1
|
Jonas JP, Rössler F, Ghafoor S, Kobe A, Pfammatter T, Schlag C, Gutschow CA, Petrowsky H, Müller PC, Oberkofler CE. Surgical therapy of celiac axis and superior mesenteric artery syndrome. Langenbecks Arch Surg 2023; 408:59. [PMID: 36690823 PMCID: PMC9870837 DOI: 10.1007/s00423-023-02803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 11/20/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Compression syndromes of the celiac artery (CAS) or superior mesenteric artery (SMAS) are rare conditions that are difficult to diagnose; optimal treatment remains complex, and symptoms often persist after surgery. We aim to review the literature on surgical treatment and postoperative outcome in CAS and SMAS syndrome. METHODS A systematic literature review of medical literature databases on the surgical treatment of CAS and SMAS syndrome was performed from 2000 to 2022. Articles were included according to PROSPERO guidelines. The primary endpoint was the failure-to-treat rate, defined as persistence of symptoms at first follow-up. RESULTS Twenty-three studies on CAS (n = 548) and 11 on SMAS (n = 168) undergoing surgery were included. Failure-to-treat rate was 28% for CAS and 21% for SMAS. Intraoperative blood loss was 95 ml (0-217) and 31 ml (21-50), respectively, and conversion rate was 4% in CAS patients and 0% for SMAS. Major postoperative morbidity was 2% for each group, and mortality was described in 0% of CAS and 0.4% of SMAS patients. Median length of stay was 3 days (1-12) for CAS and 5 days (1-10) for SMAS patients. Consequently, 47% of CAS and 5% of SMAS patients underwent subsequent interventions for persisting symptoms. CONCLUSION Failure of surgical treatment was observed in up to every forth patient with a high rate of subsequent interventions. A thorough preoperative work-up with a careful patient selection is of paramount importance. Nevertheless, the surgical procedure was associated with a beneficial risk profile and can be performed minimally invasive.
Collapse
Affiliation(s)
- J P Jonas
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - F Rössler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - S Ghafoor
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - A Kobe
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - T Pfammatter
- Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - C Schlag
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - C A Gutschow
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - H Petrowsky
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - P C Müller
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - C E Oberkofler
- Department of Surgery and Transplantation, Swiss HPB & Transplant Center Zurich, University Hospital Zurich, Zurich, Switzerland.
- Vivévis AG-Visceral, Tumor, Robotic Surgery, Clinic Hirslanden, Zurich, Switzerland.
| |
Collapse
|
2
|
Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C, Matthée E, Slootmans CAM, Ultee G, Schouten J, Gisbertz SS, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, van Etten B, Poelmann F, Vuurberg N, van den Berg JW, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TCM, van Esser S, Dekker JWT, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JWA, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CMS, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RPR, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJE, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MAH, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Silviu C, Rodica B, Florin A, Cristian Gelu R, Petre H, Guevara Castro R, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Abdelkarem Ahmed H, Elhadi A, Elnagar FA, Msherghi AAA, Wills V, Campbell C, Perez Cerdeira M, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Adelino Barbosa J, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZL, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler MI, Schofield WA, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Leturio Fernández S, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Abdullah Ben Taher F, Ekheel M, Msherghi AAA. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022. [DOI: https://doi.org/10.1093/bjs/znac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.
Methods
This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.
Results
Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.
Conclusion
The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+ , Maastricht , the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group , Almelo , the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham , Birmingham , UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen , Groningen , the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital , Tilburg , the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust , Newcastle upon Tyne , UK
- Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust , Coventry , UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust , Nottingham , UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital , Guildford , UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre , Rotterdam , the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Müller PC, Kapp JR, Vetter D, Bonavina L, Brown W, Castro S, Cheong E, Darling GE, Egberts J, Ferri L, Gisbertz SS, Gockel I, Grimminger PP, Hofstetter WL, Hölscher AH, Low DE, Luyer M, Markar SR, Mönig SP, Moorthy K, Morse CR, Müller-Stich BP, Nafteux P, Nieponice A, Nieuwenhuijzen GAP, Nilsson M, Palanivelu C, Pattyn P, Pera M, Räsänen J, Ribeiro U, Rosman C, Schröder W, Sgromo B, van Berge Henegouwen MI, van Hillegersberg R, van Veer H, van Workum F, Watson DI, Wijnhoven BPL, Gutschow CA. Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus. Dis Esophagus 2021; 34:5909885. [PMID: 32960264 DOI: 10.1093/dote/doaa101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/03/2020] [Accepted: 08/15/2020] [Indexed: 12/11/2022]
Abstract
There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.
Collapse
Affiliation(s)
- P C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J R Kapp
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - L Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - W Brown
- Oesophago-Gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Australia
| | - S Castro
- Department of Surgery, Vall d'Hebron Hospital, Barcelona, Spain
| | - E Cheong
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK
| | - G E Darling
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - J Egberts
- Department of General, Visceral-, Thoracic-, Transplantation-, and Pediatric Surgery, Kurt-Semm Center for Laparoscopic and Robotic Assisted Surgery, University Hospital Schleswig Holstein, Campus Kiel, Kiel, Germany
| | - L Ferri
- Departments of Surgery and Oncology, Montreal General Hospital, McGill University, Montreal, Canada
| | - S S Gisbertz
- Amsterdam UMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - I Gockel
- Department of Visceral, Thoracic, Transplant and Vascular surgery, University Hospital of Leipzig, Leipzig, Germany
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - W L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, USA
| | - A H Hölscher
- Center for Oesophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt am Main, Germany
| | - D E Low
- Department of General, Thoracic and Vascular Surgery, Virginia Mason Medical Center, Seattle, USA
| | - M Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - S R Markar
- Imperial College Healthcare NHS Trust and Imperial College, London, UK
| | - S P Mönig
- Division of Visceral Surgery, Department of Surgery, University of Geneva, Hospitals and School of Medicine, Geneva, Switzerland
| | - K Moorthy
- Imperial College Healthcare NHS Trust and Imperial College, London, UK
| | - C R Morse
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - B P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - P Nafteux
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - A Nieponice
- Esophageal Institute, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | - M Nilsson
- Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - C Palanivelu
- Department of Surgical Gastroenterology, GEM Hospital & Research Centre, Coimbatore, India
| | - P Pattyn
- Department of Surgery, University Center Ghent, Ghent, Belgium
| | - M Pera
- Department of Surgery, Section of Gastrointestinal Surgery, Hospital Universitario del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Räsänen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Centre, Helsinki University Hospital, Helsinki, Finland
| | - U Ribeiro
- Department of Gastroenterology, Cancer Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - C Rosman
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | - B Sgromo
- Department of Upper GI Surgery, Oxford University Hospitals, UK
| | | | - R van Hillegersberg
- Department of Surgical Oncology, University Medical Center Utrecht, The Netherlands
| | - H van Veer
- Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
| | - F van Workum
- Department of Surgical Oncology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - D I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, Australia
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - C A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
4
|
Konradsson M, van Berge Henegouwen MI, Bruns C, Chaudry MA, Cheong E, Cuesta MA, Darling GE, Gisbertz SS, Griffin SM, Gutschow CA, van Hillegersberg R, Hofstetter W, Hölscher AH, Kitagawa Y, van Lanschot JJB, Lindblad M, Ferri LE, Low DE, Luyer MDP, Ndegwa N, Mercer S, Moorthy K, Morse CR, Nafteux P, Nieuwehuijzen GAP, Pattyn P, Rosman C, Ruurda JP, Räsänen J, Schneider PM, Schröder W, Sgromo B, Van Veer H, Wijnhoven BPL, Nilsson M. Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process. Dis Esophagus 2019; 33:5585602. [PMID: 31608938 PMCID: PMC7150655 DOI: 10.1093/dote/doz074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/25/2019] [Accepted: 07/14/2019] [Indexed: 12/11/2022]
Abstract
Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.
Collapse
Affiliation(s)
- M Konradsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Gastroenterology, Landspitali National University Hospital, Reykjavik, Iceland,Address correspondence to: Magnus Konradsson, MD, Department of Clinical Science, Investigation and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden.
| | - M I van Berge Henegouwen
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - C Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - E Cheong
- Norfolk and Norwich University Hospital, Norwich, UK
| | - M A Cuesta
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - G E Darling
- Department of Surgery, Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - S S Gisbertz
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - C A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - W Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A H Hölscher
- Centre for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L E Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D E Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - M D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - N Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - S Mercer
- Queen Alexandra Hospital Portsmouth, United Kingdom
| | - K Moorthy
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - C R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | | | - P Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - C Rosman
- Department of surgery, Radboud university center Nijmegen, The Netherlands
| | - J P Ruurda
- Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - J Räsänen
- Department of General, Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - P M Schneider
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - B Sgromo
- Oxford University Hospitals, Oxford, UK
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
5
|
Gubler C, Vetter D, Schmidt HM, Müller PC, Morell B, Raptis D, Gutschow CA. Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach? Dis Esophagus 2019; 32:5267098. [PMID: 30596963 DOI: 10.1093/dote/doy126] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/26/2018] [Accepted: 12/04/2018] [Indexed: 12/11/2022]
Abstract
Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2). PEVT appears to be a safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.
Collapse
Affiliation(s)
- C Gubler
- Department of Gastroenterology, and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - H M Schmidt
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - P C Müller
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - B Morell
- Department of Gastroenterology, and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - D Raptis
- Department of HPB Surgery and Liver Transplantation, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - C A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| |
Collapse
|
6
|
Visser E, van Rossum PSN, van Veer H, Al-Naimi K, Chaudry MA, Cuesta MA, Gisbertz SS, Gutschow CA, Hölscher AH, Luyer MDP, Mariette C, Moorthy K, Nieuwenhuijzen GAP, Nilsson M, Räsänen JV, Schneider PM, Schröder W, Cheong E, van Hillegersberg R. A structured training program for minimally invasive esophagectomy for esophageal cancer- a Delphi consensus study in Europe. Dis Esophagus 2018; 31:4601761. [PMID: 29121243 DOI: 10.1093/dote/dox124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/18/2017] [Indexed: 12/11/2022]
Abstract
Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.
Collapse
Affiliation(s)
| | - P S N van Rossum
- Departments of Surgery.,Radiation Oncology, University Medical Center Utrecht, Utrecht
| | - H van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital NHS Foundation Trust
| | - M A Cuesta
- Department of Gastrointestinal Surgery, VU University Medical Center
| | - S S Gisbertz
- Department of Surgery, Academic Medical Center, Amsterdam
| | - C A Gutschow
- Department of Visceral and Transplantation Surgery, University Hospital Zurich
| | - A H Hölscher
- Department of Surgery, Center for Esophageal and Gastric Surgery, and Frankfurt
| | - M D P Luyer
- Department of Surgery, Catherina Hospital Eindhoven, Eindhoven, The Netherlands
| | - C Mariette
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - K Moorthy
- Department of Biosurgery and Surgical Technology, Imperial College, St Mary's Hospital, London, United Kingdom
| | | | - M Nilsson
- Department of Surgery, Karolinski University Hospital.,Department of Clinical Science Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - J V Räsänen
- Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland
| | - P M Schneider
- Department of Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - E Cheong
- General Surgery, Norfolk and Norwich University Hospital, Norwich
| | | |
Collapse
|
7
|
Bludau M, Hölscher AH, Bollschweiler E, Leers JM, Gutschow CA, Brinkmann S, Schröder W. Preoperative airway colonization prior to transthoracic esophagectomy predicts postoperative pulmonary complications. Langenbecks Arch Surg 2015; 400:707-14. [PMID: 26252998 DOI: 10.1007/s00423-015-1326-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 07/27/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications. METHODS In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (<24 h, 24-72 h, >72 h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints. RESULTS In 13 of 64 study patients (20.3 %), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p < 0.001), and a higher frequency of re-intubation (p < 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95 % confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8 % compared to 0 % in patients without PAC (p < 0.0001). CONCLUSION PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.
Collapse
Affiliation(s)
- M Bludau
- Department of General, Visceral and Cancer Surgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | | | | | | | | | | |
Collapse
|
8
|
Prenzel KL, Hölscher AH, Drebber U, Agavonova M, Gutschow CA, Bollschweiler E. Prognostic impact of nodal micrometastasis in early esophageal cancer. Eur J Surg Oncol 2012; 38:314-8. [PMID: 22277724 DOI: 10.1016/j.ejso.2012.01.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 01/02/2012] [Accepted: 01/05/2012] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Nodal micrometastasis is a negative prognosticator for esophageal cancer. There is a trend toward endoscopic resection for early cancer of the esophagus without lymphadenectomy. Frequency and prognostic impact of nodal micrometastasis in early cancer of the esophagus have not been investigated so far. PATIENTS AND METHODS This study includes 69 patients with a pT1-stage cancer of the esophagus (SCC: n = 26, AC: n = 43), who underwent transthoracic en-bloc esophagectomy with D2-lympadenectomy between 1996 and 2004. On routine histopathological analysis 48 patients were diagnosed as pN0. Lymph nodes (n = 1344) of these patients were further examined for the presence of isolated tumor cells with the monoclonal anti-epithelial antibody AE1/AE3. RESULTS In lymph nodes of 7 (14.6%) out of 48 pN0-patients a positive staining for AE1/AE3 as a sign for nodal micrometastasis was found. In these patients the tumor has infiltrated the submucosal layer. In patients with tumors restricted to mucosal layer (n = 20) no nodal micrometastasis was present. 5-year survival of pN0-patients with nodal micrometastasis was inferior compared to pN0-patients (57% vs. 82%; p = 0.002). CONCLUSION Almost 15% of patients with pT1 N0 M0 carcinoma of the esophagus and only those with submucosal infiltration show nodal micrometastasis. It has a significant negative impact on survival already in early esophageal cancer.
Collapse
Affiliation(s)
- K L Prenzel
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany
| | | | | | | | | | | |
Collapse
|
9
|
Gutschow CA, Schröder W, Bludau M, Vallböhmer D, Prenzel KL, Bollschweiler E, Hölscher AH. [Value of distal gastrectomy as a remedial operation for failed fundoplication]. Zentralbl Chir 2010; 136:249-55. [PMID: 21181646 DOI: 10.1055/s-0030-1247386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Failure of conventional antireflux surgery is a challenging problem. This study aims at defining the role of distal gastrectomy with Roux-en-Y diversion in the treatment of failed fundoplication. MATERIAL AND METHODS This report reviews the indications and results of 26 patients who underwent revisional antireflux surgery in our department. Distal gastrectomy and Roux-en-Y reconstruction were performed in 6 patients (group a), refundoplication in 15 (group b), and re-hiatoplasty in 5 patients (group c). RESULTS Group a patients had the longest history (p = 0.001) and the highest number of previous operative procedures (p = 0.001). In contrast, hospital stay was longer and postoperative morbidity was higher after distal gastrectomy (p = n. s.). At follow-up, symptom improvement was achieved most reliably after distal gastrectomy (groups a-c: 100%, 78.6%, and 60% of patients; p = n. s.). CONCLUSION Distal gastrectomy with Roux-en-Y diversion is a safe and reliable surgical option for selected patients after failed fundoplication. Distal gastrectomy with Roux-en-Y diversion is a reliable surgical option for selected patients after failed fundoplication. Despite a higher morbidity, this procedure represents an important addition to the surgical armamentarium, particularly in patients with a history of multiple previous interventions.
Collapse
Affiliation(s)
- C A Gutschow
- Universität zu Köln, Klinik und Poliklinik für Allgemein-, Viszeral- und Tumorchirurgie, Köln, Deutschland.
| | | | | | | | | | | | | |
Collapse
|
10
|
Prenzel KL, Hölscher AH, Vallböhmer D, Drebber U, Gutschow CA, Mönig SP, Stippel DL. Lymph node size and metastatic infiltration in adenocarcinoma of the pancreatic head. Eur J Surg Oncol 2010; 36:993-6. [PMID: 20594789 DOI: 10.1016/j.ejso.2010.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Revised: 05/02/2010] [Accepted: 06/07/2010] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Preoperative lymph node staging of pancreatic cancer by CT relies on the premise that malignant lymph nodes are larger than benign nodes. In imaging procedures lymph nodes >1 cm in size are regarded as metastatic nodes. The extend of lymphadenectomy and potential application of neoadjuvant therapy regimens could be dependent on this evaluation. PATIENTS AND METHODS In a morphometric study regional lymph nodes from 52 patients with pancreatic cancer were analyzed. The lymph nodes were counted, the largest diameter of each node was measured, and each node was analyzed for metastatic involvement by histopathological examination. The frequency of metastatic involvement was calculated and correlated with lymph node size. RESULTS A total of 636 lymph nodes were present in the 52 specimens examined for this study (12.2 lymph nodes per patient). Eleven patients had a pN0 status, whereas 41 patients had lymph nodes that were positive for cancer. Five-hundred-twenty (82%) lymph nodes were tumor-free, while 116 (18%) showed metastatic involvement on histopathologic examination. The mean (±SD) diameter of the nonmetastatic nodes was 4.3 mm, whereas infiltrated nodes had a diameter of 5.7 mm (p = 0.001). Seventy-eight (67%) of the infiltrated lymph nodes and 433 (83%) of the nonmetastatic nodes were ≤5 mm in diameter. Of 11 pN0 patients, 5 (45%) patients had at least one lymph node ≥10 mm, in contrast only 12 (29%) out of 41 pN1 patients had one lymph node ≥10 mm. CONCLUSION Lymph node size is not a reliable parameter for the evaluation of metastatic involvement in patients with pancreatic cancer.
Collapse
Affiliation(s)
- K L Prenzel
- Department of General, Visceral and Cancer Surgery, University of Cologne, Germany.
| | | | | | | | | | | | | |
Collapse
|
11
|
|
12
|
Gutschow CA, Vallböhmer D, Stolte M, Oh D, Danenberg K, Danenberg P, Schneider PM, Hölscher AH. Adenocarcinoma developing in de novo Barrett's mucosa in the remnant esophagus after esophagectomy: clinical and molecular assessment. Dis Esophagus 2008; 21:E6-8. [PMID: 18430096 DOI: 10.1111/j.1442-2050.2007.00784.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
For many patients after subtotal esophagectomy and gastric pull-up, reflux of gastric contents to the esophageal stump is the leading clinical problem. Besides symptoms such as heartburn and regurgitation, de novo formation of columnar mucosa in the esophageal remnant is a well-known and frequent phenomenon. In this context, the remnant supra-anastomotic esophagus serves as an in vivo model for the study of Barrett's carcinogenesis. We present a retrospective case analysis of a patient who developed de novo Barrett's metaplasia followed by de novo invasive carcinoma 28 months after gastric pull-up by assessing clinical and molecular parameters.
Collapse
Affiliation(s)
- C A Gutschow
- Department of Visceral and Vascular Surgery, University of Cologne, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Gutschow CA, Schröder W, Wolfgarten E, Hölscher AH. [Merendino procedure with preservation of the vagus for early carcinoma of the gastroesophageal junction]. Zentralbl Chir 2004; 129:276-81. [PMID: 15354248 DOI: 10.1055/s-2004-820307] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Optimal therapy for early carcinoma of the gastroesophageal junction remains uncertain. Treatment alternatives discussed today reach from endoluminal techniques to radical esophagectomy with 2- or 3-field lymphadenectomy. In this context, the Merendino procedure with preservation of the vagal innervation to the stomach appears as an interesting therapeutic alternative. This paper summarizes indications, operative technique, and functional results with respect to postoperative quality of life in view of 2 cases operated in our department.
Collapse
Affiliation(s)
- C A Gutschow
- Klinik und Poliklinik für Visceral- und Gefässchirurgie der Universität zu Köln.
| | | | | | | |
Collapse
|
14
|
Abstract
Dysphagia may occur after reconstruction of the cervical esophagus by jejunal interposition. It may be caused by redundancy and subsequent development of a diverticulum. The present report relates to the case of a patient who developed complete aphagia 2 months after surgery and was treated transorally by division of a common wall between diverticulum and descending jejunal limb with the use of an endoscopic stapling device. The patient started swallowing the first postoperative day and remained able to take oral food at follow-up.
Collapse
Affiliation(s)
- C A Gutschow
- Department of Visceral and Vascular Surgery, University of Cologne, Germany
| | | | | | | | | |
Collapse
|
15
|
Abstract
BACKGROUND Early squamous cell carcinoma (SCC) and early adenocarcinoma (AC) of the esophagus are potentially curable diseases. The crucial point in treatment is that the depth of tumor infiltration into the mucosal and submucosal layers is correlated with the rate of nodal metastases and therefore with long-term prognosis. METHODS AND FOCUS In submucosal SCC with a high rate of nodal metastases curative resection can be achieved only by radical esophagectomy with systematic lymphadenectomy, which remains the treatment of choice for this tumor entity. In submucosal AC the Merendino procedure may offer an alternative since lymphatic invasion occurs at a later stage than in SCC, and locoregional lymph nodes can be adequately resected. Major advantages of this operation over radical esophagectomy include the complete resection of the entire Barrett segment and the lower postoperative morbidity and mortality. Vagal-sparing esophagectomy still lacks adequate oncological evaluation for it to be recommended except in stage I a tumors. For mucosal SCC and AC endoscopic mucosal resection is the treatment of choice but requires intensive follow-up since the rate of complete resections is lower than in limited and radical surgical procedures. On the other hand, a low postoperative morbidity and the functional integrity of the tubular esophagus support the use of endoscopic mucosal resection for mucosal cancer.
Collapse
Affiliation(s)
- W Schröder
- Department of Visceral and Vascular Surgery, University of Cologne, Joseph-Stelzmann-Strasse 9, 50931, Cologne, Germany
| | | | | |
Collapse
|
16
|
Affiliation(s)
- C A Gutschow
- Department of Visceral and Vascular Surgery, University of Cologne, Germany
| | | | | |
Collapse
|
17
|
Gutschow CA, Hölscher AH. [Comment on E. Kleimann and H.J. Halbfass: On the topic of the "short esophagus" in laparoscopic antireflux surgery]. Chirurg 2001; 72:1510-1. [PMID: 11824041 DOI: 10.1007/s001040170021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- C A Gutschow
- Klinik und Poliklinik für Visceral- und Gefässchirurgie Universität zu Köln Joseph-Stelzmann-Strasse 9, 50931 Köln
| | | |
Collapse
|
18
|
Abstract
BACKGROUND Both the supine position and the existence of a gastric drainage procedure are suspected to promote reflux of duodenal juice into the denervated intrathoracic stomach. Erythromycin has been shown to weaken pyloric resistance to gastric outflow and to enhance antral motility, gastric emptying, and gallbladder contractility. METHODS The presence of bile in the gastric transplant of 79 patients was monitored over a 24-hour period with use of the Bilitec 2000 optoelectronic device 3 to 195 months after subtotal esophagectomy. Ten patients were reinvestigated after a 3-year period. Five groups were studied: group I: n = 12, no gastric drainage, never given erythromycin, group 2: n = 40, gastric drainage, never given erythromycin, group 3: n = 7, no gastric drainage, given erythromycin, group 4: n = 13, gastric drainage, given erythromycin, and group 5: n = 7, no longer given erythromycin (with or without gastric drainage). The percentage of time gastric bile absorbance was more than 0.25 was calculated for the total, supine, and upright periods of recording in reference to data from 25 healthy volunteers. RESULTS The Bilitec test was pathologic in 9 of the 12 patients of group 1 whereas it was normal in three. Gastric exposure to bile was longer in group I patients than in controls for the total (p = 0.012) and supine (0.036) periods, but the difference did not reach statistical significance for the upright period (p = 0.080). Bile exposure in group 4 did not significantly differ from controls (total: p = 0.701; supine: p = 0.124; upright: p = 0.712). Bile exposure for the total period did not significantly differ whether patients were taking erythromycin or the drug had been discontinued at the time of the study (p = 0.234); and it tended to decrease with time in patients investigated twice (p = 0.046). CONCLUSIONS Gastric exposure to bile after truncal vagotomy and transposition of the stomach up to the neck is pathologic in three quarters of patients. It is more marked in the supine than in the upright position and tends to decrease with time. The addition of a gastric drainage procedure in combination with erythromycin therapy tends to normalize gastric exposure to bile. The effects of erythromycin may persist after discontinuation of the drug.
Collapse
Affiliation(s)
- C A Gutschow
- Department of Surgery, University of Louvain, Brussels, Belgium
| | | | | | | | | | | |
Collapse
|