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Hedberg J, Sundbom M, Edholm D, Aahlin EK, Szabo E, Lindberg F, Johnsen G, Førland DT, Johansson J, Kauppila JH, Svendsen LB, Nilsson M, Lindblad M, Lagergren P, Larsen MH, Åkesson O, Löfdahl P, Mala T, Achiam MP. Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial. Dis Esophagus 2024; 37:doae010. [PMID: 38366900 PMCID: PMC11144291 DOI: 10.1093/dote/doae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.
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Affiliation(s)
- Jakob Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Edholm
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Eirik Kjus Aahlin
- Department of GI and HPB Surgery, Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Eva Szabo
- Department of Surgery, Örebro University, Örebro, Sweden
| | - Fredrik Lindberg
- Department of Surgical and Perioperative Sciences Surgery, Umeå University, Umeå, Sweden
| | - Gjermund Johnsen
- Department of Gastrointestinal Surgery, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dag Tidemann Førland
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Jan Johansson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Joonas H Kauppila
- Department of Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholn, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Oscar Åkesson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Per Löfdahl
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon. Surg Obes Relat Dis 2023; 19:403-420. [PMID: 37080885 DOI: 10.1016/j.soard.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.
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Lee JH, Kuhar S, Seo JH, Pasricha PJ, Mittal R. Computational modeling of drug dissolution in the human stomach: Effects of posture and gastroparesis on drug bioavailability. PHYSICS OF FLUIDS (WOODBURY, N.Y. : 1994) 2022; 34:081904. [PMID: 35971381 PMCID: PMC9372820 DOI: 10.1063/5.0096877] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/23/2022] [Indexed: 05/25/2023]
Abstract
The oral route is the most common choice for drug administration because of several advantages, such as convenience, low cost, and high patient compliance, and the demand and investment in research and development for oral drugs continue to grow. The rate of dissolution and gastric emptying of the dissolved active pharmaceutical ingredient (API) into the duodenum is modulated by gastric motility, physical properties of the pill, and the contents of the stomach, but current in vitro procedures for assessing dissolution of oral drugs are limited in their ability to recapitulate this process. This is particularly relevant for disease conditions, such as gastroparesis, that alter the anatomy and/or physiology of the stomach. In silico models of gastric biomechanics offer the potential for overcoming these limitations of existing methods. In the current study, we employ a biomimetic in silico simulator based on the realistic anatomy and morphology of the stomach (referred to as "StomachSim") to investigate and quantify the effect of body posture and stomach motility on drug bioavailability. The simulations show that changes in posture can potentially have a significant (up to 83%) effect on the emptying rate of the API into the duodenum. Similarly, a reduction in antral contractility associated with gastroparesis can also be found to significantly reduce the dissolution of the pill as well as emptying of the API into the duodenum. The simulations show that for an equivalent motility index, the reduction in gastric emptying due to neuropathic gastroparesis is larger by a factor of about five compared to myopathic gastroparesis.
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Affiliation(s)
| | - S. Kuhar
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, Maryland 21218, USA
| | | | - P. J. Pasricha
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA
| | - R. Mittal
- Author to whom correspondence should be addressed:
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Yano M, Sugimura K, Miyata H, Motoori M, Tanaka K, Omori T, Ohue M, Sakon M. Response to Comment on "Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy" by Dr Prakash et al. Ann Surg 2022; 276:e68-e69. [PMID: 33278170 DOI: 10.1097/sla.0000000000004659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Masahiko Yano
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keijiro Sugimura
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka Prefectural General Medical Center, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological surgery, Osaka University Graduate school of Medicine, suita, Japan
| | - Takeshi Omori
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masato Sakon
- Department of Gastroenterological surgery, Osaka International Cancer Institute, Osaka, Japan
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Benz C, Martella J, Hamwi B, Okereke I. Factors resulting in postoperative dysphagia following esophagectomy: a narrative review. J Thorac Dis 2021; 13:4511-4518. [PMID: 34422377 PMCID: PMC8339788 DOI: 10.21037/jtd-21-724] [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: 04/24/2021] [Accepted: 06/11/2021] [Indexed: 12/03/2022]
Abstract
Esophagectomy is a technically involved surgery and can have significant postoperative morbidity. Although the mortality rate following esophagectomy has decreased in recent years, this surgical procedure has a relatively high complication rate compared to other surgeries to resect cancer. One of the most common complaints after esophagectomy is dysphagia. Dysphagia after esophagectomy can significantly affect quality of life. Dysphagia is a complication following esophagectomy that can lead to respiratory deterioration and death. The most common sites of postoperative dysphagia are the gastroesophageal anastomosis, gastric conduit, pylorus and the hiatus. Without appropriate treatment of dysphagia, malnutrition and dehydration can develop. These factors can lead to significant impacts to the overall health of a patient and increase mortality. A detailed literature review provided data to support diagnostic modalities and management strategies to treat postoperative dysphagia at these common areas. A systematic, evidence-based approach to diagnosis and treatment of postoperative dysphagia allows for prompt intervention and a decrease in morbidity and mortality. Treatment options for dysphagia vary, depending on the etiology. Based on the location and mechanism of dysphagia, options include stenting, dilation and surgical revision. Early treatment of dysphagia after esophagectomy can lessen the morbidity from this complication and improve quality of life.
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Affiliation(s)
- Cecilia Benz
- Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jessica Martella
- University of Texas Medical Branch School of Medicine, Galveston, TX, USA
| | - Basel Hamwi
- University of Texas Medical Branch School of Medicine, Galveston, TX, USA
| | - Ikenna Okereke
- Division of Thoracic Surgery, Henry Ford Health, Detroit, MI, USA
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