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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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Takeuchi H, Yoshimura S, Daimon M, Sakina Y, Seki Y, Ishikawa S, Kouno Y, Tashiro J, Kawasaki S, Mori K. Late-onset lethal complication of non-surgically managed massive gastric conduit necrosis after esophagectomy: a case report. Surg Case Rep 2024; 10:148. [PMID: 38884681 PMCID: PMC11182997 DOI: 10.1186/s40792-024-01955-1] [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: 03/25/2024] [Accepted: 06/13/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Gastric conduit necrosis (GCN) after esophagectomy is a serious complication that can prove fatal. Herein, we report a rare case of GCN with a severe course that improved with conservative treatment. CASE PRESENTATION We present the case of a 78-year-old male patient who underwent an Ivor Lewis esophagectomy and developed a massive GCN. The patient was critically ill in the initial phase but recovered quickly; he also had a ruptured gallbladder and a bleeding jejunal ulcer. On the 22nd postoperative day, massive GCN was revealed on endoscopy. Considering the recovery course, careful observation with a decompressing nasal gastric tube was the treatment of choice. The GCN was managed successfully, having been completely replaced by fine mucosa within 9 months postoperatively. The patient completed his follow-up visit 5 years after surgery without any evident disease recurrence. Five and a half years after the surgery, the patient presented with progressive weakness and deterioration of renal function. Gastrointestinal endoscopy revealed a large ulcer at the anastomotic site. Three months later, computed tomography revealed a markedly thin esophageal wall, accompanied by adjacent lung consolidation. An esophagopulmonary fistula was diagnosed; surgery was not considered, owing to the patient's age and markedly deteriorating performance status. He died 2013 days after the diagnosis. CONCLUSIONS Massive GCN after esophagectomy often requires emergency surgery to remove the necrotic conduit. However, this report suggests that a conservative approach can save lives and preserve the gastric conduit in these cases, thereby augmenting the quality of life.
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Affiliation(s)
- Hiroshi Takeuchi
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Shuntaro Yoshimura
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Mitsuhiro Daimon
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Yasunobu Sakina
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Yusuke Seki
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Shintaro Ishikawa
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Yoshiharu Kouno
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Jo Tashiro
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Seiji Kawasaki
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan
| | - Kazuhiko Mori
- Department of Digestive Surgery, Mitsui Memorial Hospital, 1 Kanda Izumi-Cho, Chiyoda-Ku, Tokyo, 101-8643, Japan.
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Griffiths EA. Predictors of anastomotic leak and conduit necrosis after oesophagectomy: Results from the oesophago-gastric anastomosis audit (OGAA). EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107983. [PMID: 38613995 DOI: 10.1016/j.ejso.2024.107983] [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: 02/27/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Both anastomotic leak (AL) and conduit necrosis (CN) after oesophagectomy are associated with high morbidity and mortality. Therefore, the identification of preoperative, modifiable risk factors is desirable. The aim of this study was to generate a risk scoring model for AL and CN after oesophagectomy. METHODS Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018-December 2018. Definitions for AL and CN were those set out by the Oesophageal Complications Consensus Group. Univariate and multivariate analyses were performed to identify risk factors for both AL and CN. A risk score was then produced for both AL and CN using the derivation set, then internally validated using the validation set. RESULTS This study included 2247 oesophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% and CN rate was 2.7%. Preoperative factors that were independent predictors of AL were cardiovascular comorbidity and chronic obstructive pulmonary disease. The risk scoring model showed insufficient predictive ability in internal validation (area under the receiver-operating-characteristic curve [AUROC] = 0.618). Preoperative factors that were independent predictors of CN were: body mass index, Eastern Cooperative Oncology Group performance status, previous myocardial infarction and smoking history. These were converted into a risk-scoring model and internally validated using the validation set with an AUROC of 0.775. CONCLUSION Despite a large dataset, AL proves difficult to predict using preoperative factors. The risk-scoring model for CN provides an internally validated tool to estimate a patient's risk preoperatively.
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Affiliation(s)
- Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
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Yellinedi R, Nuvvula R, Basude M, Raju KVVN, Vashisht Y, Nusrath S. Microvascular reconstruction in salvaging the gastric conduit post-esophagectomy after iatrogenic right gastroepiploic vessel injury. Indian J Thorac Cardiovasc Surg 2024; 40:238-241. [PMID: 38389761 PMCID: PMC10879060 DOI: 10.1007/s12055-023-01633-1] [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: 07/10/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 02/24/2024] Open
Abstract
The preservation of the right gastroepiploic vessels is essential to ensure proper perfusion of the gastric conduit following esophagectomy. The loss of these vessels can lead to conduit ischemia or necrosis, resulting in significant postoperative complications. Traditional approaches such as colonic or jejunal interposition require extensive surgery and multiple anastomoses. In this report, we present our successful experience of salvaging the gastric tube through microvascular reconstruction following iatrogenic injury to the right gastroepiploic vessels in two cases. The first case involved re-anastomosis of the right gastroepiploic vein, while the second case required reconstruction of both the artery and vein during esophagectomy in a single setting. The procedures were performed by an experienced surgical team using microvascular techniques. Both patients had uneventful postoperative courses without any anastomotic leakage or major complications. Adequate perfusion of the salvaged gastric tube was confirmed intraoperatively using indocyanine green fluorescence perfusion imaging. In conclusion, immediate microvascular reconstruction offers a viable solution by restoring perfusion of the gastric tube in cases of right gastroepiploic vessel injury during esophagectomy.
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Affiliation(s)
- Rajesh Yellinedi
- Department of Plastic Surgery, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Rambabu Nuvvula
- Department of Plastic Surgery, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, India
| | - Madhunarayana Basude
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, 500034 India
| | | | - Yogesh Vashisht
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, 500034 India
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Smolenov EI, Kolobaev IV, Mironova DY, Afonin GV, Ryabov AB. [Indocyanine green in delayed esophageal reconstruction after previous extirpation]. Khirurgiia (Mosk) 2024:67-72. [PMID: 38380467 DOI: 10.17116/hirurgia202402267] [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] [Indexed: 02/22/2024]
Abstract
Advanced chemo- and radiotherapy makes it possible to expand the cohort of patients who can undergo surgical treatment for esophageal cancer. Optimization of perioperative approach, diagnosis and modern options for complications reduced early postoperative mortality after esophagectomy. Conduit ischemia with failure of esophageal-gastric or esophageal-intestinal anastomosis is one of the most serious complications. To minimize the risk of anastomotic leakage and graft necrosis in these patients, various methods of intraoperative assessment of graft viability are being investigated. Near-infrared fluorescence imaging with indocyanine green is valuable for real time assessment of graft perfusion. To date, fluorescence imaging is analyzed regarding perfusion of the gastric stalk after esophagectomy. However, there are still few or no data on this method for analysis of colonic conduit perfusion. The absence of plastic material for gastrointestinal reconstruction is the most dangerous moment in case of ischemia and necrosis of colonic graft. We present our first case of delayed retrosternal esophageal repair using intraoperative indocyanine green fluorescence imaging for assessment of conduit perfusion.
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Affiliation(s)
- E I Smolenov
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - I V Kolobaev
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - D Yu Mironova
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - G V Afonin
- Tsyb Medical Radiology Research Center, Obninsk, Russia
| | - A B Ryabov
- Herzen Moscow Research Oncology Institute, Moscow, Russia
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Horváth ÖP, Pavlovics G, Cseke L, Vereczkei A, Papp A. Dysphagia After Esophageal Replacement and Its Treatment. Dysphagia 2023; 38:1323-1332. [PMID: 36719515 PMCID: PMC10471736 DOI: 10.1007/s00455-023-10557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.
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Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary.
| | - Gábor Pavlovics
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - László Cseke
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Papp
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
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Kim HK, Jeon HW. Successful Endoscopic Vacuum Therapy for Extensive Gastric Tubing Necrosis after Ivor-Lewis Esophagectomy: A Case Report. J Chest Surg 2023; 56:362-366. [PMID: 36918520 PMCID: PMC10480393 DOI: 10.5090/jcs.22.152] [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: 12/19/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 03/16/2023] Open
Abstract
The stomach has become the most commonly used site for grafts to replace the esophagus in esophageal cancer surgery because of its good blood supply and ability to enable single-reconstruction anastomosis. However, anastomotic failure is a serious complication after esophageal cancer surgery. Unlike anastomotic leakage due to local ischemia, gastric tube necrosis is a life-threatening condition with a high mortality rate. Gastric tube necrosis involves extensive ischemia due to a decreased blood supply, and an urgent operation is mandatory in most cases. Endoscopic vacuum therapy (EVT) has been used for anastomotic leakage after esophageal surgery. In recent years, it has been successfully used for more extensive disease, including large esophageal perforation as an indication for reoperation. Hence, we report a case of extensive gastric tube necrosis treated by EVT after an Ivor Lewis operation.
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Affiliation(s)
- Hee Kyung Kim
- Department of Thoracic and Cardiovascular Surgery, St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Woo Jeon
- Department of Thoracic and Cardiovascular Surgery, Bucheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
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Çetinkaya Ç, Bilgi Z, Aslan S, Batırel HF. Evolution of a minimally invasive oesophagectomy program - effective complication management is key. Wideochir Inne Tech Maloinwazyjne 2023; 18:481-486. [PMID: 37868276 PMCID: PMC10585459 DOI: 10.5114/wiitm.2023.130326] [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: 04/15/2023] [Accepted: 06/19/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures. Aim To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management. Material and methods All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery). Results In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort. Conclusions Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.
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Affiliation(s)
- Çağatay Çetinkaya
- Department of Thoracic Surgery, Uskudar University, School of Medicine, İstanbul, Turkey
| | - Zeynep Bilgi
- Department of Thoracic Surgery, Medeniyet University, School of Medicine, İstanbul, Turkey
| | - Sezer Aslan
- Department of Thoracic Surgery, Sirnak State Hospital, Sirnak, Turkey
| | - Hasan Fevzi Batırel
- Department of Thoracic Surgery, Biruni University, School of Medicine, İstanbul, Turkey
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Long VD, Thong DQ, Hai NV, Dat TQ, Le Minh Quoc H, Nguyen DT, Anh NVT, Minh TA, Vuong NL, So JBY, Bac NH, Uyama I. Surgical outcomes and quality of life assessment of esophagectomy for cancer with colon conduit via retrosternal route. Esophagus 2023; 20:435-444. [PMID: 36609618 DOI: 10.1007/s10388-023-00984-3] [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: 01/12/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
PURPOSE Colon conduit is an alternative to a gastric conduit for esophagectomy in patients that stomach is not available. Surgical technique is complex and has a high risk of morbidities and mortality. Outcomes of patients are still lacking in the literature, thus aims of this study are to evaluate the safety, feasibility and long-term functional outcomes of patients who underwent esophagectomy for cancer with colon conduit via retrosternal route. METHODS Twenty-six patients underwent operation between August 2016 and June 2021 for malignancies. Minimally invasive esophagectomy and laparotomy were performed in accordance with the 2017 Japan Esophageal Society's guidelines. Colonic interposition was used for esophageal replacement. Outcomes were technical success, complications assessed using Clavien-Dindo classification, and patient's quality of life (QOL) based on EORTC-QOL-OES18 questionnaire. RESULTS Mean age was 56.0 ± 9.9 years and 21 patients (80.8%) were men. Mean operating time was 432 ± 66 min. Technical success was 100%. The average number of resected lymph nodes was 26 ± 14. Twelve patients (46.2%) experienced postoperative complications: 7/12 were classified as grade I-II, 3/12 as grade III, 1/12 as grade IV, and 1/12 as grade V (death). Patient's QOL improved during the follow-up period with median (25-75th percentiles) global EORTC-QOL-OES18 score was 29 (17-34); 13 (9-21), and 9 (6-16) at 3, 6, and 12 months, respectively. During the follow-up period, there were 4 late complications, 3 lymphatic recurrences, 5 distant metastases, and 6 deaths. CONCLUSIONS Colon conduit via retrosternal route after esophagectomy is feasible, safe, and could provide acceptable long-term functional outcomes.
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Affiliation(s)
- Vo Duy Long
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam.
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.
| | - Dang Quang Thong
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Viet Hai
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Tran Quang Dat
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Ho Le Minh Quoc
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Doan Thuy Nguyen
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Vu Tuan Anh
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Tran Anh Minh
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Lam Vuong
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Jimmy Bok-Yan So
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nguyen Hoang Bac
- Gastro-Intestinal Surgery Department, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 215 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
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Fumagalli Romario U, de Pascale S, Colombo S, Attanasio A, Sabbatini A, Sandrin F. Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage. Updates Surg 2023; 75:343-355. [PMID: 35851675 DOI: 10.1007/s13304-022-01332-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/06/2022] [Indexed: 01/24/2023]
Abstract
Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.
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Anoldo P, Vertaldi S, Manigrasso M, D'Amore A, De Palma GD, Milone M. Re-thoracoscopy for the management of gastric conduit dehiscence after minimally invasive McKeown esophagectomy. Int J Surg Case Rep 2023; 103:107876. [PMID: 36640467 PMCID: PMC9845996 DOI: 10.1016/j.ijscr.2023.107876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Gastric conduit dehiscence after esophagectomy represents a severe complication associated with high mortality. Surgical management is achieved through thoracotomy, but often ends up in conduit sacrifice and diversion. CASE PRESENTATION A 59-years-old man underwent minimally invasive McKeown esophagectomy for esophageal adenocarcinoma. After a worsening of the postoperative course and evidence at the CT scan and endoscopy of highly suspect gastric conduit failure, the patient underwent an exploratory thoracoscopy, which revealed a partial dehiscence of the gastric conduit treated with resection of the dehiscent gastric wall by a linear stapler on the guide of a 36-french orogastric tube. Patient had a regular postoperative course without any complications and was discharged on the 6th postoperative day. CLINICAL DISCUSSION The management of conduit necrosis is extremely challenging. There are several interventional options and it is difficult to decide the most appropriate treatment for each individual patient. In our case we decided to perform a reintervention with a thoracoscopic approach, resecting the dehiscent area of the gastric conduit. CONCLUSIONS Minimally invasive surgery is a valid option for the management of post-operative complications, including those in emergency setting. Re-suturing a partial dehiscence of gastric conduit may be feasible if tissue conditions allow.
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Affiliation(s)
- Pietro Anoldo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy.
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Anna D'Amore
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, 80131 Naples, Italy
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Ubels S, Lubbers M, Verstegen MHP, Bouwense SAW, van Daele E, Ferri L, Gisbertz SS, Griffiths EA, Grimminger P, Hanna G, Hubka M, Law S, Low D, Luyer M, Merritt RE, Morse C, Mueller CL, Nieuwenhuijzen GAP, Nilsson M, Reynolds JV, Ribeiro U, Rosati R, Shen Y, Wijnhoven BPL, Klarenbeek BR, van Workum F, Rosman C. Treatment of anastomotic leak after esophagectomy: insights of an international case vignette survey and expert discussions. Dis Esophagus 2022; 35:6566833. [PMID: 35411928 DOI: 10.1093/dote/doac020] [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: 11/18/2021] [Revised: 03/11/2022] [Accepted: 02/14/2022] [Indexed: 12/16/2022]
Abstract
Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Merel Lubbers
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Moniek H P Verstegen
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan A W Bouwense
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elke van Daele
- Department of Surgery, Ghent University Hospital, Ghent, Belgium
| | - Lorenzo Ferri
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Peter Grimminger
- Department of Surgery, University Medical Center Mainz, Mainz, Germany
| | - George Hanna
- Department of Surgery, Imperial College, London, UK
| | - Michal Hubka
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Simon Law
- Department of Surgery, Queen Mary Hospital, Hong Kong, China
| | - Donald Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, SE USA
| | - Misha Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Robert E Merritt
- Department of Surgery, Ohio State University - Wexner Medical Center, Columbus, OH, USA
| | - Christopher Morse
- Department of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carmen L Mueller
- Department of Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | | | - Magnus Nilsson
- Department of Surgery, Department of Upper Abdominal Diseases, CLINTEC, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - John V Reynolds
- Department of Surgery, Trinity St. James's Cancer Institute, Dublin, Ireland
| | - Ulysses Ribeiro
- Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Hospital IRCCS, Milan, Italy
| | - Yaxing Shen
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bastiaan R Klarenbeek
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Sanchez MV, Alicuben ET, Luketich JD, Sarkaria IS. Colon Interposition for Esophageal Cancer. Thorac Surg Clin 2022; 32:511-527. [PMID: 36266037 DOI: 10.1016/j.thorsurg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Kamarajah S, Evans R, Nepogodiev D, Hodson J, Bundred J, Gockel I, Gossage J, Isik A, Kidane B, Mahendran H, Negoi I, Okonta K, Sayyed R, van Hillegersberg R, Vohra R, Wijnhoven B, Singh P, Griffiths E, Kamarajah S, Hodson J, Griffiths E, Alderson D, Bundred J, Evans R, Gossage J, Griffiths E, Jefferies B, Kamarajah S, McKay S, Mohamed I, Nepogodiev D, Siaw-Acheampong K, Singh P, van Hillegersberg R, Vohra R, Wanigasooriya K, Whitehouse T, Gjata A, Moreno J, Takeda F, Kidane B, Guevara Castro R, Harustiak T, Bekele A, Kechagias A, Gockel I, Kennedy A, Da Roit A, Bagajevas A, Azagra J, Mahendran H, Mejía-Fernández L, Wijnhoven B, El Kafsi J, Sayyed R, Sousa M, Sampaio A, Negoi I, Blanco R, Wallner B, Schneider P, Hsu P, Isik A, Gananadha S, Wills V, Devadas M, Duong C, Talbot M, Hii M, Jacobs R, Andreollo N, Johnston B, Darling G, Isaza-Restrepo A, Rosero G, Arias-Amézquita F, Raptis D, Gaedcke J, Reim D, Izbicki J, Egberts J, Dikinis S, Kjaer D, Larsen M, Achiam M, Saarnio J, Theodorou D, Liakakos T, Korkolis D, Robb W, Collins C, Murphy T, Reynolds J, Tonini V, Migliore M, Bonavina L, Valmasoni M, Bardini R, Weindelmayer J, Terashima M, White R, Alghunaim E, Elhadi M, Leon-Takahashi A, Medina-Franco H, Lau P, Okonta K, Heisterkamp J, Rosman C, van Hillegersberg R, Beban G, Babor R, Gordon A, Rossaak J, Pal K, Qureshi A, Naqi S, Syed A, Barbosa J, Vicente C, Leite J, Freire J, Casaca R, Costa R, Scurtu R, Mogoanta S, Bolca C, Constantinoiu S, Sekhniaidze D, Bjelović M, So J, Gačevski G, Loureiro C, Pera M, Bianchi A, Moreno Gijón M, Martín Fernández J, Trugeda Carrera M, Vallve-Bernal M, Cítores Pascual M, Elmahi S, Halldestam I, Hedberg J, Mönig S, Gutknecht S, Tez M, Guner A, Tirnaksiz M, Colak E, Sevinç B, Hindmarsh A, Khan I, Khoo D, Byrom R, Gokhale J, Wilkerson P, Jain P, Chan D, Robertson K, Iftikhar S, Skipworth R, Forshaw M, Higgs S, Gossage J, Nijjar R, Viswanath Y, Turner P, Dexter S, Boddy A, Allum W, Oglesby S, Cheong E, Beardsmore D, Vohra R, Maynard N, Berrisford R, Mercer S, Puig S, Melhado R, Kelty C, Underwood T, Dawas K, Lewis W, Al-Bahrani A, Bryce G, Thomas M, Arndt A, Palazzo F, Meguid R, Fergusson J, Beenen E, Mosse C, Salim J, Cheah S, Wright T, Cerdeira M, McQuillan P, Richardson M, Liem H, Spillane J, Yacob M, Albadawi F, Thorpe T, Dingle A, Cabalag C, Loi K, Fisher O, Ward S, Read M, Johnson M, Bassari R, Bui H, Cecconello I, Sallum R, da Rocha J, Lopes L, Tercioti V, Coelho J, Ferrer J, Buduhan G, Tan L, Srinathan S, Shea P, Yeung J, Allison F, Carroll P, Vargas-Barato F, Gonzalez F, Ortega J, Nino-Torres L, Beltrán-García T, Castilla L, Pineda M, Bastidas A, Gómez-Mayorga J, Cortés N, Cetares C, Caceres S, Duarte S, Pazdro A, Snajdauf M, Faltova H, Sevcikova M, Mortensen P, Katballe N, Ingemann T, Morten B, Kruhlikava I, Ainswort A, Stilling N, Eckardt J, Holm J, Thorsteinsson M, Siemsen M, Brandt B, Nega B, Teferra E, Tizazu A, Kauppila J, Koivukangas V, Meriläinen S, Gruetzmann R, Krautz C, Weber G, Golcher H, Emons G, Azizian A, Ebeling M, Niebisch S, Kreuser N, Albanese G, Hesse J, Volovnik L, Boecher U, Reeh M, Triantafyllou S, Schizas D, Michalinos A, Balli E, Mpoura M, Charalabopoulos A, Manatakis D, Balalis D, Bolger J, Baban C, Mastrosimone A, McAnena O, Quinn A, Ó Súilleabháin C, Hennessy M, Ivanovski I, Khizer H, Ravi N, Donlon N, Cervellera M, Vaccari S, Bianchini S, Sartarelli L, Asti E, Bernardi D, Merigliano S, Provenzano L, Scarpa M, Saadeh L, Salmaso B, De Manzoni G, Giacopuzzi S, La Mendola R, De Pasqual C, Tsubosa Y, Niihara M, Irino T, Makuuchi R, Ishii K, Mwachiro M, Fekadu A, Odera A, Mwachiro E, AlShehab D, Ahmed H, Shebani A, Elhadi A, Elnagar F, Elnagar H, Makkai-Popa S, Wong L, Tan Y, Thannimalai S, Ho C, Pang W, Tan J, Basave H, Cortés-González R, Lagarde S, van Lanschot J, Cords C, Jansen W, Martijnse I, Matthijsen R, Bouwense S, Klarenbeek B, Verstegen M, van Workum F, Ruurda J, van der Sluis P, de Maat M, Evenett N, Johnston P, Patel R, MacCormick A, Young M, Smith B, Ekwunife C, Memon A, Shaikh K, Wajid A, Khalil N, Haris M, Mirza Z, Qudus S, Sarwar M, Shehzadi A, Raza A, Jhanzaib M, Farmanali J, Zakir Z, Shakeel O, Nasir I, Khattak S, Baig M, MA N, Ahmed H, Naeem A, Pinho A, da Silva R, Bernardes A, Campos J, Matos H, Braga T, Monteiro C, Ramos P, Cabral F, Gomes M, Martins P, Correia A, Videira J, Ciuce C, Drasovean R, Apostu R, Ciuce C, Paitici S, Racu A, Obleaga C, Beuran M, Stoica B, Ciubotaru C, Negoita V, Cordos I, Birla R, Predescu D, Hoara P, Tomsa R, Shneider V, Agasiev M, Ganjara I, Gunjić D, Veselinović M, Babič T, Chin T, Shabbir A, Kim G, Crnjac A, Samo H, Díez del Val I, Leturio S, Ramón J, Dal Cero M, Rifá S, Rico M, Pagan Pomar A, Martinez Corcoles J, Rodicio Miravalles J, Pais S, Turienzo S, Alvarez L, Campos P, Rendo A, García S, Santos E, Martínez E, Fernández Díaz M, Magadán Álvarez C, Concepción Martín V, Díaz López C, Rosat Rodrigo A, Pérez Sánchez L, Bailón Cuadrado M, Tinoco Carrasco C, Choolani Bhojwani E, Sánchez D, Ahmed M, Dzhendov T, Lindberg F, Rutegård M, Sundbom M, Mickael C, Colucci N, Schnider A, Er S, Kurnaz E, Turkyilmaz S, Turkyilmaz A, Yildirim R, Baki B, Akkapulu N, Karahan O, Damburaci N, Hardwick R, Safranek P, Sujendran V, Bennett J, Afzal Z, Shrotri M, Chan B, Exarchou K, Gilbert T, Amalesh T, Mukherjee D, Mukherjee S, Wiggins T, Kennedy R, McCain S, Harris A, Dobson G, Davies N, Wilson I, Mayo D, Bennett D, Young R, Manby P, Blencowe N, Schiller M, Byrne B, Mitton D, Wong V, Elshaer A, Cowen M, Menon V, Tan L, McLaughlin E, Koshy R, Sharp C, Brewer H, Das N, Cox M, Al Khyatt W, Worku D, Iqbal R, Walls L, McGregor R, Fullarton G, Macdonald A, MacKay C, Craig C, Dwerryhouse S, Hornby S, Jaunoo S, Wadley M, Baker C, Saad M, Kelly M, Davies A, Di Maggio F, McKay S, Mistry P, Singhal R, Tucker O, Kapoulas S, Powell-Brett S, Davis P, Bromley G, Watson L, Verma R, Ward J, Shetty V, Ball C, Pursnani K, Sarela A, Sue Ling H, Mehta S, Hayden J, To N, Palser T, Hunter D, Supramaniam K, Butt Z, Ahmed A, Kumar S, Chaudry A, Moussa O, Kordzadeh A, Lorenzi B, Wilson M, Patil P, Noaman I, Willem J, Bouras G, Evans R, Singh M, Warrilow H, Ahmad A, Tewari N, Yanni F, Couch J, Theophilidou E, Reilly J, Singh P, van Boxel Gijs, Akbari K, Zanotti D, Sgromo B, Sanders G, Wheatley T, Ariyarathenam A, Reece-Smith A, Humphreys L, Choh C, Carter N, Knight B, Pucher P, Athanasiou A, Mohamed I, Tan B, Abdulrahman M, Vickers J, Akhtar K, Chaparala R, Brown R, Alasmar M, Ackroyd R, Patel K, Tamhankar A, Wyman A, Walker R, Grace B, Abbassi N, Slim N, Ioannidi L, Blackshaw G, Havard T, Escofet X, Powell A, Owera A, Rashid F, Jambulingam P, Padickakudi J, Ben-Younes H, Mccormack K, Makey I, Karush M, Seder C, Liptay M, Chmielewski G, Rosato E, Berger A, Zheng R, Okolo E, Singh A, Scott C, Weyant M, Mitchell J. The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit. J Thorac Cardiovasc Surg 2022; 164:674-684.e5. [PMID: 35249756 DOI: 10.1016/j.jtcvs.2022.01.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/22/2021] [Accepted: 01/18/2022] [Indexed: 12/08/2022]
Abstract
BACKGROUND The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort. METHODS This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders. RESULTS Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses. CONCLUSIONS Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.
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Kou HW, Huang PC, Cheong CF, Chao YK, Tsai CY. Restoring the perfusion of accidentally transected right gastroepiploic vessels during gastric conduit harvest for esophagectomy using microvascular anastomosis: a case report and literature review. BMC Surg 2022; 22:292. [PMID: 35902899 PMCID: PMC9331148 DOI: 10.1186/s12893-022-01728-3] [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: 07/19/2021] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Esophagectomy remains the standard treatment for esophageal cancer or esophagogastric junction cancer. The stomach, or the gastric conduit, is currently the most commonly used substitute for reconstruction instead of the jejunum or the colon. Preservation of the right gastric and the right gastroepiploic vessels is a vital step to maintain an adequate perfusion of the gastric conduit. Compromise of these vessels, especially the right gastroepiploic artery, might result in ischemia or necrosis of the conduit. Replacement of the gastric conduit with jejunal or colonic interposition is reported when a devastating accident occurs; however, the latter procedure requires a more extensive dissection and multiple anastomosis. CASE PRESENTATION A 61-year-old male with a lower third esophageal squamous cell carcinoma (cT3N1 M0) who received neoadjuvant chemoradiation with a partial response. He underwent esophagectomy with a gastric conduit reconstruction. However, the right gastroepiploic artery was accidentally transected during harvesting the gastric conduit, and the complication was identified during the pull-up phase. An end-to-end primary anastomosis was performed by the plastic surgeon under microscopy, and perfusion of the conduit was evaluated by the ICG scope, which revealed adequate vascularization of the whole conduit. We continued the reconstruction with the revascularized gastric conduit according to the perfusion test result. Although the patient developed minor postoperative leakage of the esophagogastrostomy, it was controlled with conservative drainage and antibiotic administration. Computed tomography also demonstrated fully enhanced gastric conduit. The patient resumed oral intake smoothly later without complications and was discharged at postoperative day 43. CONCLUSION Although the incidence of vascular compromise during harvesting of the gastric conduit is rare, the risk of conduit ischemia is worrisome whenever it happens. Regarding to our presented case, with the prompt identification of the injury, expertized vascular reconstruction, and a practical intraoperative evaluation of the perfusion, a restored gastric conduit could be applied for reconstruction instead of converting to more complicated procedures.
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Affiliation(s)
- Hao-Wei Kou
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Ching Huang
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chon-Folk Cheong
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital, Linkou Branch, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Incidence of upper extremity deep vein thrombosis in the retrosternal reconstruction after esophagectomy. BMC Surg 2022; 22:91. [PMID: 35264138 PMCID: PMC8908570 DOI: 10.1186/s12893-022-01544-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Upper extremity deep vein thrombosis (UEDVT) is relatively rare but cannot be negligible because it can cause fatal complications. Although it is reported that the occurrence rate of UEDVT has increased due to central venous catheter (CVC), cancer, and surgical invasion, there is still limited information for esophagectomy. The aim of this study was to evaluate the clinical factors, including CVC placement and thromboprophylaxis approach, as well as retrosternal space’s width as a predictive factor for UEDVT in patients receiving esophagectomy. Methods This study included 66 patients who underwent esophagectomy with retrosternal reconstruction using a gastric tube. All patients routinely underwent contrast-enhanced computed tomography (CT) on the 4th postoperative day. Low-molecular-weight-heparin (LMWH) was routinely administered by the 2nd postoperative day. To evaluate retrosternal space’s width, (a) The distance from sternum to brachiocephalic artery and (b) the distance from sternum to vertebra were measured by preoperative CT, and the ratio of (a) to (b) was defined as the width of retrosternal space. Results Among all patients, 11 (16.7%) suffered from UEDVT, and none was preoperatively received CVC placement, while 7 were inserted in non-UEDVT cases. Retrosternal space’s width in patients with UEDVT was significantly smaller than that in patients without UEDVT (0.17 vs. 0.26; P < 0.0001). A cutoff value of the width was 0.21, which has high sensitivity (87%) and specificity (82%) for UEDVT prediction, respectively. Conclusion The existence of CVC may not affect the development of UEDVT, but preoperative evaluation of retrosternal ratio may predict the occurrence of UEDVT.
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Tzortzakakis A, Kalarakis G, Huang B, Terezaki E, Koltsakis E, Kechagias A, Tsekrekos A, Rouvelas I. Role of Radiology in the Preoperative Detection of Arterial Calcification and Celiac Trunk Stenosis and Its Association with Anastomotic Leakage Post Esophagectomy, an Up-to-Date Review of the Literature. Cancers (Basel) 2022; 14:cancers14041016. [PMID: 35205764 PMCID: PMC8870074 DOI: 10.3390/cancers14041016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Esophageal cancer is the sixth deadliest among all cancers worldwide. Multimodal treatment, including surgical resection of the esophagus, offers the potential for cure even in advanced cases, but esophagectomy is still associated with serious complications. Among these, anastomotic leakage has the most significant clinical impact, both in terms of prognosis and health-related quality of life. Identifying patients at a high risk for leakage is of great importance in order to modify their treatment and, if possible, avoid this complication. This review aims to study the current literature regarding the role of radiology in detecting potential risk factors associated with anastomotic leakage. The measurement of calcium plaques on the aorta, as well as the detection of narrowing of the celiac trunk and its branches, can be easily assessed by preoperative computed tomography, and can be used to individualize perioperative patient management to effectively reduce the rate of leakage. Abstract Surgical resection of the esophagus remains a critical component of the multimodal treatment of esophageal cancer. Anastomotic leakage (AL) is the most significant complication following esophagectomy, in terms of clinical implications. Identifying risk factors for AL is important for modifying patient management and improving surgical outcomes. This review aims to examine the role of radiological risk factors for AL after esophagectomy, and in particular, arterial calcification and celiac trunk stenosis. Eligible publications prior to 25 August 2021 were retrieved from Medline and Google Scholar using a predefined search algorithm. A total of 68 publications were identified, of which 9 original studies remained for in-depth analysis. The majority of these studies found correlations between calcifications in the aorta, celiac trunk, and right post-celiac arteries and AL following esophagectomy. Some studies suggest celiac trunk stenosis as a more appropriate surrogate. Our up-to-date review highlights the need for automated quantification of aortic calcifications, as well as the degree of celiac trunk stenosis in preoperative computed tomography in patients undergoing esophagectomy, to obtain robust and reproducible measurements that can be used for a definite correlation.
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Affiliation(s)
- Antonios Tzortzakakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, 141 86 Huddinge, Sweden
| | - Georgios Kalarakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Department of Radiology, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
| | - Biying Huang
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of General Surgery, Södertälje Hospital, 152 86 Södertälje, Sweden
| | - Eleni Terezaki
- Department of Emergency Medicine, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - Emmanouil Koltsakis
- Department of Radiology, Karolinska University Hospital, Solna, 171 64 Stockholm, Sweden;
| | - Aristotelis Kechagias
- Department of Digestive Surgery, Kanta-Häme Central Hospital, 13530 Hämeenlinna, Finland;
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
- Correspondence: ; Tel.: +46-70-797-68-14
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Ruchkin DV, Okonskaya DE, Karmazanovsky GG, Kozlov VA, Rymar OA, Gorin DS. Non-occlusive mesenteric ischemia in reconstructive digestive tract surgery. Khirurgiia (Mosk) 2022:18-24. [PMID: 35593624 DOI: 10.17116/hirurgia202205118] [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] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To analyze the mechanisms of non-occlusive mesenteric ischemia (NOMI) after digestive tract surgery. MATERIAL AND METHODS NOMI occurred in 10 (0.4%) patients after reconstructive digestive tract surgery between 2015 and 2021. There were 4 women and 6 men aged 29-92 years (67 [60; 71]). Patients differed from each other in the nature of baseline disease and surgical approach. All patients underwent standardized surgical interventions. There were no intraoperative complications. RESULTS Median of surgery time was 372.5 (246.25; 548.75) min, blood loss - 450 (200; 725) ml. These parameters conformed to the type of surgery. There were no specific clinical signs of NOMI. Lactic acidosis (>4 mmol/L) occurred in 7 patients after 1-3 postoperative days. In 6 patients, fulminant NOMI developed after 1-2 postoperative days with subsequent multiple organ failure syndrome and septic shock. All patients underwent emergency redo surgery. Multivisceral gastrointestinal necrosis occurred in 5 patients, gastric conduit necrosis - 3, colon necrosis - 1, gastric stump necrosis - 1 patient. Mortality rate was 80%. Two patients survived. CONCLUSION NOMI manifested as a septic shock in 60% of patients that was due to fulminant development of multivisceral necrosis after 1-2 postoperative days. Timely diagnosis of reversible NOMI in these cases was impossible. Extensive visceral necrosis in early postoperative period is probably associated with intraoperative critical ischemia of digestive organs.
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Affiliation(s)
- D V Ruchkin
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - D E Okonskaya
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - G G Karmazanovsky
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - V A Kozlov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - O A Rymar
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - D S Gorin
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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19
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Foley DM, Emanuwa EJE, Knight WRC, Baker CR, Kelly M, McEwan R, Zylstra J, Davies AR, Gossage JA. Analysis of outcomes of a transoral circular stapled anastomosis following major upper gastrointestinal cancer resection. Dis Esophagus 2021; 34:6130170. [PMID: 33554244 DOI: 10.1093/dote/doab004] [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: 07/20/2020] [Revised: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophageal anastomoses performed following esophagectomy and total gastrectomy are technically challenging with a significant risk of anastomotic leak. A safe, reliable, and easy anastomotic technique is required to improve patient outcomes and reduce morbidity. METHOD This paper analyses 328 consecutive patients who underwent transoral circular stapled esophageal anastomosis (ORVIL™) from a prospectively collected single-center database between December 2011 and February 2019. RESULTS Two hundred and twenty-seven esophagectomies and 101 gastrectomies were performed using OrVil™ anastomoses. The mean patient age was 63.7 years. Of 328 consecutive OrVil™-based anastomoses, there were 10 clinically significant anastomotic leaks requiring radiological or operative intervention (3.05%). Twenty-eight (8.54%) patients developed anastomotic stricture, all of which were successfully treated with endoscopic balloon dilatation (a median of 1 dilatation was required per patient). CONCLUSION The OrVil™ anastomotic technique is reliable and safe to perform. This is the largest reported series of the OrVil™ anastomotic technique to date. Leak rates and anastomotic dilations were similar to other reported series. Based on our experience, we consider the use of the OrVil™ device for reconstruction after major upper GI resection to be safe and reliable.
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Affiliation(s)
- Daniel M Foley
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - William R C Knight
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Cara R Baker
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Mark Kelly
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ricardo McEwan
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Janine Zylstra
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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20
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Spaulding SL, Ansari E, Xing MH, Sandler ML, O'Malley QF, Ho R, Spitzer H, Levy J, Ganz C, Khorsandi AS, Mundi N, Urken ML. Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options. Am J Otolaryngol 2021; 42:103003. [PMID: 33894689 DOI: 10.1016/j.amjoto.2021.103003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES. METHODS The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps. RESULTS The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy. CONCLUSIONS The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.
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Affiliation(s)
- Sarah L Spaulding
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Edward Ansari
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Monica H Xing
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America.
| | - Mykayla L Sandler
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Quinn F O'Malley
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Rebecca Ho
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Hannah Spitzer
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Juliana Levy
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Cindy Ganz
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Azita S Khorsandi
- Department of Radiology, New York Eye and Ear Infirmary, New York, NY 10003, United States of America
| | - Neil Mundi
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Mark L Urken
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
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21
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Gupta R, Madaan V, Kumar S, Govil D. Indocyanine green enhanced near-infrared fluorescence imaging for perfusion assessment of colonic conduit for esophageal replacement: Utility of a novel technique. J Postgrad Med 2021; 67:168-170. [PMID: 34414927 PMCID: PMC8445122 DOI: 10.4103/jpgm.jpgm_1227_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Esophagectomy, followed by esophageal replacement using gastric/colonic conduits, is a complex surgical procedure with significant perioperative morbidity. The most significant and potentially life-threatening complication associated with esophageal replacement is conduit ischaemia, resulting in anastomotic leak and conduit necrosis. Ensuring adequate perfusion of the conduit remains the key to preventing conduit ischaemia. Indocyanine green (ICG) enhanced near-infrared fluorescence imaging is a novel technique which has been used for assessing bowel perfusion. While numerous studies have focused on ICG fluorescence imaging for assessment of gastric conduit perfusion after esophagectomy, data regarding its use for colonic conduits is limited to case reports. ICG fluorescence imaging can help in resolving intraoperative issues by predicting the adequacy of colonic conduit perfusion, thereby preventing postoperative morbidity. To the best of our knowledge, this is the first report in Indian literature describing the utility of ICG fluorescence imaging for assessment of perfusion of colonic interposition.
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Affiliation(s)
- R Gupta
- Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India
| | - V Madaan
- Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India
| | - S Kumar
- Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India
| | - D Govil
- Department of Surgical Gastroenterology, Indraprastha Apollo Hospital, New Delhi, India
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22
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Abstract
Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.
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23
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Dixit J, Subash A, Gowda N, Deepak H, Amanulla. Hand Rule of 5 for a Robust Gastric Conduit in Minimal Access Onco-Surgery. Indian J Surg Oncol 2021; 12:432-436. [PMID: 34295091 DOI: 10.1007/s13193-021-01323-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jaganath Dixit
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India.,Department of Surgical Oncology, HCG Cancer Hospital, Bengaluru, Karnataka India
| | - Anand Subash
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - Naveen Gowda
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - H Deepak
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - Amanulla
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
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24
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Maglangit SACA, Macalindong SS, Dofitas RB, Cabaluna ND. Indocyanine Green (ICG) fluorescence angiography of gastric conduit after transhiatal thoracic esophagectomy with proximal gastrectomy for esophagogastric junction adenocarcinoma: A case report and initial experience at a tertiary government hospital in the Philippines. Int J Surg Case Rep 2021; 80:105653. [PMID: 33611079 PMCID: PMC7905447 DOI: 10.1016/j.ijscr.2021.105653] [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: 01/05/2021] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE We documented the initial experience in our institution where we used indocyanine green (ICG) fluorescence angiography as adjunct in the evaluation of the vascular supply of a reconstructed gastric conduit for esophageal replacement for esophagogastric junction (EGJ) cancer surgery. CASE PRESENTATION A 62-year-old patient consulted with a two-month history of melena and weight loss and unremarkable chest and abdominal physical examinations. CLINICAL FINDINGS AND INVESTIGATIONS Upper endoscopy and contrast-enhanced computed tomography scans of the chest and abdomen demonstrated an EGJ tumor with no nodal and distant metastases, which revealed adenocarcinoma on biopsy. INTERVENTION AND OUTCOME The patient underwent combined thoracoscopic-assisted and transhiatal thoracic esophagectomy with proximal gastrectomy. Esophageal reconstruction was done via a retrosternal gastric pull-up. The perfusion and viability of the gastric conduit were confirmed as per usual methods of inspection and palpation. ICG fluorescence angiography further demonstrated and confirmed the vascular perfusion of the gastric conduit and the optimal site of anastomosis. The patient had an unremarkable postoperative course with no reported anastomotic leakage and stricture formation at 12 months follow-up. RELEVANCE AND IMPACT ICG fluorescence angiography represents a feasible and promising tool in assessing viability of esophageal replacement and choosing the optimal site for anastomosis with the proximal esophagus. It can aid in choosing the most appropriate site of anastomosis to prevent ischemia-related complications such as leakage or stricture. This particular case can serve as an initial learning experience to guide surgeons in our institution in the use of ICG fluorescence angiography for esophageal replacements after esophagectomy.
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Affiliation(s)
- Sittie Aneza Camille A Maglangit
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines.
| | - Shiela S Macalindong
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
| | - Rodney B Dofitas
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
| | - Nelson D Cabaluna
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
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25
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Slooter MD, de Bruin DM, Eshuis WJ, Veelo DP, van Dieren S, Gisbertz SS, van Berge Henegouwen MI. Quantitative fluorescence-guided perfusion assessment of the gastric conduit to predict anastomotic complications after esophagectomy. Dis Esophagus 2020; 34:5917378. [PMID: 33016305 PMCID: PMC8141822 DOI: 10.1093/dote/doaa100] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Fluorescence angiography (FA) assesses anastomotic perfusion during esophagectomy with gastric conduit reconstruction, but its interpretation is subjective. This study evaluated time to fluorescent enhancement in the gastric conduit, with the aim to determine a threshold to predict postoperative anastomotic complications. METHODS In a prospective cohort study, all consecutive patients undergoing esophagectomy with gastric conduit reconstruction from July 2018 to October 2019 were included. FA was performed before anastomotic reconstruction following injection of indocyanine green (ICG). During FA, the following time points were recorded: ICG injection, first fluorescent enhancement in the lung, at the base of the gastric conduit, at the planned anastomotic site, and at ICG watershed or in the tip of the gastric conduit. Anastomotic complications including anastomotic leakage and clinically relevant strictures were documented. RESULTS Eighty-four patients were included, the majority (67 out of 84, 80%) of which underwent an Ivor Lewis procedure. After a median follow-up of 297 days, anastomotic leakage was observed in 12 out of 84 (14.3%) and anastomotic stricture in 12 out of 82 (14.6%). Time between ICG injection and enhancement in the tip was predictive for anastomotic leakage (P = 0.174, area under the curve = 0.731), and a cut-off value of 98 seconds was derived (specificity: 98%). All times to enhancement at the planned anastomotic site and ICG watershed were significantly predictive for the occurrence of a stricture, however area under the curves were <0.7. CONCLUSIONS The identified fluorescent threshold can be used for intraoperative decision making or to identify potentially high-risk patients for anastomotic leakage after esophagectomy with gastric conduit reconstruction.
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Affiliation(s)
- M D Slooter
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - D M de Bruin
- Amsterdam UMC, University of Amsterdam, Department of Biomedical Engineering and Physics, Amsterdam, the Netherlands
| | - W J Eshuis
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - D P Veelo
- Amsterdam UMC, University of Amsterdam, Department of Anesthesiology, Amsterdam, the Netherlands
| | - S van Dieren
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - S S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - M I van Berge Henegouwen
- Address correspondence to: Professor Dr M.I. van Berge Henegouwen, MD, PhD, surgeon, Department of Surgery, Amsterdam University Medical Centres (UMC), location Academic Medical Centre (AMC), Postbox 22660, 1100 DD Amsterdam, the Netherlands.
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26
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Charalabopoulos A, Davakis S, Syllaios A, Jayanthi NV, Conn G, Ahmad F, Lorenzi B. Microvascular grafting to enhance perfusion in colonic long-segment oesophageal reconstruction. Langenbecks Arch Surg 2020; 406:2507-2513. [PMID: 32918632 DOI: 10.1007/s00423-020-01988-8] [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: 06/12/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Oesophagectomy with long-segment colon reconstruction is the first-line treatment when the stomach is not available. Supercharging of the newly formed conduit can improve vascular function utilizing intraoperative perfusion imaging system, following thoracoscopic oesophagectomy for distal-oesophageal and gastroesophageal junction cancer. The purpose of this study is to examine the safety and efficacy of microvascular augmentation of left colonic interposition following oesophagectomy for oesophageal cancer. METHODS A retrospective analysis of 156 consecutive oesophagectomies between January 2016 and July 2018 was performed. All oesophagectomies involving left colon interposition with microvascular augmentation were included in the study. In all cases, oesophageal mobilization was performed thoracoscopically in prone position and the left colon was used as neo-oesophagus in an isoperistaltic fashion. Conduit perfusion was assessed with the Spy system and neck supercharging was performed using microsurgical technique. RESULTS A total of n = 5 (3.2%) patients were identified. Two cases had delayed and 3 had immediate reconstruction. The conduit was microsurgically augmented in 3 cases with both venous and arterial anastomoses (supercharging) and in 2 cases with venous anastomosis only (superdrainage). No anastomotic leak was identified. One case developed left recurrent laryngeal nerve palsy with associated aspiration pneumonia. CONCLUSIONS Supercharged colonic interposition is a safe way of oesophageal reconstruction when long-segment interposition graft is needed. In oesophageal cancer and in the absence of a viable stomach with intact gastroepiploic arcade, it should be considered a feasible option with favourable outcomes, when the expertise and facilities are available. Use of intraoperative perfusion imaging reveals improved conduit blood supply post-supercharging.
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Affiliation(s)
- Alexandros Charalabopoulos
- Regional Oesophago-Gastric Cancer Surgery Centre, Upper Gastrointestinal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Spyridon Davakis
- Regional Oesophago-Gastric Cancer Surgery Centre, Upper Gastrointestinal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK. .,Upper Gastrointestinal and General Surgery Unit, First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, 17 AgiouThoma Str., 115 27, Athens, Greece.
| | - Athanasios Syllaios
- Regional Oesophago-Gastric Cancer Surgery Centre, Upper Gastrointestinal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK.,Upper Gastrointestinal and General Surgery Unit, First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, 17 AgiouThoma Str., 115 27, Athens, Greece
| | - Naga Venkatesh Jayanthi
- Regional Oesophago-Gastric Cancer Surgery Centre, Upper Gastrointestinal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Gemma Conn
- Colorectal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Fateh Ahmad
- St. Andrews Plastic & Reconstructive Surgery Centre, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
| | - Bruno Lorenzi
- Regional Oesophago-Gastric Cancer Surgery Centre, Upper Gastrointestinal Unit, Department of General Surgery, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK
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27
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Miura K, Kubo N, Sakurai K, Tamamori Y, Murata A, Nishii T, Kodai S, Tachimori A, Shimizu S, Kanazawa A, Inoue T, Nishiguchi Y, Maeda K. Successful surgical treatment for nonocclusive mesenteric ischemia of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy for esophageal cancer: a case report and review of the literature. Surg Case Rep 2020; 6:132. [PMID: 32533278 PMCID: PMC7292838 DOI: 10.1186/s40792-020-00890-1] [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: 03/01/2020] [Accepted: 05/28/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Nonocclusive mesenteric ischemia (NOMI) has been reported to be a life-threating disease. Gastric conduit necrosis is known as a critical postoperative complication after esophagectomy for esophageal cancer. We encountered a rare case of NOMI of a wide area of the intestine accompanied by gastric conduit necrosis after esophagectomy, which was successfully treated with an emergency operation. CASE PRESENTATION A 67-year-old man presented with dysphagia. He was diagnosed with middle thoracic advanced esophageal cancer. After neoadjuvant chemotherapy, he underwent subtotal esophagectomy with lymphadenectomy and gastric conduit reconstruction. On postoperative day (POD) 2, he had diarrhea, high fever, and low blood pressure, which were treated with catecholamines. Laboratory data revealed acidosis and severe sepsis with multi-organ failure, including the kidneys. Although enhanced computed tomography did not exhibit definite findings of bowel ischemia, upper gastrointestinal endoscopy revealed necrotic mucosal changes in the whole gastric conduit. Therefore, we made a diagnosis of septic shock caused by gastric conduit necrosis and performed an emergency operation. When we explored the abdominal cavity, we found not only gastric conduit necrosis but also intermittent necrotic changes in the intestinal wall from the jejunum to the rectum. Therefore, NOMI was diagnosed. We performed an excision of the gastric conduit and 2 m of the small intestine, as well as total colectomy. After the second operation, prostaglandin E1 was administered intravenously as the treatment for NOMI, and sepsis was improved. On POD 122, he was self-discharged. He died of recurrence of lung metastasis from the esophageal cancer 9 months after the first operation. CONCLUSION When a patient has a critical status, including severe sepsis or severe acidosis, after esophagectomy, we should consider the possibility of NOMI in addition to gastric conduit necrosis and aim to diagnose and treat it immediately with an urgent operation.
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Affiliation(s)
- Kotaro Miura
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Naoshi Kubo
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan.
| | - Katsunobu Sakurai
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Yutaka Tamamori
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Akihiro Murata
- Department of Hepato-Biliary Pancreatic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Takafumi Nishii
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Shintaro Kodai
- Department of Hepato-Biliary Pancreatic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Akiko Tachimori
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Sadatoshi Shimizu
- Department of Hepato-Biliary Pancreatic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Akishige Kanazawa
- Department of Hepato-Biliary Pancreatic Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
| | - Toru Inoue
- Department of Surgery, Osaka City Juso Hospital, 2-12-27 Nonakakita, Yodogawa-ku, Osaka, 532-0034, Japan
| | - Yukio Nishiguchi
- Department of Surgery, Osaka City Juso Hospital, 2-12-27 Nonakakita, Yodogawa-ku, Osaka, 532-0034, Japan
| | - Kiyoshi Maeda
- Department of Gastroenterological Surgery, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima-ku, Osaka, 534-0021, Japan
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