1
|
de la Plaza Llamas R, Parés D, Soria Aledó V, Cabezali Sánchez R, Ruiz Marín M, Senent Boza A, Romero Simó M, Alonso Hernández N, Vallverdú-Cartié H, Mayol Martínez J. Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey. Cir Esp 2024:S2173-5077(24)00096-6. [PMID: 38615908 DOI: 10.1016/j.cireng.2024.03.008] [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: 02/16/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown. The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. METHODS Using a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. RESULTS The survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population. Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients' discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. CONCLUSIONS This study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.
Collapse
Affiliation(s)
- Roberto de la Plaza Llamas
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain.
| | - David Parés
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Víctor Soria Aledó
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario JM Morales Meseguer, Murcia, Spain
| | | | - Miguel Ruiz Marín
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Ana Senent Boza
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manuel Romero Simó
- Servicio de Cirugía General y del Aparato Digestivo, Hospital General Universitario Dr. Balmis de Alicante, Spain
| | - Natalia Alonso Hernández
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | | |
Collapse
|
2
|
Murray W, Davey MG, Robb W, Donlon NE. Management of esophageal anastomotic leaks, a systematic review and network meta-analysis. Dis Esophagus 2024:doae019. [PMID: 38525940 DOI: 10.1093/dote/doae019] [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: 10/11/2023] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 03/26/2024]
Abstract
There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.
Collapse
Affiliation(s)
- William Murray
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Mathew G Davey
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - William Robb
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Noel E Donlon
- Department of Upper Gastrointestinal Surgery, Beaumont Hospital, Dublin, Ireland
| |
Collapse
|
3
|
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: 0] [Impact Index Per Article: 0] [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.
Collapse
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
| | | |
Collapse
|
4
|
Klarenbeek BR, Fujiwara H, Scholte M, Rovers M, Shiozaki A, Rosman C. Introduction of Minimally Invasive transCervical oEsophagectomy (MICE) according to the IDEAL framework. Br J Surg 2023; 110:1096-1099. [PMID: 36960594 PMCID: PMC10416700 DOI: 10.1093/bjs/znad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 02/03/2023] [Accepted: 02/21/2023] [Indexed: 03/25/2023]
Affiliation(s)
| | - Hitoshi Fujiwara
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Mirre Scholte
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Maroeska Rovers
- Department of Health Evidence, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Atsushi Shiozaki
- Department of Surgery, Kyoto Prefectural University of Medicine Hospital, Kyoto, Japan
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| |
Collapse
|
5
|
von Bechtolsheim F, Benedix F, Hummel R, Mihaljevic A, Weitz J, Distler M. [Robot-assisted Minimally Invasive Oesophagectomy - Surgical Variants of Intrathoracic Circular Stapled Oesophagogastric Anastomosis]. Zentralbl Chir 2023; 148:19-23. [PMID: 35764303 DOI: 10.1055/a-1838-5170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Anastomotic insufficiency after oesophagectomy contributes significantly to morbidity and mortality of affected patients. A safe surgical technique can reduce the incidence of such anastomotic insufficiencies. INDICATION In the treatment of oesophageal cancer, the German guideline recommends minimally invasive or hybrid surgical procedures. In most cases, Ivor-Lewis oesophagectomy and continuity reconstruction using a gastric sleeve are performed. Circular stapler anastomosis seems to be superior. METHOD The preparation of the anastomosis starts intra-abdominally with mobilisation of the stomach and sparing of the gastroepiploic vessels. After the subsequent intrathoracic mobilisation of the oesophagus, the actual anastomosis construction can take place. Here, the oesophagus is either transected with a stapler closure or openly with scissors. This is followed by a purse-string suture on the open oesophageal stump. Alternatively, partial oesophageal opening with prior purse-string suture may later facilitate insertion of the stapler anvil. The anvil is placed in the oesophageal stump via minithoracotomy or alternatively transorally using a special gastric tube system. Subsequently, the anvil is fixated using the previously performed purse-string suture. Now the gastric sleeve can be pulled into the thorax. The oesophagus and small gastric curvature are placed extrathoracically through the minithoracotomy and a circular stapler is inserted into the gastric tube via an opening of the small curvature. The anastomosis then must be placed remotely from the gastroepiploic arcade. After construction of the anastomosis, the gastric sleeve is separated using a linear stapler. Eventually, the oesophagus and small gastric curvature can be completely recovered. Optionally, an additional suturing over the anastomosis and dissection margin of the gastric sleeve can be performed. CONCLUSION In robot-assisted oesophagectomy, the reconstruction of continuity with a circular stapler anastomosis is quite possible and seems comparatively easier to learn. Nevertheless, variations are still possible within this procedure. However, there is no scientific evidence on the advantage for any method in a direct comparison.
Collapse
Affiliation(s)
- Felix von Bechtolsheim
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Frank Benedix
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland
| | - Richard Hummel
- Klinik für Chirurgie - Allgemein-, Viszeral-, Thorax-, Gefäß- und Transplantationschirurgie, Universitätsklinikum Schleswig-Holstein Campus Lübeck, Lübeck, Deutschland
| | - Andre Mihaljevic
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Jürgen Weitz
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| | - Marius Distler
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden, Deutschland
| |
Collapse
|
6
|
Huang Y, Fu X, Fu S. Case report: Drainage tube penetrating anastomosis as a rare cause for long-term nonunion of esophagogastric anastomosis in neck. Front Surg 2023; 10:1140839. [PMID: 36911617 PMCID: PMC9992177 DOI: 10.3389/fsurg.2023.1140839] [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: 01/09/2023] [Accepted: 02/03/2023] [Indexed: 02/24/2023] Open
Abstract
Anastomotic leakage is a life-threatening complication for esophageal cancer patients who received McKeown esophagectomy. Cervical drainage tube penetrating anastomosis is a rare but noteworthy cause of long-term nonunion of esophagogastric anastomosis. Here we reported two cases of esophageal cancer patients who received McKeown esophagectomy. The first case acquired the anastomotic leakage on postoperative day (POD) 7, and lasted for 56 days. The cervical drainage tube was removed at POD 38, and the leakage healed in 25 days. The second case acquired the anastomotic leakage on POD 8 and lasted for 95 days. The cervical drainage tube was removed at POD 57, and the leakage healed in 46 days. The two cases demonstrated the duration-prolonging effect of drainage tube penetrating anastomosis, which should not be overlooked in clinical practice. We suggested paying attention to the duration of leakage, the drainage fluids amounts and characteristics, and the imaging manifestations to help diagnose. If the cervical drainage tube penetrated the anastomosis, the tube should be eliminated as soon.
Collapse
Affiliation(s)
- Yaochen Huang
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangning Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shengling Fu
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
7
|
Vanstraelen S, Coosemans W, Depypere L, Mandeville Y, Moons J, Van Veer H, Nafteux P. Real-life introduction of powered circular stapler for esophagogastric anastomosis: cohort and propensity matched score study. Dis Esophagus 2022; 36:6758201. [PMID: 36222069 PMCID: PMC10150171 DOI: 10.1093/dote/doac073] [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: 07/03/2022] [Revised: 08/12/2022] [Indexed: 12/11/2022]
Abstract
Anastomotic leakage after esophagectomy is one of the most feared complications, which results in increased morbidity and mortality. Our aim was to evaluate the impact of a powered circular stapler on complications after esophagectomy with intrathoracic anastomosis for esophageal cancer. Between May 2019 and July 2021, all consecutive oesophagectomies for cancer with intrathoracic anastomosis in a high-volume center were included in this retrospective study. Surgeons were free to choose either a manual or a powered circular stapler. Preoperative characteristics and postoperative complications were recorded in a prospective database, according to EsoData. Propensity score matching (age, body mass index, Eastern cooperative oncology group (ECOG) performance and neoadjuvant therapy) was conducted to reduce potential confounding. We included 128 patients. Powered and manual circular staplers were used in 62 and 66 patients, respectively. Fewer anastomotic leakages were observed with the powered stapler group (OR = 7.3 (95%CI: 1.58-33.7); [3.2% (n = 2) vs 19.7% (n = 13), respectively; p = 0.004]). After propensity score matching, this remained statistically significant (OR = 8.5 (95%CI: 1.80-40.1); [4.1% (n = 2) vs 20.4% (n = 10), respectively; p = 0.013]). Additionally, anastomotic diameter was significantly higher with the powered stapler (median: 29 mm (63.3%) vs 25 mm (57.1%), respectively; p < 0.0001). There was no significant difference in comprehensive complication index (p = 0.146). A decreased mean length of stay was observed in the powered stapler group (11.1 vs 18.7 days respectively; p = 0.022). Postoperative anastomotic leakage after esophageal resection was significantly reduced after the introduction of the powered circular stapler, consequently resulting in a reduced length of stay. Further evaluation on long-term strictures and quality of life are warranted to support these results.
Collapse
Affiliation(s)
- Stijn Vanstraelen
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| | - Willy Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| | - Lieven Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| | - Yannick Mandeville
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Johnny Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| | - Hans Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Disease, Metabolism, and Aging, KU Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Hung PC, Chen HY, Tu YK, Kao YS. A Comparison of Different Types of Esophageal Reconstructions: A Systematic Review and Network Meta-Analysis. J Clin Med 2022; 11:jcm11175025. [PMID: 36078955 PMCID: PMC9457433 DOI: 10.3390/jcm11175025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: A total esophagectomy with gastric tube reconstruction is the mainstream procedure for esophageal cancer. Colon interposition and free jejunal flap for esophageal reconstruction are the alternative choices when the gastric tube is not available. However, to date, a solution for the high anastomosis leakage rates among these three types of conduits has not been reported. The aim of this network meta-analysis was to investigate the rate of anastomotic leakage (AL) among the three procedures to determine the best esophageal substitute or the future direction for improving the conventional gastric pull-up (GPU). Methods: We searched PubMed, Cochrane, and Embase databases. We included esophageal cancer patients receiving esophagectomy and excluded patients with other cancer. The random effect model was used in this network meta-analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment of studies in the network meta-analysis, and funnel plots were used to evaluate publication bias. The primary outcome is anastomosis leakage; the secondary outcomes are stricture formation, length of hospital stays, and mortality rate. Results: Nine studies involving 1613 patients were included in this network meta-analysis. The trend results indicated the following. Regarding anastomosis leakage, free jejunal flap was the better procedure; regarding stricture formation, colon interposition was the better procedure; regarding mortality rate, free jejunal flap was the better procedure; regarding length of hospital stay, gastric pull-up was the better treatment. Discussion: Overall, if technically accessible, free jejunal flap is a better choice than colon interposition when gastric conduit cannot be used, but further study should be conducted to compare groups with equal supercharged patients. In addition, jejunal flap (JF) cannot replace traditional gastric pull-up (GPU) due to technical complexities, more anastomotic sites, and longer operation times. However, the GPU method with the supercharged procedure would be a possible solution to lower postoperative AL. The limitation of this meta-analysis is that the number of articles included was low; we aim to update the result when new data are available. Funding: None. Registration: N/A.
Collapse
Affiliation(s)
- Pang-Chieh Hung
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Hsuan-Yu Chen
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 106, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence:
| |
Collapse
|
9
|
Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C, Matthée E, Slootmans CAM, Ultee G, Schouten J, Gisbertz SS, Eshuis WJ, Kalff MC, Feenstra ML, van der Peet DL, Stam WT, van Etten B, Poelmann F, Vuurberg N, van den Berg JW, Martijnse IS, Matthijsen RM, Luyer M, Curvers W, Nieuwenhuijzen T, Taselaar AE, Kouwenhoven EA, Lubbers M, Sosef M, Lecot F, Geraedts TCM, van Esser S, Dekker JWT, van den Wildenberg F, Kelder W, Lubbers M, Baas PC, de Haas JWA, Hartgrink HH, Bahadoer RR, van Sandick JW, Hartemink KJ, Veenhof X, Stockmann H, Gorgec B, Weeder P, Wiezer MJ, Genders CMS, Belt E, Blomberg B, van Duijvendijk P, Claassen L, Reetz D, Steenvoorde P, Mastboom W, Klein Ganseij HJ, van Dalsen AD, Joldersma A, Zwakman M, Groenendijk RPR, Montazeri M, Mercer S, Knight B, van Boxel G, McGregor RJ, Skipworth RJE, Frattini C, Bradley A, Nilsson M, Hayami M, Huang B, Bundred J, Evans R, Grimminger PP, van der Sluis PC, Eren U, Saunders J, Theophilidou E, Khanzada Z, Elliott JA, Ponten J, King S, Reynolds JV, Sgromo B, Akbari K, Shalaby S, Gutschow CA, Schmidt H, Vetter D, Moorthy K, Ibrahim MAH, Christodoulidis G, Räsänen JV, Kauppi J, Söderström H, Manatakis DK, Korkolis DP, Balalis D, Rompu A, Alkhaffaf B, Alasmar M, Arebi M, Piessen G, Nuytens F, Degisors S, Ahmed A, Boddy A, Gandhi S, Fashina O, Van Daele E, Pattyn P, Robb WB, Arumugasamy M, Al Azzawi M, Whooley J, Colak E, Aybar E, Sari AC, Uyanik MS, Ciftci AB, Sayyed R, Ayub B, Murtaza G, Saeed A, Ramesh P, Charalabopoulos A, Liakakos T, Schizas D, Baili E, Kapelouzou A, Valmasoni M, Pierobon ES, Capovilla G, Merigliano S, Silviu C, Rodica B, Florin A, Cristian Gelu R, Petre H, Guevara Castro R, Salcedo AF, Negoi I, Negoita VM, Ciubotaru C, Stoica B, Hostiuc S, Colucci N, Mönig SP, Wassmer CH, Meyer J, Takeda FR, Aissar Sallum RA, Ribeiro U, Cecconello I, Toledo E, Trugeda MS, Fernández MJ, Gil C, Castanedo S, Isik A, Kurnaz E, Videira JF, Peyroteo M, Canotilho R, Weindelmayer J, Giacopuzzi S, De Pasqual CA, Bruna M, Mingol F, Vaque J, Pérez C, Phillips AW, Chmelo J, Brown J, Han LE, Gossage JA, Davies AR, Baker CR, Kelly M, Saad M, Bernardi D, Bonavina L, Asti E, Riva C, Scaramuzzo R, Elhadi M, Abdelkarem Ahmed H, Elhadi A, Elnagar FA, Msherghi AAA, Wills V, Campbell C, Perez Cerdeira M, Whiting S, Merrett N, Das A, Apostolou C, Lorenzo A, Sousa F, Adelino Barbosa J, Devezas V, Barbosa E, Fernandes C, Smith G, Li EY, Bhimani N, Chan P, Kotecha K, Hii MW, Ward SM, Johnson M, Read M, Chong L, Hollands MJ, Allaway M, Richardson A, Johnston E, Chen AZL, Kanhere H, Prasad S, McQuillan P, Surman T, Trochsler MI, Schofield WA, Ahmed SK, Reid JL, Harris MC, Gananadha S, Farrant J, Rodrigues N, Fergusson J, Hindmarsh A, Afzal Z, Safranek P, Sujendran V, Rooney S, Loureiro C, Leturio Fernández S, Díez del Val I, Jaunoo S, Kennedy L, Hussain A, Theodorou D, Triantafyllou T, Theodoropoulos C, Palyvou T, Elhadi M, Abdullah Ben Taher F, Ekheel M, Msherghi AAA. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022. [DOI: https://doi.org/10.1093/bjs/znac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.
Methods
This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.
Results
Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.
Conclusion
The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+ , Maastricht , the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam , Amsterdam , the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group , Almelo , the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham , Birmingham , UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham , Birmingham , UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen , Groningen , the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital , Tilburg , the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust , Newcastle upon Tyne , UK
- Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust , Coventry , UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust , Nottingham , UK
- Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital , Guildford , UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre , Rotterdam , the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
- Department of Surgery, Canisius-Wilhelmina Hospital , Nijmegen , the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre , Nijmegen , the Netherlands
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Ubels S, Verstegen M, Klarenbeek B, Bouwense S, van Berge Henegouwen M, Daams F, van Det MJ, Griffiths EA, Haveman JW, Heisterkamp J, Koshy R, Nieuwenhuijzen G, Polat F, Siersema PD, Singh P, Wijnhoven B, Hannink G, van Workum F, Rosman C. Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score. Br J Surg 2022; 109:864-871. [PMID: 35759409 PMCID: PMC10364775 DOI: 10.1093/bjs/znac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/02/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score. METHODS This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally. RESULTS Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification. CONCLUSION The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.
Collapse
Affiliation(s)
- Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Stefan Bouwense
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mark van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT hospital group, Almelo, the Netherlands
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Jan W Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Renol Koshy
- Department of Surgery, Newcastle upon Tyne Hospital NHS Trust, Newcastle upon Tyne, UK.,Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Fatih Polat
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Pritam Singh
- Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Bas Wijnhoven
- Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands.,Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | |
Collapse
|
11
|
Slaman AE, Eshuis WJ, van Berge Henegouwen MI, Gisbertz SS. Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer. Dis Esophagus 2022; 36:6611911. [PMID: 35724430 PMCID: PMC9817821 DOI: 10.1093/dote/doac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/29/2022] [Indexed: 01/11/2023]
Abstract
Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.
Collapse
Affiliation(s)
- Annelijn E Slaman
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Address correspondence to: Dr S.S. Gisbertz, Department of Surgery, Amsterdam UMC location AMC, University of Amsterdam, Cancer Center Amsterdam, Meibergdreef 9, Amsterdam, AZ 1105, the Netherlands.
| |
Collapse
|
12
|
Lee YK, Chen KC, Huang PM, Kuo SW, Lin MW, Lee JM. Selection of minimally invasive surgical approaches for treating esophageal cancer. Thorac Cancer 2022; 13:2100-2105. [PMID: 35702945 PMCID: PMC9346190 DOI: 10.1111/1759-7714.14533] [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: 01/28/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022] Open
Abstract
Minimally invasive esophagectomy has gradually been accepted as an active treatment option for surgery of esophageal cancer. However, there is no consensus about how to perform the procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown) or chest (Ivor Lewis), VATS, robotic‐assisted or reduced port approaches or various endoscopic abrasion techniques. Further studies to investigate the roles of these novel techniques are required to treat the various patient populations.
Collapse
Affiliation(s)
- Yu-Kwang Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ke-Cheng Chen
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Ming Huang
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuenn-Wen Kuo
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Mong-Wei Lin
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Jang-Ming Lee
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
13
|
Outcome von Patienten mit Anastomoseninsuffizienz nach Ösophagektomie mit verschiedenen Techniken. Zentralbl Chir 2021. [DOI: 10.1055/a-1669-1777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
14
|
Surgical Therapy of Esophageal Adenocarcinoma-Current Standards and Future Perspectives. Cancers (Basel) 2021; 13:cancers13225834. [PMID: 34830988 PMCID: PMC8616112 DOI: 10.3390/cancers13225834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/15/2021] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Simple Summary Subtotal resection of the esophagus with resection of local lymph nodes is the oncological procedure of choice for advanced esophageal cancer. Reconstruction of the intestinal tract is predominantly performed with a gastric tube. Even in specialized centers, this surgical procedure is associated with a high complication but low mortality rate. Therefore, clinical research aims to develop peri- and intra-operative strategies to improve the patient related outcome. Abstract Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.
Collapse
|