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Ubels S, Matthée E, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen MI, Daams F, Dekker JWT, van Det MJ, van Esser S, Griffiths EA, Haveman JW, Nieuwenhuijzen G, Siersema PD, Wijnhoven B, Hannink G, van Workum F, Rosman C, Heisterkamp J, Polat F, Schouten J, Singh P, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, Van Etten B, Poelmann F, Vuurberg N, Willem van den Berg J, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TC, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JW, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CM, 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 RP, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJ, 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 MA, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Koshy R, 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, Constantinoiu S, Birla R, Achim F, Rosianu CG, Hoara P, Castro RG, 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, Koshy R, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Ahmed HA, Elhadi A, Elnagar FA, Msherghi AA, Wills V, Campbell C, Cerdeira MP, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Barbosa JA, 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 AZ, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler M, Schofield W, 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, Fernández SL, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Ben Taher FA, Ekheel M, Msherghi AA. Practice variation in anastomotic leak after esophagectomy: Unravelling differences in failure to rescue. Eur J Surg Oncol 2023; 49:974-982. [PMID: 36732207 DOI: 10.1016/j.ejso.2023.01.010] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/20/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Failure to rescue (FTR) is an important outcome measure after esophagectomy and reflects mortality after postoperative complications. Differences in FTR have been associated with hospital resection volume. However, insight into how centers manage complications and achieve their outcomes is lacking. Anastomotic leak (AL) is a main contributor to FTR. This study aimed to assess differences in FTR after AL between centers, and to identify factors that explain these differences. METHODS TENTACLE - Esophagus is a multicenter, retrospective cohort study, which included 1509 patients with AL after esophagectomy. Differences in FTR were assessed between low-volume (<20 resections), middle-volume (20-60 resections) and high-volume centers (≥60 resections). Mediation analysis was performed using logistic regression, including possible mediators for FTR: case-mix, hospital resources, leak severity and treatment. RESULTS FTR after AL was 11.7%. After adjustment for confounders, FTR was lower in high-volume vs. low-volume (OR 0.44, 95%CI 0.2-0.8), but not versus middle-volume centers (OR 0.67, 95%CI 0.5-1.0). After mediation analysis, differences in FTR were found to be explained by lower leak severity, lower secondary ICU readmission rate and higher availability of therapeutic modalities in high-volume centers. No statistically significant direct effect of hospital volume was found: high-volume vs. low-volume 0.86 (95%CI 0.4-1.7), high-volume vs. middle-volume OR 0.86 (95%CI 0.5-1.4). CONCLUSION Lower FTR in high-volume compared with low-volume centers was explained by lower leak severity, less secondary ICU readmissions and higher availability of therapeutic modalities. To reduce FTR after AL, future studies should investigate effective strategies to reduce leak severity and prevent secondary ICU readmission.
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Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Eric Matthée
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | - Marc J van Det
- Department of Surgery, ZGT Hospital Group, Almelo, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jan Willem Haveman
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for 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 for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | | | | | - Fatih Polat
- Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jeroen Schouten
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Pritam Singh
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Muacevic A, Adler JR, Hindmarsh A. Beware of Rattling Underfoot: Cystic Artery Pseudoaneurysm in Acute Cholecystitis With a Cholecystostomy. Cureus 2023; 15:e33564. [PMID: 36779146 PMCID: PMC9908560 DOI: 10.7759/cureus.33564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. The pathogenesis of CAP in the context of cholecystitis is unknown but is possibly related to the inflammatory process in the vicinity of the cystic artery, leading to weakness in the wall of the artery. Though CAP has been reported in the literature, our patient had a unique presentation in the presence of a cholecystostomy catheter in situ. There were no risk factors for CAP in our patient including usage of anticoagulants, trauma, or surgical procedures. Fortunately, the blood-stained fluid in the cholecystostomy catheter effluent alerted the clinical team to a possible vascular complication in the background of ongoing cholecystitis. This finding should serve as a warning sign to alert clinicians to the possibility of CAP-beware of rattling underfoot.
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Noorani A, Tham JC, Bennett J, Gourgiotis S, Hardwick R, Sujendran V, Safranek P, Hindmarsh A. OGBN P12 Minimising the systemic effects of an oesophageal leak following high risk myotomy repair using Prophylactic Endoluminal Vacuum Therapy (EVT) - time for a change? Br J Surg 2022. [DOI: 10.1093/bjs/znac404.057] [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: 12/12/2022]
Abstract
Abstract
Background
Endoluminal Vacuum Therapy (EVT) continues to gain momentum as a first line treatment for oesophageal perforations. Outside the emergency setting there is growing interest in using EVT prophylactically to protect high-risk elective oesophageal repairs. We present a case which demonstrates the benefit of prophylactic EVT in preventing extraluminal contamination, mediastinitis and sepsis following elective oesophageal surgery.
Methods
An 80-year-old female underwent laparoscopic Hellers Myotomy and Dor Fundoplication for Type 2 Achalasia following worsening symptoms including weight loss despite nutritional optimisation. She had multiple prior balloon dilatations without long term symptom control and remained frail, with a performance status of 0 and an ASA 2. During surgery the oesophageal myotomy was challenging due to extensive scarring. Endoscopy was performed on completion of the myotomy to confirm adequacy and a 1cm oesophageal perforation at 38cm was noted. Primary repair was performed with 5 interrupted 3/0 maxon sutures. An ad-hoc EVT device was constructed using V.A.C granufoam (KCI) sutured to the end of an 18Fr nasogastric tube, and placed intraluminally in the oesophagus across the repair. Continuous negative pressure of 75mmHg was applied. Post operatively the patient was kept nil by mouth and received parenteral nutrition. Her clinical and biochemical parameters were monitored, and the progress of her oesophageal repair was assessed endoscopically.
Results
The first post-operative endoscopy was performed at day 4. On visual inspection a full thickness oesophageal defect was seen at the proximal aspect of the oesophageal repair. There was no associated leak cavity or other endoscopic evidence of extraluminal contamination. A further ad-hoc EVT device was constructed and placed intraluminally in the oesophagus across the suture repair and oesophageal wall defect. A second endoscopy was performed on day 10 post-operative and the oesophageal defect had completely healed. Despite having a documented full thickness oesophageal wall defect the patient remained clinically well throughout her post-operative recovery with no clinical signs of sepsis. The highest recorded CRP was 131 and WCC was 12.7 on day 1 and day 8 respectively. At no point was a higher level of care or input required than the general surgical ward. Her total LOS was 14 days.
Conclusions
A leak following elective oesophageal surgery is a serious complication which may result in mediastinitis, sepsis and death. This case demonstrates the utility of prophylactic EVT in reducing the impact of an oesophageal leak in patients where breakdown of the oesophageal repair occurs. Without prophylactic EVT in this case, we are certain the breakdown of the oesophageal repair would have resulted in a significant oesophageal leak with mediastinitis and sepsis which an 80-year-old patient with limited physiological reserve may not have survived. While prophylactic EVT is not a substitute for sound surgical technique, it should be considered in high-risk patients undergoing elective oesophageal surgery to reduce or prevent the septic hit consequent to an oesophageal leak if breakdown of an oesophageal repair occurs.
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Affiliation(s)
- Ayesha Noorani
- Addenbrooke’s Hospital , Cambridge , United Kingdom
- University of Cambridge , Cambridge , United Kingdom
| | | | - John Bennett
- Addenbrooke’s Hospital , Cambridge , United Kingdom
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Noorani A, Afzal Z, Bennett J, Tham JC, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Hindmarsh A. OGC P37 Towards an era of eliminating leak related morbidity from major oesophago-gastric surgery. Br J Surg 2022. [DOI: 10.1093/bjs/znac404.200] [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: 12/12/2022]
Abstract
Abstract
Background
A leak following oesophago-gastric surgery remains a life-threatening complication associated with a long intensive care stay and high mortality and morbidity. We hypothesised that Endoluminal Vacuum Therapy (EVT) could be used prophylactically to provide source control, prevent mediastinitis and minimise sepsis related morbidity if breakdown of an oesophageal or gastric anastomosis or repair occurred. In the first instance, this could be a particularly attractive adjunct in cases where technical and/or patient factors deem an anastomosis or repair as high risk.
Methods
We collected data prospectively from all patients where a prophylactic EVT device was placed during elective oesophago-gastric surgery. Primary outcome measures included length of stay (LOS) and post-operative leak rate. Prophylactic EVT was provided using an ad-hoc EVT device constructed by suturing a piece of V.A.C granufoam (KCI) to the end of an 18Fr NG tube and positioning this intraluminally across the anastomosis or area of repair at the time of surgery using endoscopic guidance. Continuous negative pressure of between 75 and 125mmHg was applied. Following removal of the EVT device, assessment of the integrity of the anastomosis or repair was made using one, or a combination of endoscopic assessment, CT with oral contrast, and clinical assessment.
Results
Prophylactic EVT was utilised in 9 patients; M:F ratio=7:2, median age 72 years (range 50–80). 8 patients had ASA 3, and 1 had ASA 2. The index surgery was resection of an epithelial cancer in 7 patients (3 partial/total gastrectomies, 4 oesophagectomies), resection of a gastric GIST in 1 patient, and a Hellers myotomy in 1 patient. All anastomosis/repairs were deemed high risk due to technical(n=3), patient(n=4) or combined (n=2) factors. Prophylactic EVT was placed for a median of 6 days (range 4–10). The integrity of the anastomosis/repair was assessed using both CT and gastroscopy (n=3), CT alone (n=3), gastroscopy alone (n=2), and clinical grounds (n=1). One patient was found to have a full thickness oesophageal defect at their first endoscopic assessment. This was managed with a further period of intraluminal EVT until the oesophageal defect healed. The patient remained clinically well throughout and was managed entirely with ward-based care. The median LOS was 11 days (range 7–96). The two longest stays were secondary to a prolonged chyle leak and longer term sequelae of a life threatening on-table bleed. In all cases the site of repair remained healthy with no evidence of early stricturing.
Conclusions
Prophylactic EVT therapy was safe and did not result in any short-term adverse events in this small cohort of patients. Although it may not prevent breakdown at the site of oesophageal anastomosis/repair and is not an alternative to sound surgical technique, the use of prophylactic EVT in high risk anastomosis could be beneficial in preventing life threatening sepsis and associated systemic effects resulting from inadequate source control. Current studies are under way to look at longer term outcomes in the form of prospective cohort studies and randomised controlled trials. This provides the oesophago-gastric community the unique opportunity to collectively eliminate life threatening leak related morbidity and mortality for once and for all.
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Affiliation(s)
- Ayesha Noorani
- Addenbrooke’s Hospital , Cambridge , United Kingdom
- University of Cambridge , Cambridge , United Kingdom
| | | | - John Bennett
- Addenbrooke’s Hospital , Cambridge , United Kingdom
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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] [What about the content of this article? (0)] [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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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.
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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
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Kamarajah SK, Evans RPT, Nepogodiev D, Hodson J, Bundred JR, Gockel I, Gossage JA, Isik A, Kidane B, Mahendran HA, Negoi I, Okonta KE, Sayyed R, van Hillegersberg R, Vohra RS, Wijnhoven BPL, Singh P, Griffiths EA, Kamarajah SK, Hodson J, Griffiths EA, Alderson D, Bundred J, Evans RPT, Gossage J, Griffiths EA, Jefferies B, Kamarajah SK, McKay S, Mohamed I, Nepogodiev D, Siaw-Acheampong K, Singh P, van Hillegersberg R, Vohra R, Wanigasooriya K, Whitehouse T, Gjata A, Moreno JI, Takeda FR, Kidane B, Guevara Castro R, Harustiak T, Bekele A, Kechagias A, Gockel I, Kennedy A, Da Roit A, Bagajevas A, Azagra JS, Mahendran HA, Mejía-Fernández L, Wijnhoven BPL, El Kafsi J, Sayyed RH, Sousa M M, Sampaio AS, Negoi I, Blanco R, Wallner B, Schneider PM, Hsu PK, Isik A, Gananadha S, Wills V, Devadas M, Duong C, Talbot M, Hii MW, Jacobs R, Andreollo NA, Johnston B, Darling G, Isaza-Restrepo A, Rosero G, Arias-Amézquita F, Raptis D, Gaedcke J, Reim D, Izbicki J, Egberts JH, Dikinis S, Kjaer DW, Larsen MH, Achiam MP, Saarnio J, Theodorou D, Liakakos T, Korkolis DP, Robb WB, Collins C, Murphy T, Reynolds J, Tonini V, Migliore M, Bonavina L, Valmasoni M, Bardini R, Weindelmayer J, Terashima M, White RE, Alghunaim E, Elhadi M, Leon-Takahashi AM, Medina-Franco H, Lau PC, Okonta KE, Heisterkamp J, Rosman C, van Hillegersberg R, Beban G, Babor R, Gordon A, Rossaak JI, Pal KMI, Qureshi AU, Naqi SA, Syed AA, Barbosa J, Vicente CS, Leite J, Freire J, Casaca R, Costa RCT, Scurtu RR, Mogoanta SS, Bolca C, Constantinoiu S, Sekhniaidze D, Bjelović M, So JBY, Gačevski G, Loureiro C, Pera M, Bianchi A, Moreno Gijón M, Martín Fernández J, Trugeda Carrera MS, Vallve-Bernal M, Cítores Pascual MA, Elmahi S, Halldestam I, Hedberg J, Mönig S, Gutknecht S, Tez M, Guner A, Tirnaksiz MB, 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 YKS, Turner P, Dexter S, Boddy A, Allum WH, 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, Bryce G, Thomas M, Arndt AT, Palazzo F, Meguid RA, Fergusson J, Beenen E, Mosse C, Salim J, Cheah S, Wright T, Cerdeira MP, McQuillan P, Richardson M, Liem H, Spillane J, Yacob M, Albadawi F, Thorpe T, Dingle A, Cabalag C, Loi K, Fisher OM, Ward S, Read M, Johnson M, Bassari R, Bui H, Cecconello I, Sallum RAA, da Rocha JRM, Lopes LR, Tercioti Jr V, Coelho JDS, Ferrer JAP, 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 TC, 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 PB, Katballe N, Ingemann T, Morten B, Kruhlikava I, Ainswort AP, Stilling NM, Eckardt J, Holm J, Thorsteinsson M, Siemsen M, Brandt B, Nega B, Teferra E, Tizazu A, Kauppila JH, 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 DK, Balalis D, Bolger J, Baban C, Mastrosimone A, McAnena O, Quinn A, Ó Súilleabháin CB, Hennessy MM, Ivanovski I, Khizer H, Ravi N, Donlon N, Cervellera M, Vaccari S, Bianchini S, Asti E, Bernardi D, Merigliano S, Provenzano L, Scarpa M, Saadeh L, Salmaso B, De Manzoni G, Giacopuzzi S, La Mendola R, De Pasqual CA, Tsubosa Y, Niihara M, Irino T, Makuuchi R, Ishii K K, Mwachiro M, Fekadu A, Odera A, Mwachiro E, AlShehab D, Ahmed HA, Shebani AO, Elhadi A, Elnagar FA, Elnagar HF, Makkai-Popa ST, Wong LF, Tan YR, Thannimalai S, Ho CA, Pang WS, Tan JH, Basave HNL, Cortés-González R, Lagarde SM, van Lanschot JJB, Cords C, Jansen WA, Martijnse I, Matthijsen R, Bouwense S, Klarenbeek B, Verstegen M, van Workum F, Ruurda JP, van der Sluis PC, de Maat M, Evenett N, Johnston P, Patel R, MacCormick A, Smith B, Ekwunife C, Memon AH, Shaikh K, Wajid A, Khalil N, Haris M, Mirza ZU, Qudus SBA, Sarwar MZ, Shehzadi A, Raza A, Jhanzaib MH, Farmanali J, Zakir Z, Shakeel O, Nasir I, Khattak S, Baig M, Noor MA, Ahmed HH, Naeem A, Pinho AC, da Silva R, Bernardes A, Campos JC, Matos H, Braga T, Monteiro C, Ramos P, Cabral F, Gomes MP, Martins PC, Correia AM, Videira JF, Ciuce C, Drasovean R, Apostu R, Ciuce C, Paitici S, Racu AE, Obleaga CV, Beuran M, Stoica B, Ciubotaru C, Negoita V, Cordos I, Birla RD, Predescu D, Hoara PA, Tomsa R, Shneider V, Agasiev M, Ganjara I, Gunjić D, Veselinović M, Babič T, Chin TS, Shabbir A, Kim G, Crnjac A, Samo H, Díez del Val I, Leturio S, Ramón JM, Dal Cero M, Rifá S, Rico M, Pagan Pomar A, Martinez Corcoles JA, Rodicio Miravalles JL, Pais SA, Turienzo SA, Alvarez LS, Campos PV, Rendo AG, García SS, Santos EPG, Martínez ET, Fernández Díaz MJ, Magadán Álvarez C, Concepción Martín V, Díaz López C, Rosat Rodrigo A, Pérez Sánchez LE, Bailón Cuadrado M, Tinoco Carrasco C, Choolani Bhojwani E, Sánchez DP, Ahmed ME, 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 BE, 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 TH, 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 LC, 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, Bouras G, Evans R, Singh M, Warrilow H, Ahmad A, Tewari N, Yanni F, Couch J, Theophilidou E, Reilly JJ, Singh P, van Boxel G, Akbari K, Zanotti D, 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 MMA, 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 IA, Karush MK, Seder CW, Liptay MJ, Chmielewski G, Rosato EL, Berger AC, Zheng R, Okolo E, Singh A, Scott CD, Weyant MJ, Mitchell JD. Textbook outcome following oesophagectomy for cancer: international cohort study. Br J Surg 2022. [DOI: https://doi.org/10.1093/bjs/znac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.
Methods
Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).
Results
Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.
Conclusion
Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.
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8
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Kamarajah SK, Evans RPT, Nepogodiev D, Hodson J, Bundred JR, Gockel I, Gossage JA, Isik A, Kidane B, Mahendran HA, Negoi I, Okonta KE, Sayyed R, van Hillegersberg R, Vohra RS, Wijnhoven BPL, Singh P, Griffiths EA, Kamarajah SK, Hodson J, Griffiths EA, Alderson D, Bundred J, Evans RPT, Gossage J, Griffiths EA, Jefferies B, Kamarajah SK, McKay S, Mohamed I, Nepogodiev D, Siaw-Acheampong K, Singh P, van Hillegersberg R, Vohra R, Wanigasooriya K, Whitehouse T, Gjata A, Moreno JI, Takeda FR, Kidane B, Guevara Castro R, Harustiak T, Bekele A, Kechagias A, Gockel I, Kennedy A, Da Roit A, Bagajevas A, Azagra JS, Mahendran HA, Mejía-Fernández L, Wijnhoven BPL, El Kafsi J, Sayyed RH, Sousa M M, Sampaio AS, Negoi I, Blanco R, Wallner B, Schneider PM, Hsu PK, Isik A, Gananadha S, Wills V, Devadas M, Duong C, Talbot M, Hii MW, Jacobs R, Andreollo NA, Johnston B, Darling G, Isaza-Restrepo A, Rosero G, Arias-Amézquita F, Raptis D, Gaedcke J, Reim D, Izbicki J, Egberts JH, Dikinis S, Kjaer DW, Larsen MH, Achiam MP, Saarnio J, Theodorou D, Liakakos T, Korkolis DP, Robb WB, Collins C, Murphy T, Reynolds J, Tonini V, Migliore M, Bonavina L, Valmasoni M, Bardini R, Weindelmayer J, Terashima M, White RE, Alghunaim E, Elhadi M, Leon-Takahashi AM, Medina-Franco H, Lau PC, Okonta KE, Heisterkamp J, Rosman C, van Hillegersberg R, Beban G, Babor R, Gordon A, Rossaak JI, Pal KMI, Qureshi AU, Naqi SA, Syed AA, Barbosa J, Vicente CS, Leite J, Freire J, Casaca R, Costa RCT, Scurtu RR, Mogoanta SS, Bolca C, Constantinoiu S, Sekhniaidze D, Bjelović M, So JBY, Gačevski G, Loureiro C, Pera M, Bianchi A, Moreno Gijón M, Martín Fernández J, Trugeda Carrera MS, Vallve-Bernal M, Cítores Pascual MA, Elmahi S, Halldestam I, Hedberg J, Mönig S, Gutknecht S, Tez M, Guner A, Tirnaksiz MB, 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 YKS, Turner P, Dexter S, Boddy A, Allum WH, 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, Bryce G, Thomas M, Arndt AT, Palazzo F, Meguid RA, Fergusson J, Beenen E, Mosse C, Salim J, Cheah S, Wright T, Cerdeira MP, McQuillan P, Richardson M, Liem H, Spillane J, Yacob M, Albadawi F, Thorpe T, Dingle A, Cabalag C, Loi K, Fisher OM, Ward S, Read M, Johnson M, Bassari R, Bui H, Cecconello I, Sallum RAA, da Rocha JRM, Lopes LR, Tercioti Jr V, Coelho JDS, Ferrer JAP, 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 TC, 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 PB, Katballe N, Ingemann T, Morten B, Kruhlikava I, Ainswort AP, Stilling NM, Eckardt J, Holm J, Thorsteinsson M, Siemsen M, Brandt B, Nega B, Teferra E, Tizazu A, Kauppila JH, 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 DK, Balalis D, Bolger J, Baban C, Mastrosimone A, McAnena O, Quinn A, Ó Súilleabháin CB, Hennessy MM, Ivanovski I, Khizer H, Ravi N, Donlon N, Cervellera M, Vaccari S, Bianchini S, Asti E, Bernardi D, Merigliano S, Provenzano L, Scarpa M, Saadeh L, Salmaso B, De Manzoni G, Giacopuzzi S, La Mendola R, De Pasqual CA, Tsubosa Y, Niihara M, Irino T, Makuuchi R, Ishii K K, Mwachiro M, Fekadu A, Odera A, Mwachiro E, AlShehab D, Ahmed HA, Shebani AO, Elhadi A, Elnagar FA, Elnagar HF, Makkai-Popa ST, Wong LF, Tan YR, Thannimalai S, Ho CA, Pang WS, Tan JH, Basave HNL, Cortés-González R, Lagarde SM, van Lanschot JJB, Cords C, Jansen WA, Martijnse I, Matthijsen R, Bouwense S, Klarenbeek B, Verstegen M, van Workum F, Ruurda JP, van der Sluis PC, de Maat M, Evenett N, Johnston P, Patel R, MacCormick A, Smith B, Ekwunife C, Memon AH, Shaikh K, Wajid A, Khalil N, Haris M, Mirza ZU, Qudus SBA, Sarwar MZ, Shehzadi A, Raza A, Jhanzaib MH, Farmanali J, Zakir Z, Shakeel O, Nasir I, Khattak S, Baig M, Noor MA, Ahmed HH, Naeem A, Pinho AC, da Silva R, Bernardes A, Campos JC, Matos H, Braga T, Monteiro C, Ramos P, Cabral F, Gomes MP, Martins PC, Correia AM, Videira JF, Ciuce C, Drasovean R, Apostu R, Ciuce C, Paitici S, Racu AE, Obleaga CV, Beuran M, Stoica B, Ciubotaru C, Negoita V, Cordos I, Birla RD, Predescu D, Hoara PA, Tomsa R, Shneider V, Agasiev M, Ganjara I, Gunjić D, Veselinović M, Babič T, Chin TS, Shabbir A, Kim G, Crnjac A, Samo H, Díez del Val I, Leturio S, Ramón JM, Dal Cero M, Rifá S, Rico M, Pagan Pomar A, Martinez Corcoles JA, Rodicio Miravalles JL, Pais SA, Turienzo SA, Alvarez LS, Campos PV, Rendo AG, García SS, Santos EPG, Martínez ET, Fernández Díaz MJ, Magadán Álvarez C, Concepción Martín V, Díaz López C, Rosat Rodrigo A, Pérez Sánchez LE, Bailón Cuadrado M, Tinoco Carrasco C, Choolani Bhojwani E, Sánchez DP, Ahmed ME, 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 BE, 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 TH, 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 LC, 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, Bouras G, Evans R, Singh M, Warrilow H, Ahmad A, Tewari N, Yanni F, Couch J, Theophilidou E, Reilly JJ, Singh P, van Boxel G, Akbari K, Zanotti D, 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 MMA, 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 IA, Karush MK, Seder CW, Liptay MJ, Chmielewski G, Rosato EL, Berger AC, Zheng R, Okolo E, Singh A, Scott CD, Weyant MJ, Mitchell JD. Textbook outcome following oesophagectomy for cancer: international cohort study. Br J Surg 2022; 109:439-449. [PMID: 35194634 DOI: 10.1093/bjs/znac016] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/08/2021] [Accepted: 01/04/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting. METHODS Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.). RESULTS Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome. CONCLUSION Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.
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9
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Afzal Z, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Bennett J, O'Neill R, Noorani A, Hindmarsh A. O-EGS08 Endoluminal Vacuum Therapy (EVT) for leaks in the upper gastrointestinal (UGI) tract; 10-years’ experience in a specialist Oesphagogastric centre. Br J Surg 2021. [DOI: 10.1093/bjs/znab429.022] [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: 11/13/2022]
Abstract
Abstract
Background
Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for UGI leaks. When compared to traditional treatments strategies EVT is reported to reduce morbidity and mortality, especially in patients with delayed presentation and established sepsis. We report the outcomes for patients with UGI leaks and perforations treated with EVT using an ad-hoc endoluminal vacuum device (EVD) in a tertiary UK hospital over a 10-year period.
Methods
Sixty-seven patients with UGI leaks from disparate causes were treated with EVT between April 2011 and July 2021. The ad-hoc EVD was constructed using a piece of open cell foam sutured around the distal end of a nasogastric tube, and placed endoscopically either through the perforation and into the extra-luminal leak cavity OR intraluminally depending on the morphology of the leak cavity. Continuous negative pressure (125mmHg) was applied. Endoscopic re-evaluation of the leak cavity with change of EVD was performed every 48-120 hours depending on the patients clinical condition. Information related to treatment and outcome was recorded prospectively.
Results
Patients had a median age of 66 years (range 23-92), and median Apache II score of 21 (range 4-36) at presentation. Fifty-two leaks were oesophageal (78%), 12 gastric (18%), 2 duodenal (3%), and 1 pharangeal (1%). The leak cause was anastomotic in 26 (39%), iatrogenic in 20 (30%), spontaneous in 19 (28%), and traumatic in 2 (3%). The median number of EVD changes required to heal the leak was 6 (range 1-27), and median length of hospital stay was 42 days (range 1-182). Successful resolution of the leak was achieved in 59 patients (88%). Eight (12%) patients died during treatment. There were no complications related to insertion of the EVD.
Conclusions
EVT is an effective treatment for UGI leaks which can be delivered safely in a tertiary oesophagogastric centre, and used to treat a wide range of leak causes in critically unwell patients. Further studies are required to develop a standardized procedure to improve the ease with which EVT can be delivered. This will enable broader adoption of EVT for this group of patients.
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Affiliation(s)
- Zeeshan Afzal
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stavros Gourgiotis
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Richard Hardwick
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Safranek
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Vijayendran Sujendran
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - John Bennett
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert O'Neill
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ayesha Noorani
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Andrew Hindmarsh
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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10
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Afzal Z, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Bennett J, O'Neill R, Noorani A, Hindmarsh A. P-EGS19 Complete oesophageal transection during thyroidectomy; Successful management of anastomotic leak using endoluminal vacuum therapy (EVT) following failed primary repair. Br J Surg 2021. [DOI: 10.1093/bjs/znab430.079] [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: 11/13/2022]
Abstract
Abstract
Background
Perforation of the cervical oesophagus is an extremely rare but recognised complication of thyroidectomy. As with all oesophageal perforations management depends on timing of diagnosis in relation to the timing of injury, the size of the oesophageal wall defect, extent of extraluminal contamination, and how unwell the patient is with respect to sepsis. We report a case of complete transection of the cervical oesophagus during total thyroidectomy and its subsequent management.
Methods
A previously well 32-year-old female had a complete cervical oesophageal transection during total thyroidectomy and neck dissection for papillary carcinoma of thyroid. This was recognised by her ENT surgeon who repaired the oesophagus primarily. Subsequently, she developed sepsis with cellulitis of her anterior chest wall. Cross-sectional imaging demonstrated a leak at the site of the cervical oesophageal repair. Gastroscopy confirmed a 50% dehiscence of the oesophageal anastomosis. Control and management of her oesophageal leak was achieved with EVT delivered using an ad-hoc endoluminal vacuum device (EVD) constructed from open cell foam sutured around the distal end of a nasogastric tube.
Results
The patient was managed in the intensive care unit (ICU) with appropriate organ support and antimicrobial cover. A surgical jejunostomy was placed to facilitate enteral feeding. EVT was delivered using the ad-hoc EVD which was placed endoscopically and situated intraluminally across the anastomotic leak site. Continuous negative pressure (125 mmHg) was applied. Six EVD changes were required to heal the leak. Her total length of stay was 41 days, of which 38 days were in ICU. There were no periprocedural complications related to using the EVD or EVT, although the patient subsequently developed an oesophageal stricture which required endoscopic dilatation.
Conclusions
Accidental complete transection of the cervical oesophagus is extremely rare. This case highlights the importance of a multidisciplinary team approach for managing such cases. EVT is an emerging treatment option for upper gastrointestinal (UGI) leaks and is reported to be safe and effective for leaks from a wide range of causes throughout the UGI tract. Successful resolution of the oesophageal leak in this unusual case demonstrates the utility of EVT in difficult clinical situations which may otherwise pose a formidable management challenge using traditional treatment strategies.
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Affiliation(s)
- Zeeshan Afzal
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stavros Gourgiotis
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Richard Hardwick
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Safranek
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Vijayendran Sujendran
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - John Bennett
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert O'Neill
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ayesha Noorani
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Andrew Hindmarsh
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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11
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Afzal Z, Gourgiotis S, Hardwick R, Safranek P, Sujendran V, Bennett J, O'Neill R, Noorani A, Hindmarsh A. P-OGC68 Prophylactic Endoluminal Vacuum Therapy (EVT) following oesophagectomy. Br J Surg 2021. [DOI: 10.1093/bjs/znab430.196] [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: 11/13/2022]
Abstract
Abstract
Background
Endoluminal vacuum therapy (EVT) is an emerging treatment strategy for the management of anastomotic leaks following oesophagectomy. However, patients are often critically unwell with mediastinitis and established sepsis by the time the leak is diagnosed. This results in a protracted recovery period regardless of the effectiveness of EVT in treating the leak. Prophylactic EVT to protect the anastomosis following oesophagectomy may reduce the incidence of anastomotic leak, and/or mediastinitis and sepsis if the anastomosis does fail. We report the outcomes of two patients considered high risk for anastomotic leak who were managed with prophylactic EVT following esophagectomy for cancer.
Methods
Two patients received prophylactic EVT following oesophagectomy between May and July 2021. The patients were considered high risk for anastomotic leak due to technical concerns with, or complications during, the operation. In both cases the oesophagogastric anastomosis (OGA) was fashioned with a circular stapler. The endoluminal vacuum device (EVD) was constructed using an 18F nasogastric tube and a piece of open cell foam, and placed intraluminally across the anastomosis under endoscopic guidance at the time of surgery. Continuous negative pressure (125mmHg) was applied. Information relating to treatment and outcome was recorded prospectively.
Results
Patient-1, a 72-year-old female, ASA 2, underwent minimally invasive oesophgectomy for an adenocarcinoma at the gastro-oesophageal junction. After creating the stapled OGA, inspection revealed the proximal (oesophageal) tissue doughnut was complete but attenuated. Patient 2, a 67-year-old male, ASA 3, underwent a hybrid Ivor Lewis oesophgectomy for a lower 1/3 oesophageal adenocarcinoma. Surgery was complicated by significant intra-abdominal bleeding requiring blood transfusion and pressor support. In both cases, endoscopic assessment of the anastomosis following removal of the prophylactic EVD was performed day seven post-operatively. The anastomoses were healthy with no evidence of a leak, dehiscence, or early stricture formation.
Conclusions
In this limited case series, prophylactic EVT of the OGA following oesophagectomy was delivered safely with no complications related to insertion of the EVD or delivery of EVT. This intervention should be considered in cases where the risk of anastomotic leak is high. An intraluminal EVD situated across the OGA may minimise the extent of extraluminal contamination, and the systemic consequences of sepsis associated with this, should an anastomotic breakdown occur. Further studies are required to determine the safety of prophylactic EVT following oesophagectomy, and whether this improves surgical outcomes by reducing the incidence and impact of anastomotic leaks.
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Affiliation(s)
- Zeeshan Afzal
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Stavros Gourgiotis
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Richard Hardwick
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Safranek
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Vijayendran Sujendran
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - John Bennett
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Robert O'Neill
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ayesha Noorani
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Andrew Hindmarsh
- Cambridge Oesophagogastric Centre, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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12
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Askari A, Wheat J, Kangatharan C, Ismail M, Gourgiotis S, Safranek P, Sujendran V, Hindmarsh A, Bennett J, Hardwick R, O'Neill R. P-OGC90 Hiatus Hernia post oesophagectomy for oesophageal cancer: incidence & outcomes. Br J Surg 2021. [DOI: 10.1093/bjs/znab430.217] [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: 11/14/2022]
Abstract
Abstract
Background
The development of a hiatus hernia following oesophagectomy is a well-documented occurrence. The aim of this study is to examine the incidence of hiatus hernia formation, the symptoms patient present with and differences between open and laparoscopic/minimally invasive surgery.
Methods
A dataset containing data on all patients from an upper GI regional tertiary referral centre were analysed. All subsequent patients who underwent oesophagectomy between Nov 2014 and Nov 2020 were included.
Results
A total of 268 patients underwent oesophagectomy over this time, of whom 81.0% (n = 217/268) were male and the median age was 68 years old (62-73 years). The median BMI at the time of operation was 27.6Kg/m2 (IQR 24.6-30.7Kg/m2). Over a median follow up of 12 months (IQR 5-21), 4.5% (n = 12/268) developed a hiatus hernia. Amongst these 12, the most common organ in the hernia was the transverse colon (66.7%, n = 8/12) and the small bowel (n = 3). The most reported symptoms in those with a hiatus hernia were respiratory symptoms (cough/breathlessness: n = 5), reflux (n = 3), vomiting (n = 3) and chest pain (n = 3). There was no correlation between BMI and the occurrence of a hiatus hernia (p = 0.145) nor were there differences across males and females in terms of hiatus hernia rates (p = 0.845). In patients who had prophylactic repair of the diaphragm (n = 126/268, 47.0%) the rate of hernia repair was no different (4.8%) compared with those who did not have a prophylactic diaphragmatic repair with sutures (4.2%, p = 0.832). There was however a correlation between the volume of intraoperative blood loss and the occurrence of a hiatus hernia, with increasing blood loss correlating with a higher likelihood of hernia occurrence (r = 0.295, p = 0.037).
Conclusions
Hiatus hernia is a relatively common occurrence after oesophageal cancer surgery, with most patients suffering from chest symptoms, pain, and reflux. Intra-operative blood loss may influence the chances of developing a hiatus hernia. Prophylactic measures such as reinforcing the diaphragm or hiatus with sutures, do not appear to affect hernia rates.
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Affiliation(s)
- Alan Askari
- Addenbrookes Hospital, Cambridge, United Kingdom
| | | | | | | | | | | | | | | | - John Bennett
- Addenbrookes Hospital, Cambridge, United Kingdom
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13
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Wheat J, Askari A, Kalyanasundaram A, Ismail M, Bennett J, Gourgiotis S, Safranek P, Sujendran V, Hindmarsh A, Hardwick R, O'Neill R. P-OGC91 Significance of the number, size and type of drains used for intercostal drainage after oesophagectomy for cancer. Br J Surg 2021. [DOI: 10.1093/bjs/znab430.218] [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: 11/13/2022]
Abstract
Abstract
Background
Pleural space drainage with intercostal drains (ICD) is performed after oesophagectomy to allow the lung to reinflate, remove excess fluid post-operatively, and signal chyle or enteric content. Enhanced recovery protocols encourage the use of the minimum number of drains for the shortest duration to facilitate rapid recovery after surgery. There is wide variability in the type, number and size of drains inserted at operation. This study sought to identify the most effective drain pattern insertion, using the need for respiratory reintervention as the primary end point and secondary outcome of the presence of pleural effusions.
Methods
All patients undergoing oesophagectomy for cancer in one unit were included between November 2014 and December 2020. The operation performed, drain sizes, sides and type were recorded. Respiratory reintervention was defined as replacement of an ICD, bronchoscopy, pleural aspiration or reintubation. The primary and secondary end points, and potential confounders such as age, histology, pre-operative stage of disease, neoadjuvant therapy, pre-existing lung disease, and anastomotic or chyle leak were recorded.
Results
The study period encompassed 258 patients who underwent oesophagectomy for cancer. Median age 69 (range 32-82), 211 male, 226 ACA:32 SCC, 224 neoadjuvant therapy, 212 right-sided thoracic operations, 46 left thoracoabdominal approach.
Post-operative respiratory reinterventions occurred in 47 patients (18.2%). At least one post-operative pleural effusion was present in 52 patients (20.2%): 9 bilateral; 26 contralateral; 17 ipsilateral to the side of thoracic surgery. 67% of effusions were contralateral to the operated side. The use of two or three ICDs (HR 371683269, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 0.938 [0.422-2.085], p < 0.875), and size 24F compared to 28F drains (HR 0, p < 0.999) are not significantly associated with post-operative respiratory reinterventions.
Similarly, the presence of post-operative pleural effusions is not significantly associated with the use of two or three ICDs (HR 240242843, p < 1), one or two operative side ICDs (HR 0, p < 1), Blake’s drains in place of rigid ICDs (HR 1.505 [0.665-3.405], p < 0.327), and size 24F compared to 28F drains (HR 1.055 [0.109-10.2], p < 0.963).
Conclusions
This study supports the use of contralateral pleural space drainage as two thirds of effusions were contralateral to the operated side. It shows no correlation between the size of drains, number of drains or use of Blakes drains and the likelihood of requiring a post-operative respiratory intervention or development of post-operative pleural effusion. Therefore the ERAS principles of the fewest number of drains for the shortest duration should be adopted.
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Affiliation(s)
| | - Alan Askari
- Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | | | - John Bennett
- Addenbrooke's Hospital, Cambridge, United Kingdom
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Evans RPT, Kamarajah SK, Bundred J, Nepogodiev D, Hodson J, van Hillegersberg R, Gossage J, Vohra R, Griffiths EA, Singh P, Evans RPT, Hodson J, Kamarajah SK, Griffiths EA, Singh P, Alderson D, Bundred J, Evans RPT, Gossage J, Griffiths EA, Jefferies B, Kamarajah SK, McKay S, Mohamed I, Nepogodiev D, Siaw- Acheampong K, Singh P, van Hillegersberg R, Vohra R, Wanigasooriya K, Whitehouse T, Gjata A, Moreno JI, Takeda FR, Kidane B, Guevara Castro R, Harustiak T, Bekele A, Kechagias A, Gockel I, Kennedy A, Da Roit A, Bagajevas A, Azagra JS, Mahendran HA, Mejía-Fernández L, Wijnhoven BPL, El Kafsi J, Sayyed RH, Sousa M, Sampaio AS, Negoi I, Blanco R, Wallner B, Schneider PM, Hsu PK, Isik A, Gananadha S, Wills V, Devadas M, Duong C, Talbot M, Hii MW, Jacobs R, Andreollo NA, Johnston B, Darling G, Isaza-Restrepo A, Rosero G, Arias-Amézquita F, Raptis D, Gaedcke J, Reim D, Izbicki J, Egberts JH, Dikinis S, Kjaer DW, Larsen MH, Achiam MP, Saarnio J, Theodorou D, Liakakos T, Korkolis DP, Robb WB, Collins C, Murphy T, Reynolds J, Tonini V, Migliore M, Bonavina L, Valmasoni M, Bardini R, Weindelmayer J, Terashima M, White RE, Alghunaim E, Elhadi M, Leon-Takahashi AM, Medina-Franco H, Lau PC, Okonta KE, Heisterkamp J, Rosman C, van Hillegersberg R, Beban G, Babor R, Gordon A, Rossaak JI, Pal KMI, Qureshi AU, Naqi SA, Syed AA, Barbosa J, Vicente CS, Leite J, Freire J, Casaca R, Costa RCT, Scurtu RR, Mogoanta SS, Bolca C, Constantinoiu S, Sekhniaidze D, Bjelović M, So JBY, Gačevski G, Loureiro C, Pera M, Bianchi A, Moreno Gijón M, Martín Fernández J, Trugeda Carrera MS, Vallve-Bernal M, Cítores Pascual MA, Elmahi S, Hedberg J, Mönig S, Gutknecht S, Tez M, Guner A, Tirnaksiz TB, 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 YKS, Turner P, Dexter S, Boddy A, Allum WH, 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 AT, Palazzo F, Meguid RA, Fergusson J, Beenen E, Mosse C, Salim J, Cheah S, Wright T, Cerdeira MP, McQuillan P, Richardson M, Liem H, Spillane J, Yacob M, Albadawi F, Thorpe T, Dingle A, Cabalag C, Loi K, Fisher OM, Ward S, Read M, Johnson M, Bassari R, Bui H, Cecconello I, Sallum RAA, da Rocha JRM, Lopes LR, Tercioti V, Coelho JDS, Ferrer JAP, 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 TC, 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 PB, Katballe N, Ingemann T, Morten B, Kruhlikava I, Ainswort AP, Stilling NM, Eckardt J, Holm J, Thorsteinsson M, Siemsen M, Brandt B, Nega B, Teferra E, Tizazu A, Kauppila JS, 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, Baili E, Mpoura M, Charalabopoulos A, Manatakis DK, Balalis D, Bolger J, Baban C, Mastrosimone A, McAnena O, Quinn A, Súilleabháin CBÓ, Hennessy MM, 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 CA, Tsubosa Y, Niihara M, Irino T, Makuuchi R, Ishii K, Mwachiro M, Fekadu A, Odera A, Mwachiro E, AlShehab D, Ahmed HA, Shebani AO, Elhadi A, Elnagar FA, Elnagar HF, Makkai-Popa ST, Wong LF, Yunrong T, Thanninalai S, Aik HC, Soon PW, Huei TJ, Basave HNL, Cortés-González R, Lagarde SM, van Lanschot JJB, Cords C, Jansen WA, Martijnse I, Matthijsen R, Bouwense S, Klarenbeek B, Verstegen M, van Workum F, Ruurda JP, van der Veen A, van den Berg JW, Evenett N, Johnston P, Patel R, MacCormick A, Young M, Smith B, Ekwunife C, Memon AH, Shaikh K, Wajid A, Khalil N, Haris M, Mirza ZU, Qudus SBA, Sarwar MZ, Shehzadi A, Raza A, Jhanzaib MH, Farmanali J, Zakir Z, Shakeel O, Nasir I, Khattak S, Baig M, Noor MA, Ahmed HH, Naeem A, Pinho AC, da Silva R, Matos H, Braga T, Monteiro C, Ramos P, Cabral F, Gomes MP, Martins PC, Correia AM, Videira JF, Ciuce C, Drasovean R, Apostu R, Ciuce C, Paitici S, Racu AE, Obleaga CV, Beuran M, Stoica B, Ciubotaru C, Negoita V, Cordos I, Birla RD, Predescu D, Hoara PA, Tomsa R, Shneider V, Agasiev M, Ganjara I, Gunjić D, Veselinović M, Babič T, Chin TS, Shabbir A, Kim G, Crnjac A, Samo H, Díez del Val I, Leturio S, Díez del Val I, Leturio S, Ramón JM, Dal Cero M, Rifá S, Rico M, Pagan Pomar A, Martinez Corcoles JA, Rodicio Miravalles JL, Pais SA, Turienzo SA, Alvarez LS, Campos PV, Rendo AG, García SS, Santos EPG, Martínez ET, Fernández Díaz MJ, Magadán Álvarez C, Concepción Martín V, Díaz López C, Rosat Rodrigo A, Pérez Sánchez LE, Bailón Cuadrado M, Tinoco Carrasco C, Choolani Bhojwani E, Sánchez DP, Ahmed ME, 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 BE, 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 TH, 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 LC, 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 JJ, Singh P, van Boxel G, 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 MMA, 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 IA, Karush MK, Seder CW, Liptay MJ, Chmielewski G, Rosato EL, Berger AC, Zheng R, Okolo E, Singh A, Scott CD, Weyant MJ, Mitchell JD. Postoperative outcomes in oesophagectomy with trainee involvement. BJS Open 2021; 5:zrab132. [PMID: 35038327 PMCID: PMC8763367 DOI: 10.1093/bjsopen/zrab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/15/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.
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Afzal Z, Gourgiotis S, Hardwick RH, Safranek PM, Sujendran V, Bennett J, O'Neill JR, Noorani A, Hindmarsh A. Management of Upper Gastrointestinal Tract Leaks Using Endoluminal Vacuum Therapy: 10-years’ Experience of a Specialist Esophago-gastric Center. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kamarajah S, Nepogodiev D, Bekele A, Cecconello I, Evans R, Guner A, Gossage J, Harustiak T, Hodson J, Isik A, Kidane B, Leon-Takahashi A, Mahendran H, Negoi I, Okonta K, Rosero G, Sayyed R, Singh P, Takeda F, van Hillegersberg R, Vohra R, White R, 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 CR, 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 GM, 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, Mpali 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, Noor M, 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 DMJ, Magadán ÁC, Concepción MV, Díaz LC, Rosat RA, Pérez SLE, Bailón CM, Tinoco CC, 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 LH, 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 G, 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. Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study. Eur J Surg Oncol 2021; 47:1481-1488. [PMID: 33451919 DOI: 10.1016/j.ejso.2020.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer. METHOD This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%). RESULTS Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC. CONCLUSION Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.
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Noorani A, Li X, Goddard M, Crawte J, Alexandrov LB, Secrier M, Eldridge MD, Bower L, Weaver J, Lao-Sirieix P, Martincorena I, Debiram-Beecham I, Grehan N, MacRae S, Malhotra S, Miremadi A, Thomas T, Galbraith S, Petersen L, Preston SD, Gilligan D, Hindmarsh A, Hardwick RH, Stratton MR, Wedge DC, Fitzgerald RC. Genomic evidence supports a clonal diaspora model for metastases of esophageal adenocarcinoma. Nat Genet 2020; 52:74-83. [PMID: 31907488 PMCID: PMC7100916 DOI: 10.1038/s41588-019-0551-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/19/2019] [Indexed: 01/23/2023]
Abstract
The poor outcomes in esophageal adenocarcinoma (EAC) prompted us to interrogate the pattern and timing of metastatic spread. Whole-genome sequencing and phylogenetic analysis of 388 samples across 18 individuals with EAC showed, in 90% of patients, that multiple subclones from the primary tumor spread very rapidly from the primary site to form multiple metastases, including lymph nodes and distant tissues-a mode of dissemination that we term 'clonal diaspora'. Metastatic subclones at autopsy were present in tissue and blood samples from earlier time points. These findings have implications for our understanding and clinical evaluation of EAC.
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Affiliation(s)
| | - Xiaodun Li
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Martin Goddard
- Department of Histopathology, Papworth Hospital NHS Trust, Cambridge, UK
| | - Jason Crawte
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Ludmil B Alexandrov
- Cellular and Molecular Medicine, University of California, San Diego, San Diego, CA, USA
| | - Maria Secrier
- Cancer Research UK Cambridge Research Institute, Cambridge, UK
| | | | - Lawrence Bower
- Cancer Research UK Cambridge Research Institute, Cambridge, UK
| | - Jamie Weaver
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | | | | | | | - Nicola Grehan
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Shona MacRae
- MRC Cancer Unit, University of Cambridge, Cambridge, UK
| | - Shalini Malhotra
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ahmad Miremadi
- Department of Histopathology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Sarah Galbraith
- Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Stephen D Preston
- Department of Histopathology, Papworth Hospital NHS Trust, Cambridge, UK
| | - David Gilligan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew Hindmarsh
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Richard H Hardwick
- Cambridge Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David C Wedge
- Big Data Institute, University of Oxford, Oxford, UK.
- Oxford NIHR Biomedical Research Centre, Oxford, UK.
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Bundred JR, Kamarajah SK, Siaw‐Acheampong K, Nepogodiev D, Jefferies B, Singh P, Evans R, Griffiths EA, Alderson D, Gossage J, McKay S, Mohamed I, van Hillegersberg R, Vohra R, Wanigsooriya K, Whitehouse T, Bagajevas A, Bekele A, Blanco‐Colino R, Da Roit A, El Kafsi‐Mawley J, Gjata A, Gockel I, Castro RG, Harustiak T, Hsu P, Isik A, Kechagias A, Kennedy A, Kidane B, Mahendran HA, Mejia L, Moreno JI, Negoi I, Santiago AJ, Sayyed R, Schneider P, Soares AS, Sousa M, Takeda FR, Vanstraten S, Wallner B, Wijnhoven B, Achiam M, Agustin T, Akbar A, Al‐Bahrani A, Al‐Khyatt W, Albertsmeier M, Alghunaim E, Alkhaffaf B, Allum W, Am F, Andreollo N, Arndt A, Babor R, Barbosa J, Bardini R, Beardsmore D, Beban G, Bernardes A, Berrisford R, Bianchi A, Bjelovic M, Boddy A, Bolca C, Bonavina L, Bryce G, Byrom R, Casaca R, Chan D, Charalabopoulos A, Cheong E, Ciotola F, Colak E, Collins C, Constantinoiu S, Costa R, Dahlke M, Darling G, Dawas K, de Manzoni G, Denewer A, Devadas M, Dexter S, Dikinis S, Dimitrios T, Dolan J, Duong C, Egberts J, Elgharably Y, Elhadi M, Elmahi S, Farias FA, Fekaj E, Fernández J, Forshaw M, Freire J, French D, Gacevski G, Gaedcke J, Gananadha S, Gijon MM, Gokhale J, Gordon A, Grimminger P, Guevara R, Guner A, Gutknecht S, Mahmoodzadeh H, Halldestam I, Hedberg J, Heisterkamp J, Higgs S, Hii M, Hindmarsh A, Hoppner J, Isaza A, Izbicki J, Jacobs R, Jain P, Johansson J, Johnston B, Kafsi J, Kassa S, Kelty C, Khan I, Khoo D, Khyatt S, Kjaer D, Korkolis D, Kreuser N, Larsen M, Lau P, Leite J, Lewis W, Liakakos T, Loureiro C, Mahendran A, Maynard N, Mcgregor R, Mcnally S, Medina‐Franco H, Meguid R, Melhado R, Mercer S, Migliore M, Mingol F, Mogoanta S, Mohri Y, Mönig S, Moreno J, Motas N, Murphy T, Naqi S, Ni R, Niazi S, Oglesby S, Okonta K, Ortiz SR, Pal K, Palazzo F, Pascher A, Pascual M, Pata G, Pera M, Puig S, Ramirez J, Raptis D, Räsänen J, Reim D, Reynolds J, Robb W, Robertson K, Rosero G, Rosman C, Rossaak J, Saarnio J, Santiago A, Schiesser M, Scurtu R, Sekhniaidze D, Sevinç B, Skipworth R, So J, Trugeda MS, Syed A, Takahashi AML, Takeda F, Talbot M, Tareen M, Terashima M, Testini M, Tewari N, Tez M, Thomas M, Tirnaksiz M, Tonini V, Tu C, Turner P, Underwood T, Uzair A, Vallve‐Bernal M, Valmasoni M, Vicente C, Videira JF, Viswanath YKS, Weindelmayer J, White R, Wigle D, Wilkerson P, Wills V, Zacharakis E, Zuluaga M. International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA). World J Surg 2019; 43:2874-2884. [PMID: 31332491 DOI: 10.1007/s00268-019-05080-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy. METHOD The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit. RESULTS Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001). CONCLUSIONS This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.
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Noorani A, Anthony-Pillai A, Pournaras D, Safranek PM, Sujendran VS, Bennett JM, Hardwick RH, Gourgiotis S, Hindmarsh A. Endoluminal Vacuum Therapy: Changing the Management of Upper Gastrointestinal Leaks. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Pournaras DJ, Hardwick RH, Safranek PM, Sujendran V, Bennett J, Macaulay GD, Hindmarsh A. Endoluminal Vacuum Therapy (E-Vac): A Treatment Option in Oesophagogastric Surgery. World J Surg 2018; 42:2507-2511. [PMID: 29372375 PMCID: PMC6060786 DOI: 10.1007/s00268-018-4463-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Leaks from the upper gastrointestinal tract often pose a management challenge, particularly when surgical treatment has failed or is impossible. Vacuum therapy has revolutionised the treatment of wounds, and its role in enabling and accelerating healing is now explored in oesophagogastric surgery. Methods A piece of open cell foam is sutured around the distal end of a nasogastric tube using a silk suture. Under general anaesthetic, the foam covered tip is placed endoscopically through the perforation and into any extra-luminal cavity. Continuous negative pressure (125 mmHg) is then applied. Re-evaluation with change of the negative pressure system is performed every 48–72 h depending on the clinical condition. Patients are fed enterally and treated with broad-spectrum antibiotics and anti-fungal medication until healing, assessed endoscopically and/or radiologically, is complete. Results Since April 2011, twenty one patients have been treated. The cause of the leak was postoperative/iatrogenic complications (14 patients) and ischaemic/spontaneous perforation (seven patients). Twenty patients (95%) completed treatment successfully with healing of the defect and/or resolution of the cavity and were subsequently discharged from our care. One patient died from sepsis related to an oesophageal leak after withdrawing consent for further intervention following a single endoluminal vacuum (E-Vac) treatment. In addition, two patients who were successfully treated with E-Vac for their leak subsequently died within 90 days of E-Vac treatment from complications that were not associated with the E-Vac procedure. In two patients, E-Vac treatment was complicated by bleeding. The median number of E-Vac changes was 7 (range 3–12), and the median length of hospital stay was 35 days (range 23–152). Conclusions E-Vac therapy is a safe and effective treatment for upper gastrointestinal leaks and should be considered alongside more established therapies. Further research is now needed to understand the mechanism of action and to improve the ease with which E-Vac therapy can be delivered.
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Affiliation(s)
- D J Pournaras
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - R H Hardwick
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - P M Safranek
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - V Sujendran
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - J Bennett
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - G D Macaulay
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
| | - A Hindmarsh
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals, Hills Rd, Cambridge, CB2 0QQ, UK
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Laliotis A, Hettiarachchi T, Rashid F, Hindmarsh A, Sujendran V. Mediastinal herniation of the biliary tract leading to bile duct: obstruction following oesophagectomy. Ann R Coll Surg Engl 2018; 100:e1-e3. [PMID: 30112944 PMCID: PMC6204511 DOI: 10.1308/rcsann.2018.0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2018] [Indexed: 11/22/2022] Open
Abstract
Surgical management of oesophageal and gastro-oesophageal junction malignancies is one of the most challenging situations confronting the surgeon. Attaining a complete circumferential resection margin of lower-third oesophageal and gastro-oesophageal junction locally advanced carcinomas requires en-bloc resection of the hiatus and all the peri-oesophageal tissue and pleura. This results in an increased risk of herniation of the abdominal organs through the enlarged hiatus, which carries significant risk of morbidity and mortality. The incidence of this complication is higher than has been reported. Surgical management of symptomatic hernias is the standard treatment while criteria for managing asymptomatic hernias are less clear. We report a rare case of a late mediastinal herniation of the pancreas and bile duct, leading to obstructive jaundice following oesophagectomy which was treated successfully in our unit.
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Affiliation(s)
- A Laliotis
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals
NHS Foundation Trust, Hills Rd, Cambridge, UK
| | - T Hettiarachchi
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals
NHS Foundation Trust, Hills Rd, Cambridge, UK
| | - F Rashid
- Luton and Dunstable University Hospital NHS Foundation Trust, Department of Surgery, Luton, UK
| | - A Hindmarsh
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals
NHS Foundation Trust, Hills Rd, Cambridge, UK
| | - V Sujendran
- Cambridge Oesophago-Gastric Centre, Addenbrooke's Hospital, Cambridge University Hospitals
NHS Foundation Trust, Hills Rd, Cambridge, UK
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Naeem T, Kumar S, Fareed K, Jah A, Hindmarsh A, Shah N, Sujendran V. Spontaneous diaphragmatic rupture following robotic prostatectomy. Ann R Coll Surg Engl 2016; 99:e44-e46. [PMID: 27659378 DOI: 10.1308/rcsann.2016.0302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Robotic surgery is an established therapy for localised prostate cancer and is replacing conventional laparoscopic prostatectomy in developed countries. Port-site hernia is a recognised, albeit small, risk following laparoscopic or robotic surgery. We report a case of spontaneous rupture of the right hemidiaphragm following robotic prostatectomy.
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Affiliation(s)
- T Naeem
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - S Kumar
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - K Fareed
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - A Jah
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - A Hindmarsh
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - N Shah
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - V Sujendran
- Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
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23
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Halliday E, Patel A, Hindmarsh A, Sujendran V. Iatrogenic oesophageal perforation during placement of an endoscopic vacuum therapy device. J Surg Case Rep 2016; 2016:rjw131. [PMID: 27470015 PMCID: PMC4964030 DOI: 10.1093/jscr/rjw131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Endoscopic vacuum-assisted closure (VAC) is increasingly being used as a means of managing perforations or anastomotic leaks of the upper gastrointestinal (GI) tract. Published outcomes are favourable, with few mentions of complications or morbidity. We present a case in which the management of a gastric perforation with endoscopic vacuum therapy was complicated by cervical oesophageal perforation. The case highlights the risks of such endoscopic therapeutic procedures and is the first report in the literature to describe significant visceral injury during placement of a VAC device for upper GI perforation. Iatrogenic oesophageal perforation is an inherent risk to upper GI endoscopy and the risk increases in therapeutic endoscopic procedures. Complications may be reduced by management under a multidisciplinary team in a centre with specialist upper GI services. There is no doubt that the endoscopic VAC approach is becoming established practice, and training in its use must reflect its increasingly widespread adoption.
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Affiliation(s)
- Edwin Halliday
- Cambridge University Hospitals NHS Foundation Trust, Upper Gastrointestinal (GI) Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Anant Patel
- Cambridge University Hospitals NHS Foundation Trust, Upper Gastrointestinal (GI) Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Andrew Hindmarsh
- Cambridge University Hospitals NHS Foundation Trust, Upper Gastrointestinal (GI) Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Vijay Sujendran
- Cambridge University Hospitals NHS Foundation Trust, Upper Gastrointestinal (GI) Unit, Addenbrooke's Hospital, Cambridge, UK
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Hategan M, Cook N, Prewett S, Hindmarsh A, Qian W, Gilligan D. Trimodality therapy and definitive chemoradiotherapy for esophageal cancer: a single-center experience and review of the literature. Dis Esophagus 2015; 28:612-8. [PMID: 24863560 DOI: 10.1111/dote.12242] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [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] [Indexed: 12/11/2022]
Abstract
In the UK, the standard of care for esophageal cancer has generally combined surgery with neoadjuvant chemotherapy, with definitive chemoradiotherapy (dCRT) being reserved for certain subgroups. Chemoradiotherapy followed by surgery (trimodality therapy) has not been widely adopted. The outcomes of patients undergoing dCRT or trimodality therapy at our cancer center between 2004 and 2012 were restrospectively analyzed. Trimodality therapy was offered to selected patients of good performance status (World Health Organisation performance status 0/1), with squamous cell carcinoma or bulky adenocarcinoma. dCRT was offered to patients of good PS but with comorbidities, upper third tumors or at patient's request. Patients received four cycles of chemotherapy with a platinum agent (mostly cisplatin) and a fluoropyrimidine (mostly 5-fluorouracil) over a total of 11 weeks. Cycles 3 and 4 were given concurrently with radiotherapy: 50 Gy in 25 fractions for dCRT and 45 Gy in 25 fractions in the trimodality group. Surgery occurred 8-10 weeks following the completion of chemoradiotherapy. The cut-off length for maximum gross tumor volume length was 10 cm. One hundred two patients were included (47 received dCRT, and 55 received trimodality treatment). The majority of tumors were stage III (80.4%), and two-thirds were located in the distal esophagus (64.7%). Median follow-up was 44 months. The 2-year overall survival (OS) was 57.3% (median OS 39.7 months) for the dCRT group and 77.8% (median not reached) for the trimodality group. The 5-year OS rates were 38% and 58%, respectively. Postoperative mortality rate was low at 1.8%, and the pathological complete response rate was 23.6%. In conclusion, trimodality treatment for patients with esophageal and junctional gastroesophageal tumors offers high rates of 2-year survival, and the potential for long-term cure. dCRT is an established alternative for patients that are not fit or suitable for surgery.
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Affiliation(s)
- M Hategan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - N Cook
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Prewett
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - A Hindmarsh
- Oesophago-Gastric Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - W Qian
- Department of Statistics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D Gilligan
- Department of Oncology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Abstract
Animal models of Barrett's metaplasia and esophageal adenocarcinoma are important to further characterize the disease and test potential therapies. This paper reviews the development of the surgical model of esophageal adenocarcinoma in the rat and considers whether this model provides a biologically accurate representation of Barrett's esophagus and esophageal adenocarcinoma in humans.
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Affiliation(s)
- A Hindmarsh
- Department of Upper GI Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
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Hindmarsh A, Bignell M, Rhodes M. Laparoscopic stenting of the common bile duct. Ann R Coll Surg Engl 2011. [PMID: 21477444 DOI: 10.1308/003588411x12851639107395b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- A Hindmarsh
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich, UK.
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27
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Hindmarsh A, Bignell M, Rhodes M. Laparoscopic stenting of the common bile duct. Ann R Coll Surg Engl 2011; 93:256-7. [DOI: 10.1308/rcsann.2011.93.3.256b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- A Hindmarsh
- Department of General Surgery, Norfolk and Norwich University Hospital Norwich, UK
| | - M Bignell
- Department of General Surgery, Norfolk and Norwich University Hospital Norwich, UK
| | - M Rhodes
- Department of General Surgery, Norfolk and Norwich University Hospital Norwich, UK
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Bignell M, Hindmarsh A, Nageswaran H, Mothe B, Jenkinson A, Mahon D, Rhodes M. Assessment of cosmetic outcome after laparoscopic cholecystectomy among women 4 years after laparoscopic cholecystectomy: is there a problem? Surg Endosc 2011; 25:2574-7. [PMID: 21424204 DOI: 10.1007/s00464-011-1589-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 01/18/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Advocates of single-port laparoscopic cholecystectomy (SPLC) claim that improved cosmetic outcome is one of its main benefits over conventional laparoscopic cholecystectomy (CLC). However, the published data quantifying the cosmetic outcome after CLC is sparse. This study aimed to determine the cosmetic outcome after CLC using a validated scar assessment tool. METHODS The patient scar assessment questionnaire was sent to all women ages 20-50 years who had undergone CLC at the Norfolk and Norwich University Hospital (Norwich), the Homerton Hospital (London), and the Musgrove Park Hospital (Taunton) in 2005 (n = 380). In all cases, the operation had been performed using a four-port technique. The patients were asked to give scores related to the appearance and symptoms associated with the scars at the time the questionnaire was completed. RESULTS Of the 380 patients, 195 responded to the questionnaire, giving a response rate of 51%. The median age of the responders was 39 years, and 63 (32%) of them had undergone previous surgery. The mean score for each section was low, indicating a favorable cosmetic outcome. This correlated with the global question answered with "excellent" for 4 of 5 categories and "good" for the remaining category. Nine patients highlighted dissatisfaction with the umbilical incision. CONCLUSIONS Patients perceive the cosmetic results after CLC as excellent. Therefore, SPLC seems to have a limited role in terms of improving cosmesis for patients undergoing cholecystectomy. Anecdotal evidence from the questionnaire suggests that the umbilical port may be the site of problems for some patients. Further investigation is needed to determine whether this is significant, especially because it may be exaggerated after SPLC.
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Affiliation(s)
- Mark Bignell
- Department of Upper GI Surgery, Norfolk and Norwich University Hospital, Norwich, Norfolk, NR4 7UY, UK
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29
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Sultan MJ, Alm A, Hindmarsh A, Greatorex RA. Security swipe cards and scanners are a potential reservoir for hospital-acquired infection. Ann R Coll Surg Engl 2008; 91:155-8. [PMID: 18990267 DOI: 10.1308/003588409x358962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Hospital-acquired infections complicate 10% of hospital admissions resulting in increased morbidity, mortality and cost to hospitals. Most hospitals issue doctors with plastic swipe cards that function as electronic keys to access clinical areas. The card is handled many times a day, often before direct patient contact. The aim of this study was to determine if swipe cards harbour potentially harmful bacteria. SUBJECTS AND METHODS On a single day, doctors working in the surgical directorate completed a questionnaire to determine their pattern of swipe card use. Cards were inoculated onto agar plates and incubated for 48 h under standard laboratory conditions, following which the number of colony forming units (CFUs) cultured from each card was determined. Representative colonies were sampled and sub-cultured for staphlococcal, enterococcal, coliform and pseudomonad species. Isolated bacterial pathogens were tested for antimicrobial sensitivity. Swipe-card scanners were swabbed for microbiological culture on the same day. RESULTS All cards were colonised with environmental bacteria (mean, 73 CFU). Of cards, 21% were contaminated with pathogenic bacteria including Staphylococcus aureus (5.1%), Pseudomonas putida (2.6%), and coliform species (12.8%). The pattern of card use did not significantly affect the amount of bacterial contamination, but infrequent use of the card and keeping the card in a pocket or wallet was associated with higher levels of contamination. Environmental bacteria were cultured from 88% of card scanners, the highest counts coming from scanners in main theatres and the day-surgery unit. CONCLUSIONS Doctors' swipe cards are contaminated with, and may therefore be a reservoir for, pathogenic bacteria implicated in hospital-acquired infection.
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Affiliation(s)
- M J Sultan
- Department of General Surgery, The Queen Elizabeth Hospital, King's Lynn, Norfolk, UK
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30
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Abstract
BACKGROUND AND PURPOSE Clayman and associates first described laparoscopic nephrectomy in 1990. This paper describes the first randomized controlled trial to compare laparoscopic with open surgery for simple and radical nephrectomy. PATIENTS AND METHODS Between 2001 and 2004, 45 patients requiring simple or radical nephrectomy (tumors as large as 8 cm) were randomized to either open surgery through a loin incision or laparoscopic nephrectomy (transperitoneal). Outcome measures included operative time, complications, hospital stay, pain scores, time to return to normal activities, and quality of life scores (EuroQol). RESULTS The mean operative time was 105 minutes in the laparoscopic group and 93 minutes in the open-surgery group (P = 0.4). Blood loss, complications, and the mortality rate were similar in the two groups, as was the hospital stay at a median of 4 days in the laparoscopic group and 5 days in the open group (P = 0.9). Postoperative visual analog pain scores averaged 3.6 in the laparoscopic group compared with 5.4 in the open group (P = 0.02). There was no difference in pain scores at 3 months. Return to normal activities was faster in the laparoscopic group at 42 days v 62 days in the open group (P = 0.04). CONCLUSIONS Laparoscopic nephrectomy is associated with less postoperative pain and a faster return to normal activities than open nephrectomy.
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Affiliation(s)
- Neil A Burgess
- Department of Urology, Norfolk and Norwich University Hospital, Norwich, UK
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Spahos T, Hindmarsh A, Cameron E, Tighe MR, Igali L, Pearson D, Rhodes M, Lewis MPN. Endoscopy waiting times and impact of the two week wait scheme on diagnosis and outcome of upper gastrointestinal cancer. Postgrad Med J 2006; 81:728-30. [PMID: 16272239 PMCID: PMC1743392 DOI: 10.1136/pgmj.2004.031104] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The NHS has introduced the two week wait scheme to detect upper gastrointestinal cancers at an early stage and improve survival rates The aim of this study was to assess the impact of this scheme and changes in endoscopy waiting times on tumour stage and resection rates over a four year period. Data were analysed prospectively for all patients diagnosed with oesophagogastric cancer between September 1998 and September 2002 and from those referred under the two week wait scheme since its introduction in 2000. Of those tumours diagnosed by this scheme (15%) only 5% were early disease (stage 1 or 2). Patients with early cancer, mainly diagnosed by routine gastroscopy, do not present with symptoms meeting the two week wait criteria. An increase in the resection rates for early disease will most probably be seen with a reduction in routine endoscopy waiting times.
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Affiliation(s)
- T Spahos
- Division of Upper Gastrointestinal Surgery, Department of General Surgery, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK.
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Mehta S, Hindmarsh A, Cheong E, Cockburn J, Saada J, Tighe R, Lewis MPN, Rhodes M. Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc 2005; 20:239-42. [PMID: 16362479 DOI: 10.1007/s00464-005-0130-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Accepted: 07/19/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. METHODS A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. RESULTS Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. CONCLUSION Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.
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Affiliation(s)
- S Mehta
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, England, United Kingdom
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Mehta S, Hindmarsh A, Rhodes M. Changes in functional gastrointestinal symptoms as a result of antireflux surgery. Surg Endosc 2005; 19:1447-50. [PMID: 16206009 DOI: 10.1007/s00464-005-0202-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2005] [Accepted: 05/31/2005] [Indexed: 01/18/2023]
Abstract
BACKGROUND This study identifies how functional symptoms are altered after antireflux surgery and whether there are any predictors of such change. METHODS A total of 206 patients underwent successful laparoscopic Nissen fundoplication. A questionnaire was sent at a median of 4.3 years (range = 0.3-8.4) after fundoplication. Patients were asked to provide scores for reflux and functional symptoms that were experienced prior to surgery and at the time of the questionnaire. RESULTS Eighty-one percent of patients responded. Scores for heartburn, regurgitation, and difficulty swallowing were felt to have significantly improved (p < 0.01). Flatulence was the only functional symptom to have significantly worsened (p < 0.01). A regression analysis incorporating prospectively collected data identified variables that were predictive of changes in functional symptoms following surgery. CONCLUSIONS Flatulence was the only functional symptom to have worsened overall after surgery. Predictors of changes in functional symptoms may help clinicians when informing patients about gastrointestinal side effects following antireflux surgery.
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Affiliation(s)
- S Mehta
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Norwich NR4 7UY, United Kingdom
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Mahon D, Rhodes M, Decadt B, Hindmarsh A, Lowndes R, Beckingham I, Koo B, Newcombe RG. Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux. Br J Surg 2005; 92:695-9. [PMID: 15898130 DOI: 10.1002/bjs.4934] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.
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Affiliation(s)
- D Mahon
- Department of Surgery, Norfolk and Norwich University Hospital, Norwich, UK
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Hindmarsh A, Koo B, Lewis MPN, Rhodes M. Laparoscopic resection of gastric gastrointestinal stromal tumors. Surg Endosc 2005; 19:1109-12. [PMID: 16021371 DOI: 10.1007/s00464-004-8168-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Accepted: 12/22/2004] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) are neoplasms with low malignant potential. They occur most commonly in the stomach, where they are amenable to laparoscopic resection. METHODS A case note review of all patients undergoing laparoscopic resection of a presumed gastric GIST at the Norfolk and Norwich University Hospital, United Kingdom, was conducted. RESULTS Since September 1995, 30 patients have undergone this procedure. The patients had a mean age of 64.2 years (range, 31-87 years) and a mean weight of 74.1 kg (range, 44-104 kg). A presumptive diagnosis of GIST was made in all the cases based on the endoscopic and radiologic appearance of the lesion. Laparoscopic resection was completed successfully in 23 patients with a mean operating time of 73.8 min (range, 26-160 min). Seven procedures were converted to open surgery: three because the tumor was deemed too large for laparoscopic resection, two because the tumor could not be identified, one because of dense peritoneal adhesions, and one because of bleeding. The mean estimated blood loss was 196 ml (range, 0-1,000 ml), and the mean hospital stay was 5 days (ranges, 1-11 days). Pathologic analysis of the resected specimens showed 22 GISTs, 3 inflammatory fibroids, 2 submucosal lipomas, 1 submucosal varix, and 1 nest of heterotopic pancreatic tissue. D: uring a median follow-up period of 18 months (range, 2-101 months) there have been two cases of recurrence. In both cases, the tumor was catagorized as high risk for aggressive behavior after primary resection. CONCLUSION Stapled laparoscopic resection is a safe and effective treatment option for nonmetastatic primary gastric GIST.
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Affiliation(s)
- A Hindmarsh
- Department of General Surgery, Norfolk and Norwich University Hospital, Norwich NR4 7UY, United Kingdom.
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Abstract
BACKGROUND The goal of this study was to assess the clinical outcome of patients undergoing laparoscopic stapled cystgastrostomy for pancreatic pseudocysts in contact with the posterior wall of the stomach. METHODS We performed a case note review of all patients who have undergone stapled laparoscopic cystgastrostomy in Norwich, UK. The cystgastrostomy was fashioned through an anterior gastrotomy using a vascular ETS stapling device in all cases. RESULTS Fifteen patients have undergone stapled laparoscopic cystgastrostomy. The procedure was completed successfully in 12 patients. Three procedures were converted to open surgery for technical reasons. There were no complications due to bleeding from the cystgastrostomy. Early complications included systemic sepsis (one), bleeding gastric ulcer (one) and pseudocyst recurrence due to partial closure of the cystgastrostomy (two). No late recurrences or other complications have been found at a median follow-up of 37 months. CONCLUSION Stapled laparoscopic cystgastrostomy is a safe and effective procedure for draining pancreatic pseudocysts in contact with the posterior wall of the stomach. The use of a hemostatic stapling device to fashion the cystgastrostomy may reduce the risk of catastrophic hemorrhage from the pseudocyst wall.
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Affiliation(s)
- A Hindmarsh
- Department of General Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK.
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Griffin JL, Muller D, Woograsingh R, Jowatt V, Hindmarsh A, Nicholson JK, Martin JE. Vitamin E deficiency and metabolic deficits in neuronal ceroid lipofuscinosis described by bioinformatics. Physiol Genomics 2002; 11:195-203. [PMID: 12388797 DOI: 10.1152/physiolgenomics.00100.2002] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The mnd mouse, a model of neuronal ceroid lipofusinosis (NCL), has a profound vitamin E deficiency in sera and brain, associated with cerebral deterioration characteristic of NCL. In this study, the vitamin E deficiency is corrected using dietary supplementation. However, the histopathological features associated with NCL remained. With use of a bioinformatics approach based on high-resolution solid and solution state 1H-NMR spectroscopy and principal component analysis (PCA), the deficits associated with NCL are defined in terms of a metabolic phenotype. Although vitamin E supplementation reversed some of the metabolic abnormalities, in particular the concentration of phenylalanine in extracts of cerebral tissue, PCA demonstrated that metabolic deficits associated with NCL were greater than any effects produced from vitamin E supplementation. These deficits included increased glutamate and N-acetyl-L-aspartate and decreased creatine and glutamine concentrations in aqueous extracts of the cortex, as well as profound accumulation of lipid in intact cerebral tissue. This is discussed in terms of faulty production of mitochondrial-associated membranes, thought to be central to the deficits in mnd mice.
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Affiliation(s)
- J L Griffin
- Biological Chemistry, Biomedical Sciences, Faculty of Medicine, Imperial College of Science, Technology and Medicine, London SW7 2AZ.
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Affiliation(s)
- A Hindmarsh
- Deptartment of Accident and Emergency, Broomfield Hospital, Chelmsford, CM1 7BU, UK
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