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Jiang M, Liang W, Chen X, Ge Y, Fang Y, Zhang H, Jiang R, Luo B. Effective management of cervical anastomotic leakage post-esophageal cancer surgery using negative pressure wound therapy with saline instillation: A case report. Asia Pac J Oncol Nurs 2025; 12:100623. [PMID: 39717627 PMCID: PMC11664288 DOI: 10.1016/j.apjon.2024.100623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 11/16/2024] [Indexed: 12/25/2024] Open
Abstract
Cervical anastomotic leakage (AL) is a severe complication following esophageal cancer surgery, leading to significant morbidity and risk of mortality. This case report describes the successful application of negative pressure wound therapy with instillation (NPWTi) in managing AL after esophageal surgery. A 61-year-old patient developed an anastomotic leak on postoperative day 7, accompanied by persistent neck pain and leakage of nutritional fluids. Treatment involved a dual-tube NPWTi system with continuous saline instillation to clean and prevent infection, maintain wound moisture, and promote tissue granulation. Within 15 days, the leakage was substantially controlled, and a barium swallow test confirmed complete closure by day 20. This case suggests NPWTi as a promising and less invasive approach to managing AL post-esophagectomy, warranting further research on its clinical efficacy and safety.
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Affiliation(s)
- Mengxiao Jiang
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wenguang Liang
- School of Nursing, Sun Yat-sen University, Guangzhou, China
| | - Xiaoping Chen
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yonglan Ge
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yanyan Fang
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Huiting Zhang
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Rongrong Jiang
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Baojia Luo
- Nursing Department, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, China
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Lemties J, Scheidt C, Jung JO, Wirsik NM, Lukomski L, Krauss D, Grabenkamp A, Stier AR, Lyu SI, Damanakis AI, Babic B, Quaas A, Schmidt T, Fuchs HF, Bruns CJ, Schröder W, Schiffmann LM. Vascularity of the gastric conduit predicts complications after Ivor-Lewis esophagectomy. Surg Endosc 2025; 39:3839-3847. [PMID: 40342097 DOI: 10.1007/s00464-025-11780-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 04/28/2025] [Indexed: 05/11/2025]
Abstract
BACKGROUND Anastomotic leakage (AL) contributes to postoperative morbidity and mortality after Ivor-Lewis esophagectomy. Vascular high-risk patients show a significantly increased risk of AL. We previously showed that laparoscopic ischemic conditioning (ISCON) of the stomach prior esophagectomy in these high-risk patients is a safe procedure that induces neoangiogenesis at the anastomotic site. Our data also suggested that this directly impacts on anastomotic healing. To further investigate the hypothesis that gastric conduit vascularization directly influences postoperative morbidity, we evaluated gastric conduit vascularity in a cohort of patients undergoing two-stage esophagectomy prior to the ISCON era. MATERIAL AND METHODS Seventy-nine patients who underwent two-stage esophagectomy from 2016 to 2021 at our center were retrospectively analyzed from a prospectively maintained database. Microvessel density (MVD) of the gastric conduit at the anastomotic region was evaluated by CD34 staining of the gastric stapler ring. Analysis of microvessel density (MVD) was performed using ImageJ. Patients were stratified into low- and high-MVD groups, and MVD was correlated with clinical outcomes. RESULTS Patients with a high MVD showed a significantly lower rate of anastomotic leakage (AL) in comparison to patients with low MVD (6.25% vs. 22.58% p=0.043). Furthermore, a high MVD was associated with a lower rate of major complications (Clavien Dindo ≥ IIIb) (12.50% vs. 38.71% p=0.012) and a shorter hospital stay (17.9 days vs. 23.1 days, p=0.045). CONCLUSION Vascularization of the stomach might function as surgical biomarker of AL in patients undergoing two-stage esophagectomy. Prospective trials have to further substantiate this finding.
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Affiliation(s)
- Julian Lemties
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - Carolin Scheidt
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jin-On Jung
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Naita M Wirsik
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Leandra Lukomski
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Dolores Krauss
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Anders Grabenkamp
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Alexander R Stier
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Su Ir Lyu
- Institute of Pathology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Alexander I Damanakis
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Benjamin Babic
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Offenbach am Main, Germany
| | - Alexander Quaas
- Institute of Pathology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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van der Aa DC, Boonstra J, Eshuis WJ, Daams F, Pouw RE, Gisbertz SS, van Berge Henegouwen MI. Risk Factors for Benign Anastomotic Stenosis After Esophagectomy for Cancer. Ann Surg Oncol 2025:10.1245/s10434-025-17401-x. [PMID: 40327192 DOI: 10.1245/s10434-025-17401-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Accepted: 04/13/2025] [Indexed: 05/07/2025]
Abstract
BACKGROUND Benign stenosis frequently occurs after esophagectomy, causing dysphagia, eating problems, and diminished quality of life. This study aimed to identify risk factors for benign anastomotic stenosis after esophagectomy for cancer. METHODS This retrospective cohort study analyzed patients who underwent esophagectomy at Amsterdam UMC from 2012 until 2022. Intrathoracic and cervical anastomoses were examined separately. Benign anastomotic stenosis was defined as stenosis at the anastomosis causing dysphagia (Ogilvie score ≥2) and requiring at least one endoscopic dilation. Predictive factors were identified using logistic regression. RESULTS The study enrolled 902 patients: 605 with intrathoracic and 297 with cervical anastomosis. Of these cases, 91.1 % were a minimally invasive esophagectomy. Stenosis occurred in 18.4 % of the intrathoracic cases and 49.8 % of the cervical cases (p < 0.001). The patients required medians of 4 and 7 dilations, respectively (p = 0.001). The median time to stenosis was 99 days for the intrathor days for the cervical anastomoses (p = 0.001). Intrathoracic stenosis was independently associated with anastomotic leakage (odds ratio [OR], 2.034; 95 % confidence interval [CI], 1.116-3.708). For the patients without leakage, a 2 mm versus a 25 mm circular stapler reduced stenosis risk (OR, 0.486; 95 % CI, 0.294-0.803), whereas use of immunosuppressants (OR, 3.492; 95 % CI, 1.186-10.279]) and chronic pulmonary disease (OR, 2.717; 95 % CI, 1.293-5.707) increased it. For cervical anastomoses, hand-sewn end-to-side anastomosis was protective (OR, 0.454; 95 % CI, 0.234-0.879). CONCLUSIONS The key risk factors for intrathoracic benign anastomotic stenosis are anastomotic leakage, smaller circular stapler size, use of immunosuppressants, and chronic pulmonary disease. For cervical anastomoses, the hand-sewn end-to side technique is protective compared with the end-to-end technique, whereas use of immunosuppressants and chronic pulmonary disease increases the risk.
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Affiliation(s)
- Dillen C van der Aa
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands.
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jelle Boonstra
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Roos E Pouw
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC location, University of Amsterdam, Amsterdam, The Netherlands
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Ledda AL, Tarantino I, Schiefer S, Ronellenfitsch U, Rebelo A, Sekulla C, Nienhüser H, Michalski C, Schmied B, Kleeff J, Klose J. Patterns of infectious complications and their implication on health system costs after esophagectomy for esophageal cancer: Real-world data from three European centers. Langenbecks Arch Surg 2025; 410:138. [PMID: 40263193 PMCID: PMC12014832 DOI: 10.1007/s00423-025-03709-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2025] [Accepted: 04/11/2025] [Indexed: 04/24/2025]
Abstract
PURPOSE Infectious complications occur frequently after esophagectomy leading to prolonged hospital stay and increased costs. This study aimed to analyze the pattern of infectious complications, the spectrum of associated microbiota, and its impact on health system costs in patients who underwent esophagectomy for esophageal cancer. METHODS All patients undergoing curative resection for histologically confirmed esophageal cancer between January 2017 and August 2022 were included. Patients' survival was analyzed by Kaplan-Meier estimate. Contingency tables were applied to assess the association between microbiota and the occurrence of infectious complications and their impact on patients' survival. RESULTS Four hundred forty-one patients who received a R0 resection for esophageal cancer were identified. Infectious complications occurred in 153 patients (34.7%). Pneumonia was the most frequent complication (28.8%) followed by anastomotic leakage (25.4%). Enterococcus and Candida species were the dominant microbiota associated with infectious complications (Candida species: OR 7.34, 95% CI 2.38-22.67) and anastomotic leakage (Enterococcus species: OR 6,15, 95% CI 1,51-24,99; Candida species: OR 7.14, 95% CI 2.48-20.56). Intensive care unit stay (mean 14.3 vs. 4.9 days, p < 0.001) and total hospital stay (mean 34.1 vs. 18.8 days, p < 0.001) were significantly longer in patients with infectious complications. Total health system costs (44.084 € vs. 25.907 €) increased after the occurrence of infectious complications. CONCLUSION Infectious complications after esophagectomy are predominantly associated with the presence of Enterococcus and Candida species, leading to increased health system costs. Preventive antibiotic and antimycotic treatment might result in reduction of infectious complications and lower health system costs.
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Affiliation(s)
- Anna Lucia Ledda
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Ignazio Tarantino
- Department of General, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, VisceralSt. Gallen, Switzerland
| | - Sabine Schiefer
- Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Ulrich Ronellenfitsch
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Artur Rebelo
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Carsten Sekulla
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Henrik Nienhüser
- Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Christoph Michalski
- Department of General, Visceral and Transplant Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Bruno Schmied
- Department of General, Endocrine and Transplantation Surgery, Kantonsspital St. Gallen, VisceralSt. Gallen, Switzerland
| | - Jörg Kleeff
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany
| | - Johannes Klose
- Department of Visceral, Vascular and Endocrine Surgery, Martin-Luther-University Halle-Wittenberg, University Medical Center Halle, Ernst-Grube-Str. 40, 06120, Halle, Germany.
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Zeng C, Zhang X, Jia B, Hu Y, Lin P, Fu J, Long H, Rong T, Su X. Impact of Anastomotic Leaks on Long-Term Survival in Patients with Esophageal Squamous Cell Carcinoma Following McKeown Esophagectomy: A Propensity Score-Matched Analysis. Ann Surg Oncol 2025:10.1245/s10434-025-17206-y. [PMID: 40198529 DOI: 10.1245/s10434-025-17206-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 03/03/2025] [Indexed: 04/10/2025]
Abstract
BACKGROUND The impact of anastomotic leak (AL) on the long-term survival of patients with esophageal squamous cell carcinoma (ESCC) remains unclear. This study investigated whether AL influences the long-term survival of patients with ESCC following McKeown esophagectomy. PATIENTS AND METHODS An original database was queried to identify patients with ESCC who underwent McKeown esophagectomy between 2012 and 2020 at a high-volume cancer center. Overall survival (OS) and disease-free survival (DFS) were compared using Kaplan-Meier (KM) curves. Cox regression analysis was used for multivariate analysis. Propensity score matching (PSM) was used to adjust for the confounding factors. RESULTS A total of 1614 patients were included, of whom 16.9% developed AL. In patients without neoadjuvant therapy, for patients with and without AL, the 5-year OS was 55.8% and 62.0%, and the 5-year DFS was 48.7% and 59.1%, respectively (OS: p = 0.37, DFS: p = 0.046). In the neoadjuvant cohort, for patients with and without AL, the 5-year OS was 57.9% and 63.2%, and the 5-year DFS was 55.4% and 58.8%, respectively (OS: p = 0.48, DFS: p = 0.78). Moreover, AL significantly increased the risk of distant recurrence in patients without neoadjuvant therapy (p = 0.023). CONCLUSIONS These findings suggest that AL negatively influences DFS in patients without neoadjuvant therapy, but does not significantly affect long-term survival in patients receiving neoadjuvant treatment. Intensive treatment and follow-up plan should be considered when patients without neoadjuvant therapy.
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Affiliation(s)
- Chufeng Zeng
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xu Zhang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Bei Jia
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Yi Hu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Tiehua Rong
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xiaodong Su
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China.
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China.
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Richter F, Ellrichmann M. Endoscopic Treatment of Anastomotic Leakage in the Upper Gastrointestinal Tract. Visc Med 2025:1-9. [PMID: 40376231 PMCID: PMC12077910 DOI: 10.1159/000545485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Accepted: 03/24/2025] [Indexed: 05/18/2025] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal tract (uGIT) is a critical condition associated with high mortality and significant morbidity. Effective management requires prompt and specialized diagnostic and therapeutic interventions through an interdisciplinary approach. In current practice, surgical intervention is infrequent and typically reserved for cases of extensive damage. Close collaboration between radiology, endoscopy, and surgery is essential for optimal care. Endoscopic therapy is the primary modality for managing AI in the upper GIT. This review offers an overview of the most common endoscopic treatment strategies for AL in this region. Summary Significant advancements have been made in the endoscopic management of AL in the uGIT in recent years. Endoscopic sutures and clips remain appropriate for smaller defects, but for larger leakages, endoscopic vacuum therapy (EVT) is gaining prominence over stent placement. Innovative approaches, such as vacuum stents and small diameter filmed drainage (FD), offer promising new therapeutic options for treating AL in the uGIT. Key Messages (1) Endoscopy plays a pivotal role in the management of AL in the upper GIT. (2) A growing body of evidence supports EVT as superior to other modalities such as sutures, tissue sealants, or clips. Notably, EVT has a lower complication rate and higher healing success compared to stent therapy in AL treatment. (3) New endoscopic techniques, including the vacuum stent and FD, represent promising advancements in the treatment of AL.
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Affiliation(s)
- Florian Richter
- Department of General, Visceral-, Thoracic-, Transplantation- and Paediatric Surgery, University Medical Center Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
| | - Mark Ellrichmann
- Interdisciplinary Endoscopy, Medical Department I, University Medical Centre Schleswig-Holstein (UKSH), Campus Kiel, Kiel, Germany
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Kamaleddine I, Popova M, Alwali A, Schafmayer C. Diagnostic Value of Postsurgical Endoscopy. Visc Med 2025:1-10. [PMID: 40342518 PMCID: PMC12058124 DOI: 10.1159/000545531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2024] [Accepted: 03/24/2025] [Indexed: 05/11/2025] Open
Abstract
Background In the last 3 decades, we have witnessed a significant shift from traditional surgical approaches to minimally invasive and robotic surgery for treating gastrointestinal (GI) conditions minimalizing the associated morbidity and mortality. Meanwhile, endoscopy has continually evolved, reshaping the landscape of both diagnostic and therapeutic procedures. The implementation of postsurgical endoscopy as a critical diagnostic tool is primarily due to its capabilities in early complication detection and providing a prompt therapy possibility, assessment of healing, management of symptoms, and surveillance for recurrence in malignancy cases. Summary This review will first delve into the history of endoscopic developments, explore the various available postoperative diagnostic tools, focusing particularly on endoscopy and showing some real-life examples. Key Messages As an essential diagnostic tool, postsurgical endoscopy plays a crucial role in the management of patients undergoing upper and lower GI surgeries. It is indispensable for ensuring an optimal postoperative result. The continuous advancements in endoscopic technology and techniques have significantly enhanced the diagnostic and therapeutic capabilities of this modality, solidifying its role in modern GI surgery. Integrating postsurgical endoscopy into routine clinical practice and learning curriculum for surgical residents is vital and essential for optimizing the postoperative care to ensure the best possible outcome for patients.
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Affiliation(s)
- Imad Kamaleddine
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Magdalena Popova
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Ahmed Alwali
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
| | - Clemens Schafmayer
- Department of General, Visceral, Thoracic, Vascular and Transplantation Surgery, Rostock University Medical Center, Rostock, Germany
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8
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Tian L, Wang Y, Che G. Association of Preoperative Sarcopenia with the Risk of Anastomotic Leakage in Surgical Esophageal Cancer Patients: A Meta-Analysis. Nutr Cancer 2025; 77:640-647. [PMID: 40100092 DOI: 10.1080/01635581.2025.2479878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2024] [Revised: 03/07/2025] [Accepted: 03/10/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND Whether preoperative sarcopenia predicts increased risk of anastomotic leakage in operated esophageal cancer patients remains unclear. This study aimed to identify the relationship between preoperative sarcopenia and the incidence of anastomotic leakage in surgical esophageal cancer. METHODS PubMed, EMBASE, CNKI and Web of Science databases were searched up to October 11, 2024. Odds ratios (ORs) and 95% confidence intervals (CIs) were combined and subgroup analysis based on the pathological type, definition of sarcopenia and history of neoadjuvant therapy were performed. RESULTS Fifteen studies with 3,785 patients were included and 368 patients developed the anastomotic leakage (9.72%). Pooled results demonstrated that preoperative sarcopenia was significantly associated with the occurrence of anastomotic leakage among surgical esophageal cancer patients (OR = 1.57, 95% CI: 1.29-1.90, p < 0.001). Subgroup analysis by the pathological type and definition of sarcopenia revealed similar results. However, subgroup analysis by the neoadjuvant therapy indicated that preoperative sarcopenia was only related to anastomotic leakage among patients without the history of neoadjuvant therapy (OR = 2.40. 95% CI: 1.61-3.58, p < 0.001), and sarcopenia was not a significant risk factor for anastomotic leakage in neoadjuvant therapy treated patients (OR = 1.06, p = 0.845). CONCLUSION Preoperative sarcopenia could serve as a risk indicator in surgical esophageal cancer patients without neoadjuvant therapy.
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Affiliation(s)
- Long Tian
- Department of Thoracic Surgery/Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Yan Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Guowei Che
- Department of Thoracic Surgery/Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, P.R. China
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Gritsiuta AI, Esper CJ, Parikh K, Parupudi S, Petrov RV. Anastomotic Leak After Esophagectomy: Modern Approaches to Prevention and Diagnosis. Cureus 2025; 17:e80091. [PMID: 40196079 PMCID: PMC11973610 DOI: 10.7759/cureus.80091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2025] [Accepted: 03/04/2025] [Indexed: 04/09/2025] Open
Abstract
Anastomotic leak (AL) remains one of the most serious complications following esophagectomy, contributing to significant morbidity, prolonged hospital stays, and increased mortality. Despite advancements in surgical techniques and perioperative care, AL continues to challenge surgeons and negatively impact patient outcomes. Various factors contribute to its development, including patient-specific comorbidities, tumor characteristics, anastomotic technique, conduit perfusion, and perioperative management. Prevention strategies have evolved with the integration of intraoperative techniques such as fluorescence-guided perfusion assessment, omental reinforcement, and meticulous surgical handling of the gastric conduit. Emerging technologies, including endoluminal vacuum therapy (EVT) and multimodal perioperative protocols, have demonstrated potential in reducing leak incidence and improving management. Diagnosing AL remains complex due to its variable presentation, necessitating a combination of clinical evaluation, inflammatory markers, imaging studies, and endoscopic assessments. While routine postoperative imaging has shown limited sensitivity, on-demand CT and endoscopic evaluations play a crucial role in early detection and intervention. This review provides a comprehensive analysis of the risk factors, prevention strategies, and diagnostic modalities for AL after esophagectomy, incorporating recent advancements and emerging technologies.
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Affiliation(s)
- Andrei I Gritsiuta
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Christopher J Esper
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Kavita Parikh
- Department of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, USA
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, USA
| | - Roman V Petrov
- Department of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, USA
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10
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Migoń J, Bąk M, Molska M, Lewandowski R, Piłat T, Zielinski P, Murawa D. Indocyanine green fluorescent imaging (ICG-FI) in esophagectomy: single-center experience. POLISH JOURNAL OF SURGERY 2025; 97:1-5. [PMID: 40247791 DOI: 10.5604/01.3001.0054.9779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2025]
Abstract
<b>Introduction:</b> Gold standard treatment for locally advanced esophageal cancer is subtotal resection of the esophagus with resection of regional lymph nodes. Despite being performed in experienced and specialized centers, this procedure is associated with a high rate of complications. Complications such as anastomotic fistula and leakage can be life-threatening, primarily resulting from inadequate blood circulation in the anastomosis area. <br><br><b>Aim:</b> The aim of the study is to present the results of intraoperative indocyanine green (ICG) application in order to verify the adequate perfusion in esophagogastric anastomosis. <br><br><b>Materials and methods:</b> This is a single-center prospective analysis of 32 patients who underwent subtotal esophagectomy with regional lymph node resection for esophageal carcinoma. In all cases, intraoperative perfusion assessment using ICG fluorescence imaging (ICG-FI) was performed. Patient characteristics, comorbidities, and postoperative outcomes were analyzed, with treatment effects monitored for up to 1 year postoperatively. <br><br><b>Results:</b> Six patients required gastric conduit reduction due to poor blood perfusion visualized by intraoperative ICG-FI. Anastomotic leakage occurred in two cases, which were managed endoscopically with endo-vac therapy and esophageal stent placement. The remaining patients did not require additional surgical interventions during the postoperative course. <br><br><b>Conclusions:</b> The use of ICG dye in esophageal surgery appears to be a beneficial tool for objective assessment of perfusion that may be a valuable prediction factor in the postoperative course.
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Affiliation(s)
- Jakub Migoń
- Clinical Department of General and Oncological Surgery, Karol Marcinkowski University Hospital in Zielona Gora, Poland, Medical College, University of Zielona Gora, Poland
| | - Michał Bąk
- Clinical Department of General and Oncological Surgery, Karol Marcinkowski University Hospital in Zielona Gora, Poland, Medical College, University of Zielona Gora, Poland
| | - Maja Molska
- Clinical Department of General and Oncological Surgery, Karol Marcinkowski University Hospital in Zielona Gora, Poland, Medical College, University of Zielona Gora, Poland
| | - Roman Lewandowski
- Medical College, University of Zielona Gora, Poland, Clinical Department of Thoracic Surgery, University Hospital of Karol Marcinkowski in Zielona Gora, Poland
| | - Tomasz Piłat
- Clinical Department of General and Oncological Surgery, Karol Marcinkowski University Hospital in Zielona Gora, Poland, Medical College, University of Zielona Gora, Poland
| | - Pawel Zielinski
- Chair of Pathomorphology and Clinical Immunology, Poznan University of Medical Sciences, Poznan, Poland
| | - Dawid Murawa
- Clinical Department of General and Oncological Surgery, Karol Marcinkowski University Hospital in Zielona Gora, Poland, Medical College, University of Zielona Gora, Poland
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11
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Yang Y, Han C, Xing X, Qin Z, Wang Q, Lan L, Zhu H. Effects of Postoperative Complications on Overall Survival Following Esophagectomy: A Meta-Analysis Using the Restricted Mean Survival Time Analysis. Thorac Cancer 2025; 16:e70011. [PMID: 39924333 PMCID: PMC11807705 DOI: 10.1111/1759-7714.70011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 01/22/2025] [Accepted: 01/24/2025] [Indexed: 02/11/2025] Open
Abstract
OBJECTIVE This study aims to conduct a comprehensive meta-analysis of the effects of postoperative complications (PCs) on survival following esophagectomy using the restricted mean survival time (RMST) analysis. METHODS A systematic literature search was performed in PubMed, Embase, Web of Science, Cochrane, and Medline, including articles published up to July 2024. Data were reconstructed from Kaplan-Meier curves, and the difference in RMST (RMSTD) and the RMST/restricted mean time loss (RMTL) ratios were calculated to examine the effects of PCs on overall survival. RESULTS A total of 12 articles, including 7925 patients, met the inclusion criteria. RMSTD estimates indicate that patients with overall PCs survived an average of 0.04 years shorter (RMSTD = -0.04, 95% CI: -0.06, -0.03) than those without PCs at the 1-year follow-up and 0.39 years shorter (RMSTD = -0.39, 95% CI: -0.55, -0.22) at the 5-year follow-up. Patients with anastomotic leaks survived an average of 0.34 years shorter (RMSTD = -0.34, 95% CI: -0.49, -0.19), and patients with pulmonary complications survived an average of 0.63 years shorter (RMSTD = -0.63, 95% CI: -0.81, -0.45) at the 5-year follow-up. Additionally, RMTL ratios were estimated to be 1.21 (95% CI: 1.12, 1.31) for overall PCs, 1.19 (95% CI: 1.11, 1.28) for anastomotic leaks, and 1.53 (95% CI: 1.36, 1.73) for pulmonary complications at the 5-year follow-up, respectively. CONCLUSIONS Our findings quantified the annual negative impact of PCs of esophageal cancer on overall patient survival following esophagectomy. Increased efforts are needed to enhance prevention, early screening, and timely treatment for complications, particularly for patients with pulmonary complications.
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Affiliation(s)
- Yongbo Yang
- First Department of Thoracic SurgeryPeking University Cancer Hospital and InstituteBeijingChina
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of EducationPeking University Cancer Hospital and InstituteBeijingChina
| | - Chunyang Han
- The First Clinical SchoolHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Xing Xing
- School of Public HealthPeking UniversityBeijingChina
| | - Zhen Qin
- School of Public HealthPeking UniversityBeijingChina
| | - Qianning Wang
- School of Public HealthPeking UniversityBeijingChina
| | - Lu Lan
- School of Public HealthPeking UniversityBeijingChina
| | - He Zhu
- School of Public HealthPeking UniversityBeijingChina
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12
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Popa C, Schlanger D, Aiolfi A, ElShafei M, Triantafyllou T, Theodorou D, Skrobic O, Simic A, Al Hajjar N, Bonavina L. Biomarkers associated with anastomotic leakage after esophagectomy: a systematic review. Langenbecks Arch Surg 2025; 410:55. [PMID: 39875600 PMCID: PMC11775071 DOI: 10.1007/s00423-025-03617-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 01/16/2025] [Indexed: 01/30/2025]
Abstract
PURPOSE Anastomotic leakage (AL) is one of the most important complications that occurs after upper gastrointestinal surgery, registering rates of 20-30% after esophagectomy. The role of systemic inflammatory biomarkers to predict anastomotic leaks is controversial and needs systematization. METHODS A systematic review based on the PRISMA guidelines criteria was performed. PubMed, Scopus, and Embase were queried using MESH Terms and All Fields key words to identify studies investigating a range of immune-inflammatory factors in predicting AL. RESULTS Twenty-four studies were included in this review. The total number of included patients was 5903, ranging in each study from 42 to 612. The included studies reported patients that underwent different techniques of esophagectomy (Ivor Lewis, McKeown, Orringer or thoracoabdominal esophagectomy) and 23 out of 24 studies included patients that underwent neoadjuvant treatment. While different biomarkers at different timepoints were analyzed, most studies have indicated postoperative biomarkers, between day 3 and day 5 to reach statistical significance. CONCLUSIONS Systemic inflammatory biomarkers represent potential risk stratification and predicting tools for AL after esophageal surgery, but more studies need to be conducted to validate their clinical utility.
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Affiliation(s)
- Călin Popa
- University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Regional Institute of Gastroenterology and Hepatology O. Fodor Cluj-Napoca, Croitorilor 19-21, 400162, Cluj-Napoca-Napoca, Romania
| | - Diana Schlanger
- University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Regional Institute of Gastroenterology and Hepatology O. Fodor Cluj-Napoca, Croitorilor 19-21, 400162, Cluj-Napoca-Napoca, Romania.
| | - Alberto Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - Moustafa ElShafei
- Krakenhaus Nordwest, Allgemein-Viszeral- Und Minimal Invasive Chirurgie, Frankfurt, Germany
| | | | | | - Ognjan Skrobic
- Department of Esophageal and Gastric Surgery, University Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Aleksandar Simic
- Department of Esophageal and Gastric Surgery, University Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Nadim Al Hajjar
- University of Medicine and Pharmacy Iuliu Hatieganu Cluj-Napoca, Regional Institute of Gastroenterology and Hepatology O. Fodor Cluj-Napoca, Croitorilor 19-21, 400162, Cluj-Napoca-Napoca, Romania
| | - Luigi Bonavina
- Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
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13
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Tange FP, Peul RC, van den Hoven P, Koning S, Kruiswijk MW, Faber RA, Verduijn PS, van Rijswijk CSP, Galema HA, Hilling DE, van Dijk SPJ, van Ginhoven TM, Keereweer S, Mureau MAM, Feitsma EA, Noltes ME, Kruijff S, Driessen C, Achiam MP, Schepers A, van Schaik J, Mieog JSD, Vahrmeijer AL, Hamming JF, van der Vorst JR. Establishing reference curves for vital tissue perfusion using quantitative near-infrared fluorescence imaging with indocyanine green. Langenbecks Arch Surg 2025; 410:28. [PMID: 39777554 PMCID: PMC11706885 DOI: 10.1007/s00423-024-03589-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Accepted: 12/19/2024] [Indexed: 01/11/2025]
Abstract
PURPOSE Assessment of tissue perfusion using near-infrared fluorescence (NIR) with indocyanine green (ICG) is gaining popularity, however reliable and objective interpretation remains a challenge. Therefore, this study aimed to establish reference curves for vital tissue perfusion across target tissues using this imaging modality. METHODS Data from five prospective study cohorts conducted in three Dutch academic medical centres between December 2018 and June 2023 was included. Quantitative analysis using time-intensity curves was performed in ten target tissues, including the colon, ileum, gastric conduit, deep inferior epigastric artery perforator (DIEP) flap, skin of the foot, trachea, sternocleidomastoid muscle (SCM), carotid artery, parathyroid gland, and skin of the neck. RESULTS A total of 178 patients were included in this study, representing 303 target tissues. Three different patterns of reference curves were identified based on a subjective assessment. Seven out of ten tissues showed a reference curve with rapid inflow (median time-to-max (tmax): 13.0-17.8 s, median maximum-normalized-slope (slope norm): 10.6-12.6%/sec), short outflow (median area-under-the-curve of tmax + 60 s (AUC60): 65.0-85.1%) followed by a gradual/absent outflow. Secondly, the DIEP flap and SCM tissue showed a reference curve with longer inflow (median tmax: 24.0, 22.0 s, median slope norm: 9.3, 9.7%/sec respectively) and reduced outflow (median AUC60: 89.1, 89.0% respectively). Thirdly, the skin of the foot showed slow inflow (median tmax 141.1 s, median norm slope 2.1%/sec) without outflow. CONCLUSION This study demonstrates reference curves for vital tissue perfusion of multiple target tissues identified with ICG NIR fluorescence imaging, providing a critical step towards the clinical implementation of this technique.
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Affiliation(s)
- Floris P Tange
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Roderick C Peul
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pim van den Hoven
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Stefan Koning
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Mo W Kruiswijk
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Robin A Faber
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Pieter S Verduijn
- Department of Plastic and Reconstructive Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands
| | - Carla S P van Rijswijk
- Department of Interventional Radiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Hidde A Galema
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Denise E Hilling
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Sam P J van Dijk
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Tessa M van Ginhoven
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Doctor Molewaterplein 40, 3015 GD, Rotterdam, the Netherlands
| | - Stijn Keereweer
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Eline A Feitsma
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Milou E Noltes
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Caroline Driessen
- Department of Plastic and Reconstructive Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Michael P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
| | - Abbey Schepers
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Joost R van der Vorst
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
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14
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Liu C, Lan TL, Tsai PC, Chien LI, Huang CS, Huang PI, Hsu PK. Managing esophageal squamous cell carcinoma after cervical radiotherapy for a head and neck cancer: esophagectomy remains a viable option. Dis Esophagus 2025; 38:doae099. [PMID: 39509284 DOI: 10.1093/dote/doae099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 10/03/2024] [Accepted: 10/25/2024] [Indexed: 11/15/2024]
Abstract
Managing esophageal squamous cell carcinoma (ESCC) in patients with a history of cervical radiotherapy for a head and neck cancer (HNC) often requires a careful evaluation of esophagectomy due to concerns regarding complications and prognosis. This study evaluates the periesophagectomy and oncological outcomes of such patients. Patients diagnosed with ESCC between January 2010 and August 2023 and who had undergone esophagectomy with cervical anastomosis were retrospectively reviewed. Patients were categorized into two groups based on the presence (group 1) or absence (group 2) of a history of radiotherapy for as HNC. After 1: 2 propensity score matching, the perioperative and oncological outcomes, including overall survival (OS) and recurrence-free survival (RFS), were evaluated. A total of 481 patients, 32 in group 1 and 449 in group 2, were included. After matching, group 1 patients and 64 patients in the group 2 were analyzed. All the patients in group 1 were males, and their mean age was 56 years. The median radiation dose was 69 Gy. The rates of anastomosis leakage, pneumonia, respiratory failure, and reoperation were comparable between the two groups. However, vocal cord palsy occurred more frequently in group 1, particularly in those with recurrent laryngeal nerve lymph node dissection (37.5%). The 3-year OS (69.6% vs. 75.2%; p = 0.26) and RFS (50.8% vs. 55.9%; p = 0.63) were similar between groups 1 and 2. In conclusion, perioperative and oncological outcomes were comparable between ESCC patients with and without prior HNC radiotherapy, supporting esophagectomy as a feasible option.
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Affiliation(s)
- Chia Liu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tien-Li Lan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Heavy Particles and Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ping-Chung Tsai
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Ling-I Chien
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Sheng Huang
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pin-I Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Heavy Particles and Radiation Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Po-Kuei Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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15
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Zhao H, Koyanagi K, Ninomiya Y, Kazuno A, Yamamoto M, Shoji Y, Yatabe K, Kanamori K, Tajima K, Mori M. Modification of the lesser curvature incision line enhanced gastric conduit perfusion as determined by indocyanine green fluorescence imaging and decreased the incidence of anastomotic leakage following esophagectomy. Esophagus 2025; 22:68-76. [PMID: 39304552 PMCID: PMC11717851 DOI: 10.1007/s10388-024-01089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024]
Abstract
AIM This study aimed to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of gastric conduit as determined by indocyanine green fluorescence imaging and reducing the incidence of anastomotic leakage. METHODS A total of 272 patients who underwent esophagectomy at our institute between 2014 and 2022 were enrolled in this study. These patients were divided based on two different types of cutlines on the lesser curvature: conventional group (n = 141) following the traditional cutline and modified group (n = 131) adopting a modified cutline. Gastric conduit perfusion was assessed by ICG fluorescence imaging, and clinical outcomes after esophagectomy were evaluated. RESULTS The distance from the pylorus to the cutline was significantly longer in the modified group compared with the conventional group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall was significantly higher in the modified group than that in the conventional group (median: 2.81 cm/s vs. 2.54 cm/s, p = 0.001). Furthermore, anastomotic leakage was significantly lower (p = 0.024) and hospital stay was significantly shorter (p < 0.001) in the modified group compared with the conventional group. Multivariate analysis identified blood flow speed in the gastric conduit wall as the only variable significantly associated with anastomotic leakage. CONCLUSIONS ICG fluorescence imaging is a feasible, reliable method for the assessment of gastric conduit perfusion. Modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomotic site, and reduce the risk of anastomotic leakage after esophagectomy.
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Affiliation(s)
- Hongbo Zhao
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yoshiaki Shoji
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Kanamori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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16
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Alanazi M, Ali B, Alonazi I, Garneau PY, Ronald D, Pescarus R. Stent-Over-Sponge (SOS) as a Rescue Technique for Leak Post-Bariatric Surgery: Experience From Hôpital du Sacré-Coeur, Canada. Cureus 2025; 17:e77285. [PMID: 39931622 PMCID: PMC11809667 DOI: 10.7759/cureus.77285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2025] [Indexed: 02/13/2025] Open
Abstract
Leaks and fistulas are serious complications following gastrointestinal surgeries, traditionally managed by self-expandable metal stents and endoscopic vacuum therapy. The stent-over-sponge (SOS) technique is a new modality used as a rescue option when other interventions fail. This report presents the case of a 60-year-old female patient who underwent revisional bariatric surgery and developed a leak post-operation. Initial management included endoscopic debridement and the placement of an Endo-VAC system. Due to technical difficulties, the sponge was left in an endoluminal position, leading to migration. A partially covered stent was placed to prevent further migration and facilitate healing. The patient experienced complications, including hematemesis, but ultimately achieved complete leak closure and is asymptomatic six months post-treatment. In this case, the SOS technique demonstrates its safety and efficacy in dealing with post-operative leaks in patients having undergone bariatric surgery, which would justify performing more extended evaluative studies.
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Affiliation(s)
- Majed Alanazi
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
| | - Bandar Ali
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
| | - Ibrahim Alonazi
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
| | - Pierre Y Garneau
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
| | - Denis Ronald
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
| | - Radu Pescarus
- Surgical Gastroenterology, Minimally Invasive and Bariatric Surgery, Hôpital du Sacré-Coeur, Centre Intégré Universitaire de Santé et de Services Sociaux, Montréal, CAN
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17
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Patton A, Davey MG, Quinn E, Reinhardt C, Robb WB, Donlon NE. Minimally invasive vs open vs hybrid esophagectomy for esophageal cancer: a systematic review and network meta-analysis. Dis Esophagus 2024; 37:doae086. [PMID: 39387393 DOI: 10.1093/dote/doae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Revised: 08/21/2024] [Accepted: 09/27/2024] [Indexed: 10/15/2024]
Abstract
Robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal carcinoma has emerged as the contemporary alternative to conventional laparoscopic minimally invasive (LMIE), hybrid (HE) and open (OE) surgical approaches. No single study has compared all four approaches with a view to postoperative outcomes. A systematic search of electronic databases was undertaken. A network meta-analysis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-network meta-analysis guidelines. Statistical analysis was performed using R and Shiny. Seven randomised controlled trials (RCTs) with 1063 patients were included. Overall, 32.9% of patients underwent OE (350/1063), 11.0% underwent HE (117/1063), 34.0% of patients underwent LMIE (361/1063), and 22.1% of patients underwent RAMIE (235/1063). OE had the lowest anastomotic leak rate 7.7% (27/350), while LMIE had the lowest pulmonary 10.8% (39/361), cardiac 0.56% (1/177) complications, re-intervention rates 5.08% (12/236), 90-day mortality 1.05% (2/191), and shortest length of hospital stay (mean 11.25 days). RAMIE displayed the lowest 30-day mortality rate at 0.80% (2/250). There was a significant increase in pulmonary complications for those undergoing OE (OR 3.63 [95% confidence interval: 1.4-9.77]) when compared to RAMIE. LMIE is a safe and feasible option for esophagectomy when compared to OE and HE. The upcoming RCTs will provide further data to make a more robust interrogation of the surgical outcomes following RAMIE compared to conventional open surgery to determine equipoise or superiority of each approach as the era of minimally invasive esophagectomy continues to evolve (International Prospective Register of Systematic Reviews Registration: CRD42023438790).
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Affiliation(s)
- Andrew Patton
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Eogháin Quinn
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Ciaran Reinhardt
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - William B Robb
- Department of Surgery, St. James's Hospital and Trinity College Dublin, Dublin, Republic of Ireland
| | - Noel E Donlon
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Republic of Ireland
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Ishida H, Fukutomi T, Taniyama Y, Sato C, Okamoto H, Ozawa Y, Ando R, Shinozaki Y, Unno M, Kamei T. Serum C-reactive protein and procalcitonin levels in patients with pneumonia and anastomotic leakage in the postoperative period after esophagectomy. Gen Thorac Cardiovasc Surg 2024; 72:746-751. [PMID: 39073695 DOI: 10.1007/s11748-024-02065-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 07/22/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE Despite being a less-invasive procedure, esophagectomy can cause severe infectious complications, such as pneumonia and anastomotic leakage. Herein, we aimed to clarify the inflammatory characteristics of pneumonia/anastomotic leakage after esophagectomy by assessing the difference between the postoperative trends of serum C-reactive protein (CRP) and procalcitonin (PCT) levels in patients with pneumonia/anastomotic leakage using the values on the consecutive postoperative day (POD). METHODS This study included 439 patients who underwent minimally invasive esophagectomy. Serum CRP and PCT levels were measured on PODs 1-7, 10, and 14. Pneumonia and anastomotic leakage were defined as Clavien-Dindo grades ≥ 2. RESULTS Pneumonia and anastomotic leakage occurred in 96 and 51 patients, respectively. The CRP and PCT levels peaked on POD 3 (11.6 ± 6.8 mg/dL) and POD 2 (0.69 ± 2.9 ng/mL), respectively. Between PODs 3 and 14, CRP levels were significantly higher in patients with pneumonia and anastomotic leakage than in those without complications (P < 0.001). Between PODs 3 and 14, PCT levels were significantly higher in patients with pneumonia; however, on most PODs, there were no significant differences in PCT levels between patients with and without anastomotic leakage. CONCLUSION Inflammatory reactions caused by pneumonia may be more intense than those caused by anastomotic leakage after esophagectomy. Postoperative trends in serum CRP and PCT levels may vary depending on the complication type. Pneumonia and anastomotic leakage after esophagectomy can be potentially distinguished by the postoperative trend of PCT values before detailed examinations, such as computed tomography and endoscopy.
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Affiliation(s)
- Hirotaka Ishida
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan.
| | - Toshiaki Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
- Department of Surgery, National Hospital Organization Mito Medical Center, Ibaraki, Japan
| | - Yusuke Taniyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Chiaki Sato
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Hiroshi Okamoto
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Yohei Ozawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Ryohei Ando
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Yasuharu Shinozaki
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-Machi, Aoba-ku, Sendai-Shi, Miyagi, Japan
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Nguyen H, Pham DH, Luong TH, Nguyen XH, Nguyen DH, Nguyen AK. Laparoscopic and thoracoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation for esophageal cancer: a prospective multicenter case-series outcome. BMC Surg 2024; 24:312. [PMID: 39407237 PMCID: PMC11481371 DOI: 10.1186/s12893-024-02605-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Accepted: 09/30/2024] [Indexed: 10/19/2024] Open
Abstract
INTRODUCTION To mitigate gastroparesis as well as other post-operative complications, we undertook a prospective multicenter study to assess the feasibility, safety, and efficacy in the short-term outcomes of laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation. METHODS A prospective descriptive study on 37 patients with laparoscopic and thoracoscopic whole stomach esophagectomy with preoperative pyloric balloon dilatation from January 2019 to March 2023. The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. RESULTS In our study, all patients were male, with dysphagia as the predominant symptom (45.9%). Esophageal cancer incidence was similar between middle and lower thirds. Nodules were the primary finding on esophagoscopy (48.6%). Preoperative pyloric dilation averaged 31.2 min without complications. Surgical duration ranged from 225 to 400 min (mean 305). Gastric tube fluid volume averaged 148.9 ± 110.66 ml per day. Among 34 post-operative cases underwent gastric transit scans, most had non-dilated stomachs with efficient pyloric drug circulation. Three cases required prolonged ventilation, precluding pyloric circulation scans. Four patients developed chylous fistula, one requiring chest tube embolization. Recurrent laryngeal nerve damage occurred in 10.8% of cases. CONCLUSION After evaluating esophageal cancer patients undergoing laparoscopic whole-stomach esophagectomy with preoperative pyloric balloon dilatation, it was found that this procedure is safe, effective, and significantly reduces postoperative gastroparesis and related complications.
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Affiliation(s)
- Hoang Nguyen
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Duc Huan Pham
- Center for Gastroenterology - Hepatobiliary - Urology - Vinmec Times City International Hospital, Hanoi, Vietnam
| | - Tuan Hiep Luong
- Center of Digestive Surgery, Bach Mai Hospital, Hanoi, Vietnam.
| | - Xuan Hoa Nguyen
- Department of Digestive Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Dang Hung Nguyen
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - An Khang Nguyen
- Department of General Surgery, Hanoi Medical University Hospital, Hanoi, Vietnam
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Starkey A, Lincoln L, Fenton-Lee D, Christie LJ. An audit of perioperative speech pathology intervention on improving enhanced recovery after surgery in oesophagectomy patients. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024:1-6. [PMID: 39223801 DOI: 10.1080/17549507.2024.2388066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
PURPOSE To evaluate the impact of a speech-language pathology (SLP) pathway on recovery following oesophagectomy. METHOD An audit was conducted at a single metropolitan public hospital in Sydney, Australia. Patients between 2014-2021 undergoing a three-stage oesophagectomy (n = 41) were included in the study. The sample was divided into two groups, those who received usual care (2014-2019) and those who received perioperative SLP assessment and intervention (2020-2021), with data collected across swallowing and health outcomes. Patient demographics and outcomes between the two groups were compared. RESULT Patients who received perioperative SLP intervention commenced oral intake faster postoperatively (SLP intervention group Mdn = 6.50 days, IQR = 6.00-7.00; usual care group Mdn = 9.00 days, IQR = 7.00-13.25; p = 0.001). There was no statistically significant difference between groups in rates of aspiration on the postoperative leak test (p = 0.32). No statistically significant differences were found between the two groups in length of hospital stay or number of swallowing-related medical images completed during their admission. CONCLUSION Perioperative SLP intervention has a positive impact on commencing oral intake following a three-stage oesophagectomy, however, it does not have a significant impact on rates of aspiration postoperatively. This pathway may contribute to enhanced recovery after oesophagectomy.
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Affiliation(s)
- Amelia Starkey
- Speech Pathology Department, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Laura Lincoln
- Speech Pathology Department, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Douglas Fenton-Lee
- Upper Gastrointestinal and General Surgery, St Vincent's Health Network Sydney, Darlinghurst, Australia
| | - Lauren J Christie
- Allied Health Research Unit, St Vincent's Health Network Sydney, Darlinghurst, Australia
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, North Sydney, Australia
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21
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Agarwal L, Dash NR, Pal S, Madhusudhan KS, Mani V. Single-Center Randomized Trial Comparing Feeding Jejunostomy with Nasojejunal Tube Placement in Patients Undergoing Transhiatal Esophagectomy Post-Neoadjuvant Therapy for Esophageal Cancer. J Gastrointest Cancer 2024; 55:1282-1290. [PMID: 38954187 DOI: 10.1007/s12029-024-01080-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Enteral nutrition is the preferred mode of nutrition following esophagectomy. However, the preferred mode of enteral nutrition (feeding jejunostomy (FJ) vs. nasojejunal (NJ) tube) remains contentious. In this randomized controlled trial (RCT), we compared FJ with NJ tube feeding in terms of safety, feasibility, efficacy, and quality-of-life (QOL) parameters in Indian patients undergoing trans-hiatal esophagectomy (THE) for carcinoma esophagus. MATERIALS AND METHODS This single-center, two-armed (FJ and NJ tube), non-inferiority RCT was conducted from March 2020 to January 2024. Forty-eight patients underwent THE with posterior-mediastinal-gastric pull-up and were randomized to NJ and FJ arms (24 in each group). The postoperative complications, catheter efficacy, and QOL parameters were compared between the two groups till the 6-week follow-up. RESULTS In this RCT, we found no significant difference in the occurrence of catheter-related complications, postoperative complication rate, catheter efficacy, and visual analog pain scores between patients with NJ tube and FJ, following THE for esophageal cancer. There was a significantly better self-reported physical domain QOL score noted in the NJ group, both at the time of discharge (44.7 ± 6.2 vs 39.8 + 5.6; p value, 0.005) and at the 6-week follow-up (55.4 ± 5.2 vs 48.6 ± 4.5; p value, < 0.001). CONCLUSION Based on the findings of our RCT, we conclude that both enteral access methods (NJ vs. FJ) exhibit comparable incidences of catheter-related complications. The use of NJ tube is a viable alternative to a surgical FJ, has the benefit of early removal, and saves the distress associated with a tube per abdomen.
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Affiliation(s)
- Lokesh Agarwal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | | | - Vignesh Mani
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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22
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Lederer AK, Ittermann I, Chikhladze S, Marjanovic G, Kousoulas L. Multiple surgical revisions in patients with anastomotic leakage: A retrospective cohort analysis. Curr Probl Surg 2024; 61:101543. [PMID: 39168529 DOI: 10.1016/j.cpsurg.2024.101543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Ann-Kathrin Lederer
- Center for Complementary Medicine, Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Ira Ittermann
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Sophia Chikhladze
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Goran Marjanovic
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Lampros Kousoulas
- Department of General and Visceral Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.
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23
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Chen X, Dang Y, Zhang Q, Ma Y, Yao L, Wang H, Xu J, Xu Y, Zhang R. MFI-11 in Chinese elderly esophageal cancer patients with postoperative adverse outcomes. BMC Geriatr 2024; 24:677. [PMID: 39138432 PMCID: PMC11323644 DOI: 10.1186/s12877-024-05281-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND Frailty becomes more pronounced with advancing age, tightly intertwined with adverse clinical outcomes. Across diverse medical disciplines, frailty is now universally recognized as not only a risk factor but also a predictive indicator for unfavorable clinical prognosis. METHODS This study was a retrospective cohort study that included clinical data from patients (aged ≥ 65 years) with esophageal cancer treated surgically at the First Affiliated Hospital of Anhui Medical University in 2021. For each patient, we calculated their 11-index modified frailty index(mFI-11) scores and categorized the patients into a frailty group (mFI-11hign) and a non-frailty group (mFI-11low) based on the optimal grouping cutoff value of 0.27 from a previous study. The primary study index was the incidence of postoperative pulmonary infection, arrhythmia, anastomotic fistula, chylothorax, and electrolyte disturbance complications. Secondary study indicators included postoperative ICU stay, total hospitalization time, readmission rate within 30 days of discharge, and mortality within 30 days after surgery. We performed univariate and multivariate analyses to assess the association between mFI-11 and adverse outcomes as well as postoperative complications. RESULTS Five hundred and fifteen patients were included, including 64.9% (334/515) in the non-frailty group and 35.1% (181/515) in the frailty group. Comparing postoperative complication rates between the two groups revealed lower incidences of postoperative anastomotic fistula (21.5% vs. 4.5%), chylothorax (16.0% vs. 2.1%), cardiac arrhythmia (61.9% vs. 9.9%), pulmonary infections (85.1% vs. 26.6%), and electrolyte disturbance (84.5% vs. 15.0%) in patients of the non-frailty group was lower than that in the frailty group (p < 0.05). mFI-11 showed better prognostic results in predicting postoperative complications. anastomotic fistula (area under the ROC curve AUROC = 0.707), chylothorax (area under the ROC curve AUROC = 0.744), pulmonary infection (area under the ROC curve AUROC = 0.767), arrhythmia (area under the ROC curve AUROC = 0.793), electrolyte disturbance (area under the ROC curve AUROC = 0.832), and admission to ICU (area under the ROC curve AUROC = 0.700). CONCLUSION Preoperative frail elderly patients with esophageal cancer have a high rate of postoperative complications. mFI-11 can be used as an objective indicator for identifying elderly patients at risk for esophageal cancer.
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Affiliation(s)
- Xiu Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Yan Dang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Qi Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Yuhang Ma
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Long Yao
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Hanlin Wang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Junrui Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Yuefeng Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China
| | - Renquan Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, China.
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Li Y, Zhang D, Zhao D. Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study. World J Surg Oncol 2024; 22:118. [PMID: 38702817 PMCID: PMC11067194 DOI: 10.1186/s12957-024-03400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery. METHODS A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied. RESULTS There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups. CONCLUSIONS Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.
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Affiliation(s)
- Yu Li
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China.
| | - Danjie Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
| | - Danwen Zhao
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
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25
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Li C, Song W, Zhang J, Xu Z, Luo Y. A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy. Aging (Albany NY) 2024; 16:7733-7751. [PMID: 38696304 PMCID: PMC11131977 DOI: 10.18632/aging.205780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. METHODS In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. RESULTS Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. CONCLUSIONS This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.
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Affiliation(s)
- Chenglin Li
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Wei Song
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Jialing Zhang
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Zhongneng Xu
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Yonggang Luo
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
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Nijssen DJ, Joosten JJ, Osterkamp J, van den Elzen RM, de Bruin DM, Svendsen MBS, Dalsgaard MW, Gisbertz SS, Hompes R, Achiam MP, van Berge Henegouwen MI. Quantification of fluorescence angiography for visceral perfusion assessment: measuring agreement between two software algorithms. Surg Endosc 2024; 38:2805-2816. [PMID: 38594365 PMCID: PMC11078848 DOI: 10.1007/s00464-024-10794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/09/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) may reduce perfusion-related complications of gastrointestinal anastomosis. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for visceral perfusion assessment between two independently developed quantification software implementations. METHODS This retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analyzed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland-Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations. RESULTS Seventy pre-anastomosis ICG-FA recordings were included in the study. The Bland-Altman analysis indicated a mean relative difference of + 58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < 0.001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively). CONCLUSION This is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.
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Affiliation(s)
- D J Nijssen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J Osterkamp
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - M B S Svendsen
- Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Computer Science, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - M W Dalsgaard
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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Liu B, Ma H, Liu X, Minervini F, Rao M, Campisi A, Cheng J, Xing W. Effect of sternocleidomastoid flap repair and endoscopic injection of emulsified adipose tissue stromal vascular fraction in the treatment of refractory cervical anastomotic leak contaminating mediastinum. J Thorac Dis 2024; 16:2668-2673. [PMID: 38738227 PMCID: PMC11087614 DOI: 10.21037/jtd-24-442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/22/2024] [Indexed: 05/14/2024]
Abstract
Mediastinal infection caused by anastomotic leak is hard to cure, mainly because the poor drainage at the site of mediastinal infection leads to persistent cavity infection, which in turn becomes a refractory mediastinal abscess cavity after minimally invasive esophagectomy (MIE)-McKeown. Herein, we explored sternocleidomastoid (SCM) muscle flaps and emulsified adipose tissue stromal vascular fraction containing adipose-derived stem-cells to address this issue. We studied 10 patients with esophageal cancer who underwent MIE-McKeown + 2-field lymphadenectomy and developed anastomotic and mediastinal leak and received new technology treatment in the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to March 2022. The clinical data and prognosis of the patients were collected and analyzed. A total of 5 patients received this surgery, and no other complications occurred during the perioperative period. Among the 5 patients, 1 patient was partially cured, and 4 patients were completely cured. During the follow-up 3 months postoperatively, all these 5 patients could eat regular food smoothly, and no relapse of leak and mediastinal infection occurred. The new surgical method has achieved good results in the treatment of anastomotic leak. Compared with the traditional thoracotomy, it is a less invasive and feasible surgical approach, which can be used as a supplement to the effective surgical treatment of cervical anastomotic leak contaminating the mediastinum.
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Affiliation(s)
- Baoxing Liu
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Haibo Ma
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Xingyu Liu
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Fabrizio Minervini
- Division of Thoracic Surgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Madhuri Rao
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Alessio Campisi
- Department of Thoracic Surgery, University and Hospital Trust-Ospedale Borgo Trento, Verona, Italy
| | - Jiwei Cheng
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Wenqun Xing
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
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Seo HW, Jeon YJ, Cho JH, Kim HK, Choi YS, Zo JI, Shim YM. Treatment Patterns and Outcomes of Anastomotic Leakage after Esophagectomy for Esophageal Cancer. J Chest Surg 2024; 57:152-159. [PMID: 38228498 DOI: 10.5090/jcs.23.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/22/2023] [Accepted: 11/21/2023] [Indexed: 01/18/2024] Open
Abstract
Background Anastomotic leakage (AL) following esophagectomy represents a serious complication that often results in prolonged hospitalization and necessitates repeated interventions, including nothing-by-mouth (NPO) restriction, endoscopic vacuum therapy (EVT), or surgical repair. In this study, we evaluated the patterns and outcomes of AL treatment. Methods We retrospectively reviewed the medical records of patients who underwent esophagectomy for esophageal cancer at a single center between 2003 and 2020. Of 3,096 examined cases, 181 patients (5.8%) with AL were included in the study: 114 patients (63%) with cervical anastomosis (CA) and 67 (37%) with intrathoracic anastomosis (TA). Results The incidence of AL was 11.9% in the CA and 3.2% in the TA group (p<0.001). Among patients with CA who developed AL, 87 (76.3%) were managed with NPO, 15 (13.2%) with EVT, and 12 (10.5%) with surgical repair. Over 90% of patients with cervical AL resumed an oral diet by the time of discharge, regardless of treatment method. Among patients with TA and AL, 36 (53.7%) received NPO, 25 (37.7%) underwent EVT, and 6 (9%) required surgery. Of these, 34 patients who were managed with NPO and 19 with EVT could resume an oral diet. However, only 2 patients who underwent surgery resumed an oral diet, and 2 patients required additional EVT. Conclusion Although patients with CA displayed a higher incidence of AL, their rate of successful oral intake exceeded that of those with TA, regardless of treatment method. Among patients exhibiting AL with TA, EVT was more commonly employed than in CA cases, and it appears effective.
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Affiliation(s)
- Hyo Won Seo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hentschel F, Mollenhauer G, Siemssen B, Paasch C, Mantke R, Lüth S. Placing vacuum sponges in esophageal anastomotic leaks - how we do it. Langenbecks Arch Surg 2024; 409:86. [PMID: 38441680 PMCID: PMC10914858 DOI: 10.1007/s00423-024-03272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.
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Affiliation(s)
- Florian Hentschel
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany.
- Zentrum für Innere Medizin II, Hochschulklinikum Brandenburg der MHB, Hochstr. 29, 14770, Brandenburg an der Havel, Germany.
| | - Götz Mollenhauer
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | | | - Christoph Paasch
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
- Shouldice Hospital, Thornhill, ON, Canada
| | - René Mantke
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | - Stefan Lüth
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
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Takahashi M, Toyama H, Takahashi K, Kaiho Y, Ejima Y, Yamauchi M. Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study. BMC Anesthesiol 2024; 24:29. [PMID: 38238681 PMCID: PMC10795296 DOI: 10.1186/s12871-024-02410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.
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Affiliation(s)
- Misaki Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroaki Toyama
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yutaka Ejima
- Department of Surgical Center and Supply, Sterilization, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Xuefen Z, Yuanyuan B, Qin L, Xiaoyang W. Nutritional care in patients undergoing laparoscopic/minimally invasive surgeries for gastrointestinal tumours. Wideochir Inne Tech Maloinwazyjne 2023; 18:625-638. [PMID: 38239578 PMCID: PMC10793145 DOI: 10.5114/wiitm.2023.130468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/24/2023] [Indexed: 01/22/2024] Open
Abstract
The introduction of minimally invasive surgeries for gastrointestinal tumours has been associated with many favourable postoperative outcomes and a reduced impact on nutritional status. The literature review begins by discussing the impact of minimally invasive procedures on the nutritional status of patients with gastrointestinal tumours, followed by indications for enteral nutrition (EN) in this population, including preoperative nutritional support and postoperative nutritional support. The review then examines the evidence that favours the use of EN in this population, including studies demonstrating improved outcomes with preoperative EN and reduced postoperative complications with postoperative EN. It also discusses potential strategies for improving outcomes with EN, such as early initiation of feeding and individualized nutrition plans. Overall, current evidence shows that EN improves outcomes, reduces complications, and enhances the quality of life. However, the optimal timing, composition of EN, and long-term outcomes are still unclear, indicating the need for future investigations.
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Affiliation(s)
- Zhou Xuefen
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Bian Yuanyuan
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Li Qin
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Wu Xiaoyang
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
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Hong Z, Cui B, Lu Y, Bai X, Yang N, He X, Wu X, Cheng T, Jin D, Zhao J, Gou Y. Efficacy and Quality of Life with the Modified Versus the Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study. Ann Surg Oncol 2023; 30:8223-8230. [PMID: 37535270 DOI: 10.1245/s10434-023-14033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy and postoperative quality of life for patients with esophageal cancer treated by either the modified or the traditional thoracolaparoscopic McKeown procedure. METHODS This retrospective case-control study included 269 patients with esophageal cancer admitted to three medical centers in China from February 2020 to August 2022. The patients were divided according to surgical method into the layered hand-sewn end-to-end invagination anastomosis group (modified group) and the traditional hand anastomosis group (traditional group). Propensity score-matching (PSM) was used to maintain balance and comparability between the two groups. RESULTS The differences in age and tumor location between the patients in the traditional and modified groups were statistically significant. After PSM, the aforementioned factors were statistically insignificant. After PSM, each group had 101 patients. The modified group showed the greater advantage in terms of postoperative hospital stay (P = 0.036), incidence of anastomotic leak (P = 0.009), and incidence of gastroesophageal reflux (P < 0.001), and the difference was statistically significant. The results of the Quality of Life Questionnaire Core 30 (QLQ-C30) and Quality of Life Questionnaire Oesophageal Cancer Module 18 (QLQ-OES18) scales showed that the modified group also had the advantage over the traditional group in terms of physical function, overall health status, loss of appetite, eating, reflux, obstruction, and loss of appetite scores at the first and third months after surgery. CONCLUSION The modified thoraco-laparoscopic McKeown procedure is a safe and effective surgical approach that can significantly reduce the incidence of postoperative anastomotic leak and gastroesophageal reflux, shorten the postoperative hospital stay, and improve the postoperative quality of life for patients with esophageal cancer.
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Affiliation(s)
- Ziqiang Hong
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Baiqiang Cui
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Yingjie Lu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Xiangdou Bai
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Ning Yang
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoyang He
- Department of Thoracic Surgery, Hebei Province Chest Hospital, Shijiazhuang, China
| | - Xusheng Wu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Cheng
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jing Zhao
- Lanzhou First People's Hospital, Lanzhou, China.
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
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Lee J, Jeon JH, Yoon SH, Shih BCH, Jung W, Hwang Y, Cho S, Kim K, Jheon S. The Optimal Treatment Strategy for Postoperative Anastomotic Leakage After Esophagectomy: a Comparative Analysis Between Endoscopic Vacuum Therapy and Conventional Treatment. J Gastrointest Surg 2023; 27:2899-2906. [PMID: 38040922 DOI: 10.1007/s11605-023-05637-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/18/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. METHODS A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). RESULTS The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4-142] days vs. 70 [8-604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). CONCLUSIONS EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.
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Affiliation(s)
- Joonseok Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
| | - Seung Hwan Yoon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Beatrice Chia-Hui Shih
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Woohyun Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Yoohwa Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sukki Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sanghoon Jheon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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35
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Pattynama LMD, Pouw RE, Henegouwen MIVB, Daams F, Gisbertz SS, Bergman JJGHM, Eshuis WJ. Endoscopic vacuum therapy for anastomotic leakage after upper gastrointestinal surgery. Endoscopy 2023; 55:1019-1025. [PMID: 37253387 PMCID: PMC10602657 DOI: 10.1055/a-2102-1691] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/19/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Recently, endoscopic vacuum therapy (EVT) was introduced as treatment for anastomotic leakage after upper gastrointestinal (GI) surgery. The aim of this study was to describe the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center. METHODS Patients treated with EVT for anastomotic leakage after upper GI surgery were included retrospectively (January 2018-June 2021) and prospectively (June 2021-October 2021). The primary end point was the EVT success rate. Secondary end points included mortality and adverse events. RESULTS 38 patients were included (31 men; mean age 66 years): 27 had undergone an esophagectomy with gastric conduit reconstruction and 11 a total gastrectomy with esophagojejunal anastomosis. EVT was successful in 28 patients (74 %, 95 %CI 57 %-87 %). In 10 patients, EVT failed: deceased owing to radiation pneumonitis (n = 1), EVT-associated complications (n = 2), and defect closure not achieved (n = 7). Mean duration of successful EVT was 33 days, with a median of six EVT-related endoscopies. Median hospital stay was 45 days. CONCLUSION This initial experience with EVT for anastomotic leakage after upper GI surgery demonstrated a success rate of 74 %. EVT is a promising therapy that could prevent further major surgery. More experience with the technique and its indications will likely improve success rates in the future.
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Affiliation(s)
- Lisanne M. D. Pattynama
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Roos E. Pouw
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jacques J. G. H. M. Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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Latorre-Rodríguez AR, Huang J, Schaheen L, Smith MA, Hashimi S, Bremner RM, Mittal SK. Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience. Langenbecks Arch Surg 2023; 408:397. [PMID: 37831200 DOI: 10.1007/s00423-023-03121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. METHODS After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. RESULTS During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality. CONCLUSION The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
| | - Jasmine Huang
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Lara Schaheen
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Samad Hashimi
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA.
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Wang W, Xie JB, Yang TB, Huang SJ, Chen BY. Outcomes of early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophageal cancer surgery: a randomized clinical trial. J Cardiothorac Surg 2023; 18:268. [PMID: 37794501 PMCID: PMC10552382 DOI: 10.1186/s13019-023-02370-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND This study aims to investigate the outcomes of patients who received early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy due to esophageal cancer. METHODS A prospective randomized clinical trial was performed between March 2020 and June 2022. Patients who were scheduled for thoracoscopic and laparoscopic esophagectomy due to esophageal cancer were enrolled. Then, these patients were assigned to the control group (traditional postoperative care) and study group (traditional postoperative care with early bronchoscopic sputum aspiration and lavage). The outcomes, which included the length of hospital stay and medical expenses, and postoperative complications, which included pulmonary infection, atelectasis, respiratory dysfunction and anastomotic leakage, were compared between these two groups. RESULTS A total of 106 patients were enrolled for the present study, and 53 patients were assigned for the control and study groups. There were no statistically significant differences in gender, age, and location of the esophageal cancer between the two groups. Furthermore, the length of hospital stay was statistically significantly shorter and the medical expenses were lower during hospitalization in the study group, when compared to the control group (12.3 ± 1.2 vs. 18.8 ± 1.3 days, 5.5 ± 0.9 vs. 7.2 ± 1.2 Chinese Yuan, respectively; all, P < 0.05). Moreover, there were statistically significantly fewer incidences of overall complications in study group, when compared to the control group (20.7% vs.45.2%, P < 0.05). CONCLUSIONS For patients with esophageal cancer, early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy can shorten the length of hospital stay, and lower the medical expense and incidence of postoperative complications.
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Grants
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
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Affiliation(s)
- Wu Wang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China.
| | - Jin-Biao Xie
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Tian-Bao Yang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Shi-Jie Huang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Bo-Yang Chen
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
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Sun S, Wang Z, Huang C, Li K, Liu X, Fan W, Zhang G, Li X. Different gastric tubes in esophageal reconstruction during esophagectomy. Esophagus 2023; 20:595-604. [PMID: 37490217 PMCID: PMC10495279 DOI: 10.1007/s10388-023-01021-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.
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Affiliation(s)
- Shaowu Sun
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Zhulin Wang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Chunyao Huang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Kaiyuan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Xu Liu
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Wenbo Fan
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
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Housman B, Lee DS, Flores R. A narrative review of anastomotic leak in the Ivor Lewis esophagectomy: expected, accepted, but preventable. Transl Cancer Res 2023; 12:2405-2419. [PMID: 37859730 PMCID: PMC10583019 DOI: 10.21037/tcr-23-515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/01/2023] [Indexed: 10/21/2023]
Abstract
Background and Objective Anastomotic leak (AL) remains a common and highly morbid complication after Ivor Lewis Esophagectomy. Leak is associated with increased morbidity, mortality, strictures and even cancer recurrence. Unfortunately, despite advances in surgical technique and perioperative care, the reported frequency of AL has remained largely unchanged. Methods A PubMed search for all English-language articles that discuss Ivor Lewis esophagectomy, AL, risk factors, and outcomes was conducted from 1901 to 2023 prioritizing research from randomized trials that evaluated outcomes from patients undergoing esophagectomy. Key Content and Findings This narrative review will discuss the prevailing literature on AL, risk factors and outcomes with a focus on its relationship to the Ivor Lewis esophagectomy (ILE). In particular, we emphasize that the gastric conduit, as commonly created for most esophagectomy procedures, is inherently vulnerable to ischemia. We will show trends in the literature that have contributed to the high rate of postoperative complications, with a focus on the AL. In addition, we propose that the traditional Ivor Lewis procedure itself is a risk factor for AL. We review a surgical alternative that increases blood supply of the conduit, and is associated with reduced leak, no strictures, and improved surgical outcomes. Conclusions Multiple factors contribute to AL after esophagectomy; including several current surgical practices. We believe that some of them, especially the commonly accepted approach to the gastric conduit, can be modified to optimize tissue perfusion. With further investigation, we may reduce the incidence of short and long-term anastomotic complications and improve surgical outcomes.
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Affiliation(s)
- Brian Housman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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41
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Jeon YH, Yun JK, Jeong YH, Gong CS, Lee YS, Kim YH. Surgical outcomes of 500 robot-assisted minimally invasive esophagectomies for esophageal carcinoma. J Thorac Dis 2023; 15:4745-4756. [PMID: 37868885 PMCID: PMC10586984 DOI: 10.21037/jtd-23-637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/04/2023] [Indexed: 10/24/2023]
Abstract
Background In 2003, robot-assisted minimally invasive esophagectomy (RAMIE) was first reported to overcome the technical limitations of minimally invasive esophagectomy. RAMIE requires repeated modifications to set up the robotic system, and sufficient experience is required to gain technical proficiency. This study aimed to identify the learning periods and the outcomes of RAMIE for esophageal carcinoma. Methods We retrospectively reviewed 500 consecutive RAMIE cases for esophageal cancer from December 2008 to February 2021. The learning curve for RAMIE was identified using cumulative sum analysis. Results In a total of 500 RAMIE patients, the Ivor Lewis and McKeown operation were performed in 267 patients (53.4%) and 192 patients (38.4%), respectively. We classified learning periods into the learning phase (first 50 cases), the developing phase (51-150 case), and the stable phase (151-500 case). The rates of vocal cord palsy (42.0% vs. 28.4%) and anastomotic leakage (10.0% vs. 6.4%) were reduced after the learning phase. The mean total operative time (420 vs. 373 min), the mean length of stay (21.6 vs. 16.7 days), and the rate of anastomotic stricture (27.0% vs. 12.4%) were significantly reduced after reaching stable phase. In the stable phase, the proportion of the Ivor Lewis operation (26.0% vs. 67.1%), neoadjuvant chemoradiation therapy (14.0% vs. 25.7%), and bilateral cervical node dissection cases (12.0% vs. 22.0%) were significantly increased. Conclusions Fifty procedures might be needed to achieve early proficiency, and extensive experience of more than 150 procedures is needed for quality stabilization.
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Affiliation(s)
- Yun-Ho Jeon
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jae Kwang Yun
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Ho Jeong
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Chung-Sik Gong
- Division of Stomach Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yoon Se Lee
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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42
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Lim ZY, Mohan S, Balasubramaniam S, Ahmed S, Siew CCH, Shelat VG. Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green. World J Gastrointest Surg 2023; 15:1841-1857. [PMID: 37901741 PMCID: PMC10600780 DOI: 10.4240/wjgs.v15.i9.1841] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
Indocyanine green (ICG) is a water-soluble fluorescent dye that is minimally toxic and widely used in gastrointestinal surgery. ICG facilitates anatomical identification of structures (e.g., ureters), assessment of lymph nodes, biliary mapping, organ perfusion and anastomosis assessment, and aids in determining the adequacy of oncological margins. In addition, ICG can be conjugated to artificially created antibodies for tumour markers, such as carcinoembryonic antigen for colorectal, breast, lung, and gastric cancer, prostate-specific antigen for prostate cancer, and cancer antigen 125 for ovarian cancer. Although ICG has shown promising results, the optimization of patient factors, dye factors, equipment, and the method of assessing fluorescence intensity could further enhance its utility. This review summarizes the clinical application of ICG in gastrointestinal surgery and discusses the emergence of novel dyes such as ZW-800 and VM678 that have demonstrated appropriate pharmacokinetic properties and improved target-to-background ratios in animal studies. With the emergence of robotic technology and the increasing reporting of ICG utility, a comprehensive review of clinical application of ICG in gastrointestinal surgery is timely and this review serves that aim.
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Affiliation(s)
- Zavier Yongxuan Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Swetha Mohan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | | | - Saleem Ahmed
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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43
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Su P, Huang C, Lv H, Zhang Z, Tian Z. Prediction model using risk factors associated with anastomotic leakage after minimally invasive esophagectomy. Pak J Med Sci 2023; 39:1345-1349. [PMID: 37680807 PMCID: PMC10480737 DOI: 10.12669/pjms.39.5.8050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 04/24/2023] [Accepted: 06/26/2023] [Indexed: 09/09/2023] Open
Abstract
Objective To explore the risk factors of anastomotic leakage after minimally invasive esophagectomy (MIE) and to build a prediction model of the probability of postoperative anastomotic leakage. Methods Clinical data of patients undergoing MIE, admitted in the Fourth Hospital of Hebei Medical University from March 2018 to March 2022, were retrospectively selected, and risk factors of anastomotic leakage after MIE were analyzed by univariate and multivariate logistic regression. A prediction nomogram model was established based on the independent risk factors, and its prediction effect was evaluated. Results A total of 308 patients were included. Thirty patients had postoperative anastomotic leakage, with an incidence of 9.74%. Logistic regression analysis showed that age, postoperative delirium, pleural adhesion, postoperative pulmonary complications, high postoperative white blood cell count and low lymphocyte count were risk factors for postoperative anastomotic leakage. A nomograph prediction model was constructed based on these risk factors. The predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The calculated C-index value (Bootstrap method) was 0.9609, indicating that the nomograph prediction model had a good discrimination ability. By drawing the receiver operating characteristic (ROC) curve, we showed that the area under the curve (AUC) of the nomograph prediction model was 0.9609 (95%CI: 0.937-0.985), which indicated a good prediction efficiency of the model. Conclusions The nomograph prediction model based on the independent risk factors of anastomotic leakage after MIE can accurately predict the probability of postoperative anastomotic leakage.
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Affiliation(s)
- Peng Su
- Peng Su, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Chao Huang
- Chao Huang, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Huilai Lv
- Huilai Lv, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Zhen Zhang
- Zhen Zhang, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Ziqiang Tian
- Ziqiang Tian, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
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44
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Stuart CM, Gergen AK, Byers S, Vigneshwar N, Madsen H, Johnson J, Oase K, Garduno N, Marsh M, Pratap A, Mitchell JD, David EA, Randhawa SK, Meguid RA, McCarter MD, Stewart CL. ASO Author Reflections: Gastric Ischemic Preconditioning Prior to Esophagectomy: Laparoscopic Gastric Ischemic Preconditioning. Ann Surg Oncol 2023; 30:5826-5827. [PMID: 37294387 DOI: 10.1245/s10434-023-13715-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Christina M Stuart
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA.
| | - Anna K Gergen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Sara Byers
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Navin Vigneshwar
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Helen Madsen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Jocelyn Johnson
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Kristen Oase
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Nicole Garduno
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Megan Marsh
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Akshay Pratap
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado School of Medicine, Aurora, USA
| | - John D Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Elizabeth A David
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Simran K Randhawa
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Robert A Meguid
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Martin D McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Camille L Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
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45
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Çetinkaya Ç, Bilgi Z, Aslan S, Batırel HF. Evolution of a minimally invasive oesophagectomy program - effective complication management is key. Wideochir Inne Tech Maloinwazyjne 2023; 18:481-486. [PMID: 37868276 PMCID: PMC10585459 DOI: 10.5114/wiitm.2023.130326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/19/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures. Aim To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management. Material and methods All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery). Results In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort. Conclusions Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.
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Affiliation(s)
- Çağatay Çetinkaya
- Department of Thoracic Surgery, Uskudar University, School of Medicine, İstanbul, Turkey
| | - Zeynep Bilgi
- Department of Thoracic Surgery, Medeniyet University, School of Medicine, İstanbul, Turkey
| | - Sezer Aslan
- Department of Thoracic Surgery, Sirnak State Hospital, Sirnak, Turkey
| | - Hasan Fevzi Batırel
- Department of Thoracic Surgery, Biruni University, School of Medicine, İstanbul, Turkey
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Agarwal L, Dash NR, Pal S, Agarwal A, Madhusudhan KS. Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study. J Gastrointest Cancer 2023; 54:759-767. [PMID: 35965285 DOI: 10.1007/s12029-022-00856-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL. METHODS Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors. RESULTS A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL. CONCLUSION Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.
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Affiliation(s)
- Lokesh Agarwal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Ayushi Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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Scheese D, Alwatari Y, Rustom S, He G, Puig CA, Julliard WA, Shah RD. Chest vs. neck anastomotic leak post esophagectomy for malignancy: rate, predictors, and outcomes. J Thorac Dis 2023; 15:3593-3604. [PMID: 37559658 PMCID: PMC10407498 DOI: 10.21037/jtd-23-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Anastomotic leak is a major contributor to comorbidity and mortality following esophagectomy. We sought to assess rate and predictors of leak after esophagectomy and compare outcomes of chest versus neck anastomotic leaks. METHODS A retrospective review was performed utilizing National-Surgical-Quality-Improvement-Program data from 2016-2019 for patients undergoing esophagectomy for malignancy. Preoperative characteristics and postoperative outcomes were compared. Patients were classified into two groups: Ivor Lewis esophagectomy [ILE, chest leak (CL)] and transhiatal esophagectomy (THE)/McKeown esophagectomy [ME, neck leak (NL)]. Multivariable regression models were constructed to determine predictors of each type of leak and postoperative complications. RESULTS A total of 1,665 patients underwent esophagectomy with 14.1% reported post-operative leak, 61% of patients underwent ILE while 39% underwent THE or ME. Of patients who underwent ILE, 13.8% had CL with complications including significantly higher length of stay and mortality compared to patients without leak. Independent predictors of CL included: diabetes, hypertension, advanced disease stage, chronic steroid use, and operative time. Ninety-five patients (14.6%) who underwent either THE or ME had NL with similar complications. Diabetes, pre-operative white blood cell (WBC), and operative time were independent predictors for NL. On multivariable regression, CL was associated with greater odds of requiring intervention compared with NL. CONCLUSIONS Post-esophagectomy CL and NL are associated with higher morbidity and mortality. Diabetes and operative time were independent predictors for both leaks while steroid use, hypertension, and advanced disease stage predicted CL. CL was associated with greater odds of needing an intervention, but contrary to conventional wisdom, was not associated with higher morbidity or mortality.
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Affiliation(s)
| | - Yahya Alwatari
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Salem Rustom
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Gene He
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Carlos A. Puig
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Walker A. Julliard
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Rachit D. Shah
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
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Grantham JP, Hii A, Shenfine J. Combined and intraoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:1485-1500. [PMID: 37555117 PMCID: PMC10405120 DOI: 10.4240/wjgs.v15.i7.1485] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions. AIM To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes. METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness. RESULTS Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness. CONCLUSION Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- Department of General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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Mitchell W, Roser T, Heard J, Logarajah S, Ok J, Jay J, Osman H, Jeyarajah DR. Regional Anesthetic Use in Trans-Hiatal Esophagectomy. Are They Worth Consideration? A Case Series. Local Reg Anesth 2023; 16:99-111. [PMID: 37456592 PMCID: PMC10349603 DOI: 10.2147/lra.s398331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA. Methods This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission. Results The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain. Conclusion The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study's population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy. Trial Registration This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.
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Affiliation(s)
- William Mitchell
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
| | - Thomas Roser
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
| | - Jessica Heard
- Methodist Richardson Medical Center, Richardson, TX, USA
| | | | - John Ok
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - John Jay
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - Houssam Osman
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - D Rohan Jeyarajah
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
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50
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Bartella I, Brunner S, Schiffmann LM, Schiller P, Schmidt T, Fuchs HF, Chon S, Bruns CJ, Schröder W. Clinical utility and applicability of the,Esophagus Complication Consensus Group' (ECCG) classification of anastomotic leakage following hybrid Ivor-Lewis esophagectomy. Langenbecks Arch Surg 2023; 408:258. [PMID: 37391512 DOI: 10.1007/s00423-023-03001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/25/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) remains the leading surgical complication following Ivor-Lewis (IL) esophagectomy. Different treatment options of AL exist but outcome is difficult to compare due to a lack of generally accepted classifications. This retrospective study was conducted to analyze the clinical significance of a recently proposed classification based on the management of AL. PATIENTS AND METHODS A cohort of 954 consecutive patients undergoing hybrid IL esophagectomy (laparoscopy/thoracotomy) was analysed. AL was defined according to the,Esophagus Complication Consensus Group' (ECCG) criteria depending on its treatment: conservative (AL type I), interventional endoscopic (AL type II), and surgical (AL type III). Primary outcome was single or multiple organ failure (Clavien-Dindo IVA/B) associated with AL. RESULTS Overall morbidity was 63.0% and 8.8% (84/954 patients) developed an AL postoperatively. Three patients (3.5%) had an AL type I, 57 patients (67.9%) an AL type II and 24 patients (28.6%) an AL type III. For patients managed surgically, AL was diagnosed significantly earlier (median days: AL type III: 2 vs AL type II: 6, p < 0.001). Associated organ failure (CD IVA/B) was significantly lower for AL type II as compared to AL type III (21.1% versus 45.8%, p < 0.0001). In-hospital mortality was 3.5% for AL type II and 8.3% for AL type III (p = 0.789). There was no difference for re-admission to ICU and overall length of hospital stay. CONCLUSION The proposed ECCG classification is simply to apply and discriminates the post-treatment severity of AL but does not aid to implement a treatment algorithm.
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Affiliation(s)
- Isabel Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Stefanie Brunner
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Petra Schiller
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Seung Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany.
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