1
|
Murray W, Davey MG, Robb W, Donlon NE. Management of esophageal anastomotic leaks, a systematic review and network meta-analysis. Dis Esophagus 2024; 37:doae019. [PMID: 38525940 DOI: 10.1093/dote/doae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.
Collapse
Affiliation(s)
- William Murray
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Mathew G Davey
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - William Robb
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Noel E Donlon
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
2
|
Hoeppner J. [Technique of Colon Interposition for Oesophageal Replacement for Oesophageal Cancer]. Zentralbl Chir 2024; 149:178-186. [PMID: 38417814 DOI: 10.1055/a-2262-8552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024]
Abstract
Nowadays, it is only relatively rare and in selected situations that colonic interposition is chosen rather than the stomach as a reconstructive organ for replacing the oesophagus. The colon is a reliable organ for tubular replacement of the oesophagus when the stomach is not available for reconstruction. Colon interposition is a complex and complicated operation. It requires a specific indication and thorough preoperative preparation. From a technical point of view, colon interposition places high demands on the selection and surgical dissection of the vascular supply to the reconstructed organ. The reconstruction route and elevation of the interposition graft to the proximal oesophagus and the need to create 3 or 4 gastrointestinal anastomoses also place significantly higher demands than reconstruction using a gastric tube. Overall, despite the significant surgery-related morbidity, good functional results and a good quality of life can usually be achieved. The surgical technique applied in our own practice is described in detail. An overview from literature on the results of colonic interposition is given, particularly with regard to surgical complications and quality of life after colon interposition.
Collapse
Affiliation(s)
- Jens Hoeppner
- Klinik für Allgemein- und Viszeralchirurgie, Klinikum Lippe, Universitätsklinikum OWL - Campus Lippe, Detmold, Deutschland
| |
Collapse
|
3
|
Fujita T, Shigeno T, Kajiyama D, Sato K, Fujiwara N, Daiko H. A novel device to assess the oxygen saturation and congestion status of the gastric conduit in thoracic esophagectomy. BMC Surg 2024; 24:17. [PMID: 38191379 PMCID: PMC10775575 DOI: 10.1186/s12893-023-02303-0] [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: 08/22/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND In thoracic esophagectomy, anastomotic leakage is one of the most important surgical complications. Indocyanine green (ICG) is the most widely used method to assess tissue blood flow; however, this technique has been pointed out to have disadvantages such as difficulty in evaluating the degree of congestion, lack of objectivity in evaluating the degree of staining, and bias easily caused by ICG injection, camera distance, and other factors. Evaluating tissue oxygen saturation (StO2) overcomes these disadvantages and can be performed easily and repeatedly. It is also possible to measure objective values including the degree of congestion. We evaluate novel imaging technology to assess tissue oxygen saturation (StO2) in the gastric conduit during thoracic esophagectomy. METHODS Fifty patients were enrolled, with seven excluded due to intraoperative findings, leaving 43 for analysis. These patients underwent thoracic esophagectomy for esophageal cancer. The device was used intraoperatively to evaluate tissue oxygen saturation (StO2) and total hemoglobin index (T-HbI), which guided the optimal site for gastric tube anastomosis. The efficacies of StO2 and T-HbI in relation to short-term outcomes were analyzed. RESULTS StO2, indicating blood supply to the gastric tube, remained stable beyond the right gastroepiploic artery (RGEA) end but significantly decreased distally to the demarcation line (p < 0.05). T-HbI, indicative of congestion, significantly decreased past the RGEA (p < 0.05). Three patients experienced anastomotic leakage. These patients exhibited significantly lower StO2 (p < 0.01) and higher T-HbI (p < 0.01) at both the RGEA end and the demarcation line. Furthermore, the anastomotic site, usually within 3 cm of the RGEA's anorectal side, also showed significantly lower StO2 (p < 0.01) and higher T-HbI (p < 0.01) in patients with anastomotic leakage. CONCLUSIONS The novel device provides real-time, objective evaluations of blood flow and congestion in the gastric tube. It proves useful for safer reconstruction during thoracic esophagectomy, particularly by identifying optimal anastomosis sites and predicting potential anastomotic leakage.
Collapse
Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Takashi Shigeno
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Daisuke Kajiyama
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Naoto Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| |
Collapse
|
4
|
Tada N, Kobara H, Tashima T, Fukui H, Asai S, Ichinona T, Kojima K, Uchita K, Nishiyama N, Tani J, Morishita A, Kondo A, Okano K, Isomoto H, Sumiyama K, Masaki T, Dohi O. Outcomes of Endoscopic Intervention Using Over-the-Scope Clips for Anastomotic Leakage Involving Secondary Fistula after Gastrointestinal Surgery: A Japanese Multicenter Case Series. Diagnostics (Basel) 2023; 13:2997. [PMID: 37761364 PMCID: PMC10528500 DOI: 10.3390/diagnostics13182997] [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: 08/01/2023] [Revised: 09/13/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions. METHODS We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020. RESULTS The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates. CONCLUSION OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.
Collapse
Affiliation(s)
- Naoya Tada
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
| | - Tomoaki Tashima
- Department of Gastroenterology, Saitama Medical University International Medical Center, Saitama 350-1298, Japan;
| | - Hayato Fukui
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (H.F.); (O.D.)
| | - Satoshi Asai
- Department of Gastroenterology, Tane General Hospital, Osaka 550-0025, Japan; (S.A.); (T.I.)
| | - Takumi Ichinona
- Department of Gastroenterology, Tane General Hospital, Osaka 550-0025, Japan; (S.A.); (T.I.)
| | - Koji Kojima
- Department of Gastroenterology, Kochi Red Cross Hospital, Kochi 780-0026, Japan; (K.K.); (K.U.)
| | - Kunihisa Uchita
- Department of Gastroenterology, Kochi Red Cross Hospital, Kochi 780-0026, Japan; (K.K.); (K.U.)
| | - Noriko Nishiyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
| | - Joji Tani
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
| | - Asahiro Morishita
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
| | - Akihiro Kondo
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (A.K.); (K.O.)
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (A.K.); (K.O.)
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Faculty of Medicine, Tottori University, Tottori 683-8504, Japan;
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo 105-8461, Japan;
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu 761-0793, Japan; (H.K.); (N.N.); (J.T.); (A.M.); (T.M.)
| | - Osamu Dohi
- Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan; (H.F.); (O.D.)
| |
Collapse
|
5
|
Anoldo P, Vertaldi S, Manigrasso M, D'Amore A, De Palma GD, Milone M. Re-thoracoscopy for the management of gastric conduit dehiscence after minimally invasive McKeown esophagectomy. Int J Surg Case Rep 2023; 103:107876. [PMID: 36640467 PMCID: PMC9845996 DOI: 10.1016/j.ijscr.2023.107876] [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: 12/06/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Gastric conduit dehiscence after esophagectomy represents a severe complication associated with high mortality. Surgical management is achieved through thoracotomy, but often ends up in conduit sacrifice and diversion. CASE PRESENTATION A 59-years-old man underwent minimally invasive McKeown esophagectomy for esophageal adenocarcinoma. After a worsening of the postoperative course and evidence at the CT scan and endoscopy of highly suspect gastric conduit failure, the patient underwent an exploratory thoracoscopy, which revealed a partial dehiscence of the gastric conduit treated with resection of the dehiscent gastric wall by a linear stapler on the guide of a 36-french orogastric tube. Patient had a regular postoperative course without any complications and was discharged on the 6th postoperative day. CLINICAL DISCUSSION The management of conduit necrosis is extremely challenging. There are several interventional options and it is difficult to decide the most appropriate treatment for each individual patient. In our case we decided to perform a reintervention with a thoracoscopic approach, resecting the dehiscent area of the gastric conduit. CONCLUSIONS Minimally invasive surgery is a valid option for the management of post-operative complications, including those in emergency setting. Re-suturing a partial dehiscence of gastric conduit may be feasible if tissue conditions allow.
Collapse
Affiliation(s)
- Pietro Anoldo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy.
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Anna D'Amore
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| |
Collapse
|