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Li X, Yu L, Yang J, Fu M, Tan H. Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study. Perioper Med (Lond) 2024; 13:46. [PMID: 38807202 PMCID: PMC11134948 DOI: 10.1186/s13741-024-00407-6] [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: 10/13/2023] [Accepted: 05/23/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE). METHODS Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery. RESULTS In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). CONCLUSIONS Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased. TRIAL REGISTRATION Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).
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Affiliation(s)
- Xiaoxi Li
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Ling Yu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Jiaonan Yang
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Miao Fu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China
| | - Hongyu Tan
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Anesthesiology, Peking University Cancer Hospital & Institute, #52 Fucheng Street, Haidian District, Beijing, 100142, China.
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Liu Y, Zhou J, Gu Y, Hu W, Lin H, Shang Q, Zhang H, Yang Y, Yuan Y, Chen L. Will synchronous esophageal and lung resection increase the incidence of anastomotic leaks? A multicenter retrospective study. Int J Surg 2024; 110:1653-1662. [PMID: 38181122 PMCID: PMC10942245 DOI: 10.1097/js9.0000000000001018] [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: 09/20/2024] [Accepted: 12/11/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, the authors retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study. METHODS Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a four-center prospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score-matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted. RESULTS Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio propensity score-matched EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly ( P =0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic>wedge resection, P =0.016) and site of resected lobe (upper>middle/low lobe; P =0.027), and a nomogram was established to predict the occurrence of leaks accurately (area under the curve=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group ( P =0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS ( P =0.027). CONCLUSION Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.
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Affiliation(s)
- Yixin Liu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Jianfeng Zhou
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yimin Gu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, Shangjin Nanfu hospital of Chengdu
| | - Weipeng Hu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, Sanya People’s Hospital
| | - Haonan Lin
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan, People’s Republic of China
| | - Qixin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Hanlu Zhang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yushang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Longqi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University
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Nijbroek SGLH, Hol L, Serpa Neto A, van Meenen DMP, Hemmes SNT, Hollmann MW, Schultz MJ. Safety and Feasibility of Intraoperative High PEEP Titrated to the Lowest Driving Pressure (ΔP)-Interim Analysis of DESIGNATION. J Clin Med 2023; 13:209. [PMID: 38202214 PMCID: PMC10780246 DOI: 10.3390/jcm13010209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/18/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
Uncertainty remains about the best level of intraoperative positive end-expiratory pressure (PEEP). An ongoing RCT ('DESIGNATION') compares an 'individualized high PEEP' strategy ('iPEEP')-titrated to the lowest driving pressure (ΔP) with recruitment maneuvers (RM), with a 'standard low PEEP' strategy ('low PEEP')-using 5 cm H2O without RMs with respect to the incidence of postoperative pulmonary complications. This report is an interim analysis of safety and feasibility. From September 2018 to July 2022, we enrolled 743 patients. Data of 698 patients were available for this analysis. Hypotension occurred more often in 'iPEEP' vs. 'low PEEP' (54.7 vs. 44.1%; RR, 1.24 (95% CI 1.07 to 1.44); p < 0.01). Investigators were compliant with the study protocol 285/344 patients (82.8%) in 'iPEEP', and 345/354 patients (97.5%) in 'low PEEP' (p < 0.01). Most frequent protocol violation was missing the final RM at the end of anesthesia before extubation; PEEP titration was performed in 99.4 vs. 0%; PEEP was set correctly in 89.8 vs. 98.9%. Compared to 'low PEEP', the 'iPEEP' group was ventilated with higher PEEP (10.0 (8.0-12.0) vs. 5.0 (5.0-5.0) cm H2O; p < 0.01). Thus, in patients undergoing general anesthesia for open abdominal surgery, an individualized high PEEP ventilation strategy is associated with hypotension. The protocol is feasible and results in clear contrast in PEEP. DESIGNATION is expected to finish in late 2023.
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Affiliation(s)
- Sunny G. L. H. Nijbroek
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
- Department of Anesthesiology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Liselotte Hol
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands;
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC 3004, Australia
| | - David M. P. van Meenen
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Sabrine N. T. Hemmes
- Department of Anesthesiology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek Hospital, 1066 CX Amsterdam, The Netherlands;
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands; (S.G.L.H.N.); (L.H.); (D.M.P.v.M.); (M.W.H.)
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam UMC Location AMC, 1105 AZ Amsterdam, The Netherlands;
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
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Nath VG, Govindaraj Raman S, M T, V C K, Micheal M, Earjala JK, A L, A AR, U A. Short-Term Outcomes and Quality of Life Following Minimally Invasive Esophagectomy in a Tertiary Care Center in Southern India. Cureus 2023; 15:e49245. [PMID: 38143675 PMCID: PMC10743200 DOI: 10.7759/cureus.49245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
INTRODUCTION With the advent of multimodality therapy and minimally invasive surgical approaches, patients suffering from carcinoma esophagus are showing promising outcomes. Hence, the frontier needs to be widened to assess the postoperative quality of life (QoL) of those surviving carcinoma esophagus. The objective of the study was to determine the short-term outcomes of minimally invasive esophagectomy (MIE) /hybrid esophagectomies in carcinoma esophagus and the organ-specific QoL in survivors of MIE for carcinoma esophagus, and to compare health-related QoL in patients following MIE for carcinoma esophagus with the general population. METHODS AND MATERIALS A longitudinal study design was used to evaluate the short-term postoperative outcomes of patients undergoing MIE for carcinoma esophagus between July 1, 2021, to July 15, 2022, and analyze the QoL of those patients who survived at one year without tumor recurrence. QoL was assessed using the European Organization for the Research and Treatment of Cancer (EORTC) QoL Questionnaire (EORTC QLQ-C30) and the EORTC QoL Questionnaire - Oesophageal Cancer Module (EORTC QLQ-OES18). RESULTS A total of 15 patients who underwent minimal invasive/hybrid esophagectomy for esophageal carcinomawere included. Of these, 13 patients underwent hybrid esophagectomy while two patients underwent thoraco-laparoscopic esophagectomy. Squamous cell carcinoma was observed as the most common histological variant (60%) while 33% were adenocarcinoma and 6.7% lymphoma. The most common site of the tumor was the lower one-third esophagus (60%). Nine out of 15 patients developed postoperative complications needing prolonged ICU stay. One major anastomotic leak as well as one conduit necrosis was observed among 15 cases operated. Median length of hospital stay was 16 (IQR 12-24). QoL was assessed among 12 patients at the one-year follow-up excluding mortality cases and patients with tumor recurrence. The patients following MIE for carcinoma esophagus were observed to have low scores in physical functioning, role functioning, and social function when compared with the general population. Cognitive functioning and emotional function were not found to be significantly different. No statistically significant difference was observed in the global health status among the two groups. There was no significant difference found in the general symptoms score comparison of the MIE patients with the general population. When it comes to organ-specific symptom scales, reflux was observed as a major issue among the patients who survived carcinoma esophagus after undergoing MIE. Dysphagia and dry mouth received low scores suggestive of minor issues. Though analysis of global health QoL scores of those with postoperative complications and those who had uneventful recovery at one year revealed a higher score for the latter, it was not statistically significant. CONCLUSION Postoperative complications can prolong hospital stay, delay resuming normal work, and affect the global QoL of patients compared with those who recovered uneventfully. Physical and role functions were observed to be deficient among survived patients when compared with the normal population. Nutritional prehabilitation, cutting-edge surgical practice including minimally invasive techniques, minimizing deviation from normal postoperative recovery by high-quality ICU care, and postoperative rehabilitation are the cornerstones to ensure better QoL.
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Affiliation(s)
- Vivek G Nath
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | | | - Thiruvarul M
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | | | - Mathews Micheal
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Joel Kumar Earjala
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Lokeshwaran A
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Arun Raja A
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
| | - Aravindan U
- Department of Surgical Gastroenterology & GI Oncology, Thanjavur Medical College, Thanjavur, IND
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Joosten JJ, Slooter MD, van den Elzen RM, Bloemen PR, Gisbertz SS, Eshuis WJ, Daams F, de Bruin DM, van Berge Henegouwen MI. Perfusion assessment by fluorescence time curves in esophagectomy with gastric conduit reconstruction: a prospective clinical study. Surg Endosc 2023:10.1007/s00464-023-10107-9. [PMID: 37208482 PMCID: PMC10338581 DOI: 10.1007/s00464-023-10107-9] [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: 01/18/2023] [Accepted: 04/30/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND Intraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications. METHODS This prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T0, Tmax, Fmax, slope, Time-to-peak) as outflow parameters (T90% and T80%). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL. RESULTS One hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as Tmax were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3-2.5) and 1.7 (IQR 1.0-3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T90% 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that Tmax might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%. CONCLUSION This study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction. A significant predictive value remains to be determined in future studies.
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Affiliation(s)
- J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M D Slooter
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - P R Bloemen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - W J Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - F Daams
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Department of Biomedical Engineering, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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Intraoperative conditions of patients undergoing pancreatoduodenectomy. Surg Oncol 2023; 46:101897. [PMID: 36630813 DOI: 10.1016/j.suronc.2022.101897] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/18/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a severe complication following pancreatoduodenectomy (PD). Previous research in colorectal surgery demonstrated suboptimal intraoperative conditions to be related with an increased risk of anastomotic leakage. Aim of this study was to evaluate the intraoperative condition of patients undergoing PD by both assessing whether these known intraoperative modifiable risk factors in colorectal surgery are also present during PD and by measuring compliance to intraoperative ERAS guidelines. Secondly, to determine the relation of these factors with POPF. MATERIALS AND METHODS This prospective single center study included patients undergoing PD from 2016 to 2020. Parameters regarding the patient's general condition, local perfusion, oxygenation, surgical factors and ERAS elements were measured with a checklist intraoperatively, before the creation of the pancreatojejunal anastomosis. Uni- and multivariable logistic regression analyses were performed. RESULTS 83 patients were included. POPF occurred in 27.7% (9.0% grade B, 10.0% grade C). Patients with POPF significantly had more other postoperative complications compared to patients without POPF (100% vs. 76.2%, p = 0.017). A suboptimal intraoperative condition was observed in 89.2%. Overall compliance to the intraoperative ERAS guideline was 0%. In univariable analysis, soft pancreatic tissue, pancreatic duct <3 mm, tumor location and intraoperative vasopressor administration were significantly associated with POPF. In multivariable analysis, only soft pancreatic tissue was independently associated with POPF (OR 13.627; 95% CI 1.656-112.157, p = 0.015). CONCLUSION Awareness amongst surgeons and anesthesiologists should be created. The influence of these intraoperative factors on POPF should be further evaluated in future, larger studies.
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Simitian GS, Hall DJ, Leverson G, Lushaj EB, Lewis EE, Musgrove KA, McCarthy DP, Maloney JD. Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience. Surg Open Sci 2022; 11:26-32. [DOI: 10.1016/j.sopen.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/21/2022] [Accepted: 11/14/2022] [Indexed: 11/18/2022] Open
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Effects of intra-operative ventilation with positive end-expiratory pressure on peri-operative fluid and vasopressor management in patients undergoing minimally invasive oesophagectomy: posthoc analysis of a randomised clinical trial. Eur J Anaesthesiol 2022; 39:841-843. [PMID: 36101912 DOI: 10.1097/eja.0000000000001707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Zheng XD, Li SC, Lu C, Zhang WM, Hou JB, Shi KF, Zhang P. Safety and efficacy of minimally invasive McKeown esophagectomy in 1023 consecutive esophageal cancer patients: a single-center experience. J Cardiothorac Surg 2022; 17:36. [PMID: 35292067 PMCID: PMC8922768 DOI: 10.1186/s13019-022-01781-2] [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: 04/15/2021] [Accepted: 03/06/2022] [Indexed: 12/24/2022] Open
Abstract
Objective By analyzing the perioperative, postoperative complications and long-term overall survival time, we summarized the 8-year experience of minimally invasive McKeown esophagectomy for esophageal cancer in a single medical center. Methods This retrospective follow-up study included 1023 consecutive patients with esophageal cancer who underwent MIE-McKeown between Mar 2013 and Oct 2020. Relevant variables were collected and evaluated. Overall survival (OS) and disease-free survival (DFS) were analyzed by Kaplan–Meier method. Results For 1023 esophageal cancer undergoing MIE-McKeown, the main intraoperative complications were bleeding (3.0%, 31/1023) and tracheal injury (1.7%, 17/1023). There was no death occurred during operation. The conversion rate of thoracoscopy to thoracotomy was 2.2% (22/1023), and laparoscopy to laparotomy was 0.3% (3/1023). The postoperative morbidity of complications was 36.2% (370/1023), of which anastomotic leakage 7.7% (79/1023), pulmonary complication 13.4% (137/1023), chylothorax 2.3% (24/1023), and recurrent laryngeal nerve injury 8.8% (90/1023). The radical resection rate (R0) was 96.0% (982/1023), 30-day mortality was 0.3% (3/1023). For 1000 cases with squamous cell carcinoma, the estimated 3-year and 5-year overall survival was 37.2% and 17.8% respectively. In addition, neoadjuvant chemotherapy offered 3-year disease-free survival rate advantage in advanced stage patients (for stage IV: 7.2% vs. 1.8%). Conclusions This retrospective single center study demonstrates that MIE-McKeown procedure is feasible and safe with low perioperative and postoperative complications’ morbidity, and acceptable long-term oncologic results.
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Affiliation(s)
- Xiao-Dong Zheng
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Shi-Cong Li
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Chao Lu
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China
| | - Wei-Ming Zhang
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Jian-Bin Hou
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Ke-Feng Shi
- Department of Thoracic Surgery, Anyang Tumor Hospital, The Fourth Affiliated Hospital of Henan University of Science and Technology, HuanBin North Road, No. 1, Anyang, 455000, Henan, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, AnShan Road No. 154, Heping District, Tianjin, 30052, China.
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Herzberg J, Strate T, Guraya SY, Honarpisheh H. Risk factors for anastomotic leakage after surgical resections for esophageal cancer. Langenbecks Arch Surg 2021; 406:1859-1866. [PMID: 33990866 DOI: 10.1007/s00423-021-02139-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/21/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Surgery for esophageal cancer is a challenging procedure that is associated with a high rate of complications such as sepsis, nutritional disorders, and anastomotic leakage (AL). The rate of complications following esophageal surgery rises exponentially in the presence of risk factors. This study aims to identify the risk factors for AL following esophageal cancer surgery. METHODS In this retrospective study, we recorded comorbidities, tumor specific factors, nutritional status, and surgical complications of all patients who underwent surgical resections for esophageal cancers between January 2015 and December 2019. The occurrence of potential risk factors for AL was compared between groups with and without AL. We analyzed the categorical variables by Chi-square or Fisher's exact test, and the continuous variable by the Mann-Whitney U test and multivariable regression analyses. RESULTS From 92 patients, AL was found in 12 (13%) patients. All cases with AL had hypoproteinemia; a protein level < 5 g/dl was an independent risk factor for AL (p value 0.009). The logistic regression analysis showed a positive correlation between hypoproteinemia and AL (coefficient 1.83, significance 0.01). Additionally, squamous cell carcinoma (SCC) of the esophagus had a positive correlation with AL (coefficient 1.89, significance 0.01). CONCLUSION In our study, hypoproteinemia and SCC were significant risk factors for AL after esophageal cancer surgery. Optimization of preoperative hypoproteinemia using a standardized nutritional protocol is recommended. More research is essential to determine the correlation of SCC with AL.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany.
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Human Honarpisheh
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
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Walsh KJ, Zhang H, Tan KS, Pedoto A, Desiderio DP, Fischer GW, Bains MS, Jones DR, Molena D, Amar D. Use of vasopressors during esophagectomy is not associated with increased risk of anastomotic leak. Dis Esophagus 2020; 34:5907947. [PMID: 32944749 PMCID: PMC8024447 DOI: 10.1093/dote/doaa090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
Vasopressor use during esophagectomy has been reported to increase the risk of postoperative anastomotic leak and associated morbidity. We sought to assess the association between vasopressor use and fluid (crystalloid and colloid) administration and anastomotic leak following open esophagectomy. Patients who underwent open Ivor Lewis esophagectomy were identified from a prospective institutional database. The primary outcome was postoperative anastomotic leak (any grade) and analyzed using logistic regression models. Postoperative anastomotic leak developed in 52 of 327 consecutive patients (16%) and was not significantly associated with vasopressor use or fluid administered in either univariable or multivariable analyses. Increasing body mass index was the only significant characteristic of both univariable (P = 0.004) and multivariable analyses associated with anastomotic leak (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = 0.007). Of the 52 patients that developed an anastomotic leak, 12 (23%) were grade 1, 21 (40%) were grade 2 and 19 (37%) were grade 3. In our cohort, only body mass index, and not intraoperative vasopressor use and fluid administration, was significantly associated with increased odds of postoperative anastomotic leak following open Ivor Lewis esophagectomy.
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Affiliation(s)
- Kevin J Walsh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Hao Zhang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessia Pedoto
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Dawn P Desiderio
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Manjit S Bains
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Amar
- Address correspondence to: David Amar, MD, Director of Thoracic Anesthesia, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M-304, New York, NY 10021, USA.
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12
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Baltin C, Kron F, Urbanski A, Zander T, Kron A, Berlth F, Kleinert R, Hallek M, Hoelscher AH, Chon SH. The economic burden of endoscopic treatment for anastomotic leaks following oncological Ivor Lewis esophagectomy. PLoS One 2019; 14:e0221406. [PMID: 31461487 PMCID: PMC6713440 DOI: 10.1371/journal.pone.0221406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/06/2019] [Indexed: 02/07/2023] Open
Abstract
Background Complications after surgery for esophageal cancer are associated with significant resource utilization. The aim of this study was to analyze the economic burden of two frequently used endoscopic treatments for anastomotic leak management after esophageal surgery: Treatment with a Self-expanding Metal Stent (SEMS) and Endoscopic Vacuum Therapy (EVT). Materials and methods Between January 2012 and December 2016, we identified 60 German-Diagnosis Related Group (G-DRG) cases of patients who received a SEMS and / or EVT for esophageal anastomotic leaks. Direct costs per case were analyzed according to the Institute for Remuneration System in Hospitals (InEK) cost-accounting approach by comparing DRG payments on the case level, including all extra fees per DRG catalogue. Results In total, 60 DRG cases were identified. Of these, 15 patients were excluded because they received a combination of SEMS and EVT. Another 6 cases could not be included due to incomplete DRG data. Finally, N = 39 DRG cases were analyzed from a profit-center perspective. A further analysis of the most frequent DRG code -G03- including InEK cost accounting, revealed almost twice the deficit for the EVT group (N = 13 cases, € - 9.282 per average case) compared to that for the SEMS group (N = 9 cases, € - 5.156 per average case). Conclusion Endoscopic treatments with SEMS and EVT for anastomotic leaks following oncological Ivor Lewis esophagectomies are not cost-efficient for German hospitals. Due to longer hospitalization and insufficient reimbursements, EVT is twice as costly as SEMS treatment. An adequate DRG cost compensation is needed for SEMS and EVT.
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Affiliation(s)
- Christoph Baltin
- Department of Orthopedics and Trauma Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Kron
- FOM University of Applied Sciences, Essen, Germany
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | - Alexander Urbanski
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Anna Kron
- FOM University of Applied Sciences, Essen, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Robert Kleinert
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Michael Hallek
- Department of Internal Medicine Med I, University Hospital of Cologne, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
- * E-mail:
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