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Ayoade OF, Canavan ME, De Santis WP, Zhan PL, Boffa DJ. Surgical and endoscopic management of clinical T1b esophageal cancer. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00533-6. [PMID: 38925509 DOI: 10.1016/j.jtcvs.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/16/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVE Esophageal cancers that invade the submucosa (T1b) have increased risk for occult lymph node metastases. To avoid the morbidity and recovery from esophagectomy, patients with cT1bN0 tumors have been increasingly managed endoscopically. We hypothesized that tumor attributes could predict upstaging and outcome associated with surgical and endoscopic treatment. Our objective was to evaluate the comparative effectiveness of esophagectomy across different cT1bN0 tumor attributes. METHODS Treatment-naïve patients who underwent endoscopic management or esophagectomy for a clinical stage cT1bN0 esophageal cancer diagnosed between 2010 and 2018 in the National Cancer Database were identified. Factors associated with upstaging were assessed by logistic regression. Adjusted survival was assessed by Kaplan-Meier analysis of 528 propensity-matched pairs and accelerated time failure models, stratified across tumor attributes. RESULTS Overall, 1469 patients classified as cT1bN0 were identified; 926 underwent esophagectomy and 543 were managed endoscopically. In general, patients who were managed endoscopically were older (median, 71; interquartile range, 63-78; vs 66; interquartile range, 60-72; P < .0001) with smaller tumors compared with the patients who were managed with esophagectomy. Nodal upstaging was associated with lymphovascular invasion (odds ratio [OR], 6.88; confidence interval [CI], 4.39-10.77; P < .0001), poor tumor differentiation (OR, 2.77; CI, 1.30-5.88; P = .0081), and tumor size >1 cm (OR, 3.19; CI, 1.49-6.83, P = .0028). Overall survival was better among propensity-matched patients who underwent esophagectomy (5-year 68.4% vs 59.7% endoscopic, P < .001). However, accelerated time failure models suggested similar outcomes among patients with well-differentiated tumors managed surgically or endoscopically. CONCLUSIONS Esophagectomy was associated with improved survival for cT1bN0 esophageal cancer; however, endoscopic treatment may achieve similar survival in patients with favorable tumor attributes. Further study is warranted.
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Affiliation(s)
- Oluwaseun F Ayoade
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Maureen E Canavan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn; Yale Cancer Outcomes Public Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Conn
| | - Will P De Santis
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Peter L Zhan
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Daniel J Boffa
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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Gibiino G, Binda C, Secco M, Giuffrida P, Coluccio C, Perini B, Fabbri S, Liverani E, Jung CFM, Fabbri C. Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1941. [PMID: 38003990 PMCID: PMC10672978 DOI: 10.3390/medicina59111941] [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: 09/05/2023] [Revised: 10/25/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023]
Abstract
Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.
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Affiliation(s)
- Giulia Gibiino
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Matteo Secco
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Paolo Giuffrida
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Barbara Perini
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University Hospital of Padua, 35128 Padua, Italy
| | - Stefano Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Elisa Liverani
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit Ospedale Morgagni—Pierantoni, Forlì—Ospedale M. Bufalini, Cesena—AUSL, 47521 Romagna, Italy; (G.G.); (M.S.); (P.G.); (C.C.); (B.P.); (S.F.); (E.L.); (C.F.M.J.); (C.F.)
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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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Wu G, Niu L, Yang Y, Tian S, Liu Y, Wang C, Zhao P. Risk Factors of Benign Stricture of Anastomotic Stoma after Esophagectomy and Therapeutic Effect of Stent Implantation. Emerg Med Int 2022; 2022:2605592. [PMID: 36081957 PMCID: PMC9448601 DOI: 10.1155/2022/2605592] [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: 06/20/2022] [Accepted: 07/30/2022] [Indexed: 11/28/2022] Open
Abstract
With the increase in the number of patients and prolongation of their lives after esophagectomy for esophageal cancer, the quality of life after surgery has attracted more and more attention. Although anastomotic stenosis is a common complication, it seriously affects the quality of life and psychological state of patients or even threatens their lives. At present, the exact independent influencing factors of anastomotic stenosis after esophageal cancer surgery have not been determined, and relevant treatment options are still controversial. Here, we analyzed the independent risk factors leading to good postoperative anastomotic stenosis, in order to provide a basis for late prevention. At the same time, we deeply discussed the advantages and safety of stent implantation in the treatment of anastomotic stenosis.
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Affiliation(s)
- Guoliang Wu
- Department of Interventional Radiology, Harrison International Peace Hospital, Hengshui, Hebei 053000, China
| | - Lihua Niu
- Department of Ultrasound, Hengshui Chinese Medicine Hospital, Hengshui, Hebei 053000, China
| | - Yanlin Yang
- Department of Interventional Radiology, Harrison International Peace Hospital, Hengshui, Hebei 053000, China
| | - Shaoyong Tian
- Department of Interventional Radiology, Harrison International Peace Hospital, Hengshui, Hebei 053000, China
| | - Yanru Liu
- Department of Culture and Education, Hengshui Health School, Hengshui, Hebei 053000, China
| | - Chunyan Wang
- Department of Radiology, Hengshui Chinese Medicine Hospital, Hengshui, Hebei 053000, China
| | - Pengfei Zhao
- Department of Radiology, Hengshui Chinese Medicine Hospital, Hengshui, Hebei 053000, China
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Senne M, Werner CR, Schempf U, Thiel K, Königsrainer A, Wichmann D. Comparison of Two Endoscopic Therapeutic Interventions as Primary Treatment for Anastomotic Leakages after Total Gastrectomy. Cancers (Basel) 2022; 14:cancers14122982. [PMID: 35740645 PMCID: PMC9220783 DOI: 10.3390/cancers14122982] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary An esophagojejunal anastomotic leak after oncological gastrectomy is a life-threatening complication. Endoscopic treatment offers the possibility of minimally invasive diagnosis and immediate effective therapy in one session. A retrospective, single-center analysis of two different endoscopic strategies as first-line treatment options was performed. Abstract Introduction: An esophagojejunal anastomotic leak following an oncological gastrectomy is a life-threatening complication, and its management is challenging. A stent application and endoscopic negative pressure therapy are possible therapeutic options. A clinical comparison of these strategies has been missing until now. Methods: A retrospective analysis of 14 consecutive patients endoscopically treated for an anastomotic leak after a gastrectomy between June 2014 and December 2019 was performed. Results: The mean time of the diagnosis of the leakage was 7.14 days after surgery. Five patients were selected for a covered stent, and nine patients received endoscopic negative pressure therapy. In the stent group, the mean number of endoscopies was 2.4, the mean duration of therapy was 26 days, and the mean time of hospitalization was 30 days. In patients treated with endoscopic negative pressure therapy, the mean number of endoscopies was 6.0, the mean days of therapy duration was 14.78, and the mean days of hospitalization was 38.11. Treatment was successful in all patients in the stent-based therapy group and in eight of nine patients in the negative pressure therapy group. Discussion: Good clinical results in preserving the anastomosis and providing sepsis control was achieved in all patients. Stent therapy resulted in anastomosis healing with a lower number of endoscopies, a shorter time of hospitalization, and rapid oral nutrition.
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Affiliation(s)
- Moritz Senne
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (M.S.); (K.T.); (A.K.); (D.W.)
| | - Christoph R. Werner
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany;
- Correspondence: ; Tel.: +49-7071-29685921
| | - Ulrike Schempf
- Department of Gastroenterology, Gastrointestinal Oncology, Hepatology, Infectiology, and Geriatrics, University Hospital Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany;
| | - Karolin Thiel
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (M.S.); (K.T.); (A.K.); (D.W.)
| | - Alfred Königsrainer
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (M.S.); (K.T.); (A.K.); (D.W.)
| | - Dörte Wichmann
- Department of General, Visceral and Transplantation Surgery, University Hospital Tübingen, Hoppe-Seyler-Str. 3, 72076 Tübingen, Germany; (M.S.); (K.T.); (A.K.); (D.W.)
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