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Hauge T, Dretvik T, Johnson E, Mala T. Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center. Dis Esophagus 2024:doae040. [PMID: 38745429 DOI: 10.1093/dote/doae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 04/13/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.
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Affiliation(s)
- Tobias Hauge
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Thomas Dretvik
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Egil Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
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2
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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3
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [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: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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4
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Momblan D, Gimeno Garcia AZ, Busquets D, Juzgado D, García Lledó J, Ferrero E, Tejedor-Tejada J, Junquera F, Díaz-Tasende J, Moris M, Rodriguez de Santiago E, Gornals J, Garrido C, Gonzalez-Vazquez S, Guarner-Argente C, Repiso A, Esteban JM, Loras C, Seoane A, Fernández-Simon A, Guevara HC, Ibarzabal A, Morales X, Curell A, Cardenas A, Ríos J, de Lacy AM, Sendino O. Endoscopic Vacuum Therapy for Upper Gastrointestinal Leaks and Perforations: Analysis From a Multicenter Spanish Registry. Am J Gastroenterol 2023; 118:1797-1806. [PMID: 37606066 DOI: 10.14309/ajg.0000000000002475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Endoscopic vacuum therapy (EVT) is a novel technique for closing upper gastrointestinal (UGI) defects. Available literature includes single-center retrospective cohort studies with small sample sizes. Furthermore, evidence about factors associated with EVT failure is scarce. We aimed to assess the efficacy and safety of EVT for the resolution of UGI defects in a multicenter study and to investigate the factors associated with EVT failure and in-hospital mortality. METHODS This is a prospective cohort study in which consecutive EVT procedures for the treatment of UGI defects from 19 Spanish hospitals were recorded in the national registry between November 2018 and March 2022. RESULTS We included 102 patients: 89 with anastomotic leaks and 13 with perforations. Closure of the defect was achieved in 84 cases (82%). A total of 6 patients (5.9%) had adverse events related to the EVT. The in-hospital mortality rate was 12.7%. A total of 6 patients (5.9%) died because of EVT failure and 1 case (0.9%) due to a fatal adverse event. Time from diagnosis of the defect to initiation of EVT was the only independent predictor for EVT failure (odds ratio [OR] 1.03, 95% confidence interval [CI] 1.01-1.05, P = 0.005). EVT failure (OR 24.5, 95% CI 4.5-133, P = 0.001) and development of pneumonia after EVT (OR 246.97, 95% CI 11.15-5,472.58, P = 0.0001) were independent predictors of in-hospital mortality. DISCUSSION EVT is safe and effective in cases of anastomotic leak and perforations of the upper digestive tract. The early use of EVT improves the efficacy of this technique.
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Affiliation(s)
- Dulce Momblan
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Antonio Z Gimeno Garcia
- Department of Gastroenterology, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
| | - David Busquets
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Doctor Josep Trueta, Girona, Spain
| | - Diego Juzgado
- Department of Gastroenterology, Hospital Quirón Madrid, Madrid, Spain
| | - Javier García Lledó
- Department of Gastroenterology, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Esther Ferrero
- Department of General and Digestive Surgery, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | | | - Félix Junquera
- Department of Gastroenterology, Hospital de Sabadell, Institut d´Investigació i Innovació Parc Taulí I3PT, CIBERehd, Sabadell, Spain
| | - José Díaz-Tasende
- Department of Gastroenterology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Maria Moris
- Department of Gastroenterology and Hepatology, Hospital Universitario Marques de Valdecilla, Santander, Spain
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, IRYCIS, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Joan Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carmen Garrido
- Endoscopy Unit, Department of Gastroenterology, Son Espases University Hospital, Illes Balears, Spain
| | | | | | - Alejandro Repiso
- Department of Gastroenterology, Hospital Virgen de la Salud, Toledo, Spain
| | - Jose Miguel Esteban
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Loras
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mútua de Terrassa, Terrassa, Spain
| | - Agustín Seoane
- Department of Gastroenterology, Hospital del Mar Medical Research Institute, Barcelona, Spain
| | | | - Henry Cordova Guevara
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Ainitze Ibarzabal
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Xavier Morales
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Anna Curell
- Department of Gastrointestinal Surgery, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Andrés Cardenas
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Ríos
- Department of Clinical Farmacology, Hospital Clinic and Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Maria de Lacy
- Department of Gastrointestinal Surgery, ICMDM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Oriol Sendino
- Endoscopy Unit, Department of Gastroenterology, IDIBAPS, CIBERehd, Hospital Clinic de Barcelona, Barcelona, Spain
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5
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Medas R, Ferreira-Silva J, Girotra M, Barakat M, Tabibian JH, Rodrigues-Pinto E. Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:19-34. [PMID: 37818397 PMCID: PMC10561327 DOI: 10.1159/000527202] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 08/22/2022] [Indexed: 10/12/2023]
Abstract
Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Joel Ferreira-Silva
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Mohit Girotra
- Digestive Health Institute, Swedish Medical Center, Seattle, Washington, USA
| | - Monique Barakat
- Division of Gastroenterology, Stanford University, Stanford, California, USA
| | - James H. Tabibian
- Division of Gastroenterology, Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California, USA
- UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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6
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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7
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Oikonomakis I, Jansson DT, Skoog P, Nilsson KF, Meehan AD, Hörer TM, Jansson K. Fully covered self‐expandable metal stent placed over a stapled colon anastomosis in an animal model: A pilot study of colon metabolism over the stent. JGH OPEN 2022; 6:338-343. [PMID: 35601129 PMCID: PMC9120904 DOI: 10.1002/jgh3.12747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 11/29/2022]
Abstract
Background and Aim Anastomotic leakage (AL) in colorectal resection and primary anastomosis is a common and feared complication. Fully covered self‐expandable metal stents (FCSEMSs) have been used for the treatment of AL. It is still unknown whether FCSEMSs affect anastomosis healing negatively by causing ischemia. In an animal study, we investigated the metabolic effects over a FCSEMS covering a stapled colon anastomosis. Methods Seven pigs were investigated using microdialysis after laparotomy, colon resection, and anastomosis with stent placement. Measurements were done at the proximal and distal ends of the anastomosis and at a reference catheter placed at the small intestine. Measurements of glucose, pyruvate, lactate, glycerol, and the lactate/pyruvate ratio (L/P) were carried out. Results Lactate and L/P were significantly higher at the oral part of the anastomosis, while glucose showed a small declining tendency. At the distal part of the anastomosis, glucose decreased significantly after the resection but did not reach zero. Lactate increased significantly whereas L/P increased only slightly. Glycerol levels were stable. Conclusion Colon resection caused initially hypermetabolism in the intestinal ends next to the resection site. This hypermetabolism neither deteriorated nor turned into ischemia during the initial postoperative course, but the start of hypoxemia could not be excluded during the study and after the placement of an FCSEMS.
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Affiliation(s)
- Ioannis Oikonomakis
- Department of Surgery, Colorectal Unit, Faculty of Medicine and Health Örebro University Örebro Sweden
| | | | - Per Skoog
- Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine Sahlgrenska University Hospital and Academy Gothenburg Sweden
- Örebro University and Sahlgrenska University, Faculty of Medicine and Health Örebro Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Adrian D Meehan
- Department of Geriatrics, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Kjell Jansson
- Department of Surgery, Colorectal Unit, Faculty of Medicine and Health Örebro University Örebro Sweden
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8
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Hayami M, Klevebro F, Tsekrekos A, Samola Winnberg J, Kamiya S, Rouvelas I, Nilsson M, Lindblad M. Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience. Dis Esophagus 2021; 34:6046267. [PMID: 33367786 DOI: 10.1093/dote/doaa122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 12/11/2022]
Abstract
Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.
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Affiliation(s)
- Masaru Hayami
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Johanna Samola Winnberg
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Satoshi Kamiya
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Mats Lindblad
- Department of Upper Abdominal Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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9
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Gjeorgjievski M, Imam Z, Cappell MS, Jamil LH, Kahaleh M. A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks. J Clin Gastroenterol 2021; 55:551-576. [PMID: 33234879 DOI: 10.1097/mcg.0000000000001451] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/02/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus. OBJECTIVE To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed. DESIGN A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes. RESULTS Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise. CONCLUSION Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
| | - Zaid Imam
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Mitchell S Cappell
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Laith H Jamil
- Departments of Gastroenterology & Hepatology
- Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Michel Kahaleh
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical Center, New Brunswick, NJ
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10
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Liesenfeld LF, Schmidt T, Zhang-Hagenlocher C, Sauer P, Diener MK, Müller-Stich BP, Hackert T, Büchler MW, Schaible A. Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery. J Surg Res 2021; 267:516-526. [PMID: 34256194 DOI: 10.1016/j.jss.2021.06.007] [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: 01/25/2021] [Revised: 04/25/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery. MATERIALS AND METHODS Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success. RESULTS In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05). CONCLUSION SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.
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Affiliation(s)
- Lukas F Liesenfeld
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Peter Sauer
- Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc 2021; 93:1283-1299.e2. [PMID: 33075368 DOI: 10.1016/j.gie.2020.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. METHODS This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019. RESULTS Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. CONCLUSIONS Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.
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12
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Zhong L, Zhong J, Tan Z, Wei Y, Su X, Wen Z, Rong T, Hu Y, Luo K. An Approach to Accelerate Healing and Shorten the Hospital Stay of Patients With Anastomotic Leakage After Esophagectomy: An Explorative Study of Systematic Endoscopic Intervention. Front Oncol 2021; 11:657955. [PMID: 34079758 PMCID: PMC8166318 DOI: 10.3389/fonc.2021.657955] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 04/19/2021] [Indexed: 12/09/2022] Open
Abstract
Objective To explore the comprehensive role of systemic endoscopic intervention in healing esophageal anastomotic leak. Methods In total, 3919 consecutive patients with esophageal cancer who underwent esophagectomy and immediate esophageal reconstruction were screened. In total, 203 patients (5.10%) diagnosed with anastomotic leakage were included. The participants were divided into three groups according to differences in diagnosis and treatment procedures. Ninety-four patients received conventional management, 87 patients received endoscopic diagnosis only, and the remaining 22 patients received systematic endoscopic intervention. The primary endpoint was overall healing of the leak after oncologic esophageal surgery. The secondary endpoints were the time from surgery to recovery and the occurrence of adverse events. Results 173 (85.2%; 95% CI, 80.3-90.1%) of the 203 patients were successfully healed, with a mean healing time of 66.04 ± 3.59 days (median: 51 days; range: 13-368 days), and the overall healing rates differed significantly among the three groups according to the stratified log-rank test (P<0.001). The median healing time of leakage was 37 days (95% CI: 33.32-40.68 days) in the endoscopic intervention group, 51 days (95% CI: 44.86-57.14 days) in the endoscopic diagnostic group, and 67 days (95% CI: 56.27-77.73 days) in the conventional group. The overall survival rate was 78.7% (95% CI: 70.3 to 87.2%) in the conventional management group, 89.7% (95% CI: 83.1 to 96.2%) in the endoscopic diagnostic group and 95.5% (95% CI: 86.0 to 100%) in the systematic endoscopic intervention group. Landmark analysis indicated that the speed of wound healing in the endoscopic intervention group was 2-4 times faster at any period than that in the conservative group. There were 20 (21.28%) deaths among the 94 patients in the conventional group, 9 (10.34%) deaths among the 87 patients in the endoscopic diagnostic group and 1 (4.55%) death among the 22 patients in the endoscopic intervention group; this difference was statistically significant (Fisher exact test, P < 0.05). Conclusion Tailored endoscopic treatment for postoperative esophageal anastomotic leakage based on endoscopic diagnosis is feasible and effective. Systematic endoscopic intervention shortened the treatment period and reduced mortality and should therefore be considered in the management of this disease.
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Affiliation(s)
- LeQi Zhong
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - JiuDi Zhong
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - ZiHui Tan
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - YiTong Wei
- Department of Thoracic Suegry, The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - XiaoDong Su
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - ZheSheng Wen
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - TieHua Rong
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute (GECI), Guangzhou, China
| | - Yi Hu
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute (GECI), Guangzhou, China
| | - KongJia Luo
- Sun Yat-Sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Guangdong Esophageal Cancer Institute (GECI), Guangzhou, China
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13
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Carter TS, Philips P, Egger M, Scoggins C, Martin RCG. Outcomes of Esophageal Stent Therapy for the Management of Anastomotic Leaks. Ann Surg Oncol 2021; 28:4960-4966. [PMID: 33730227 DOI: 10.1245/s10434-021-09669-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The purpose of this study was to present the optimal patient selection for esophageal stenting after esophageal resection to investigate possible factors leading to treatment success or treatment failure in these patients. METHODS This was a prospective, observational study of patients from January 2005 to May 2019 with an esophageal anastomotic leak that were treated with a self-expandable stent (SES). RESULTS A total of 34 patients were treated. All achieved technical success (100%); 33 (97%) achieved clinical success. No patient had to have reoperative surgery based on their leak management. The stenting in-hospital mortality was 0% with 1 patient (2%) with a 90-day mortality from possible leak-related death. Patients had their stents removed with a median of 106 days. CONCLUSIONS Stenting for an anastomotic leak after resection offers a safe and effective method of treatment and is successful in the majority of cases. Critical to success is optimal patient selection, adequate leak drainage, and optimal stent selection and placement.
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Affiliation(s)
- Toni S Carter
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Prejesh Philips
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Michael Egger
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Charles Scoggins
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Robert C G Martin
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA.
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Chen X, Yuan X, Chen Z, Zhu L. Endoscopic injection of human fibrin sealant in treatment of intrathoracic anastomotic leakage after esophageal cancer surgery. J Cardiothorac Surg 2020; 15:96. [PMID: 32408886 PMCID: PMC7227310 DOI: 10.1186/s13019-020-01127-w] [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: 03/16/2020] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To investigate the application of endoscopic injection of human fibrin sealant in treatment of patients with intrathoracic anastomotic leakage after esophagectomy. METHODS A total of 179 patients who underwent intrathoracic anastomosis after esophageal cancer surgery in our department From December 2012 to May 2015 were retrospectively analyzed. The clinical data and treatment of 7 patients with postoperative intrathoracic anastomotic leakage were analyzed and discussed. On Day 28 after operation, the 7 patients were given endoscopic injection of human fibrin sealant to seal the anastomotic leakage, and the changes in drainage volume, body temperature, CRP, white blood cell count and other indicators were compared before and after endoscopic intervention. RESULTS After endoscopic injection of human fibrin sealant in all 7 patients with intrathoracic anastomotic leakage, the volume of para-anastomotic drainage, CRP, and WBC count were improved compared with those before treatment. Relevant data were analyzed, and the differences were statistically significant (P = 0.019, P = 0.001, P = 0.014, respectively). No statistically significant difference was observed in the body temperature before and after treatment (P = 0.217). CONCLUSION For patients with intrathoracic anastomotic leakage after esophageal cancer surgery, endoscopic injection of human fibrin sealant to seal the anastomotic leakage has positive therapeutic effects of reducing exudation around the anastomotic leakage, reducing systemic inflammatory response, and improving clinical symptoms including dysphagia, weight loss without trying, chest pain, pressure or burning, worsening indigestion or heartburn and coughing or hoarseness.
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Affiliation(s)
- Xueyu Chen
- Department of Thoracic Surgery, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201801, China
| | - Xiaoqin Yuan
- Department of Gastroenterology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201801, China
| | - Zhongyuan Chen
- Department of Thoracic Surgery, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201801, China
| | - Lianggang Zhu
- Department of Thoracic Surgery, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, Shanghai, 201801, China.
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Álvarez Delgado A. Endoscopic closure systems for perforations, fistulas, and leaks. In expert hands or in all endoscopy units? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:335-337. [PMID: 32338013 DOI: 10.17235/reed.2020.7112/2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Improvement and innovation have been ongoing in gastrointestinal (GI) endoscopy for the last few years, including highly maneuverable endoscopes, high-definition visualization, digital chromoendoscopy, and wide working channels, which allow a correct identification, catheterization, and delimitation of early neoplastic lesions. Technological innovation has also provided novel devices, both to perform treatments and prevent complications.
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17
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Clinical score predicting a successful endoscopic approach of esophageal anastomotic leaks: external validation. Eur J Gastroenterol Hepatol 2020; 32:490-495. [PMID: 31834047 DOI: 10.1097/meg.0000000000001621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Recently, a clinical prediction rule has been proposed to predict the chance of successful endoscopic stenting in benign esophageal anastomotic leakage, perforation and fistula. We aimed to validate this score in a cohort of patients with anastomotic leaks managed with self-expanding metal esophageal stents, by assessing technical and clinical success rates and comparing the agreement between the predicted and the actual clinical success. METHODS A multicenter retrospective cohort study including patients submitted to endoscopic stenting due to anastomotic leak was conducted. Variables of the score (leak size, location and C-reactive protein) were collected and the chance of success (≤50, 50-70 and ≥70%) and its accuracy was assessed. RESULTS Fifty-three patients, submitted to esophageal stenting after cancer (n = 47) and bariatric surgery were included. Clinical success was achieved in 62% of patients. The area under the ROC curve to differentiate between successful and failed therapies showed a good discriminative power of the score (AUC 0.705; P < 0.01). For a predicted chance of success >50%, the positive predictive value was 72.5%; for a chance of success ≤50%, the negative predictive value was 69.2%. CONCLUSIONS The application of this predictive model in patients with anastomotic leaks proved to be valid in a different cohort from that in which it was derived. Its usefulness in clinical practice may be anticipated, favoring stenting in patients with a chance of success >50%. However, we must be cautious in patients with a lower probability of success and a case-by-case decision should be made.
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18
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Plum PS, Herbold T, Berlth F, Christ H, Alakus H, Bludau M, Chang DH, Bruns CJ, Hölscher AH, Chon SH. Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy. World J Surg 2019; 43:862-869. [PMID: 30377723 DOI: 10.1007/s00268-018-4832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. METHODS Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. RESULTS Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. CONCLUSIONS The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
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Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - De-Hua Chang
- Institute of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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Nunes G, Patita M, Pinto-Marques P. Avoiding Stent-in-Stent Retrieval Strategy for Partially Covered Stents in Anastomotic Leakages: An Innovative Approach. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:212-214. [PMID: 31192291 PMCID: PMC6528086 DOI: 10.1159/000490922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 06/01/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Gonçalo Nunes
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Marta Patita
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Pedro Pinto-Marques
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
- Gastroenterology Department, Hospital da Luz, Lisbon, Portugal
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20
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Vermeulen BD, Siersema PD. Diagnosis and endoscopic treatment of esophageal leakage: a systematic review. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.
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Affiliation(s)
- Jeffrey R Watkins
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA 98104, USA.
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Rausa E, Asti E, Aiolfi A, Bianco F, Bonitta G, Bonavina L. Comparison of endoscopic vacuum therapy versus endoscopic stenting for esophageal leaks: systematic review and meta-analysis. Dis Esophagus 2018; 31:5043493. [PMID: 29939229 DOI: 10.1093/dote/doy060] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/05/2018] [Indexed: 12/11/2022]
Abstract
Esophageal leaks remain a life-threatening postoperative complication of esophagectomy. Currently, self-expanding metal stents (SEMS) represent the endoscopic mainstay of treatment. Recently, endoscopic vacuum therapy (EVT) has emerged and shown promising results in these patients. We conducted an electronic systematic search using MEDLINE databases (PubMed, EMBASE, and Web of Science) looking for studies comparing EVT and SEMS for the treatment of esophageal leak and/or perforation. Four studies including 163 patients matched the inclusion criteria. Esophageal leak closure rate is significantly higher with EVT than SEMS [pooled odds ratio 5.51 (95% CI 2.11-14.88; P < 0.001)]. Additionally, EVT has a shorter treatment duration [pooled mean difference -9.0 days (95% CI 16.6-1.4; P = 0.021)], lower major complication (P = 0.011), and in-hospital mortality (P = 0.002) rate compared to SEMS. EVT for esophageal leak is feasible and safe. It has the potential to become the new gold standard in the endoscopic treatment of esophageal leaks and perforations. However, further comparative studies with SEMS are needed to strengthen the current evidence.
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Affiliation(s)
- E Rausa
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - E Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - A Aiolfi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - F Bianco
- Department of General Surgery, ASST - Bergamo Est Ospedale Bolognini Seriate, Bergamo, Italy
| | - G Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
| | - L Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano)
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Abstract
PURPOSE OF REVIEW Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects. RECENT FINDINGS The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.
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Affiliation(s)
- Ignacio Fernández-Urién
- Complejo Hospitalario de Navarra – Gastroenterology, Pamplona, Navarra, Spain,Corresponding author Ignacio Fernández-Urién Hospital of Navarra – GastroenterologyIrunlarrea 3 Pamplona 31002Spain34-948296500
| | - Juan Vila
- Complejo Hospitalario de Navarra – Gastroenterology, Pamplona, Navarra, Spain
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Bemelman WA, Baron TH. Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae. Gastroenterology 2018; 154:1938-1946.e1. [PMID: 29454791 DOI: 10.1053/j.gastro.2018.01.067] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 02/06/2023]
Abstract
Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.
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Affiliation(s)
- Willem A Bemelman
- Department of Surgery, The Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill North Carolina. todd_baron.@med.unc.edu
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Delayed perforation after endoscopic submucosal dissection treated successfully by temporary stent placement. Clin J Gastroenterol 2017; 11:118-122. [DOI: 10.1007/s12328-017-0808-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/04/2017] [Indexed: 12/28/2022]
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Persson S, Rouvelas I, Irino T, Lundell L. Outcomes following the main treatment options in patients with a leaking esophagus: a systematic literature review. Dis Esophagus 2017; 30:1-10. [PMID: 28881894 DOI: 10.1093/dote/dox108] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 07/28/2017] [Indexed: 12/11/2022]
Abstract
Leakage from the esophagus and gastroesophageal junction can be lethal due to uncontrolled contamination of the mediastinum. The most predominant risk factors for the subsequent clinical outcome are the patients' delay as well as the delay of diagnosis. Two major therapeutic concepts have been advocated: either prompt closure of the leakage by insertion of a self-expandable metal stent (SEMS) or more traditionally, surgical exploration. The objective of this review is to carefully scrutinize the recent literature and assess the outcomes of these two therapeutic alternatives in the management of iatrogenic perforation-spontaneous esophageal rupture as separated from those with anastomotic leak. A systematic web-based search using PubMed and the Cochrane Library was performed, reviewing literature published between January 2005 and December 2015. Eligible studies included all studies that presented data on the outcome of SEMS or surgical exploration in case of esophageal leak (including >3 patients). Only patients older than 15 years of age by the time of admission were included. Articles in other languages but English were excluded. Treatment failure was defined as a need for change in therapeutic strategy due to uncontrolled sepsis and mediastinitis, which usually meant rescue esophagectomy with end esophagostomy, death occurring as a consequence of the leakage or development of an esophagorespiratory fistula and/or other serious life threatening complications. Accordingly, the corresponding success rate is composed of cases where none of the failures above occurred. Regarding SEMS treatment, 201 articles were found, of which 48 were deemed relevant and of these, 17 articles were further analyzed. As for surgical management, 785 articles were retrieved, of which 82 were considered relevant, and 17 were included in the final analysis. It was not possible to specifically extract detailed clinical outcomes in sufficient numbers, when we tried to separately analyze the data in relation to the cause of the leakage: i.e. iatrogenic perforation-spontaneous esophageal rupture and anastomotic leak. As for SEMS treatment, originally 154 reports focused on iatrogenic perforation, 116 focused on spontaneous ruptures, and only four described the outcome following trauma and foreign body management. Only five studies used a prospective protocol to assess treatment efficacy. Regarding a leaking anastomosis, 80 reports contained information about the outcome after treatment of esophagogastrostomies and 35 reported the clinical course after an esophagojejunostomy. An overall success rate of 88% was reported among the 371 SEMS-treated patients, where adequate data were available, with a reported in hospital mortality amounting to 7.5%. Regarding the surgical exploration strategy, the vast majority of patients had an attempt to repair the defect by direct or enforced suturing. This surgical approach also included procedures such as patching with pleura or with a diaphragmatic flap. The overall reported success rate was 83% (305/368) and the in-hospital mortality was 17% (61/368). The current literature suggests that a SEMS-based therapy can be successfully applied as an alternative therapeutic strategy in esophageal perforation rupture.
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Affiliation(s)
- S Persson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - I Rouvelas
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - T Irino
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L Lundell
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
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Abstract
OPINION STATEMENT Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.
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Abstract
Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents. Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse complications. This review summarizes the modern history of esophageal stent use in the treatment of esophageal perforation as well as the evidenced based recommendations for the use of esophageal stent placement in the treatment of acute esophageal perforation.
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Affiliation(s)
- Gabie K B Ong
- Department of Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA
| | - Richard K Freeman
- Division of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA
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