Prevention of gastroduodenal content reflux and delayed gastric emptying after esophagectomy: gastric tube reconstruction with duodenal diversion plus Roux-en-Y anastomosis

Perioperative corticosteroids for reducing postoperative complications following esophagectomy: an updated systematic review and meta-analysis

BACKGROUND

This updated systematic review and meta-analysis aims to evaluate the efficacy and safety of perioperative corticosteroid administration versus placebo for esophageal cancer patients following scheduled esophagectomy.

METHODS

We searched databases through June 30, 2023. We included articles on randomized controlled trials (RCTs) comparing perioperative corticosteroid administration with placebo in esophageal cancer patients with esophagectomy. The outcomes were the death rate during hospitalization, length of hospital stay, and short-term complications. Risk ratios (RRs) and corresponding 95% confidence interval (CIs) for each estimated effect size were applied for dichotomous outcomes, and the mean difference (MD) and corresponding 95% CIs for each estimated effect size were applied for continuous outcomes. We used GRADE to evaluate the quality of each of the outcome and the level of recommendations.

RESULTS

Nine RCTs with 508 participants were included in this study. Severe outcomes, including the length of hospital stay, leakage, mortality during the hospitalization period in the corticosteroid group was comparable to that in the control group, but positive effects of corticosteroid administration were observed on the length of intensive care unit stay (MD -3.1, 95% CI - 5.43 to - 0.77), cardiovascular disorders (RR 0.44, 95% CI 0.21-0.94) and other general complications (RR 0.49, 95% CI 0.29-0.85).

CONCLUSIONS

Peri-operative intravenous corticosteroid administration may reduce cardiovascular disorders, other general complications and the length of ICU stay without carrying severe outcomes. More high quality RCTs are warranted to further investigate the effects of corticosteroids on postoperative mortality and complications for esophageal cancer patients with esophagectomy.

SYSTEMATIC REVIEW REGISTRATION

Cochrane, registration number: 196.

Surgical intervention for late gastric conduit obstruction

OBJECTIVES

Gastric emptying delay after oesophagectomy may occur in conduits exposed to pleural forces of respiration or anatomic obstruction. Remedial operations addressing both causes are rarely reported. The study aim was to categorize severe gastric conduit obstruction (GCO) and report the outcome of surgical revision.

METHODS

A single-institution, retrospective study of gastric conduit revision following oesophagectomy for oesophageal cancer investigated incidence, risk factors and categories of conduit obstruction. Evaluation consisted of contrast studies, computed tomogram and endoscopy. Interventions were categorized according to obstructive cause and included pyloroplasty, hiatal hernia reduction and thoraco-abdominal conduit repositioning.

RESULTS

Among 1246 oesophagectomies over a 17-year period, 14 patients (1.1%) required post-oesophagectomy relief of GCO. Two additional patients presented after oesophagectomy elsewhere. Before oesophagectomy, 18.8% (3/16) and 62.5% (10/16) of patients were on chronic opioid and psychotropic medications, respectively. Distinct anatomic features separated obstruction into 3 categories: pyloric in 31% (5/16), extrinsic in 12.5% (2/16) and combined in 56.3% (9/16). Operative revision led to complete symptom resolution in 50% (8/16) of patients and symptom improvement in 43.8% (7/16) of patients. One patient (1/16, 6.25%) in the combined obstruction group did not improve with surgical revision.

CONCLUSIONS

GCO after oesophagectomy rarely requires surgical revision. Potential association with medications affecting oesophageal and gastric motility requires further investigation. Classification of obstruction identifies a patient subset with lower success after surgical revision.

Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy

OBJECTIVE

This prospective randomized phase-II trial examined whether gastric reconstruction with duodenal diversion plus Roux-en-Y anastomosis(RY) minimized gastroduodenal reflux and delayed gastric emptying compared with standard gastric reconstruction.

SUMMARY BACKGROUND DATA

There is no established standard surgical procedure to prevent both gastroduodenal reflux and delayed gastric emptying simultaneously.

METHODS

Sixty patients with thoracic esophageal cancer scheduled to undergo esophagectomy with retrosternal gastric tube reconstruction were randomly allocated to standard gastric reconstruction (non-RY, n = 31) or gastric reconstruction with duodenal diversion plus RY (n = 29) groups. Primary endpoint was quality of life assessed by DAUGS-32 score 1 year after surgery. Secondary endpoints were the extent of postoperative duodenal juice reflux into the gastric tube, postoperative morbidity, endoscopic findings, body weight changes, and nutritional status.

RESULTS

Preoperative clinicopathological characteristics and postoperative morbidity did not differ significantly between groups. However, operation time and blood loss volume were significantly higher in the RY group. Pancreatic amylase concentrations in the gastric conduit on postoperative days 2, 3, and 7 were higher in the non-RY group. Postoperative endoscopic examination showed residual gastric content in 7 of 17 patients in the non-RY group but in none in the RY group (P = 0.012). Quality of life was significantly favorable in the RY group with regard to reflux symptoms and food passage dysfunction. Postoperative body weight changes, serum albumin levels, and peripheral blood lymphocyte counts were not significantly different between groups.

CONCLUSION

Gastric reconstruction with duodenal diversion plus RY is effective in improving both gastroduodenal reflux and delayed gastric emptying.

Optimal mobilization of the stomach and the best place in the gastric tube for intrathoracic anastomosis

Esophagectomy with gastric tube reconstruction is a highly complex surgical procedure. With regard to mobilization of the stomach and optimal gastric tube preparation and anastomosis, there are several important intraoperative steps that can influence the outcome of the operation. This study aims to describe the optimal mobilization of the stomach for gastric tube reconstruction and explore the best place in the gastric tube for intrathoracic anastomosis after esophagectomy. A search of the literature was performed and results are described in a descriptive review. Based on literature and our own experience we describe important operating steps for laparoscopic stomach mobilisation for gastric tube reconstruction. Steps to create additional length include preserving the left gastroepiploic artery, transecting the right gastric artery, extended duodenal mobilization, and duodenal diversion with roux-Y reconstruction. Several techniques for intrathoracic anastomosis are described in literature. Several imaging techniques, of which fluorescence imaging is the most commonly used, are available to assess the vascularization of the gastric tube and to assist in determining the best place in the gastric tube for intra thoracic anastomosis. Although there is little evidence of exact technique on stomach mobilization and location for an intrathoracic anastomosis, many techniques are used by different authors with varying results.

The value of oral contrast ultrasonography in the diagnosis of gastric cancer in elderly patients

BACKGROUND

This study aims to investigate the value of oral contrast ultrasonography (OCUS) in the diagnosis of gastric cancer in elderly patients.

METHODS

OCUS data obtained from patients ≥ 60 years old were retrospectively analyzed and compared with gastroscopy results.

RESULTS

Among the 12,716 subjects examined by OCUS, 5021 subjects were ≥ 60 years old, which accounted for 39.48% (5021/12,716). Gastritis, gastric polyp, benign ulcer, and gastric cancer were detected by OCUS in 1099 patients. Among them, 196 patients underwent gastroscopy. Furthermore, ulcerative lesions were detected in 32 patients by OCUS and in 51 patients by gastroscopy, and the coincidence rate was 62.74%. Among these patients, gastric cancer was diagnosed in 18 patients by OCUS with a detection rate of 1.64% (18/1099) and detected in 19 patients by gastroscopy with a diagnostic coincidence rate of 94.73% (18/19). Furthermore, benign ulcer was detected in 14 patients by OCUS and in 32 patients by gastroscopy, and the diagnostic coincidence rate was 43.75% (14/32).

CONCLUSION

OCUS helps to timely detect senile gastric cancer and can be used as a suitable technique for the detection of gastric diseases.