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Richter F, Conrad C, Hoffmann J, Reichert B, von Schoenfels W, Schafmayer C, Egberts JH, Becker T, Ellrichmann M. Endoluminal Vacuum Therapy Using a New "Fistula Sponge" in Treating Defects of the Upper Gastrointestinal Tract-A Comparative, Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1105. [PMID: 39064534 PMCID: PMC11279286 DOI: 10.3390/medicina60071105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 06/17/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Anastomotic insufficiencies (AI) and perforations of the upper gastrointestinal tract (uGIT) result in high morbidity and mortality. Endoscopic stent placement and endoluminal vacuum therapy (EVT) have been established as surgical revision treatment options. The Eso-Sponge® is the only licensed EVT system with limitations in treating small defects (<10 mm). Therefore, a fistula sponge (FS) was developed for the treatment of such defects as a new therapeutic approach. The aim of this study was to evaluate both EVT options' indications, success rates, and complications in a retrospective, comparative approach. Materials and Methods: Between 01/2018 and 01/2021, the clinical data of patients undergoing FS-EVT or conventional EVT (cEVT; Eso-Sponge®, Braun Melsungen, Melsungen, Germany) due to AI/perforation of the uGIT were recorded. Indication, diameter of leakage, therapeutic success, and complications during the procedure were assessed. FSs were prepared using a nasogastric tube and a porous drainage film (Suprasorb® CNP, Lohmann & Rauscher, Rengsdorf, Germany) sutured to the distal tip. Results: A total of 72 patients were included (20 FS-EVT; 52 cEVT). FS-EVT was performed in 60% suffering from AI (cEVT = 68%) and 40% from perforation (cEVT = 32%; p > 0.05). FS-EVT's duration was significantly shorter than cEVT (7.6 ± 12.0 d vs. 15.1 ± 14.3 d; p = 0.014). The mean diameter of the defect was 9 mm in the FS-EVT group compared to 24 mm in cEVT (p < 0.001). Therapeutic success was achieved in 90% (FS-EVT) and 91% (cEVT; p > 0.05). Conclusions: EVT comprises an efficient treatment option for transmural defects of the uGIT. In daily clinical practice, fistulas < 10 mm with large abscess formations poses a special challenge since intraluminal cEVT usually is ineffective. In these cases, the concept of extraluminal FS placement is safe and effective.
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Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Claudio Conrad
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
| | - Julia Hoffmann
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Benedikt Reichert
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Witigo von Schoenfels
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Clemens Schafmayer
- Department of General Surgery, University Hospital Rostock, 18057 Rostock, Germany;
| | | | - Thomas Becker
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany; (F.R.); (J.H.); (B.R.); (W.v.S.); (T.B.)
| | - Mark Ellrichmann
- Department of Internal Medicine I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, 24105 Kiel, Germany;
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Ascari F, De Pascale S, Rosati R, Giacopuzzi S, Puccetti F, Weindelmayer J, Cusin S, Leone B, Fumagalli Romario U. Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2). J Gastrointest Surg 2024; 28:1072-1077. [PMID: 38705367 DOI: 10.1016/j.gassur.2024.04.024] [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: 03/12/2024] [Revised: 04/23/2024] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. METHODS Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. RESULTS A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. CONCLUSION The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.
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Affiliation(s)
- Filippo Ascari
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Stefano De Pascale
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Giacopuzzi
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Francesco Puccetti
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Jacopo Weindelmayer
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Sofia Cusin
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Barbara Leone
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Uberto Fumagalli Romario
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy.
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Van Daele E, Vanommeslaeghe H, Peirsman L, Van Nieuwenhove Y, Ceelen W, Pattyn P. Early postoperative systemic inflammatory response as predictor of anastomotic leakage after esophagectomy: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:757-765. [PMID: 38704210 DOI: 10.1016/j.gassur.2024.02.003] [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: 01/10/2024] [Revised: 01/22/2024] [Accepted: 02/03/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Postesophagectomy anastomotic leakage occurs in up to 16% of patients and is the main cause of morbidity and mortality. The leak severity is determined by the extent of contamination and the degree of sepsis, both of which are related to the time from onset to treatment. Early prediction based on inflammatory biomarkers such as C-reactive protein (CRP) levels, white blood cell counts, albumin levels, and combined Noble-Underwood (NUn) scores can guide early management. This review aimed to determine the diagnostic accuracy of these biomarkers. METHODS This study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the PROSPERO (International Prospective Register of Systematic Reviews) database. Two reviewers independently conducted searches across PubMed, MEDLINE, Web of Science, and Embase. Sources of bias were assessed, and a meta-analysis was performed. RESULTS Data from 5348 patients were analyzed, and 13% experienced leakage. The diagnostic accuracy of the serum biomarkers was analyzed, and pooled cutoff values were identified. CRP levels were found to have good diagnostic accuracy on days 2 to 5. The best discrimination was identified on day 2 for a cutoff value < 222 mg/L (area under the curve = 0.824, sensitivity = 81%, specificity = 88%, positive predictive value = 38.6%, and negative predictive value = 98%). A NUn score of >10 on day 4 correlated with poor diagnostic accuracy. CONCLUSION The NUn score failed to achieve adequate accuracy. CRP seems to be the only valuable biomarker and is a negative predictor of postesophagectomy leakage. Patients with a CRP concentration of <222 mg/L on day 2 are unlikely to develop a leak, and patients can safely proceed through their enhanced recovery after surgery protocol. Patients with a CRP concentration of <127 mg/L on day 5 can be safely discharged when clinically possible.
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Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Louise Peirsman
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
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Di J, Lu XS, Sun M, Zhao ZM, Zhang CD. Hospital volume-mortality association after esophagectomy for cancer: a systematic review and meta-analysis. Int J Surg 2024; 110:3021-3029. [PMID: 38353697 PMCID: PMC11093504 DOI: 10.1097/js9.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Postoperative mortality plays an important role in evaluating the surgical safety of esophagectomy. Although postoperative mortality after esophagectomy is partly influenced by the yearly hospital surgical case volume (hospital volume), this association remains unclear. METHODS Studies assessing the association between hospital volume and postoperative mortality in patients who underwent esophagectomy for esophageal cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random effects model. The dose-response association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with PROSPERO. RESULTS Fifty-six studies including 385 469 participants were included. A higher-volume hospital significantly reduced the risk of postesophagectomy mortality by 53% compared with their lower-volume counterparts (odds ratio, 0.47; 95% CI: 0.42-0.53). Similar results were found in subgroup analyses. Volume-outcome analysis suggested that postesophagectomy mortality rates remained roughly stable after the hospital volume reached a plateau of 45 esophagectomies per year. CONCLUSIONS Higher-volume hospitals had significantly lower postesophagectomy mortality rates in patients with esophageal cancer, with a threshold of 45 esophagectomies per year for a high-volume hospital. This remarkable negative correlation showed the benefit of a better safety in centralization of esophagectomy to a high-volume hospital.
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Affiliation(s)
| | | | - Min Sun
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, People’s Republic of China
| | - Zhe-Ming Zhao
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
| | - Chun-Dong Zhang
- Central Laboratory
- Department of Surgical Oncology, The Fourth Affiliated Hospital of China Medical University, Shenyang
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Ouazzani S, Lemmers A, Gonzalez JM, Closset J, El Moussaoui I, Devière J, Barthet M. Digestive neo-epithelialization after endoscopic stenting for upper digestive tract complete disunion. Endoscopy 2024. [PMID: 38485138 DOI: 10.1055/a-2288-4725] [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: 04/25/2024]
Abstract
BACKGROUND Complete digestive disunion due to anastomotic necrosis is considered a contraindication to endoscopic repair. However, recent publications have suggested that endoscopic treatment by insertion of a self-expandable metal stent (SEMS) is possible. The report of this patient series aims to demonstrate the use of endoscopic management in selected cases with complete digestive disunion. METHODS Seven consecutive patients with complete and circumferential upper gastrointestinal anastomotic disunion were treated at two European tertiary care centers between 2009 and 2021 by endoscopic insertion of an SEMS. Treatment was performed with a therapeutic gastroscope under general anesthesia, carbon dioxide insufflation, and fluoroscopic guidance, after surgical or percutaneous drainage. RESULTS All patients were successfully treated by endoscopic insertion of fully or partially covered SEMS left in place for a median of 8 weeks, with a median of 3 endoscopic sessions. Digestive neo-epithelialization was associated with a restored circumferential gut lumen in all cases. The rate of stent migration was 23% and three patients (43%) experienced symptomatic strictures, which were successfully treated by endoscopic dilation. CONCLUSION Complete digestive rupture could be successfully treated by endoscopy in selected cases, adding proof-of-concept data regarding guided tissue regeneration alongside SEMS placement.
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Affiliation(s)
- Sohaib Ouazzani
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
- Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix-Marseille Université, Marseille, France
| | - Arnaud Lemmers
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Michel Gonzalez
- Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix-Marseille Université, Marseille, France
| | - Jean Closset
- Department of Abdominal Surgery, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Imad El Moussaoui
- Department of Abdominal Surgery, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology and Hepatopancreatology, Erasme Hospital, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille (AP-HM), Aix-Marseille Université, Marseille, France
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Lee J, Jeon JH, Yoon SH, Shih BCH, Jung W, Hwang Y, Cho S, Kim K, Jheon S. The Optimal Treatment Strategy for Postoperative Anastomotic Leakage After Esophagectomy: a Comparative Analysis Between Endoscopic Vacuum Therapy and Conventional Treatment. J Gastrointest Surg 2023; 27:2899-2906. [PMID: 38040922 DOI: 10.1007/s11605-023-05637-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/18/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. METHODS A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). RESULTS The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4-142] days vs. 70 [8-604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). CONCLUSIONS EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.
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Affiliation(s)
- Joonseok Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
| | - Seung Hwan Yoon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Beatrice Chia-Hui Shih
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Woohyun Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Yoohwa Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sukki Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sanghoon Jheon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
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Yu WQ, Zhai LX, Shi GD, Tang JY, Gao HJ, Wei YC. Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy. Asian J Surg 2023; 46:3727-3733. [PMID: 37085421 DOI: 10.1016/j.asjsur.2023.03.185] [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: 10/11/2022] [Revised: 12/11/2022] [Accepted: 03/31/2023] [Indexed: 04/23/2023] Open
Abstract
OBJECTIVES For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. METHODS The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. RESULTS All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p < 0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p = 0.002) and more patients required an additional opioid analgesia after esophagectomy (p = 0.282). CONCLUSIONS In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.
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Affiliation(s)
- Wen-Quan Yu
- Department of Thoracic Surgery, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Li-Xue Zhai
- Department of Ultrasonography, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Guo-Dong Shi
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jia-Yu Tang
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hui-Jiang Gao
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China.
| | - Yu-Cheng Wei
- Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China.
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Åkesson O, Abrahamsson P, Johansson G, Haney M, Falkenback D, Hermansson M, Jeremiasen M, Johansson J. Surface microdialysis measures local tissue metabolism after Ivor Lewis esophagectomy; an attempt to predict anastomotic defect. Dis Esophagus 2023; 36:doac111. [PMID: 36572400 DOI: 10.1093/dote/doac111] [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: 12/22/2021] [Revised: 11/23/2022] [Accepted: 11/26/2022] [Indexed: 07/28/2023]
Abstract
Anastomotic defect (AD) after esophagectomy can lead to severe complications with need for surgical or endoscopic intervention. Early detection enables early treatment and can limit the consequences of the AD. As of today, there are limited methods to predict AD. In this study, we have used microdialysis (MD) to measure local metabolism at the intrathoracic anastomosis. Feasibility and possible diagnostic use were investigated. Sixty patients planned for Ivor Lewis esophagectomy were enrolled. After construction of the anastomosis, surface MD (S-MD) probes were attached to the outer surface of the esophageal remnant and the gastric conduit in close vicinity of the anastomosis and left in place for 7 postoperative days (PODs). Continuous sampling of local tissue concentrations of metabolic substances (glucose, lactate, and pyruvate) was performed postoperatively. Outcome, defined as AD or not according to Esophagectomy Complications Consensus Group definitions, was recorded at discharge or at first postoperative follow up. Difference in concentrations of metabolic substances was analyzed retrospectively between the two groups by means of artificial neural network technique. S-MD probes can be attached and removed from the gastric tube reconstruction without any adverse events. Deviating metabolite concentrations on POD 1 were associated with later development of AD. In subjects who developed AD, no difference in metabolic concentrations between the esophageal and the gastric probe was recorded. The technical failure rate of the MD probes/procedure was high. S-MD can be used in a clinical setting after Ivor Lewis esophagectomy. Deviation in local tissue metabolism on POD 1 seems to be associated with development of AD. Further development of MD probes and procedure is required to reduce technical failure.
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Affiliation(s)
- Oscar Åkesson
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Pernilla Abrahamsson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Göran Johansson
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Michael Haney
- Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
| | - Dan Falkenback
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Michael Hermansson
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Martin Jeremiasen
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jan Johansson
- Department of Surgery, Skåne University Hospital and Department of Clinical Sciences, Lund University, Lund, Sweden
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Wang Z, Sun S, Li K, Huang C, Liu X, Zhang G, Li X. Feasibility analysis of combined surgery for esophageal cancer. World J Surg Oncol 2023; 21:41. [PMID: 36765428 PMCID: PMC9912580 DOI: 10.1186/s12957-023-02930-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND As the preoperative examination of esophageal cancer has improved, the likelihood of finding diseases in other organs that require surgical treatment has also increased. The purpose of this study was to explore the feasibility of combined surgery for esophageal cancer by analyzing the occurrence of postoperative complications in patients with esophageal cancer. METHODS The clinical characteristics of 1566 patients with esophageal cancer who underwent thoracic surgery in our hospital between January 2017 and September 2022 were analyzed retrospectively. The feasibility of combined surgery for esophageal cancer was analyzed by comparing postoperative complications in patients who underwent simple esophageal cancer surgery (SEC) with those in patients who underwent combined surgery for esophageal cancer (COEC). The tendency scores of patients in the COEC and SEC groups (1:2) were matched to balance the confounding clinical factors, and the difference in postoperative complications was further analyzed. Moreover, we performed a subgroup analysis of esophagectomy combined with lung resection (ECL). In addition, the independent risk factors for postoperative Clavien-Dindo ≥ grade III complications of esophageal cancer were analyzed by multivariate logistic regression. RESULTS A total of 1566 patients (1147 (73.2%) males and 419 (26.8%) females), with an average age of 64.2 years, were analyzed. There was no significant difference in postoperative complications between the SEC and COEC groups according to the Clavien-Dindo classification (P=0.713). An analysis of the complications revealed that those in the COEC group had a higher incidence of lung consolidation than those in the SEC group (P=0.007). However, when we performed propensity score matching (PSM) on the SEC and COEC groups, there was still no significant difference in complications according to the Clavien-Dindo classification (P=0.346); furthermore, when a detailed analysis of complications was performed, there was no significant difference between the two. In subgroup analysis, after we performed PSM in ECL patients and SEC patients, we also found no significant difference in postoperative complications between patients with ECL and patients with SEC. In addition, we found that a history of diabetes (OR=1.604, P=0.029, 95% CI=1.049-2.454), a history of coronary heart disease (OR=1.592, P=0.046, 95% CI=1.008-2.515), diffusing capacity of the lungs for carbon monoxide (DLCO) (OR=0.916, P=0.024, 95% CI=0.849-0.988), and ALB level (OR=0.955, P=0.007, 95% CI=0.924-0.987) were independent factors that influenced postoperative complications in esophageal cancer patients with grade III or higher complications. CONCLUSION Combined surgery for esophageal cancer does not increase the incidence of postoperative complications. In addition, a history of diabetes mellitus or coronary heart disease, carbon monoxide dispersion, and preoperative ALB level are independent risk factors for grade III or higher postoperative complications of esophageal cancer.
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Affiliation(s)
- Zhulin Wang
- grid.412633.10000 0004 1799 0733Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan Province China
| | - Shaowu Sun
- grid.412633.10000 0004 1799 0733Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan Province China
| | - Kaiyuan Li
- grid.412633.10000 0004 1799 0733Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan Province China
| | - Chunyao Huang
- grid.412633.10000 0004 1799 0733Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan Province China
| | - Xu Liu
- grid.412633.10000 0004 1799 0733Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052 Henan Province China
| | - Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China.
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China.
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10
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Suction Drainage for Anastomotic Leakage After Ivor Lewis Esophagectomy. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:31-36. [PMID: 36730429 DOI: 10.1097/sle.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anastomotic leakage is one of the most life-threatening complications after Ivor Lewis esophagectomy (ILE), with various treatment strategies. Endoscopic techniques are emerging as a less invasive alternative to surgery. Among the current endoscopic techniques, a single placement of an endoluminal nasogastric tube inside the cavity with controlled suction drainage (SD) seems to be an attractive option. The aim of this study was to evaluate the efficacy of SD as treatment for anastomotic leakage after ILE. METHODS This retrospective analysis was performed among patients who underwent ILE in a high-volume esophageal cancer center in the Netherlands. Patients with an anastomotic leakage that received SD as primary treatment were selected. A nasogastric tube was endoscopically placed into the cavity of the leakage for controlled suction with 15 mm Hg. RESULTS A total of 34 patients received SD and was successful in 26 patients (77%). Seven patients (21%) developed empyema despite the SD for which additional video-assisted thoracoscopic surgery was performed. Mortality was 5.9% (2 patients) and median intensive care unit and hospital stay were 3 days (1 to 9) and 25 days (14 to 43), respectively. The median time to closure of the leak was 41 days (23 to 65). A total of 16 patients underwent home treatment for a median of 23 (14 to 42) days. CONCLUSIONS Controlled SD seems to be an effective treatment for anastomotic leakage after ILE. This therapy can safely and effectively be completed in an ambulant, outpatient setting.
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11
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The VACStent trial: combined treatment of esophageal leaks by covered stent and endoscopic vacuum therapy. Surg Endosc 2023; 37:3657-3668. [PMID: 36639580 PMCID: PMC10156910 DOI: 10.1007/s00464-023-09861-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic treatment of esophageal leaks, mostly by covered stents or endoscopic vacuum therapy (EVT), has largely improved the clinical outcome in the last decade. However, both techniques suffer from significant limitations. Covered stents are hampered by a high rate of migration and missing functional drainage, whereas endoluminal EVT devices are limited by obstruction of the GI tract. The new design of the VACStent makes it a fully covered stent within a polyurethane sponge cylinder, allowing EVT while stent passage is still open. Initial clinical applications have demonstrated the fundamental concept of the VACStent. METHOD A prospective multicenter open-label study was performed with the primary endpoint safe practicality, complete leak coverage, and effective suction-treatment of esophageal leaks. Secondary endpoints were prevention of septic conditions, successful leak healing, and complications, in particular stent-migration, local erosions and bleeding. RESULTS Fifteen patients with different, mostly postoperative anastomotic leaks were enrolled in three centers. A total of 41 VACStents were implanted. The mean number of VACStents per patient was 2.7, with a mean duration of VACStent treatment of 15 days. The primary endpoint was met in all VACStent applications (41/41 implants), resulting in a leak healing rate of 80% (12/15 patients). Septic episodes were prevented in 93% (14/15 patients) and there was no mortality. There were no severe device-related adverse events (SADE) nor significant local bleeding or erosion. Minor stent-dislocation and migration, respectively, was observed in 7%. Oral intake of liquids or food was documented in 87% (13/15 patients). One anastomotic stenosis was seen during follow-up. CONCLUSIONS VACStent treatment is a safe and effective treatment in esophageal leaks which can be covered by the sponge cylinder. Its application was described as easy and resembling that of conventional GI stents, with an impressive clinical success rate comparable to EVT outcomes. The VACStent offers a new option for clinical treatment of critical situations in esophageal perforations and anastomotic sutureline failures.
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12
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Chon SH, Brunner S, Müller DT, Lorenz F, Stier R, Streller L, Eckhoff J, Straatman J, Babic B, Schiffmann LM, Schröder W, Schmidt T, Bruns CJ, Fuchs HF. Time to endoscopic vacuum therapy-lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center. Surg Endosc 2023; 37:741-748. [PMID: 36344896 PMCID: PMC9640783 DOI: 10.1007/s00464-022-09754-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE OF THE STUDY In esophageal surgery, anastomotic leak (AL) remains one of the most severe and critical adverse events after oncological esophagectomy. Endoscopic vacuum therapy (EVT) can be used to treat AL; however, in the current literature, treatment outcomes and reports on how to use this novel technique are scarce. The aim of this study was to evaluate the outcomes of patients with an AL after IL RAMIE and to determine whether using EVT as an treatment option is safe and feasible. MATERIAL AND METHODS This study includes all patients who developed an Esophagectomy Complications Consensus Group (ECCG) type II AL after IL RAMIE at our center between April 2017 and December 2021. The analysis focuses on time to EVT, duration of EVT, and follow up treatments for these patients. RESULTS A total of 157 patients underwent an IL RAMIE at our hospital. 21 patients of these (13.4%) developed an ECCG type II AL. One patient died of unrelated Covid-19 pneumonia and was excluded from the study cohort. The mean duration of EVT was 12 days (range 4-28 days), with a mean of two sponge changes (range 0-5 changes). AL was diagnosed at a mean of 8 days post-surgery (range 2-16 days). Closure of the AL with EVT was successful in 15 out of 20 patients (75%). Placement of a SEMS (Self-expandlable metallic stent) after EVT was performed in four patients due to persisting AL. Overall success rate of anastomotic sealing independently of the treatment modality was achieved in 19 out of 20 Patients (95%). No severe EVT-related adverse events occurred. CONCLUSION This study shows that EVT can be a safe and effective endoscopic treatment option for ECCG type II AL.
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Affiliation(s)
- Seung-Hun Chon
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
- Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Stefanie Brunner
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
- Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Dolores T Müller
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Florian Lorenz
- Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Raphael Stier
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lea Streller
- Interdisciplinary Endoscopy Unit, Department of Gastroenterology and Hepatology, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Jennifer Eckhoff
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Jennifer Straatman
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Benjamin Babic
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Thomas Schmidt
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Christiane J Bruns
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Hans F Fuchs
- Interdisciplinary Endoscopy Unit, Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
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Kim MS, Shin S, Kim HK, Choi YS, Zo JI, Shim YM, Cho JH. Role of intraoperative feeding jejunostomy in esophageal cancer surgery. J Cardiothorac Surg 2022; 17:191. [PMID: 35987831 PMCID: PMC9392926 DOI: 10.1186/s13019-022-01944-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 08/15/2022] [Indexed: 12/25/2022] Open
Abstract
Background Feeding jejunostomy was routinely placed during esophagectomy to ensure postoperative enteral feeding. Improved anastomosis technique and early oral feeding strategy after esophagectomy has led to question the need for the routine placement of feeding jejunostomy. The aim of this study is to evaluate role of feeding jejunostomy during Ivor Lewis operation.
Methods We retrospectively reviewed 414 patients who underwent the Ivor Lewis operations from January 2015 to December 2018. Results 61 patients (14.7%) received jejunostomy insertion. The most common indication for jejunostomy was neoadjuvant concurrent chemoradiation therapy (CCRT). 48 patients (79%) had jejunostomy removed within 60 days after the surgery and the longest duration of jejunostomy inserted state was 121 days. About two-third of the patients with jejunostomy had never prescribed with an enteral feeding product. Among 353 patients without intraoperative feeding jejunostomy, 11(3.1%) received delayed jejunostomy insertion. Graft-related problems (6 patients), cancer progression (3 patients), acute lung injury (1 patient), and swallowing difficulty (1 patient) were reasons for delayed feeding jejunostomy insertion. Complication rate was relatively high as 24 patients (33.3%) out of 72 patients with jejunostomy insertion had complications and 7 patients (9.7%) visited ER more than twice with jejunostomy-related complications. Conclusion Only 3.6% patients who underwent the Ivor Lewis operation during 4-year span had anastomosis leakage. Although one-third of the patients with jejunostomy were benefited with alternative method of feeding after discharge, high complication rate regarding jejunostomy should be also considered. We believe feeding jejunostomy should not be applied routinely with prophylactic measures and should be reserved to very carefully selected patients with multiple high-risk factors.
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14
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Chon SH, Scherdel J, Rieck I, Lorenz F, Dratsch T, Kleinert R, Gebauer F, Fuchs HF, Goeser T, Bruns CJ. A new hybrid stent using endoscopic vacuum therapy in treating esophageal leaks: a prospective single-center experience of its safety and feasibility with mid-term follow-up. Dis Esophagus 2022; 35:6375055. [PMID: 34561712 DOI: 10.1093/dote/doab067] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/02/2021] [Indexed: 12/11/2022]
Abstract
Self-expandable metal stents (SEMS) and endoscopic vacuum therapy (EVT) are endoscopic options for treating leaks of the esophagus. VACStent® is a variant of SEMS that aims to combine the advantages of SEMS and EVT in one device. Due to this unique construction, VACStent® can build a barrier to the leak and facilitate wound healing with EVT, all while maintaining intestinal passage. We present the first prospective feasibility study of VACStent® for treating leaks of the upper gastrointestinal tract. Between September 2019 and November 2020, we performed a prospective, investigator-initiated, single-center study and included all patients who underwent endoscopic stenting with VACStent® for various kinds of esophageal leaks, such as spontaneous, iatrogenic or anastomotic leaks. We included 20 patients, who underwent a total of 24 endoscopic VACStent® implantations. Technical success of the application of the VACStent® was achieved in all interventions (n = 24, 100%). Overall, clinical success in closing the leaks with VACStent® treatment was achieved in 60% of patients (12/20). No severe VACStent® treatment-related adverse events occurred. Oral feeding with supplement high-energy drinks failed in all patients due to clogging of the suction tube. VACStent® is a safe and feasible endoscopic treatment option for leaks of the upper gastrointestinal tract. However, our data could not show the expected advantage of orally feeding the patients during the treatment with the VACStent® in its current form. Efficacy of VACStent® compared to EVT or SEMS needs to be investigated in a further study. ClinicalTrials.gov Identifier: NCT03962179.
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Affiliation(s)
- Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Julia Scherdel
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Isabel Rieck
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Florian Lorenz
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Dratsch
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Robert Kleinert
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Gebauer
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
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15
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Chon SH, Berlth F, Dratsch T, Plum PS, Lorenz F, Goeser T, Bruns CJ. Outcome of prophylactic endoscopic vacuum therapy for high-risk anastomosis after esophagectomy. MINIM INVASIV THER 2022; 31:1079-1085. [DOI: 10.1080/13645706.2022.2051719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Thomas Dratsch
- Department of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Patrick Sven Plum
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
| | - Florian Lorenz
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital of Cologne, Cologne, Germany
| | - Christiane J. Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Cologne, Germany
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16
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Jung CFM, Hallit R, Müller-Dornieden A, Calmels M, Goere D, Chaput U, Camus M, Gonzalez JM, Barthet M, Jacques J, Legros R, Barrioz T, Kück F, Seif Amir Hosseini A, Ghadimi M, Kunsch S, Ellenrieder V, Wedi E, Barret M. Endoscopic internal drainage and low negative-pressure endoscopic vacuum therapy for anastomotic leaks after oncologic upper gastrointestinal surgery. Endoscopy 2022; 54:71-74. [PMID: 33506454 DOI: 10.1055/a-1375-8151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Endoscopic internal drainage (EID) with double-pigtail stents or low negative-pressure endoscopic vacuum therapy (EVT) are treatment options for leakage after upper gastrointestinal oncologic surgery. We aimed to compare the effectiveness of these techniques. METHODS Between 2016 and 2019, patients treated with EID in five centers in France and with EVT in Göttingen, Germany were included and retrospectively analyzed using univariate analysis. Pigtail stents were changed every 4 weeks; EVT was repeated every 3-4 days until leak closure. RESULTS 35 EID and 27 EVT patients were included, with a median (interquartile range [IQR]) leak size of 0.75 cm (0.5-1.5). Overall treatment success was 100 % (95 % confidence interval [CI] 90 %-100 %) for EID vs. 85.2 % (95 %CI 66.3 %-95.8 %) for EVT (P = 0.03). The median (IQR) number of endoscopic procedures was 2 (2-3) vs. 3 (2-6.5; P = 0.003) and the median (IQR) treatment duration was 42 days (28-60) vs. 17 days (7.5-28; P < 0.001), for EID vs. EVT, respectively. CONCLUSION EID and EVT provide high closure rates for upper gastrointestinal anastomotic leaks. EVT provides a shorter treatment duration, at the cost of a higher number of procedures.
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Affiliation(s)
- Carlo Felix Maria Jung
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Rachel Hallit
- Department of Gastroenterology and Gastrointestinal Oncology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
| | - Annegret Müller-Dornieden
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Mélanie Calmels
- Department of Digestive Surgery, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Diane Goere
- Department of Digestive Surgery, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Ulriikka Chaput
- Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Marine Camus
- Department of Gastroenterology, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris and Sorbonne University, Paris, France
| | - Jean Michel Gonzalez
- Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Jérémie Jacques
- Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
| | - Romain Legros
- Department of Endoscopy and Gastroenterology, Dupuytren University Hospital, Limoges, France
| | - Thierry Barrioz
- Department of Gastroenterology, Poitiers University Hospital, Poitiers, France
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center, University of Göttingen, Göttingen, Germany
| | - Ali Seif Amir Hosseini
- Institute for Diagnostic and Interventional Radiology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Ghadimi
- Department of General, Visceral and Pediatric Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Steffen Kunsch
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany
| | - Edris Wedi
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, Göttingen, Germany.,Department of Gastroenterology, Gastrointestinal Oncology and Interventional Endoscopy, Sana Klinikum Offenbach, Offenbach, Germany
| | - Maximilien Barret
- Department of Gastroenterology and Gastrointestinal Oncology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France
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17
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Plat VD, van Rossen TM, Daams F, de Boer NK, de Meij TGJ, Budding AE, Vandenbroucke-Grauls CMJE, van der Peet DL. Esophageal microbiota composition and outcome of esophageal cancer treatment: a systematic review. Dis Esophagus 2021; 35:6425236. [PMID: 34761269 PMCID: PMC9376764 DOI: 10.1093/dote/doab076] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/24/2021] [Accepted: 10/10/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The role of esophageal microbiota in esophageal cancer treatment is gaining renewed interest, largely driven by novel DNA-based microbiota analysis techniques. The aim of this systematic review is to provide an overview of current literature on the possible association between esophageal microbiota and outcome of esophageal cancer treatment, including tumor response to (neo)adjuvant chemo(radio)therapy, short-term surgery-related complications, and long-term oncological outcome. METHODS A systematic review of literature was performed, bibliographic databases were searched and relevant articles were selected by two independent researchers. The Newcastle-Ottawa scale was used to estimate the quality of included studies. RESULTS The search yielded 1303 articles, after selection and cross-referencing, five articles were included for qualitative synthesis and four studies were considered of good quality. Two articles addressed tumor response to neoadjuvant chemotherapy and described a correlation between high intratumoral Fusobacterium nucleatum levels and a poor response. One study assessed surgery-related complications, in which no direct association between esophageal microbiota and occurrence of complications was observed. Three studies described a correlation between shortened survival and high levels of intratumoral F. nucleatum, a low abundance of Proteobacteria and high abundances of Prevotella and Streptococcus species. CONCLUSIONS Current evidence points towards an association between esophageal microbiota and outcome of esophageal cancer treatment and justifies further research. Whether screening of the individual esophageal microbiota can be used to identify and select patients with a predisposition for adverse outcome needs to be further investigated. This could lead to the development of microbiota-based interventions to optimize esophageal microbiota composition, thereby improving outcome of patients with esophageal cancer.
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Affiliation(s)
- Victor D Plat
- Address correspondence to: Mr Victor Dirk Plat, MD, Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, De Boelelaan 1117, ZH 7F020, 1081 HV Amsterdam, The Netherlands.
| | - Tessel M van Rossen
- Department of Medical Microbiology and Infection Control, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Nanne K de Boer
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism (AGEM) Research Institute, Amsterdam UMC, VU University Medical Center Amsterdam, The Netherlands
| | - Tim G J de Meij
- Department of Pediatric Gastroenterology and Hepatology, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Christina M J E Vandenbroucke-Grauls
- Department of Medical Microbiology and Infection Control, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
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18
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Chon SH, Töx U, Lorenz F, Rieck I, Wagner BJ, Kleinert R, Fuchs HF, Goeser T, Quaas A, Bruns CJ. A Novel Hybrid Stent with Endoscopic Vacuum Therapy for Treating Leaks of the Upper Gastrointestinal Tract. Visc Med 2021; 37:403-409. [PMID: 34722723 DOI: 10.1159/000512320] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/14/2020] [Indexed: 12/13/2022] Open
Abstract
Introduction Self-expanding metal stents (SEMS) are an established option for treating leaks in the upper gastrointestinal tract, and endoscopic vacuum therapy (EVT) has become a promising alternative. A novel approach is the use of an esophageal hybrid SEMS (VACStent®), which can maintain esophageal passage during EVT. We present the first study demonstrating successful use of the VACStent® for treating leaks of the upper gastrointestinal tract. Method We performed a retrospective, single-center study of all patients who underwent endoscopic stenting with the VACStent® of leaks in the upper gastrointestinal tract. Results Indications for treatment with the VACStent® were: iatrogenic esophageal perforation (n = 1), spontaneous perforation (n = 2), esophageal fistula (n = 2), and anastomotic leak after upper gastrointestinal surgery (n = 5). Successful application of the VACStent® was achieved in all patients (n = 10; 100%) with a total of 15 interventions. VACStent® therapy was used as a first-line treatment in 5 patient (success rate 80%; 4 out 5 patients) and as a second-line treatment after failed previous endoscopic therapy in 5 patients (success rate 60%; 3 out of 5 patients). Overall, VACStent® treatment was successful in 70% of the patients (7 out of 10). No severe VACStent® treatment-related adverse events occurred. Conclusion The initial experience has been that the technical application of the VACStent® is safe and technically feasible. However, due to the small number of patients this study could not show the clear advantages of this novel hybrid stent. More studies are necessary to show significant advantages.
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Affiliation(s)
- Seung-Hun Chon
- Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| | - Ulrich Töx
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Florian Lorenz
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Isabel Rieck
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | | | - Robert Kleinert
- Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, University Hospital Cologne, Cologne, Germany
| | - Alexander Quaas
- Department of Pathology, University Hospital Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer, and Transplant Surgery, University Hospital Cologne, Cologne, Germany
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19
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Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy. Nutrients 2021; 13:nu13103616. [PMID: 34684617 PMCID: PMC8539606 DOI: 10.3390/nu13103616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/06/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5–8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0–4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2–6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8–15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0–16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.
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20
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Veziant J, Gaillard M, Barat M, Dohan A, Barret M, Manceau G, Karoui M, Bonnet S, Fuks D, Soyer P. Imaging of postoperative complications following Ivor-Lewis esophagectomy. Diagn Interv Imaging 2021; 103:67-78. [PMID: 34654670 DOI: 10.1016/j.diii.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.
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Affiliation(s)
- Julie Veziant
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Martin Gaillard
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Anthony Dohan
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Maximilien Barret
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology and Digestive Oncology, Hôpital Cochin, APHP.Centre, 75014 Paris, France
| | - Gilles Manceau
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Mehdi Karoui
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Stéphane Bonnet
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Philippe Soyer
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
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21
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van Kooten RT, Voeten DM, Steyerberg EW, Hartgrink HH, van Berge Henegouwen MI, van Hillegersberg R, Tollenaar RAEM, Wouters MWJM. Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses. Ann Surg Oncol 2021; 29:1358-1373. [PMID: 34482453 PMCID: PMC8724192 DOI: 10.1245/s10434-021-10734-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy. BACKGROUND Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%. METHODS We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer. RESULTS Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m2 were associated with increased risk for mortality. CONCLUSIONS Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.
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Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - Daan M Voeten
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Department of Surgery, Dutch Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
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22
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Aziz M, Haghbin H, Sharma S, Weissman S, Saleem S, Lee-Smith W, Kobeissy A, Nawras A, Alastal Y. Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: Systematic review and meta-analysis. Endosc Int Open 2021; 9:E1371-E1380. [PMID: 34466361 PMCID: PMC8367451 DOI: 10.1055/a-1508-5947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/05/2021] [Indexed: 01/29/2023] Open
Abstract
Background and study aims Esophageal defects (leaks, fistulas, and perforations) are associated with significant morbidity and mortality. Endoluminal vacuum-assisted closure (EVAC) is a novel intervention that entails the use of sponges in the defect along with negative pressure to achieve granulation tissue formation and healing and has been gaining popularity. We performed a systematic review and pooled analysis of available literature to assess the safety and effectiveness of EVAC for esophageal defects. Patients and methods We queried PubMed/Medline, Embase, Cochrane, and Web of Science through September 25, 2020 to include all pertinent articles highlighting the safety and effectiveness profile of EVAC for esophageal defects. Pooled rates, 95 % confidence intervals (CIs), and heterogeneity ( I 2 ) were assessed for each outcome. Results A total of 18 studies with 423 patients were included (mean age 64.3 years and males 74.4 %). The technical success for EVAC was 97.1 % (CI: 95.4 %-98.7 %, I 2 = 0 %). The clinical success was 89.4 % (CI: 85.6 %-93.1 %, I 2 = 36.8 %). The overall all-cause mortality and adverse events (AEs) noted were 7.1 % (CI: 4.7 %-9.5 %, I 2 = 0 %) and 13.6 % (CI: 8.0 %-19.1 %, I 2 = 68.9 %), respectively. The pooled need for adjuvant therapy was 15.7 % (CI: 9.8 %-21.6 %, I 2 = 71.1 %). Conclusions This systematic review and meta-analysis showed high rates of technical success, clinical success, and low all-cause mortality and AEs using EVAC. Although the technique is a promising alternative, the lack of comparative studies poses a challenge in making definite conclusions regarding use of EVAC compared to other endoscopic modalities, such as clips and stents.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Hossein Haghbin
- Department of Internal Medicine, University of Toledo, Toledo, Ohio, United States
| | - Sachit Sharma
- Department of Internal Medicine, Promedica Toledo Hospital, Toledo, Ohio, United States
| | - Simcha Weissman
- Department of Internal Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, New Jersey, United States
| | - Saad Saleem
- Department of Internal Medicine, Sunrise Hospital and Medical center, Las Vegas, Nevada, United States
| | - Wade Lee-Smith
- Mulford Health Sciences Library, University of Toledo, Toledo, Ohio, United States
| | - Abdallah Kobeissy
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Yaseen Alastal
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
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23
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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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24
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Giulini L, Nasser CA, Tank J, Papp M, Stein HJ, Dubecz A. Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis. Eur J Cardiothorac Surg 2021; 59:1279-1285. [PMID: 33448299 DOI: 10.1093/ejcts/ezaa473] [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: 08/02/2020] [Revised: 11/15/2020] [Accepted: 11/25/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Robotic-assisted oesophagectomy for cancer has been increasingly employed worldwide; however, the benefits of this technique compared to conventional minimally invasive oesophagectomy are unclear. Since 2016, hybrid robotic minimally invasive oesophagectomy (R-HMIE) has increasingly replaced hybrid laparoscopic minimally invasive oesophagectomy (HMIE) as the standard of care in our institution. The aim of this study was to compare these procedures. METHODS Over a 10-year period, 686 patients underwent oesophagectomy at our institution. Out of these patients, 128 patients with cancer were treated with a hybrid minimally invasive technique. Each patient who underwent R-HMIE was matched according to gender, age, comorbidity, American Society of Anesthesiologists classification, Union International Contre le Cancer stage, localization, histology and neoadjuvant treatment with a patient who underwent HMIE. Perioperative parameters were extracted from our database and compared between the 2 groups. RESULTS After the matching procedure, 88 patients were included in the study. Between HMIE and R-HMIE, no significant differences (P > 0.05) were found in operating time (median 281 vs 300 min), R0 resection rate (n = 42 vs 42), harvested lymph nodes (median 28 vs 24), hospital stay (median 19 vs 17 days) and intensive care unit stay (median 7 vs 6.5 days). Regarding surgical complications, no difference could be observed either (n = 42 vs 44). CONCLUSIONS Minimally invasive oesophagectomy remains a challenging operation with high morbidity even in a high-volume institution. According to our intra- and short-term results, we have found no difference between R-HMIE and HMIE.
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Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Corinna A Nasser
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marton Papp
- Centre for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Hubert J Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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25
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Vrakopoulou GZ, Toutouzas KG, Giannios P, Panousopoulos SG, Theodoropoulos C, Danas E, Liakea A, Papalois AE, Zografos G, Larentzakis A. Impact of Deserosalization on Small Bowel Anastomosis Healing in Swine: A Pilot Study. In Vivo 2021; 34:2423-2429. [PMID: 32871768 DOI: 10.21873/invivo.12056] [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: 06/04/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Healing is related to gastrointestinal anastomotic leak, which is a severe and common complication. This study aimed to investigate the feasibility and the impact of deserosalization on healing of jejuno-jejunal anastomoses in an animal model. MATERIALS AND METHODS Seven swine underwent three types of side-to-side jejuno-jejunal anastomosis twice and survived seven days. Three different types of jejuno-jejunal side-to-side anastomoses were performed twice at 20-cm distance from each other in each animal: no serosa removal, one-sided, and two-sided serosa removal, respectively. Bursting pressure, tissue hydroxyproline concentration, and pathology scores were evaluated. RESULTS Hydroxyproline tissue concentration was a mean±standard deviation of 0.37±0.09, 0.38±0.08, and 0.30±0.05 nmoI/ml respectively (p<0.05). Bursting pressure was a mean±standard deviation of 59.02±8.60, 73.20±11.09, and 100.01±7.49 mmHg, respectively (p<0.001). The histopathological assessment did not find any statistically significant differences. CONCLUSION Deserosalization in jejuno-jejunal anastomosis was technically feasible and seemed to improve mechanical strength and collagen deposition in this experimental porcine model. Further investigation is warranted.
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Affiliation(s)
- Gavriella-Zoi Vrakopoulou
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos G Toutouzas
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Giannios
- Institute for Research in Biomedicine (IRB Barcelona), The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Sotirios-Georgios Panousopoulos
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalampos Theodoropoulos
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eugene Danas
- First Department of Pathology, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aliki Liakea
- First Department of Pathology, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Apostolos E Papalois
- Experimental, Educational and Research Center ELPEN, Pikermi, Greece.,School of Medicine, European University Cyprus, Nicosia, Cyprus
| | - George Zografos
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Larentzakis
- First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, Athens Medical School, National and Kapodistrian University of Athens, Athens, Greece
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26
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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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27
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Yu WQ, Gao HJ, Shi GD, Tang JY, Wang HF, Hu SY, Wei YC. Development and validation of a nomogram to predict anastomotic leakage after esophagectomy for esophageal carcinoma. J Thorac Dis 2021; 13:3549-3565. [PMID: 34277050 PMCID: PMC8264723 DOI: 10.21037/jtd-21-209] [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: 01/31/2021] [Accepted: 04/29/2021] [Indexed: 11/20/2022]
Abstract
Background This study aimed to identify variables associated with anastomotic leakage after esophagectomy and established a tool for anastomotic leakage prediction. Methods Twenty-six preoperative and postoperative variables were retrospectively collected from esophageal cancer patients who were treated with radical esophagectomy from January 2018 to June 2020 in the Affiliated Hospital of Qingdao University. SPSS Version 23.0 and Empower Stats software were used for establishing a nomogram after screening relevant variables by univariate and multivariate Logistic regression analyses. The established nomogram was identified by depicting the receiver operating characteristic (ROC) curves and calibration curve, which was verified by 1,000 bootstrap resamples method. Results A total of 604 eligible esophageal cancer patients were included, of which 51 (8.4%) patients had anastomotic leakage. Multivariate Logistic regression analysis showed that smoking, anastomotic location, anastomotic technique, prognostic nutritional index (PNI) and ASA score were independent risks of anastomotic leakage. The area under curve (AUC) of ROC in the established nomogram was 0.764 (95% CI, 0.69–0.83). The internal validation confirmed that the nomogram had a great discrimination ability (AUC =0.766). Depicted calibration curve demonstrated a well-fitted prediction and observation probability. In addition, the decision curve analysis concluded that the newly established nomogram is significant for clinical decision-making. Conclusions This nomogram provided the individual prediction of anastomotic leakage for esophageal cancer patients after surgery, which might benefit treatment results for patients and clinicians, as well as pre-and postoperative intervention strategy-making.
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Affiliation(s)
- Wen-Quan Yu
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hui-Jiang Gao
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Guo-Dong Shi
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jia-Yu Tang
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hua-Feng Wang
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Shi-Yu Hu
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Yu-Cheng Wei
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Aoyama T, Atsumi Y, Kawahara S, Tamagawa H, Tamagawa A, Ozawa Y, Maezawa Y, Kano K, Murakawa M, Kazama K, Segami K, Hara K, Numata M, Oshima T, Yukawa N, Masuda M, Rino Y. The Clinical Impact of the Age-adjusted Charlson Comorbidity Index on Esophageal Cancer Patients Who Receive Curative Treatment. In Vivo 2021; 34:2783-2790. [PMID: 32871815 DOI: 10.21873/invivo.12103] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/22/2020] [Accepted: 06/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/AIM We investigated the impact of the age-adjusted Charlson comorbidity index (ACCI) on esophageal cancer survival and recurrence after curative treatment. PATIENTS AND METHODS This study included 122 patients who underwent curative surgery followed by adjuvant chemotherapy for esophageal cancer between 2005 and 2017. The risk factors for the overall survival (OS) and recurrence-free survival (RFS) were identified. RESULTS An ACCI of 5 was regarded as the optimal critical point of classification considering the survival rates. The OS rates at 3 and 5 years after surgery were 64.2% and 54.4% in the low-ACCI group, respectively, and 42.3% and 29.2% in high-ACCI group, respectively (p=0.035). The RFS rates at 3 and 5 years after surgery were 50.2% and 43.6% in the low-ACCI group, respectively, and 28.5% and 21.3% in high-ACCI group, respectively (p=0.021). A multivariate analysis demonstrated that ACCI was a significant independent risk factor for both the OS and RFS. CONCLUSION ACCI is a risk factor for survival in patients who undergo curative treatment for esophageal cancer. An effective plan for the perioperative care and surgical strategy should be developed according to ACCI.
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Affiliation(s)
- Toru Aoyama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yosuke Atsumi
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | | | - Hiroshi Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Ayako Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yukihiro Ozawa
- Department of Surgery, Miura City Hospital, Miura, Japan
| | - Yukio Maezawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kazuki Kano
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masaaki Murakawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kenki Segami
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kentaro Hara
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masakatsu Numata
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Takashi Oshima
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Zhang C, Li XK, Hu LW, Zheng C, Cong ZZ, Xu Y, Luo J, Wang GM, Gu WF, Xie K, Luo C, Shen Y. Predictive value of postoperative C-reactive protein-to-albumin ratio in anastomotic leakage after esophagectomy. J Cardiothorac Surg 2021; 16:133. [PMID: 34001160 PMCID: PMC8130324 DOI: 10.1186/s13019-021-01515-w] [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: 04/05/2021] [Accepted: 05/07/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Among the many possible postoperative complications, anastomotic leakage (AL) is the most common and serious. Therefore, the purpose of this study was to explore the ability of various inflammatory and nutritional markers to predict postoperative AL in patients after esophagectomy. Methods A total of 273 patients were retrospectively evaluated and enrolled into this study. Perioperative, surgery-related, tumor-related and laboratory tests data were extracted and analyzed. The discriminatory ability and optimal cut-off value was evaluated according to the receiver operating characteristic (ROC) curve analysis. Univariate and multivariate analyses were performed to access the potential risk factors for AL. Results The overall incidence of AL was 12.5% (34/273). C-reactive protein-to-albumin ratio (CRP/ALB ratio) [AUC 0.943 (95% confidence interval (CI) = 0.911–0.976, p < 0.001)] and operation time [AUC 0.747 (95% CI = 0.679–0.815, p < 0.001)] had the greatest discrimination on AL prediction. Multivariate analysis demonstrated that CRP/ALB ratio and operation time were two independent risk factors for AL, and CRP/ALB ratio (OR = 102.909, p < 0.001) had an advantage over operation time (OR = 9.363, p = 0.020; Table 3). Conclusion Operation time and postoperative CRP/ALB ratio were two independent predictive indexes for AL. Postoperative CRP/ALB ratio greater than 3.00 indicated a high risk of AL. For patients with abnormal postoperative CRP/ALB ratio, early non-operative treatment or surgical intervention are needed to reduce the serious sequelae of AL.
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Affiliation(s)
- Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiao Kun Li
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.
| | - Li Wen Hu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Gao Ming Wang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou School of Clinical Medicine of Nanjing Medical University, Nanjing, China
| | - Wen Feng Gu
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Kai Xie
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Chao Luo
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China. .,Department of Thoracic Surgery, Xuzhou Central Hospital, Xuzhou School of Clinical Medicine of Nanjing Medical University, Nanjing, China. .,Department of Cardiothoracic Surgery, Jinling Hospital, School of Clinical Medicine, Southern Medical University, Guangzhou, China.
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30
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Li XK, Hua TT, Zhang C, Xu Y, Wu WJ, Zheng C, Wang GM, Qiang Y, Cong ZZ, Yi J, Shen Y. The ratio of gastric tube length to thorax length: a vital factor affecting leak after esophageal cervical anastomosis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:458. [PMID: 33850855 PMCID: PMC8039640 DOI: 10.21037/atm-20-6082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Esophagogastric anastomotic leak (AL) is a severe complication following esophageal resection. This study aims to explore preliminarily whether the ratio of the gastric conduit length to the thorax length can be regarded as a potential prognostic variable for AL, and if so, a cut-off value can be found to divide the patients into distinct risk groups. Methods We retrospectively reviewed the clinical data of 273 patients who underwent esophagectomy. The gastric conduit length, the thorax length, and other covariates were collected. Logistic regression was first conducted to probe the rationality of the ratio as a risk indicator of AL. Then the dichotomizing analysis was applied to find the optimal cut-off value. Results The incidence of AL was 12.5% (34/273). The coefficient of the ratio in the logistic regression equation was –7.901 with P<0.001, which indicated that the larger the ratio, the smaller the risk of AL. Further smoothed scatter plots revealed that a potential step function of the ratio of AL incidence exists, of which the steep part ranges from 1.74 to 1.90. Results of the accurate cut-off value search through a minimum P value approach give the optimal dichotomization point of 1.79. Conclusions The ratio of the gastric conduit length to the thorax length can reflect the tension in the anastomosis. The research proposes that surgeons can control the length of the gastric conduit during reconstruction to reduce the tension in the anastomosis and thus lead to a decrease in the incidence of AL.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Tian-Tian Hua
- Department of Epidemiology and Biostatistics, School of Public Health, Southeast University, Nanjing, China
| | - Chi Zhang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Chao Zheng
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Gao-Ming Wang
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jinling Hospital, Jinling School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
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31
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Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A. Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 2021; 21:72. [PMID: 33593301 PMCID: PMC7885467 DOI: 10.1186/s12876-021-01651-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).
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Affiliation(s)
- Chengcheng Christine Zhang
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Lukas Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Al Lawati Y, Alkaaki A, Luis Ramírez García Luna J, Skothos E, Mueller C, Spicer J, Mulder D, Ferri L, Cools-Lartigue J. The Predictive Value of Inflammatory Biomarkers in Esophageal Anastomotic Leaks. Ann Thorac Surg 2021; 112:1790-1796. [PMID: 33440175 DOI: 10.1016/j.athoracsur.2020.12.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 11/14/2020] [Accepted: 12/01/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study investigated the role of the neutrophil-to-lymphocyte ratio (NLR) in predicting anastomotic leak (AL) after esophagectomy for esophageal adenocarcinoma. METHODS This is a retrospective analysis of a prospectively collected database from the McGill University Health Center. Included were all patients with esophageal adenocarcinoma who underwent esophagectomy between 2005 and 2016. Patients with chronic infections, concurrent active malignancies, and autoimmune conditions were excluded. NLR values were obtained on postoperative days (POD) 0, 1, 2, and 3. Receiver operating characteristic curve study and multivariable logistic analysis were conducted to evaluate the diagnostic value of NLR. RESULTS The study included 330 patients, and AL developed in 16%. Mean NLR values on POD1, 2, and 3 were higher in patients with leaks (20 vs 14 on POD1, P < .001; 20 vs 12 on POD2, P < .001; and 19 vs 10 on POD3, P < .001). The NLR value on POD3 was associated with an area under the curve of 70% and a negative predictive value of 92.4%. Multivariable analyses identified higher American Society of Anesthesiologists Physical Status Classification, increasing NLR trend (between POD1 and POD3), POD1 NLR, POD2 NLR, and POD3 NLR as independent factors associated with AL. CONCLUSIONS Patients who developed AL demonstrate higher mean NLR values in the early postoperative period with rising trends. Conversely a low NLR is associated with a high negative predictive value for AL. This simple metric allows risk stratification that may guide treatment decisions in esophagectomy patients.
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Affiliation(s)
- Yaseen Al Lawati
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Aroub Alkaaki
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | | | - Elena Skothos
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Carmen Mueller
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - David Mulder
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University, Montreal, Quebec, Canada.
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33
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Hedberg J, Linder G, Sundbom M. Peri-anastomotic microdialysis lactate assessment after esophagectomy. Esophagus 2021; 18:783-789. [PMID: 34052933 PMCID: PMC8387264 DOI: 10.1007/s10388-021-00846-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Esophagectomy is the cornerstone in curative treatment for esophageal and gastroesophageal junctional cancer. Esophageal resection is an advanced procedure with many complications, whereof anastomotic leak is the most dreaded. This study aimed to monitor the microcirculation with microdialysis analysis of local lactate levels in real-time on both sides of the esophagogastric anastomosis in totally minimally invasive Ivor-Lewis esophagectomy. MATERIALS AND METHODS Twenty-five patients planned for esophageal resection with gastric conduit reconstruction and intrathoracic anastomosis were recruited. A sampling device, the OnZurf® Probe, along with the CliniSenz® Analyser (Senzime AB, Uppsala Sweden) was utilized for measurements. Lactate levels from both sides of the anastomosis were analysed in real time, on site, by a transportable analyser device. Measurements were made every 30 min during the first 24 h, and thereafter every 2 hours for up to 4 days. RESULTS All probes could be positioned as planned and on the third postoperative day 19/25 and 15/25 of the esophageal and gastric probes, respectively, continued to deliver measurements. In total, 89.6% (1539/1718) and 72.4% (1098/1516) of the measurements were deemed successful. The average lactate level on the esophageal side of the anastomosis and the gastric conduit ranged between 1.1-11.5 and 0.8-7.0 mM, respectively. Two anastomotic leaks occurred, one of which had persisting high lactate levels on the gastric side of the anastomosis. CONCLUSION Application and use of the novel CliniSenz® analyser system, in combination with the OnZurf® Probe was feasible and safe. Continuous monitoring of analytes from the perianastomotic area has the potential to improve care after esophageal resection.
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Affiliation(s)
- Jakob Hedberg
- Department of Surgical Sciences, Uppsala University, 75185 Akademiska Sjukhuset, Uppsala, Sweden
| | - Gustav Linder
- Department of Surgical Sciences, Uppsala University, 75185 Akademiska Sjukhuset, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, 75185 Akademiska Sjukhuset, Uppsala, Sweden
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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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35
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Aoyama T, Atsumi Y, Hara K, Tamagawa H, Tamagawa A, Komori K, Hashimoto I, Maezawa Y, Kazama K, Kano K, Murakawa M, Numata M, Oshima T, Yukawa N, Masuda M, Rino Y. Risk Factors for Postoperative Anastomosis Leak After Esophagectomy for Esophageal Cancer. In Vivo 2020; 34:857-862. [PMID: 32111795 DOI: 10.21873/invivo.11849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/03/2020] [Accepted: 01/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIM The present study aimed to identify risk factors for anastomosis leak (AL) after esophagectomy for esophageal cancer. PATIENTS AND METHODS One-hundred twenty-two patients who underwent esophagectomy for esophageal cancer between 2008 and 2018 were included. The rate of AL was measured based on the definition of leak as adapted from the Surgical Infection Study Group. To identify the risk factors for AL, logistic regression analysis was used. RESULTS AL was found in 44 of the 122 patients (36.1%). Among the factors examined, the lymph node dissection status (p=0.007) and preoperative serum albumin level (p=0.022) were significant independent risk factors for AL. The incidence of AL was 26.7% (20 of 75) among patients who received 2-field lymph node dissection and 51.1% (24 of 47) among those who received 3-field lymph node dissection. The incidence of AL was 29.9% (23 of 77) in the preoperative serum albumin levels ≥4.0 g/dl group and 46.7% (21 of 45) in the serum albumin levels <4.0 g/dl group. CONCLUSION Lymph node dissection status and preoperative serum albumin levels were risk factors for AL in patients who received esophagectomy for esophageal cancer.
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Affiliation(s)
- Toru Aoyama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yosuke Atsumi
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kentaro Hara
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroshi Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Ayako Tamagawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Keisuke Komori
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Itaru Hashimoto
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yukio Maezawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Keisuke Kazama
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Kazuki Kano
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masaaki Murakawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Masakatsu Numata
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Takashi Oshima
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama, Japan
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Use of Argon Plasma Coagulation and Endoscopic Hemoclips for Postsurgical Gastrointestinal Fistula. Case Rep Gastrointest Med 2020; 2020:8835437. [PMID: 33224539 PMCID: PMC7673945 DOI: 10.1155/2020/8835437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/01/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022] Open
Abstract
A 72-year-old male was diagnosed with a duodenal mass and underwent extensive surgical resection. The patient's post-op course was complicated by an anastomotic leak that was first treated conservatively; however, his condition continued to deteriorate. An upper endoscopy was performed, which showed misplacement of drain forming a fistulous track through the lumen of the bowel. We removed the drain and used argon plasma coagulation to de-epithelize the lumen and closed the fistula with hemostasis clips. The patient's clinical status improved significantly. Our case emphasizes the success of endoscopic techniques as an alternative option in the management of postsurgical anastomotic leaks and fistulas in the right clinical setting and patient population.
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Walsh KJ, Zhang H, Tan KS, Pedoto A, Desiderio DP, Fischer GW, Bains MS, Jones DR, Molena D, Amar D. Use of vasopressors during esophagectomy is not associated with increased risk of anastomotic leak. Dis Esophagus 2020; 34:5907947. [PMID: 32944749 PMCID: PMC8024447 DOI: 10.1093/dote/doaa090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/15/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
Vasopressor use during esophagectomy has been reported to increase the risk of postoperative anastomotic leak and associated morbidity. We sought to assess the association between vasopressor use and fluid (crystalloid and colloid) administration and anastomotic leak following open esophagectomy. Patients who underwent open Ivor Lewis esophagectomy were identified from a prospective institutional database. The primary outcome was postoperative anastomotic leak (any grade) and analyzed using logistic regression models. Postoperative anastomotic leak developed in 52 of 327 consecutive patients (16%) and was not significantly associated with vasopressor use or fluid administered in either univariable or multivariable analyses. Increasing body mass index was the only significant characteristic of both univariable (P = 0.004) and multivariable analyses associated with anastomotic leak (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = 0.007). Of the 52 patients that developed an anastomotic leak, 12 (23%) were grade 1, 21 (40%) were grade 2 and 19 (37%) were grade 3. In our cohort, only body mass index, and not intraoperative vasopressor use and fluid administration, was significantly associated with increased odds of postoperative anastomotic leak following open Ivor Lewis esophagectomy.
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Affiliation(s)
- Kevin J Walsh
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Hao Zhang
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alessia Pedoto
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Dawn P Desiderio
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA,Weill Cornell Medical College, New York, NY, USA
| | - Manjit S Bains
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Amar
- Address correspondence to: David Amar, MD, Director of Thoracic Anesthesia, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M-304, New York, NY 10021, USA.
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Abstract
Gastrointestinal (GI) leak is a well-known and catastrophic surgical complication. Its impact on patients, surgeons, and the healthcare system is tremendous. Efforts to constraint the occurrence and consequences of GI leak contributed to better assessment and management planning, especially with advanced technology. Detail information about the problem extent and new management options became available and effective for specific categories. Therefore, a full and accurate assessment and understanding of the disease presentation assists in choosing the appropriate management plan. The pathophysiologic process encompasses a severe inflammatory process with a superimposed infection inside sterile body tissue and cavities initiated by contaminated GI leaked content. The extent of the morbidity resulting from GI perforation and leak is variable and may not be predictable. Leak might not be the same in every case. Patients with GI leak present at variable severity depending on several factors. Accordingly, management should be individualized to target the underlying pathophysiology and the extent of the complication. Operative intervention and repair of the perforation site surgically or endoscopically are the standard of care frequently used. However, it may not always be needed. In this article, a practical review of the diversity and underlying pathologies of GI leak will be presented to inform case-specific management plans.
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Affiliation(s)
- Faiz Tuma
- General Surgery, Central Michigan University College of Medicine, Saginaw, USA
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Tsuji T, Saito H, Hayashi K, Kadoya S, Bando H. T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage following esophagectomy for esophagogastric junction cancer: A case report. Int J Surg Case Rep 2020; 73:79-83. [PMID: 32650259 PMCID: PMC7341059 DOI: 10.1016/j.ijscr.2020.06.095] [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: 05/19/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Intrathoracic esophagogastric anastomotic leakage is considered the most severe complication. We successfully performed T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage. PRESENTATION OF CASE A 44-year-old man visited a local hospital because of vomiting during the night. Upon examination, the patient was diagnosed with c-T2N0M0 stage II adenocarcinoma in Barrett's esophagus. We performed laparoscopic proximal gastrectomy and lower esophagectomy and gastric conduit reconstruction using the posterior mediastinal route with intrathoracic anastomosis under thoracoscopy. The patient developed fever, chest pain and dyspnea on postoperative day 5. We diagnosed anastomotic leakage and performed reoperation via thoracoscopy. The perforation, which was approximately 8 mm in length, was found on the back side of the esophagogastric anastomosis. There was no clear finding of necrosis in the gastric tube or the esophagus. After sufficiently deterging the thoracic cavity, a T-drain was inserted through the perforation and fixed. After fistula formation, the T-drain was slowly phased out. The postoperative course was uneventful. DISCUSSION It is important to note that early treatment of severe leaks is mandatory to limit related mortality. However, current therapies for treating anastomotic leakage are still inefficient and controversial. CONCLUSION T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage could be minimally invasive and effective.
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Affiliation(s)
- Toshikatsu Tsuji
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 9208530, Japan.
| | - Hiroshi Saito
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 9208530, Japan.
| | - Kengo Hayashi
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 9208530, Japan.
| | - Shinichi Kadoya
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 9208530, Japan.
| | - Hiroyuki Bando
- Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital, 2-1 Kuratsukihigashi, Kanazawa, Ishikawa, 9208530, Japan.
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Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study). Trials 2020; 21:448. [PMID: 32487210 PMCID: PMC7265255 DOI: 10.1186/s13063-020-04366-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality. Methods/design The NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient’s health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled. Discussion The two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF. Trial registration ClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.
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Omentoplasty Decreases Leak Rate After Esophagectomy: a Meta-analysis. J Gastrointest Surg 2020; 24:1237-1243. [PMID: 31197696 DOI: 10.1007/s11605-019-04284-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 05/26/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare the efficacy of omentoplasty with non-omentoplasty in the prevention of postoperative anastomotic leakage, and to investigate the safety of omentoplasty. METHODS Literature searches were performed of the Medline, EMBASE, and Cochrane Library databases. Studies that compared the efficacy of omentoplasty and non-omentoplasty after esophagectomy were selected. A meta-analysis was performed on anastomotic leakage, anastomotic stenosis, hospital mortality, and length of hospital stay. Results were reported as odds ratio (OR), weighted mean difference (WMD), or relative risk (RR), with 95% confidence intervals. RESULTS Six studies involving a total of 1608 patients met inclusion criteria. Compared with the non-omentoplasty group, the incidence of anastomotic leakage in the omentoplasty group (OR, 0.37; 95% CI, 0.23-0.60; P < 0.0001) was significantly reduced and the length of hospital stay (WMD, 2.13; 95% CI, 3.57-0.69; P = 0.004) was significantly shortened. However, there was no significant difference in the incidence of anastomotic strictures (OR, 0.82; 95% CI, 0.37-1.80; P = 0.61) or in-hospital mortality (OR, 0.61; 95% CI, 0.25-1.51; P = 0.29). CONCLUSIONS Omentoplasty after esophagectomy is a safe and effective method to prevent anastomotic leakage.
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Kamarajah SK, Bundred JR, Singh P, Pasquali S, Griffiths EA. Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis. BJS Open 2020; 4:563-576. [PMID: 32445431 PMCID: PMC7397345 DOI: 10.1002/bjs5.50298] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Current evidence on the benefits of different anastomotic techniques (hand‐sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes. Methods This was a systematic review and network meta‐analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non‐randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta‐analysis of postoperative anastomotic leaks and strictures was performed. Results Of 4192 articles screened, 15 randomized and 22 non‐randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001). Conclusion LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.
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Affiliation(s)
- S K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - J R Bundred
- College of Medical and Dental Sciences, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - P Singh
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Regional Oesophago-Gastric Unit, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - S Pasquali
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - E A Griffiths
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Huang C, Yao H, Huang Q, Lu H, Xu M, Wu J. A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy. BMC Surg 2020; 20:64. [PMID: 32252738 PMCID: PMC7137293 DOI: 10.1186/s12893-020-00726-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 03/25/2020] [Indexed: 01/25/2023] Open
Abstract
Background Anastomotic leakage is a dangerous postoperative complication of oesophageal surgery. The present study aimed to develop a simple and practical scoring system to predict the risk of anastomotic leakage after oesophageal resection. Methods A consecutive series of 330 patients who underwent oesophageal cancer surgery from January 2016 to January 2018 at the Shanghai Chest Hospital were included to develop a prediction model. Anastomotic leakage was evaluated using oesophagography, computed tomography, or flexible endoscopy. Least absolute shrinkage and selection operator regression based on a generalized linear model was used to select variables for the anastomotic leakage risk model while avoiding overfitting. Multivariable logistic regression analysis was applied to build forest plots and a prediction model. The concordance index or the area under the curve was used to judge the discrimination, and calibration plots verified the consistency. Internal validation of the model was conducted, and the clinical usefulness and threshold screening of the model were evaluated by decision curve analysis. Results The factors included in the predictive nomogram included Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia. The model displayed a discrimination performance with a concordance index of 0.690 (95% confidence interval: 0.620–0.760) and good calibration. A concordance index value of 0.664 was maintained during the internal validation. The calibration curve showed good agreement between the actual observations and the predicted results. Conclusion The present prediction model, which requires only seven variables and includes Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia, may be useful for predicting anastomotic leakage in patients after oesophagectomy.
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Affiliation(s)
- Chengya Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Haixia Yao
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Qi Huang
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Huijie Lu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Meiying Xu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China
| | - Jingxiang Wu
- Department of Anaesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, No. 241 Huaihai Rd. West, Shanghai, China.
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Critical appraisal of gastric conduit ischaemic conditioning (GIC) prior to oesophagectomy: A systematic review and meta-analysis. Int J Surg 2020; 77:77-82. [PMID: 32198097 DOI: 10.1016/j.ijsu.2020.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Anastomotic leaks remain a major complication following oesophagectomy, accounting for high morbidity and mortality. Recently, gastric ischaemic conditioning (GIC) has been proposed to improve anastomotic integrity through neovascularisation of the gastric conduit. This systematic review and meta-analysis aim to determine the impact of GIC on postoperative outcomes following oesophagectomy. METHODS A systematic literature search was performed to identify studies reporting GIC for any indication of oesophageal resection up to April 25, 2019. The primary outcome was anastomotic leak. Secondary outcomes were conduit necrosis, anastomotic strictures, overall and major complications or in-hospital mortality. Meta-analyses were conducted using random-effects modelling. RESULTS Nineteen studies reported on GIC, of which 13 were comparative studies. GIC was performed through ligation in 13 studies and embolisation in six studies. GIC did not appear to reduce anastomotic leakages (OR 0.80, CI95: 0.51-1.24, p = 0.3), anastomotic strictures (OR 0.75, CI95: 0.35-1.60, p = 0.5), overall complications (OR 1.02, CI95: 0.48-2.16, p = 0.9), major complications (OR 1.06, CI95: 0.53-2.11, p = 0.9), or in-hospital mortality (OR 0.70, CI95: 0.32-1.53, p = 0.4). However, GIC was associated with reduced rates of conduit necrosis (OR 0.30, CI95: 0.11-0.77, p = 0.013). CONCLUSION GIC does not appear to reduce overall rates of anastomotic leakage after oesophagectomy but seems to reduce severity of leakages. More in depth studies are recommended.
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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.
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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
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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The Effect of Postoperative Complications After Minimally Invasive Esophagectomy on Long-term Survival: An International Multicenter Cohort Study. Ann Surg 2020; 274:e1129-e1137. [PMID: 31972650 DOI: 10.1097/sla.0000000000003772] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.
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Al-Asiry J, Lord R, Mohammed N. Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract. Ther Adv Gastrointest Endosc 2020; 12:2631774519895845. [PMID: 31909396 PMCID: PMC6935768 DOI: 10.1177/2631774519895845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022] Open
Abstract
Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.
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Affiliation(s)
- Jamal Al-Asiry
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard Lord
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Noor Mohammed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Surface Microdialysis Detects Ischemia After Esophageal Resection—An Experimental Animal Study. J Surg Res 2020; 245:537-543. [DOI: 10.1016/j.jss.2019.07.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/11/2019] [Accepted: 07/18/2019] [Indexed: 01/16/2023]
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Guo W, Zhu L, Wu Y, Yang S, Du H, Zhou X, Che J, Hang J, Li H. Endoscope-assisted mediastinal drainage therapy for anastomosis leakage after esophagectomy: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:747. [PMID: 32042763 DOI: 10.21037/atm.2019.11.103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Anastomosis leakage after esophagectomy is a major threat which leads to many subsequent complications even mortality. But current diagnosis and treatment methods are inefficient. This retrospective study aims to evaluate the utilization of endoscope-assisted mediastinal drainage therapy in treatment for anastomosis leakage after esophagectomy. Methods Between January 2014 and June 2018, 51 patients were confirmed anastomosis leakage using gastroscopy. Of them, 23 patients were treated with endoscope-assisted mediastinal drainage therapy (drainage group); and the other 28 patients received endoscope-assisted biomedical fibrin glue occlusion (occlusion group). Short-term clinical outcomes were examined. Factors related to length of postoperative hospitalization (LPH) was analyzed. Results Endoscope provided highly accurate information on the condition of anastomosis leakage. And there was no evidence that early endoscopy could cause damage to the anastomosis or gastric conduit. One patient from drainage group and two from occlusion group discharged against medical advice. Other 48 patients were completely cured without reoperation or mortality. The median LPH was 32 days in drainage group (range from 17 to 80 days) and 81 days in occlusion group (range from 32 to 190 days), respectively (P<0.05). Linear regression indicated statistically significant correlation between LPH and length from diagnosis to drainage or occlusion (R=0.688, P<0.001). Conclusions Endoscope-assisted mediastinal drainage therapy is a satisfactory treatment for anastomosis leakage. Early diagnosis and treatment may facilitate the recovery of anastomosis leakage and reduce LPH.
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Affiliation(s)
- Wei Guo
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Lianggang Zhu
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Yuquan Wu
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Su Yang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hailei Du
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Xiang Zhou
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Jiaming Che
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Junbiao Hang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200025, China
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Harbison GJ, Vossler JD, Yim NH, Murayama KM. Outcomes of robotic versus non-robotic minimally-invasive esophagectomy for esophageal cancer: An American College of Surgeons NSQIP database analysis. Am J Surg 2019; 218:1223-1228. [DOI: 10.1016/j.amjsurg.2019.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/05/2019] [Accepted: 08/10/2019] [Indexed: 02/07/2023]
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