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Li C, Song W, Zhang J, Xu Z, Luo Y. A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy. Aging (Albany NY) 2024; 16:7733-7751. [PMID: 38696304 PMCID: PMC11131977 DOI: 10.18632/aging.205780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. METHODS In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. RESULTS Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. CONCLUSIONS This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.
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Affiliation(s)
- Chenglin Li
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Wei Song
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Jialing Zhang
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Zhongneng Xu
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Yonggang Luo
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
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van de Beld JJ, Crull D, Mikhal J, Geerdink J, Veldhuis A, Poel M, Kouwenhoven EA. Complication Prediction after Esophagectomy with Machine Learning. Diagnostics (Basel) 2024; 14:439. [PMID: 38396478 PMCID: PMC10888312 DOI: 10.3390/diagnostics14040439] [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: 11/21/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 02/25/2024] Open
Abstract
Esophageal cancer can be treated effectively with esophagectomy; however, the postoperative complication rate is high. In this paper, we study to what extent machine learning methods can predict anastomotic leakage and pneumonia up to two days in advance. We use a dataset with 417 patients who underwent esophagectomy between 2011 and 2021. The dataset contains multimodal temporal information, specifically, laboratory results, vital signs, thorax images, and preoperative patient characteristics. The best models scored mean test set AUROCs of 0.87 and 0.82 for leakage 1 and 2 days ahead, respectively. For pneumonia, this was 0.74 and 0.61 for 1 and 2 days ahead, respectively. We conclude that machine learning models can effectively predict anastomotic leakage and pneumonia after esophagectomy.
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Affiliation(s)
- Jorn-Jan van de Beld
- Faculty of EEMCS, University of Twente, 7500 AE Enschede, The Netherlands
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - David Crull
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Julia Mikhal
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
- Faculty of BMS, University of Twente, 7500 AE Enschede, The Netherlands
| | - Jeroen Geerdink
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Anouk Veldhuis
- Hospital Group Twente (ZGT), 7609 PP Almelo, The Netherlands
| | - Mannes Poel
- Faculty of EEMCS, University of Twente, 7500 AE Enschede, The Netherlands
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Sugita S, Miyata K, Shimizu D, Ebata T, Yokoyama Y. A risk scoring system for early diagnosis of anastomotic leakage after subtotal esophagectomy for esophageal cancer. Jpn J Clin Oncol 2023; 53:936-941. [PMID: 37370213 DOI: 10.1093/jjco/hyad072] [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: 04/10/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most critical postoperative complications after subtotal esophagectomy in patients with esophageal cancer. This study attempted to develop an optimal scoring system for stratifying the risk for AL. METHODS The study included 171 patients who underwent subtotal esophagectomy for esophageal cancer followed by esophagogastrostomy in the cervical region from January 2011 to April 2021 at Nagoya University Hospital. AL was defined by radiologic or endoscopic evidence of anastomotic breakdown using some modalities. A risk scoring system for an early diagnosis of AL was established using factors determined in the multivariate analysis. A score was calculated for each patient, and the patients were classified into three categories according to the risk for AL: low-, intermediate- and high-risk. The trend of the risk for AL among the categories was evaluated. RESULTS Twenty-nine patients (17%) developed AL. Multivariate analysis demonstrated that sinistrous gross features of drain fluid (P < 0.001; odds ratio (OR), 10.2), radiologic air bubble sign (P < 0.001; OR, 15.0) and the level of drain amylase ≥280 U/L on postoperative Day 7 (P < 0.001; OR, 9.0) were significantly associated with AL. According to the matching number of the above three risk factors and categorization into three risk groups, the incidence of AL was 6.1% (8/131) in the low-risk group, 45.5% (15/33) in the intermediate-risk group and 85.7% (6/7) in the high-risk group (area under curve, 0.81; 95% confidence interval, 0.72-0.90). CONCLUSIONS The present AL-risk scoring system may be useful in postoperative patient care after subtotal esophagectomy.
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Affiliation(s)
- Shizuki Sugita
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Shimizu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Preoperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Amroun K, Deguelte S, Djerada Z, Ramont L, Perrenot C, Rached L, Renard Y, Rhaiem R, Kianmanesh R. High amylase concentration in drainage liquid can early predict proximal and distal intestinal anastomotic leakages: A prospective observational study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2023; 28:5. [PMID: 36974108 PMCID: PMC10039101 DOI: 10.4103/jrms.jrms_273_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/14/2021] [Accepted: 06/09/2022] [Indexed: 02/03/2023]
Abstract
Background Anastomotic leak (AL) is a serious complication in digestive surgery. Early diagnosis might allow clinicians to anticipate appropriate management. The aim of this study was to assess the predictive value of amylase concentration in drain fluid for the early diagnosis of digestive tract AL. Materials and Methods Hundred and fourteen consecutive patients "at risk" of AL, in whom a flexible drainage was placed by surgeon's choice after digestive anastomosis were included. Patients with eso-gastric, bilio-digestive, and pancreatic anastomoses were excluded. Drain amylase measurement (DAM) was routinely performed on postoperative day (POD) 1, 3, 5-7. DAM values were compared between patients with postoperative AL versus patients without AL. A receiver-operating curve (ROC) with calculation of the areas under the ROC curves area under curves was performed and a cutoff value of DAM was calculated. Results AL occurred in 25 patients (AL group) and 89 patients did not present AL (C group). The mean DAM was significantly higher in AL group versus C Group on POD 1, 3, and 5. A cutoff value of 307 IU/L predicted the occurrence of AL with a sensitivity and specificity of 91% and 100%, respectively. Positive and negative predictive values were 100% and 97.5%, respectively. Patients with AL had an elevated DAM prior to the appearance of any clinical signs of AL. Conclusion High level DAM could accurately predict AL for proximal and distal digestive tract anastomoses. This simple, noninvasive, and low-cost method can accurately predict early AL and help physicians to perform appropriate imaging and treatment.
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Muir D, Antonowicz S, Whiting J, Low D, Maynard N. Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language. Dis Esophagus 2022; 35:6603615. [PMID: 35673848 DOI: 10.1093/dote/doac022] [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: 01/16/2022] [Revised: 03/17/2022] [Indexed: 12/24/2022]
Abstract
In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.
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Affiliation(s)
- Duncan Muir
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Stefan Antonowicz
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Jack Whiting
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Donald Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Stuart SK, Kuypers TJL, Martijnse IS, Heisterkamp J, Matthijsen RA. C-reactive protein and drain amylase: their utility in ruling out anastomotic leakage after minimally invasive Ivor-Lewis esophagectomy. Scand J Gastroenterol 2022; 58:448-452. [PMID: 36346047 DOI: 10.1080/00365521.2022.2141076] [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] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) is one of the most feared complications after esophagectomy for esophageal cancer. We investigated the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL. METHODS This is a retrospective study of 193 patients who underwent a minimally invasive Ivor-Lewis procedure between January 2017 and October 2021. Mean CRP and median drain amylase levels between patients with and without AL were compared during the first five postoperative days (POD). ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP. RESULTS In 30 of the 193 patients (16%), AL was diagnosed with a median time to diagnosis of 9 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 59, 110 and 106 mg/L had a high sensitivity of 93%, 90% and 90% on POD 3, 4 and 5. No difference in median drain amylase levels was observed. CONCLUSIONS CRP levels with a cut-off point of 110 mg/L on POD 4 do not improve earlier detection of AL, but have a high sensitivity for excluding AL. The value of drain amylase in the first 5 days after surgery is limited.
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Affiliation(s)
- Sanne K Stuart
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Toon J L Kuypers
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ingrid S Martijnse
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Robert A Matthijsen
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
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Bull A, Pucher PH, Lagergren J, Gossage JA. Chest drainage after oesophageal resection: A systematic review. Dis Esophagus 2022; 35:6377510. [PMID: 34585242 DOI: 10.1093/dote/doab069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/01/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery. METHODS A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores. RESULTS Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300 mL did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59). CONCLUSION Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies.
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Affiliation(s)
- Alexander Bull
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London SE1 7EH, UK
| | - Philip H Pucher
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London SE1 7EH, UK.,Department of General Surgery, Portsmouth University Hospital NHS Trust, Portsmouth PO6 3LY, UK
| | - Jesper Lagergren
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London SE1 7EH, UK.,School of Cancer and Pharmaceutical Sciences, Kings College London, London SE5 9NU, UK.,Department of Molecular medicine and Surgery, Karolinska Institutet, Stockholm 17177, Sweden
| | - James A Gossage
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London SE1 7EH, UK.,School of Cancer and Pharmaceutical Sciences, Kings College London, London SE5 9NU, UK
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Comparison of pleural drain amylase and serum C-reactive protein for early detection of intrathoracic esophago-gastric anastomotic leaks. Langenbecks Arch Surg 2022; 407:2715-2724. [PMID: 35581392 DOI: 10.1007/s00423-022-02550-4] [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: 02/28/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Early detection of anastomotic leaks following esophagectomy has the potential to reduce hospital length of stay and mortality. The aim of this study was to compare the predictive value of pleural drain amylase and serum C-reactive protein for the early diagnosis of leak. METHODS A retrospective observational cohort study was conducted on 121 patients who underwent Ivor Lewis esophagectomy and intrathoracic gastric conduit reconstruction. Pleural drain amylase levels were measured daily until postoperative day (POD) 5 and compared with CRP values measured on POD 3, 5, and 7. Specificity and sensitivity for both tests, and the respective ROC curves, were calculated. RESULTS Anastomotic leak occurred in 12 patients. There was a significant statistical association between pleural drain amylase and serum CRP levels and the presence of anastomotic leakage. Pleural drain amylase cutoff of 209 IU/L on POD 2 yielded a sensitivity of 75% and a specificity of 94% (AUC = 0.813), whereas CRP cutoff value of 22.5 mg/dL on POD 3 yielded a sensitivity of 56% and a specificity of 92% (AUC = 0.772). The negative likelihood ratio of pleural drain amylase was 0.27 and 0.12 on POD 2 and 5, respectively. There was no statistically significant difference between ROC curves of amylase and CRP on POD 3 and 5 (p = 0.79 and p = 0.14, respectively). CONCLUSIONS Pleural drain amylase seems more efficient than serum CRP for early detection of esophago-gastric anastomotic leak. The practice of monitoring drain amylase and CRP may allow safer implementation of enhanced postoperative recovery pathway.
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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: 20] [Impact Index Per Article: 6.7] [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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Linden PA, Towe CW, Worrell SG, Jiang B, Ho VP, Argote-Greene L, Bachman K, Perry Y. Drain Amylase: A Simple and Versatile Method of Detecting Esophageal Anastomotic Leaks. Ann Thorac Surg 2021; 113:1794-1800. [PMID: 34437855 DOI: 10.1016/j.athoracsur.2021.07.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/15/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Anastomotic leak following esophagectomy is a significant cause of morbidity. Perianastomotic drain amylase is accurate in detecting leaks, but it is unclear whether its accuracy is affected by comorbid conditions, anastomotic method, or anastomotic location. We hypothesized that drain amylase would accurately discriminate leak in a variety of settings. METHODS We reviewed 290 consecutive patients undergoing esophagectomy with gastric conduit reconstruction. Patient comorbidities, operative variables, and drain amylase were collected. The diagnosis of a leak was based on the level of intervention required, and was characterized as "clinically significant" if it required wound opening, endoscopic or surgical intervention. Receiver operating characteristic curves analysis was performed to determine the accuracy of amylase to detect leak for each patient variable. RESULTS 53/290 (18.3%) esophagectomies had an anastomotic leak, of which 33/290 (11.4%) were clinically significant. Drain amylase was a strong predictor of anastomotic leak on postoperative days 3-7, regardless of patient comorbidities, location of anastomosis, or technique of anastomosis, but was less accurate in the diagnosis of leak in current smokers (AUC 0.530 vs 0.752, p= 0.006). A maximum drain amylase value no higher than 35 on postoperative 3, 4 or 5 was 88% sensitive in detecting leak at any point postoperatively. A value >=150 was 88% specific in diagnosing leak CONCLUSIONS: Drain amylase is a versatile method for early detection of anastomotic leaks. Its accuracy is unaffected by neoadjuvant treatment, location or type of anastomosis or patient comorbidities, but may be less accurate in active smokers.
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Affiliation(s)
- Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH.
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Stephanie G Worrell
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Vanessa P Ho
- Department of Surgery, Metrohealth Hospital and Case Western Reserve School of Medicine, Cleveland, OH
| | - Luis Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Katelynn Bachman
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
| | - Yaron Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH
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11
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Early detection of anastomotic leakage after esophagectomy using drain amylase levels. Esophagus 2021; 18:522-528. [PMID: 33641017 DOI: 10.1007/s10388-021-00827-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/16/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early diagnosis of anastomotic leakage (AL) after esophagectomy is essential to minimize postoperative complications. In this study, we hypothesized that drain amylase levels may be useful for early AL detection, and measuring drain amylase levels could reduce severe postoperative AL incidence. We, therefore, analyzed the usefulness of measuring drain fluid amylase levels after esophagectomy, in esophageal cancer patients. METHODS From January 2016 to March 2020, 134 patients with esophageal cancer who underwent surgical resection with esophagogastric anastomosis in the cervical region were included. The patients were divided into a group whose cervical drain fluid amylase levels were not measured (No-AMY Group) and a group whose cervical drain fluid amylase levels were measured daily until postoperative day (POD) 7 (AMY Group). The incidence of severe AL was compared between groups. In the AMY Group, we also investigated the association between AL and drain amylase levels. RESULTS Drain amylase levels were significantly higher in AL-positive cases than in AL-negative cases (P < 0.001). Receiver operating characteristic curve analysis revealed the drain amylase level cut-off value for AL diagnosis was 1800 U/L on POD 2 (Area under the curve = 0.835; P = 0.027). The incidence of ≥ grade III AL was significantly lower in the AMY Group than in the No-AMY Group (2 vs. 10%, P = 0.047). CONCLUSIONS Cervical drain fluid amylase levels can be a useful screening method for early detection of AL after esophagectomy for esophageal cancer and may help reduce incidence of severe postoperative AL.
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12
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Horn A, Assalia A, Sayida S, Mahajna A. Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study. Surg Innov 2021; 29:44-49. [PMID: 34144654 DOI: 10.1177/15533506211027830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.
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Affiliation(s)
- Amyt Horn
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Ahmad Assalia
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Sa'd Sayida
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
| | - Ahmad Mahajna
- Department of General Surgery, Faculty of Medicine, 574334Rambam Health Care Campus and the Bruce Rappaport, Institute of Technology, Haifa, Israel
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13
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Barbaro A, Eldredge TA, Shenfine J. Diagnosing anastomotic leak post-esophagectomy: a systematic review. Dis Esophagus 2021; 34:5889927. [PMID: 33565590 DOI: 10.1093/dote/doaa076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/13/2020] [Accepted: 06/26/2020] [Indexed: 12/11/2022]
Abstract
Esophagectomy is the gold-standard treatment for esophageal cancer; however, postoperative anastomotic leakage remains the primary concern for surgeons. No consensus exists on the optimal investigations to predict an anastomotic leak. This systematic review aims to identify a single test or combination of tests with acceptable sensitivity and specificity to identify anastomotic leak after esophagectomy and to formulate a diagnostic algorithm to facilitate surgical decision-making. A systematic review of PubMed and EMBASE databases was undertaken to evaluate diagnostic investigations for anastomotic leak post-esophagectomy. Each study was reviewed and where possible, the sensitivity, specificity, positive predictive value, and negative predictive value were extracted. The review identified 3,204 articles, of which 49 met the inclusion criteria. Investigations most commonly used for diagnosis of anastomotic leak were: C-reactive protein (CRP), oral contrast imaging, computed tomography (CT), pleural drain amylase concentration, and the 'NUn score'. The sensitivity of CRP for detecting anastomotic leak varied from 69.2% to 100%. Oral contrast studies sensitivities varied between 16% and 87.5% and specificity varied from 20% to 100%. Pleural drain amylase sensitivities ranged between 75% and 100% and specificity ranged from 52% to 95.5%. The NUn score sensitivities ranged from 0% to 95% and specificity from 49% to 94.4%. No single investigation was identified to rule out anastomotic leak in asymptomatic patients. However, the authors propose a diagnostic algorithm incorporating CRP, pleural drain amylase concentration, and CT with oral contrast to aid clinicians in predicting anastomotic leak to facilitate safe, timely discharge post-esophagectomy.
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Affiliation(s)
- Antonio Barbaro
- Department of Surgery, The Royal Adelaide Hospital, Adelaide, Australia
| | - Thomas A Eldredge
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Department of Surgery, The Queen Elizabeth Hospital, Adelaide, Australia
| | - Jonathan Shenfine
- Discipline of Surgery, University of Adelaide, Adelaide, Australia.,Division of Surgery, Flinders Medical Centre, Bedford Park, Australia
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14
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de Mooij CM, Maassen van den Brink M, Merry A, Tweed T, Stoot J. Systematic Review of the Role of Biomarkers in Predicting Anastomotic Leakage Following Gastroesophageal Cancer Surgery. J Clin Med 2019; 8:E2005. [PMID: 31744186 PMCID: PMC6912692 DOI: 10.3390/jcm8112005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022] Open
Abstract
Anastomotic leakage (AL) following gastroesophageal cancer surgery remains a serious postoperative complication. This systematic review aims to provide an overview of investigated biomarkers for the early detection of AL following esophagectomy, esophagogastrectomy and gastrectomy. All published studies evaluating the diagnostic accuracy of biomarkers predicting AL following gastroesophageal resection for cancer were included. The Embase, Medline, Cochrane Library, PubMed and Web of Science databases were searched. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) 2 tool. Twenty-four studies evaluated biomarkers in the context of AL following gastroesophageal cancer surgery. Biomarkers were derived from the systemic circulation, mediastinal and peritoneal drains, urine and mediastinal microdialysis. The most commonly evaluated serum biomarkers were C-reactive protein and leucocytes. Both proved to be useful markers for excluding AL owing to its high specificity and negative predictive values. Amylase was the most commonly evaluated peritoneal drain biomarker and significantly elevated levels can predict AL in the early postoperative period. The associated area under the receiver operating characteristic (AUROC) curve values ranged from 0.482 to 0.994. Current biomarkers are poor predictors of AL after gastroesophageal cancer surgery owing to insufficient sensitivity and positive predictive value. Further research is needed to identify better diagnostic tools to predict AL.
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Affiliation(s)
- Cornelius Maarten de Mooij
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Martijn Maassen van den Brink
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Audrey Merry
- Department of Epidemiology, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands;
| | - Thais Tweed
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
| | - Jan Stoot
- Department of Surgery, Zuyderland Medical Center, 6126BG Sittard-Geleen, The Netherlands; (M.M.v.d.B.); (T.T.); (J.S.)
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15
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De Pasqual CA, Weindelmayer J, Laiti S, La Mendola R, Bencivenga M, Alberti L, Giacopuzzi S, de Manzoni G. Perianastomotic drainage in Ivor-Lewis esophagectomy, does habit affect utility? An 11-year single-center experience. Updates Surg 2019; 72:47-53. [DOI: 10.1007/s13304-019-00674-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 08/05/2019] [Indexed: 01/10/2023]
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Abstract
Anastomotic leakage (AL) is one of the most critical and detrimental complications in esophageal surgery. Early diagnosis and timely therapeutic action are necessary if patients are to avoid AL-related problems. However, there is no gold standard or consensus for early diagnosis. In this review, we focus on summarizing the definition and types of AL and modalities for early diagnosis of AL after esophagectomy.
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Affiliation(s)
- Seok Whan Moon
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, The Catholic University of Korea, College of Medicine, Suwon, Republic of Korea
| | - Jae Kil Park
- Department of Thoracic and Cardiovascular Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
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17
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Gao C, Xu G, Wang C, Wang D. Evaluation of preoperative risk factors and postoperative indicators for anastomotic leak of minimally invasive McKeown esophagectomy: a single-center retrospective analysis. J Cardiothorac Surg 2019; 14:46. [PMID: 30819240 PMCID: PMC6394086 DOI: 10.1186/s13019-019-0864-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/17/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Minimally invasive McKeown esophagectomy is an important surgical approach for esophageal cancer. Anastomotic leak is one of its common and serious complications. We assumed that the preoperative risk factors and postoperative indicators would predict or detect anastomotic leak. METHODS Between December 2016 and July 2017, patients underwent minimally invasive McKeown esophagectomy were identified and their preoperative variables and postoperative test indicators were recorded. Fisher's exact test, 2-tailed unpaired t test, nonparametric test and logistic regression were used to compare these datum between patients with or without anastomotic leak (AL). Receiver Operator Characteristic (ROC) curve was used to identify the best cut-off value of drainage amylase concentration for distinguishing anastomotic leak. RESULTS In all the 96 patients included, 12 patients were diagnosed as anastomotic leak by the esophagram. No differences in preoperative variables were observed between patients with and without AL. Patients in AL group appeared to have a lower prealbumin concentration in AL group on POD (postoperative day) 4(P = 0.05), POD 5(P = 0.04), POD 6 (P = 0.06). Prealbumin concentration cutoff value of 128 g/L on postoperative day 5 is 100.00% sensitive and 50.00% specific for predicting esophageal leaks. Drain amylases levels were higher in patients with anastomotic leak than those without anastomotic leak on POD 3(P = 0.03), POD 4(P = 0.01), POD 5(P < 0.001), POD 6(P < 0.001). The drain amylase cutoff value of 85 IU/L on postoperative day 4 was 75.00% sensitive and 84.00% specific for detecting esophageal leaks; the cutoff value of 65 IU/L on postoperative day 5 was 91.67% sensitive and 80.77% specific. The cutoff of 55/L on POD 6 is 100% sensitive and 86.96% specific. CONCLUSION Drainage amylase concentration on postoperative days may help to discover anastomotic leak in early stage after minimally invasive McKeown esophagectomy. Prealbumin concentration below 128 g/L on POD 5 might be potential risk factor for anastomotic leak.
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Affiliation(s)
- Chuan Gao
- Department of Thoracic Surgery, Jinling Hospital, No.34 Yanggongjing, Qinhuai District, Nanjing, 210002, China
| | - Gang Xu
- Department of Thoracic Surgery, Jinling Hospital, No.34 Yanggongjing, Qinhuai District, Nanjing, 210002, China
| | - Changyong Wang
- Department of Thoracic Surgery, Jinling Hospital, No.34 Yanggongjing, Qinhuai District, Nanjing, 210002, China
| | - Dong Wang
- Department of Thoracic Surgery, Jinling Hospital, No.34 Yanggongjing, Qinhuai District, Nanjing, 210002, China.
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18
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Giulini L, Dubecz A, Solymosi N, Tank J, Renz M, Thumfart L, Stein HJ. Prognostic Value of Chest-Tube Amylase Versus C-Reactive Protein as Screening Tool for Detection of Early Anastomotic Leaks After Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2019; 29:192-197. [DOI: 10.1089/lap.2018.0656] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Luca Giulini
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Attila Dubecz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Norbert Solymosi
- Center for Bioinformatics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Julian Tank
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marcus Renz
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Lucas Thumfart
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Hubert J. Stein
- Department of Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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Yu WS, Jung J, Shin H, Roh Y, Byun GE, Kim DJ, Haam S, Park SY. Amylase level in cervical drain fluid and anastomotic leakage after cervical oesophagogastrostomy. Eur J Cardiothorac Surg 2019; 56:5305058. [PMID: 30715298 DOI: 10.1093/ejcts/ezz008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/02/2019] [Indexed: 02/28/2024] Open
Abstract
OBJECTIVES Anastomotic leakage after oesophageal cancer surgery is a serious complication. The purpose of this study was to evaluate the possibility of anastomotic leakage by repeatedly measuring amylase levels in the fluid obtained from the drainage tube inserted at the cervical anastomotic site. METHODS Ninety-nine patients who underwent oesophagectomy and cervical oesophagogastrostomy between April 2014 and March 2017 were retrospectively reviewed. A drainage tube was placed at the anastomotic site, and amylase levels were measured daily from postoperative day (POD) 1 until oral feeding or confirmation of anastomotic leakage. The amylase levels were analysed with a linear mixed model. RESULTS The mean age of the patients was 64.9 ± 9.0 years, and there were 89 (89%) male patients. Almost all pathologies (92%) were squamous cell carcinomas. The anastomotic methods were as follows: 63 (63%) circular stapled, 33 (33%) hand-sewn and 3 (3%) semistapled. Anastomotic leakage was confirmed in 10 (10%) patients. The amylase levels increased until POD 2 in both the leakage and non-leakage groups, but the levels subsequently decreased in the non-leakage group, whereas the levels peaked on POD 3 in the leakage group. On performing the linear mixed model analysis, anastomotic leakage was significantly associated with the trends in postoperative amylase levels in the drainage tube (P < 0.001). Trends in the serum C-reactive protein levels and white blood cell count were not significantly associated with anastomotic leakage. CONCLUSIONS Amylase level trends measured in the cervical drain fluid can be a useful indicator of anastomotic leakage after cervical oesophagogastrostomy.
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Affiliation(s)
- Woo Sik Yu
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Joonho Jung
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Hyejung Shin
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Yunho Roh
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Korea
| | - Go Eun Byun
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seokjin Haam
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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20
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Jiang B, Ho VP, Ginsberg J, Fu SJ, Perry Y, Argote-Greene L, Linden PA, Towe CW. Decision analysis supports the use of drain amylase-based enhanced recovery method after esophagectomy. Dis Esophagus 2018; 31:4994958. [PMID: 29757360 DOI: 10.1093/dote/doy041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Postesophagectomy anastomotic leak is a common postsurgical complication. The current standard method of detecting leak is esophagram usually late in the postoperative period. Perianastomotic drain amylase level had shown promising results in early detection anastomosis leak. Previous studies have shown that postoperative day 4 amylase level is more specific and sensitive than esophagram. The purpose of this study is to determine if implementing a drain amylase-based screening method for anastomotic leak can reduce length of stay and hospital cost relative to a traditional esophagram-based pathway. The drain amylase protocol we propose uses postoperative day 4 drain amylase level to direct the initiation of PO intake and discharge. We designed a decision analysis tree using TreeAge Pro software to compare the drain amylase-based screening method to the standard of care, the esophagram. We performed a retrospective review of postesophagectomy patients from a tertiary academic medical center (University hospital Cleveland medical center) where amylase level was measured routinely postoperatively. The patients were separated into amylase-based pathway group and the standard of care group based on their postop management. The length of stay, costs, complications, and leak rate of these two groups were used to inform the decision analysis tree. In the base-case analysis, the decision analysis demonstrated that an amylase-based screening method can reduce the hospital stay by one day and reduced costs by ∼$3,000 compared to esophagram group. To take the variability of the data into consideration, we performed a Monte Carlo simulation. The result showed again a median saving of 0.71 days and ∼$2,500 per patient in hospital cost. A ballistic sensitivity analysis was performed to show that the sensitivity of postoperative day 4 amylase level in detecting a leak was the most important factor in the model. We conclude that implementing an amylase-based screening method for anastomotic leak in postesophagectomy patient can significantly reduce hospital cost and length of stay. This study demonstrates a novel protocol to improve postesophagectomy care. Based on this result, we believe a prospective multicenter study is appropriate.
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Affiliation(s)
| | | | - J Ginsberg
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - S J Fu
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - Y Perry
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - L Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - P A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
| | - C W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, Ohio, USA
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21
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Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Abdominal Drainage and Amylase Measurement for Detection of Leakage After Gastrectomy for Gastric Cancer. J Gastrointest Surg 2018; 22:1163-1170. [PMID: 29736661 DOI: 10.1007/s11605-018-3789-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/16/2018] [Indexed: 01/31/2023]
Abstract
PURPOSE To investigate the value of daily measurement of drain amylase for detecting leakage in gastric cancer surgery. METHODS This was a retrospective analysis including all patients who underwent a gastrectomy for gastric cancer. From January 2013 until December 2015, an intra-abdominal drain was routinely placed. Drain amylase was measured daily. Receiver operator characteristic curves were created to assess the ability of amylase to predict leakage. Sensitivity, specificity, and negative and positive predictive value of amylase in drain fluid were determined. Leakage of the gastrojejunostomy or esophagojejunostomy, enteroenterostomy, duodenal stump, or pancreas was diagnosed by CT scan, endoscopy, or during re-operation. From January 2016 until April 2017, no drain was inserted. Surgical outcome and postoperative complications were compared between both groups. RESULTS Median drain amylase concentrations were higher for each postoperative day in patients with leakage. The optimal cutoff value was 1000 IU/L (sensitivity 77.8%, specificity 98.2%, negative predictive value 96.6%). Sixty-seven consecutive procedures were performed with a drain and 40 procedures without. No differences in group characteristics were observed except for gender. Fourteen patients (13.1%) had a leakage. The incidence and severity of leakage were not different between the patients with and without a drain. There was no significant difference in time to diagnosis (1 vs. 0 days; p 0.34), mortality rate (7.5 vs. 2.5%; p 0.41), and median length of hospital stay (9 days in both groups; p 0.46). CONCLUSION Daily amylase measurement in drain fluid does not influence the early recognition and management of leakage in gastric cancer surgery.
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23
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Ribeiro IB, Gestic MA, Utrini MP, Chaim FDM, Chaim EA, Cazzo E. DRAIN AMYLASE LEVELS MAY INDICATE GASTROJEJUNOSTOMY LEAKS AFTER ROUX-EN-Y GASTRIC BYPASS. ARQUIVOS DE GASTROENTEROLOGIA 2018; 55:66-72. [PMID: 29561980 DOI: 10.1590/s0004-2803.201800000-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 11/28/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Although the incidence of leaks after Roux-en-Y gastric bypass (RYGB) significantly decreased over time, their detection still remains challenging. OBJECTIVE This study aimed to determine the usefulness of drain amylase levels to detect leaks after RYGB. METHODS This is a population-based study which enrolled 170 individuals who underwent RYGB. Drain amylase levels were determined on the first and fourth postoperative days. Two thresholds were evaluated: three times higher than the serum levels (parameter I) and higher than 250 IU/L (parameter II). The main outcomes evaluated were perioperative morbidity, the occurrence of leaks, 30-day readmissions and reoperations, hospital stay, and mortality. RESULTS Considering the parameter I, high drain amylase levels were significantly associated with leaks (12.5% vs 0; P<0.00001). Considering the parameter II, high drain amylase levels were significantly associated with longer hospital stay (8±5.7 vs 4.5±1.3 days; P=0.00032), 30-day reoperations (50% vs 3%; P=0.000285), and leaks (50% vs 0; P<0.00001). The parameter I presented a sensitivity of 100% and specificity of 95.9%, whereas the parameter II presented a sensitivity of 100% and a specificity of 99.4%. CONCLUSION The determination of drain amylase levels after RYGB was a significant indicator of leaks, hospital stay, and 30-day reoperations. This finding reinforces the importance of abdominal drainage in the RYGB within this context.
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Affiliation(s)
- Igor Braga Ribeiro
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Martinho Antonio Gestic
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Murillo Pimentel Utrini
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Felipe David Mendonça Chaim
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Elinton Adami Chaim
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
| | - Everton Cazzo
- Departamento de Cirurgia, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), SP, Brasil
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Lubbers M, van Det MJ, Kreuger MJ, Hoekstra R, Hendriksen EM, Vermeer M, Kouwenhoven EA. Totally minimally invasive esophagectomy after neoadjuvant chemoradiotherapy: Long-term oncologic outcomes. J Surg Oncol 2018; 117:651-658. [DOI: 10.1002/jso.24935] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/02/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Merel Lubbers
- Department of Surgery; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
| | - Marc J. van Det
- Department of Surgery; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
| | - Mariska J. Kreuger
- Department of Surgery; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
| | - Ronald Hoekstra
- Department of Medical Oncology; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
| | - Ellen M. Hendriksen
- Department of Radiation Oncology; Medisch Spectrum Twente (MST) Enschede; Enschede The Netherlands
| | - Marloes Vermeer
- Department of Epidemiology and Statistics; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
| | - Ewout A. Kouwenhoven
- Department of Surgery; Hospital Group Twente (ZGT) Almelo; Almelo The Netherlands
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25
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Miller DL, Helms GA, Mayfield WR. Evaluation of Esophageal Anastomotic Integrity With Serial Pleural Amylase Levels. Ann Thorac Surg 2018; 105:200-206. [DOI: 10.1016/j.athoracsur.2017.07.053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 06/03/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023]
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26
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Goense L, van Rossum PSN, Kandioler D, Ruurda JP, Goh KL, Luyer MD, Krasna MJ, van Hillegersberg R. Stage-directed individualized therapy in esophageal cancer. Ann N Y Acad Sci 2016; 1381:50-65. [PMID: 27384385 DOI: 10.1111/nyas.13113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 05/05/2016] [Indexed: 12/16/2022]
Abstract
Esophageal cancer is the eighth most common cancer worldwide, and the incidence of esophageal carcinoma is rapidly increasing. With the advent of new staging and treatment techniques, esophageal cancer can now be managed through various strategies. A good understanding of the advances and limitations of new staging techniques and how these can guide in individualizing treatment is important to improve outcomes for esophageal cancer patients. This paper outlines the recent progress in staging and treatment of esophageal cancer, with particularly attention to endoscopic techniques for early-stage esophageal cancer, multimodality treatment for locally advanced esophageal cancer, assessment of response to neoadjuvant treatment, and the role of cervical lymph node dissection. Furthermore, advances in robot-assisted surgical techniques and postoperative recovery protocols that may further improve outcomes after esophagectomy are discussed.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Daniela Kandioler
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Khean-Lee Goh
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Mark J Krasna
- Meridian Cancer Care, Jersey Shore University Medical Center, Neptune, New Jersey
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27
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Goense L, van Rossum PSN, Weijs TJ, van Det MJ, Nieuwenhuijzen GA, Luyer MD, van Leeuwen MS, van Hillegersberg R, Ruurda JP, Kouwenhoven EA. Aortic Calcification Increases the Risk of Anastomotic Leakage After Ivor-Lewis Esophagectomy. Ann Thorac Surg 2016; 102:247-52. [PMID: 27112648 DOI: 10.1016/j.athoracsur.2016.01.093] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/24/2015] [Accepted: 01/28/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Anastomotic leakage is associated with increased morbidity and mortality after esophagectomy. Calcification of the arteries supplying the gastric tube has been identified as a risk factor for leakage of the cervical anastomosis, but its potential contribution to the risk of intrathoracic anastomotic leakage has not been elucidated. This study evaluated the relationship between calcification and the occurrence of leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy. METHODS Consecutive patients who underwent minimally invasive esophagectomy for cancer at 2 institutions were analyzed. Diagnostic computed tomography images were used to detect calcification of the arteries supplying the gastric tube (eg, aorta, celiac axis). Multivariable logistic regression analysis was used to determine the relationship between vascular calcification and anastomotic leakage. RESULTS Of 167 included patients, anastomotic leakage occurred in 40 (24%). In univariable analysis, leakage was most frequently observed in patients with calcification of the aorta (major calcification: 37% leakage [16 of 43]; minor calcification: 32% [18 of 56]; no calcification: 9% [6 of 70], p < 0.001). Calcification of other studied arteries was not significantly associated with leakage. A significant association with leakage remained for minor (odds ratio, 5.4; 95% confidence interval, 1.7 to 16.5) and major (odds ratio, 7.0; 95% confidence interval, 1.9 to 26.4) aortic calcifications in multivariable analysis. CONCLUSIONS Atherosclerotic calcification of the aorta is an independent risk factor for leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy for cancer. The calcification scoring system may aid in patient selection and lead to earlier diagnosis of this potentially fatal complication.
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Affiliation(s)
- Lucas Goense
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter S N van Rossum
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Teus J Weijs
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | | | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Maarten S van Leeuwen
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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