastric ischemic preconditioning may be associated with a reduced incidence of overall and severe anastomotic leakage. Randomized studies are necessary to further evaluate its impact on leakage, refine the technique and define patient populations that will benefit the most.
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Affiliation(s)
| | - Stavros A Antoniou
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus.,Department of General Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Dimitrios Ntourakis
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Aris Angouridis
- Department of Internal Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Elizabeth O Johnson
- Department of Anatomy & Surgery, European University of Cyprus, Nicosia, Cyprus
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18
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Cai M, Weng Y, Wang Z, Zhu J, You Q. Prevention of Esophageal-Stomach Anastomosis Leakage After Esophagectomy—an Analysis of 1243 Patients. Indian J Surg 2020. [DOI: 10.1007/s12262-020-02100-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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19
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Hoek VT, Edomskis PP, Menon AG, Kleinrensink GJ, Lagarde SM, Lange JF, Wijnhoven BPL. Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis. Eur J Surg Oncol 2020; 46:1975-1988. [PMID: 32883552 DOI: 10.1016/j.ejso.2020.06.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/08/2020] [Accepted: 06/12/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Leakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery. METHOD Embase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A "random-effects model" was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I2-test. RESULTS From the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7-24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42-3.34)), celiac axis (OR 1.62(CI 1.15-2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27-5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I2 = 71% and 59%, respectively) but not for the right branches of the celiac axis (I2 = 0%). CONCLUSION This meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.
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Affiliation(s)
- Vincent T Hoek
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Pim P Edomskis
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Anand G Menon
- Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, the Netherlands
| | - Gert-Jan Kleinrensink
- Department of Neuroscience-Anatomy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Johan F Lange
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Surgery, IJsselland Ziekenhuis, Capelle aan den IJssel, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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20
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Luo J, Zhuo ZG, Zhu YK, Deng HY, Song TN, Alai GH, Shen X, Lin YD. Fixed in the neck or pushed back into the thorax?-Impact of cervical anastomosis position on anastomosis healing. J Thorac Dis 2020; 12:2153-2160. [PMID: 32642120 PMCID: PMC7330304 DOI: 10.21037/jtd.2020.04.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Cervical anastomotic leakage remains a great challenge for thoracic surgeons in the surgical treatment of esophageal cancer. Among the factors affecting cervical anastomosis healing, the surgical technique is the key controllable element. This study aimed to identify the risk factors of cervical anastomotic leakage after McKeown esophagectomy, especially those controllable surgical factors. Methods A retrospective review of patients who underwent McKeown esophagectomy in the past eight years in West China Hospital was performed. Patients with cervical anastomotic leakage were assigned to leakage group (LG) while the left was enrolled in the none-leakage group (NLG). Multivariate logistic regression analysis was used to identify independent risk factors of anastomotic leakage. Results A total of 518 patients were enrolled in the final analysis. In the baseline comparison, the difference in fixation of anastomosis in the neck, anastomosis mode, diabetes, and hypertension between the LG and NLG reached statistically significant. Moreover, the statistical difference of cervical fixation, anastomosis mode, and hypertension remained significant in the multivariate logistic regression analysis. Conclusions The cervical anastomosis fixation, anastomosis mode, and hypertension are independent risk factors of gastroesophageal cervical anastomotic leakage.
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Affiliation(s)
- Jun Luo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ze-Guo Zhuo
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yun-Ke Zhu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Han-Yu Deng
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China.,Lung Cancer Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Tie-Niu Song
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Gu-Ha Alai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xu Shen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yi-Dan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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21
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Ma L, Liu C, Mei J, Chen LQ. Successful Cervical Esophageal Reconstruction Using Gastric Conduit Without Gastroepiploic Artery. Ann Thorac Surg 2019; 107:e409-e410. [DOI: 10.1016/j.athoracsur.2018.09.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 09/04/2018] [Accepted: 09/21/2018] [Indexed: 10/27/2022]
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22
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Mingol-Navarro F, Ballester-Pla N, Jimenez-Rosellon R. Ischaemic conditioning of the stomach previous to esophageal surgery. J Thorac Dis 2019; 11:S663-S674. [PMID: 31080643 DOI: 10.21037/jtd.2019.01.43] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
A gastric conduit is most frequently used for reconstruction in oesophageal surgery, and ischemia of the conduit is the most fragile aspect of the esophagogastric anastomosis with as consequence the anastomotic leakage. In order to avoid it, the concept of ischaemic conditioning of the stomach previous to surgery has been designed. The basis of ischemic conditioning is that interrupting vascularization of the stomach before making the anastomosis eases the gastric fundus adaptation to ischemic conditions. It consists of the interruption of the principal feeding arteries of the stomach (except the right gastroepiploic artery) weeks before esophagectomy. Previously published literature contemplates two different techniques: angiographic embolization or laparoscopic ligation or division of vessels. In this study, the anatomic and physio-pathologic background of ischemic preconditioning is described and the published current evidence is reviewed.
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23
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Athanasiou A, Hennessy M, Spartalis E, Tan BHL, Griffiths EA. Conduit necrosis following esophagectomy: An up-to-date literature review. World J Gastrointest Surg 2019; 11:155-168. [PMID: 31057700 PMCID: PMC6478597 DOI: 10.4240/wjgs.v11.i3.155] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 02/06/2023] Open
Abstract
Esophageal conduit ischaemia and necrosis is an uncommon but devastating complication of esophagectomy and remains one of the most challenging issues in surgical practice. The incidence, time interval to develop symptoms, and clinical presentation are highly variable with no predictable pattern. Evidence comes from case reports and case series rather than randomized controlled trials. We describe the issues surrounding conduit necrosis affecting the stomach, jejunum and colon as an esophageal replacement and the advantages, disadvantages and challenges of each type of reconstruction. Diagnosis is challenging for the most experienced surgeon. Upper gastrointestinal endoscopy and computed tomography thorax with both oral and intravenous contrast is the gold standard. Management, either conservative or interventional is also a difficult decision. Management options include conservative treatment and more aggressive treatments such as stent insertion, surgical debridement and repair of the esophagus using jejunum, colon or a musculocutaneous flap. In spite of recent advances in surgical techniques, there is no reliable strategy to manage esophageal conduit necrosis. Our review covers the pathophysiology and clinical significance of esophageal necrosis while highlighting current techniques of prevention, diagnosis and treatment of this life-threatening condition.
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Affiliation(s)
- Antonios Athanasiou
- Department of Upper GI, Bariatric and Minimally Invasive Surgery, St. James' University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, United Kingdom
| | - Mairead Hennessy
- Department of Anaesthesia, University Hospital of Waterford, Waterford X91 ER8E, Ireland
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens, Medical School, Athens 11527, Greece
| | - Benjamin H L Tan
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
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Girotti PNC, Königsrainer I. Surgical concepts in esophageal cancer. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2019; 12:46-50. [DOI: 10.1007/s12254-018-0467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 12/12/2018] [Indexed: 08/30/2023]
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Gastric Ischemic Conditioning Prior to Esophagectomy Is Associated with Decreased Stricture Rate and Overall Anastomotic Complications. J Gastrointest Surg 2018; 22:1501-1507. [PMID: 29845573 DOI: 10.1007/s11605-018-3817-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 05/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. METHODS We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. RESULTS Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). CONCLUSIONS Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.
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Quan YH, Kim M, Kim HK, Kim BM. Fluorescent image-based evaluation of gastric conduit perfusion in a preclinical ischemia model. J Thorac Dis 2018; 10:5359-5367. [PMID: 30416783 DOI: 10.21037/jtd.2018.08.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background This study evaluated near-infrared (NIR) fluorescent images to assess gastric conduit perfusion after an esophagectomy in a porcine model of gastric conduit ischemia. The time necessary to acquire a sufficient fluorescent signal to confirm ischemia in the gastric conduit after peripheral or central venous injection of indocyanine green (ICG) was also investigated. Methods A reversible gastric conduit ischemic pig model was established through ligation and release of the right gastroepiploic artery (RGEA, n=10). The esophageal reconstruction was performed to create an esophagogastric anastomosis. After ligation of the RGEA, ICG was injected into an ear vein (n=6) or the inferior vena cava (n=4). Under fluorescent imaging system guidance, the fluorescent signal-to-background ratio (SBR) in the gastric conduit or esophagus was measured during the entire procedure. We estimated the time necessary to acquire fluorescent signals in the gastric conduit using two different injection routes. Results When the RGEA was ligated, the SBR in the esophagus was significantly higher than that in the gastric conduit (P=0.02), and the SBR in the gastric conduit recovered within 180 s after release of the ligation. The time to acquire a fluorescent signal was faster with a central route than with a peripheral route (P=0.04). Conclusions We successfully created an ischemic animal model of the gastric conduit. Using this animal model, we evaluated the sensitivity and applicability of the fluorescent imaging system for observation and identification of ischemic areas during an esophagectomy.
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Affiliation(s)
- Yu Hua Quan
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, College of Medicine, Korea University, Seoul, Korea
| | - Minji Kim
- Department of Bio-Convergence, Korea University, Seoul, Korea
| | - Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Department of Biomedical Sciences, College of Medicine, Korea University, Seoul, Korea
| | - Beop-Min Kim
- Department of Bio-Convergence, Korea University, Seoul, Korea
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Grimminger PP, Goense L, Gockel I, Bergeat D, Bertheuil N, Chandramohan SM, Chen KN, Chon SH, Denis C, Goh KL, Gronnier C, Liu JF, Meunier B, Nafteux P, Pirchi ED, Schiesser M, Thieme R, Wu A, Wu PC, Buttar N, Chang AC. Diagnosis, assessment, and management of surgical complications following esophagectomy. Ann N Y Acad Sci 2018; 1434:254-273. [PMID: 29984413 DOI: 10.1111/nyas.13920] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 05/13/2018] [Accepted: 06/05/2018] [Indexed: 12/15/2022]
Abstract
Despite improvements in operative strategies for esophageal resection, anastomotic leaks, fistula, postoperative pulmonary complications, and chylothorax can occur. Our review seeks to identify potential risk factors, modalities for early diagnosis, and novel interventions that may ameliorate the potential adverse effects of these surgical complications following esophagectomy.
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Affiliation(s)
- Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, Johannes Gutenberg University, Mainz, Germany
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Damien Bergeat
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital, Rennes, France
| | | | - Ke-Neng Chen
- Department of Thoracic Surgery I, Beijing University Cancer Hospital, Beijing, China
| | - Seung-Hon Chon
- Department of General, Visceral and Tumor Surgery, University Hospital of Cologne, Cologne, Germany
| | - Collet Denis
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Khean-Lee Goh
- Combined Endoscopy Unit, University of Malaya Medical Center, Kuala Lumpur, Malaysia
| | - Caroline Gronnier
- Department of Digestive Surgery, University Hospital of Bordeaux, Bordeaux, France
| | - Jun-Feng Liu
- Department of Thoracic Surgery, Fourth Hospital, Hebei Medical University, Shijiazhuang, China
| | - Bernard Meunier
- Department Hepatobiliary and Digestive Surgery, Rennes University Hospital, Rennes, France
| | - Phillippe Nafteux
- Department of Thoracic Surgery, University Hospitals, Leuven, Belgium
| | - Enrique D Pirchi
- Department of Surgery, Hospital Britanico de Buenos Aires, Buenos Aires, Argentina
| | | | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital of Leipzig, Leipzig, Germany
| | - Aaron Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Peter C Wu
- Department of Surgery, University of Washington, Seattle, Washington
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andrew C Chang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Borggreve AS, Kingma BF, Domrachev SA, Koshkin MA, Ruurda JP, Hillegersberg R, Takeda FR, Goense L. Surgical treatment of esophageal cancer in the era of multimodality management. Ann N Y Acad Sci 2018; 1434:192-209. [DOI: 10.1111/nyas.13677] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/05/2018] [Accepted: 02/23/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Alicia S. Borggreve
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
- Moscow Clinical Scientific Center Moscow Russia
| | - B. Feike Kingma
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | | | | | - Jelle P. Ruurda
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Richard Hillegersberg
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
| | - Flavio R. Takeda
- Sao Paulo Institute of CancerUniversity of Sao Paulo School of Medicine Sao Paulo Brazil
| | - Lucas Goense
- Department of Surgery, University Medical Center UtrechtUtrecht University Utrecht the Netherlands
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Miró M, Farran L, Estremiana F, Miquel J, Escalante E, Aranda H, Bettonica C, Galán M. Does gastric conditioning decrease the incidence of cervical oesophagogastric anastomotic leakage? Cir Esp 2018; 96:102-108. [PMID: 29459004 DOI: 10.1016/j.ciresp.2017.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/12/2017] [Accepted: 11/08/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Oesophageal reconstruction by gastroplasty with cervical anastomosis has a higher incidence of dehiscence. The aim of the study is to analyse the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning of the gastric conduit. METHODS Prospective analysis of patients who underwent gastric conditioning two weeks prior to oesophageal reconstruction, from January 2001 to January 2014. The conditioning was performed by angiographic embolization of the left and right gastric artery, and splenic artery. The main variable analysed was the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis. Secondary variables analysed were the result of the conditioning, complications arising from that procedure and in the postoperative period, and mean length of postconditioning and postoperative hospital stay. RESULTS Gastric conditioning was indicated in 97 patients, with neoplasia being the most frequent aetiology motivating the oesophageal reconstruction (76%). 96 procedures were successfully carried out, arterial embolization was complete in 80 (83%). The morbidity rate was 13%, with no mortality. Postoperative morbidity was 45%; the most frequent complications associated with the surgery were respiratory problems. Six (7%) patients experienced cervical fistula, and all received conservative treatment. The rate of postoperative mortality was 7%. CONCLUSIONS In our serie the incidence of anastomotic leakage in patients undergoing gastroplasty with cervical anastomosis following angiographic ischaemic conditioning is 7%. Angiographic ischaemic conditioning is a procedure with acceptable morbidity.
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Affiliation(s)
- Mónica Miró
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España.
| | - Leandre Farran
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Fernando Estremiana
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Jordi Miquel
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Elena Escalante
- Unidad de Angiorradiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Humberto Aranda
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Carla Bettonica
- Unidad de Cirugía Esofágica, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
| | - Maica Galán
- Unidad de Tumores Esofágicos, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Barcelona, España
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Borggreve AS, Goense L, van Rossum PSN, van Hillegersberg R, de Jong PA, Ruurda JP. Generalized cardiovascular disease on a preoperative CT scan is predictive for anastomotic leakage after esophagectomy. Eur J Surg Oncol 2018; 44:587-593. [PMID: 29452856 DOI: 10.1016/j.ejso.2018.01.225] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 01/12/2018] [Accepted: 01/22/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recent studies demonstrated that calcification of arteries supplying the gastric tube is associated with anastomotic leakage after esophagectomy. However, it remains unclear whether this association only derives from local flow limitations, or generalized vascular disease as well. The purpose of this study was to determine whether calcification throughout the entire cardiovascular system is associated with anastomotic leakage. METHODS Consecutive patients who underwent an esophagectomy with gastric tube reconstruction and cervical anastomosis for esophageal cancer were analyzed. Diagnostic CT images were scored for the presence of arterial calcification on 10 locations based on a visual grading system. The association with anastomotic leakage was studied using logistic regression analysis. RESULTS A total of 406 patients were included for analysis of whom 104 developed anastomotic leakage (25.6%). Presence of calcification in the coronary arteries (minor calcification: 36.5% leakage; no calcification: 18.1%, p = .001), supra-aortic arteries (minor calcification: 30.9% leakage; major calcification: 35.3%; no calcification: 16.1%, p = .007 and p < .001, respectively) and thoracic aorta (major calcification: 33.3% leakage; no calcification: 19.4%, p = .011) was associated with leakage. In multivariable analysis, minor calcification of the coronary arteries (OR 2.29, 95% CI: 1.28-4.12, p = .005) and calcification of the supra-aortic arteries (OR 2.48, 95% CI: 1.30-4.74, p = .006 for minor calcification and OR 2.72, 95% CI: 1.49-4.99, p = .001 for major calcification) remained independently associated with leakage. CONCLUSIONS Calcification of the coronary and supra-aortic arteries on routine CT are predictive of cervical anastomotic leakage after esophagectomy. These results suggest that generalized cardiovascular disease is a strong indicator for the risk of leakage.
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Affiliation(s)
- Alicia S Borggreve
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands
| | - Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands
| | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands
| | - Pim A de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584, CX Utrecht, The Netherlands.
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Schröder W, Lambertz R, van Hillegesberger R, Bruns C. [Differentiated surgical approach for adenocarcinoma of the gastroesophageal junction]. Chirurg 2017; 88:1010-1016. [PMID: 29098306 DOI: 10.1007/s00104-017-0544-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
For adenocarcinoma of the gastroesophageal junction (GEJ) the classification of Siewert with its three subtypes is well established as a practical approach to surgical treatment. Transthoracic esophagectomy with gastric tube formation is generally accepted as the surgical standard for adenocarcinoma of the distal esophagus (GEJ type I). Intrathoracic esophagogastrostomy has become the most frequently used anastomotic technique (Ivor Lewis esophagectomy). Both the abdominal and thoracic part can be safely performed with a minimally invasive access. For subcardiac gastric cancer (GEJ type III) transhiatal extended gastrectomy is the resection of choice. For true cardiac carcinomas (GEJ type II) it has not yet been decided which of the abovementioned surgical procedures offers the best long-term survival. If technically possible in terms of a complete resection, transhiatal extended gastrectomy should be preferred because of a better postoperative quality of life. For GEJ type II tumors a minimally invasive approach is not recommended if the extent of resection cannot be safely determined preoperatively.
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Affiliation(s)
- W Schröder
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland.
| | - R Lambertz
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland
| | | | - C Bruns
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universitätsklinik Köln, Kerpener Str. 62, 90933, Köln, Deutschland
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Pham TH, Melton SD, McLaren PJ, Mokdad AA, Huerta S, Wang DH, Perry KA, Hardaker HL, Dolan JP. Laparoscopic ischemic conditioning of the stomach increases neovascularization of the gastric conduit in patients undergoing esophagectomy for cancer. J Surg Oncol 2017; 116:391-397. [PMID: 28556988 DOI: 10.1002/jso.24668] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 04/16/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Gastric ischemic preconditioning has been proposed to improve blood flow and reduce the incidence of anastomotic complications following esophagectomy with gastric pull-up. This study aimed to evaluate the effect of prolonged ischemic preconditioning on the degree of neovascularization in the distal gastric conduit at the time of esophagectomy. METHODS A retrospective review of a prospectively maintained database identified 30 patients who underwent esophagectomy. The patients were divided into three groups: control (no preconditioning, n = 9), partial (short gastric vessel ligation only, n = 8), and complete ischemic preconditioning (left and short gastric vessel ligation, n = 13). Microvessel counts were assessed, using immunohistologic analysis to determine the degree of neovascularization at the distal gastric margin. RESULTS The groups did not differ in age, gender, BMI, pathologic stage, or cancer subtype. Ischemic preconditioning durations were 163 ± 156 days for partial ischemic preconditioning, compared to 95 ± 50 days for complete ischemic preconditioning (P = 0.2). Immunohistologic analysis demonstrated an increase in microvessel counts of 29% following partial ischemic preconditioning (P = 0.3) and 67% after complete ischemic preconditioning (P < 0.0001), compared to controls. CONCLUSIONS Our study indicates that prolonged ischemic preconditioning is safe and does not interfere with subsequent esophagectomy. Complete ischemic preconditioning increased neovascularization in the distal gastric conduit.
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Affiliation(s)
- Thai H Pham
- Surgical Services, North Texas Dallas Veterans Affairs Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shelby D Melton
- Pathology Services, North Texas Dallas Veterans Affairs Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Patrick J McLaren
- Division of Gastrointestinal and General Surgery and the Digestive Health Center, Department of Surgery, Oregon Health & Science University Medical Center, Portland, Oregon
| | - Ali A Mokdad
- Surgical Services, North Texas Dallas Veterans Affairs Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sergio Huerta
- Surgical Services, North Texas Dallas Veterans Affairs Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - David H Wang
- Hematology Oncology, North Texas Dallas Veterans Affairs Medical Center and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kyle A Perry
- Department of Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Hope L Hardaker
- Division of Gastrointestinal and General Surgery and the Digestive Health Center, Department of Surgery, Oregon Health & Science University Medical Center, Portland, Oregon
| | - James P Dolan
- Division of Gastrointestinal and General Surgery and the Digestive Health Center, Department of Surgery, Oregon Health & Science University Medical Center, Portland, Oregon
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Superior Thoracic Aperture Size is Significantly Associated with Cervical Anastomotic Leakage After Esophagectomy. World J Surg 2017; 41:2598-2604. [DOI: 10.1007/s00268-017-4047-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Goense L, van Dijk WA, Govaert JA, van Rossum PSN, Ruurda JP, van Hillegersberg R. Hospital costs of complications after esophagectomy for cancer. Eur J Surg Oncol 2016; 43:696-702. [PMID: 28012715 DOI: 10.1016/j.ejso.2016.11.013] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to estimate the economic burden of postoperative complications after esophagectomy for cancer, in order to optimally allocate resources for quality improvement initiatives in the future. METHODS A retrospective analysis of prospectively collected clinical and financial outcomes after esophageal cancer surgery in a tertiary referral center in the Netherlands was performed. Data was extracted from consecutive patients registered in the Dutch Upper GI Cancer Audit between 2011 and 2014 (n = 201). Costs were measured up to 90-days after hospital discharge and based on Time-Driven Activity-Based Costing. The additional costs were estimated using multiple linear regression models. RESULTS The average total cost for one patient after esophagectomy was €37,581 (±31,372). The estimated costs of an esophagectomy without complications were €23,476 (±6496). Mean costs after minor (47%) and severe complications (29%) were €31,529 (±23,359) and €59,167 (±42,615) (p < 0.001), respectively. The 5% most expensive patients were responsible for 20.3% of the total hospital costs assessed in this study. Patient characteristics associated with additional costs in multivariable analysis included, age >70 (+€2,922, p = 0.036), female gender (+€4,357, p = 0.005), COPD (+€5,415, p = 0.002), and a history of thromboembolic events (+€6,213, p = 0.028). Complications associated with a significant increase in costs in multivariable analysis included anastomotic leakage (+€4,123, p = 0.008), cardiac complications (+€5,711, p = 0.003), chyle leakage (+€6,188, p < 0.001) and postoperative bleeding (+€31,567, p < 0.001). CONCLUSIONS Complications and severity of complications after esophageal surgery are associated with a substantial increase in costs. Although not all postoperative complications can be prevented, implementation of preventive measures to reduce complications could result in a considerable cost reduction and quality improvement.
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Affiliation(s)
- L Goense
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | | | - J A Govaert
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - P S N van Rossum
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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Djakovic Z, Djakovic I, Cesarec V, Madzarac G, Becejac T, Zukanovic G, Drmic D, Batelja L, Zenko Sever A, Kolenc D, Pajtak A, Knez N, Japjec M, Luetic K, Stancic-Rokotov D, Seiwerth S, Sikiric P. Esophagogastric anastomosis in rats: Improved healing by BPC 157 and L-arginine, aggravated by L-NAME. World J Gastroenterol 2016; 22:9127-9140. [PMID: 27895400 PMCID: PMC5107594 DOI: 10.3748/wjg.v22.i41.9127] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/28/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To cure typically life-threatening esophagogastric anastomosis in rats, lacking anastomosis healing and sphincter function rescue, in particular.
METHODS Because we assume esophagogastric fistulas represent a particular NO-system disability, we attempt to identify the benefits of anti-ulcer stable gastric pentadecapeptide BPC 157, which was in trials for ulcerative colitis and currently for multiple sclerosis, in rats with esophagocutaneous fistulas. Previously, BPC 157 therapies have promoted the healing of intestinal anastomosis and fistulas, and esophagitis and gastric lesions, along with rescued sphincter function. Additionally, BPC 157 particularly interacts with the NO-system. In the 4 d after esophagogastric anastomosis creation, rats received medication (/kg intraperitoneally once daily: BPC 157 (10 μg, 10 ng), L-NAME (5 mg), or L-arginine (100 mg) alone and/or combined or BPC 157 (10 μg, 10 ng) in drinking water). For rats underwent esophagogastric anastomosis, daily assessment included progressive stomach damage (sum of the longest diameters, mm), esophagitis (scored 0-5), weak anastomosis (mL H2O before leak), low pressure in esophagus at anastomosis and in the pyloric sphincter (cm H2O), progressive weight loss (g) and mortality. Immediate effect assessed blood vessels disappearance (scored 0-5) at the stomach surface immediately after anastomosis creation.
RESULTS BPC 157 (all regimens) fully counteracted the perilous disease course from the very beginning (i.e., with the BPC 157 bath, blood vessels remained present at the gastric surface after anastomosis creation) and eliminated mortality. Additionally, BPC 157 treatment in combination with L-NAME nullified any effect of L-NAME that otherwise intensified the regular course. Consistently, with worsening (with L-NAME administration) and amelioration (with L-arginine), either L-arginine amelioration prevails (attenuated esophageal and gastric lesions) or they counteract each other (L-NAME + L-arginine); with the addition of BPC 157 (L-NAME + L-arginine + BPC 157), there was a marked beneficial effect. BPC 157 treatment for esophagogastric anastomosis, along with NOS-blocker L-NAME and/or NOS substrate L-arginine, demonstrated an innate NO-system disability (as observed with L-arginine effectiveness). BPC 157 distinctively affected corresponding events: worsening (obtained with L-NAME administration that was counteracted); or amelioration (L-arginine + BPC 157-rats correspond to BPC 157-rats).
CONCLUSION Innate NO-system disability for esophagogastric anastomoses, including L-NAME-worsening, suggests that these effects could be corrected by L-arginine and almost completely eliminated by BPC 157 therapy.
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Strosberg DS, Merritt RE, Perry KA. Preventing anastomotic complications: early results of laparoscopic gastric devascularization two weeks prior to minimally invasive esophagectomy. Surg Endosc 2016; 31:1371-1375. [DOI: 10.1007/s00464-016-5122-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/13/2016] [Indexed: 12/15/2022]
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