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Chen C, Ding C, He Y, Guo X. High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy. Eur J Cardiothorac Surg 2024; 65:ezae050. [PMID: 38341665 DOI: 10.1093/ejcts/ezae050] [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: 10/10/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy. METHODS A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching. RESULTS After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002). CONCLUSIONS For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.
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Affiliation(s)
- Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital Affiliated with Fudan University, Shanghai, China
| | - Chengzhi Ding
- Department of Thoracic Surgery, Henan Provincial People's Hospital; Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yi He
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xufeng Guo
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Stuart CM, Mott NM, Dyas AR, Byers S, Gergen AK, Mungo B, Stewart CL, McCarter MD, Randhawa SK, David EA, Mitchell JD, Meguid RA. The Effect of Laparoscopic Gastric Ischemic Preconditioning Prior to Esophagectomy on Anastomotic Stricture Rate and Comparison with Esophagectomy-Alone Controls. Ann Surg Oncol 2024:10.1245/s10434-024-15096-0. [PMID: 38413507 DOI: 10.1245/s10434-024-15096-0] [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: 12/20/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied. METHODS This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP. RESULTS Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20). CONCLUSION LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted.
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Affiliation(s)
- Christina M Stuart
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Nicole M Mott
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sara Byers
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K Gergen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benedetto Mungo
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Martin D McCarter
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simran K Randhawa
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A David
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Czerwonko ME, Farjah F, Oelschlager BK. Reducing Conduit Ischemia and Anastomotic Leaks in Transhiatal Esophagectomy: Six Principles. J Gastrointest Surg 2023; 27:2316-2324. [PMID: 37752385 DOI: 10.1007/s11605-023-05835-1] [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: 04/02/2023] [Accepted: 08/14/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Transhiatal esophagectomy (THE) is an accepted approach for distal esophageal (DE) and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection and high anastomotic leak rates. We have used laparoscopic assistance to perform a THE (LapTHE) as our preferred method of resection for GEJ and DE cancers for over 20 years. Our unique approach and experience may provide technical insights and perhaps superior outcomes. METHODS We reviewed all patients who underwent LapTHE for DE and GEJ malignancy over 10 years (2011-2020). We included 6 principles in our approach: (1) minimize dissection trauma using laparoscopy; (2) routine Kocher maneuver; (3) division of lesser sac adhesions exposing the entire gastroepiploic arcade; (4) gaining excess conduit mobility, allowing resection of proximal stomach, and performing the anastomosis with a well perfused stomach; (5) stapled side-to-side anastomosis; and (6) routine feeding jejunostomy and early oral diet. RESULTS One hundred and forty-seven patients were included in the analysis. The median number of lymph nodes procured was 19 (range 5-49). Negative margins were achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days. Overall major complication rate was 24% (17-32%), 90-day mortality was 2.0% (0.4-5.8%), and reoperation was 5.4% (2.4-10%). Three patients (2.0%, 0.4-5.8%) developed anastomotic leaks. Median follow-up was 901 days (range 52-5240). Nine patients (6.1%, 2.8-11%) developed anastomotic strictures. CONCLUSIONS Routine use of LapTHE for DE and GEJ cancers and inclusion of these six operative principles allow for a low rate of anastomotic complications relative to national benchmarks.
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Affiliation(s)
- Matias E Czerwonko
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA.
| | - Farhood Farjah
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - Brant K Oelschlager
- Department of Surgery, Division of General Surgery, University of Washington Medical Center, Seattle, WA, USA
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Soriano C, Wee J. Advances in conduits and anastomotic techniques employed in esophageal cancer resections: A review. J Surg Oncol 2023; 127:228-232. [PMID: 36630091 DOI: 10.1002/jso.27179] [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: 11/18/2022] [Revised: 12/01/2022] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
Esophageal surgery has evolved significantly since the first esophagectomy, with advancements in diagnosis allowing medicine to keep pace with the disease's increasing incidence. Multimodal treatment improves outcomes, but surgical resection remains imperative for local control, with various techniques in existence but none demonstrating clear superiority. More recently, minimally invasive and robotic surgery have further reduced perioperative morbidity. This review discusses techniques for esophageal resection, with attention to the options available for anastomosis and reconstructive conduits.
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Affiliation(s)
- Carlos Soriano
- Department of Thoracic and Cardiac Surgery, The Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jon Wee
- Department of Thoracic and Cardiac Surgery, The Brigham and Women's Hospital, Boston, Massachusetts, USA
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Honório FCC, Tustumi F, Pinheiro Filho JEL, Marques SSB, Glina FPA, Henriques AC, Dias AR, Waisberg J. Esophagojejunostomy after total gastrectomy: A systematic review and meta‐analysis comparing hand‐sewn and stapled anastomosis. J Surg Oncol 2022; 126:161-167. [DOI: 10.1002/jso.26909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 01/27/2023]
Affiliation(s)
| | - Francisco Tustumi
- Department of Surgery Hospital Estadual Mario Covas Santo André Sao Paulo Brazil
- Department of Gastroenterology Faculdade de Medicina da Universidade de São Paulo SP São Paulo 0000‐0003‐2775‐8068 Brazil
| | | | | | | | | | - André Roncon Dias
- Department of Surgery Hospital Estadual Mario Covas Santo André Sao Paulo Brazil
| | - Jaques Waisberg
- Department of Surgery Hospital Estadual Mario Covas Santo André Sao Paulo Brazil
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Kang K, Wang S, Xiong F, Kai J, Wang J, Li B. Esophageal cancer with a double aortic arch: a case report and literature review. J Cardiothorac Surg 2022; 17:33. [PMID: 35277193 PMCID: PMC8915513 DOI: 10.1186/s13019-022-01774-1] [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: 08/19/2021] [Accepted: 02/19/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Double aortic arch (DAA) is an extremely rare vascular malformation, even more so when coexisting with esophageal cancer. METHODS We report a new case of DAA with esophageal cancer recently seen at our Thoracic Tumor Clinic and review cases of DAA coexisting with esophageal cancer reported in the literature of English language from 2010 to 2020. The purposes of our literature review were to explore how to best achieve radical esophagectomy while reducing postoperative complications. The clinical manifestations, diagnostic method, surgical approach, reconstruction route, and the extent of lymphadenectomy of esophageal cancer with DAA were analyzed in detail. RESULTS AND CONCLUSION For such patients, 3D computed tomography is necessary for preoperative diagnosis. The surgical approach should consider factors such as the location of the tumor in the esophagus and whether the tumor is surrounded by DAA, as well as the position of the descending aorta and the requirements for the surgical field for lymphadenectomy. If esophageal reconstruction is required, the retrosternal route is preferred. We recommend that only patients with positive results of intraoperative frozen biopsy of recurrent laryngeal nerve lymph nodes should undergo three-field lymphadenectomy, which may be the best method to achieve radical esophagectomy for middle and lower esophageal cancers with DAA while minimizing postoperative complications.
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Affiliation(s)
- Kai Kang
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China
| | - Sheng Wang
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China
| | - Fei Xiong
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China.
| | - Jindan Kai
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China.
| | - Jianjian Wang
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China
| | - Binfeng Li
- Thoracic Surgery, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, Hubei, 430079, China
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 61:999-1000. [DOI: 10.1093/ejcts/ezac003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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8
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Jiang H, Hua R, Sun Y, Guo X, Liu Z, Su Y, Li B, Yang Y, Zhang H, Li Z. Risk Factors for Anastomotic Complications After Radical McKeown Esophagectomy. Ann Thorac Surg 2021; 112:944-951. [DOI: 10.1016/j.athoracsur.2020.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/26/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023]
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9
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Shang QX, Yang YS, Xu LY, Yang H, Li Y, Li Y, Wu ZY, Fu JH, Yao XD, Xu XE, Wu JY, Fan ZW, Yuan Y, Chen LQ. Prognostic Role of Nodal Skip Metastasis in Thoracic Esophageal Squamous Cell Carcinoma: A Large-Scale Multicenter Study. Ann Surg Oncol 2021; 28:6341-6352. [PMID: 33738720 DOI: 10.1245/s10434-020-09509-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 12/04/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Nodal-skip metastasis (NSM) is found in esophageal squamous cell carcinoma (ESCC), but its prognostic role is controversial. This study aimed to investigate the prognostic value of NSM for thoracic ESCC patients. METHODS Categorization of NSM was according to the N groupings of Japan Esophagus Society (JES) staging system, which is dependent on tumor location. Using the Kaplan-Meier method and Cox-regression analysis, this study retrospectively analyzed the overall survival (OS) for 2325 ESCC patients after radical esophagectomy at three high-volume esophageal cancer centers. Predictive models also were constructed. RESULTS The overall NSM rate was 20% (229/1141): 37.4% in the in upper, 12.9% in the middle, and 22.2% in the lower thoracic ESCC. The patients with NSM always had a better prognosis than those without NSM. Furthermore, NSM was an independent prognostic factor for thoracic ESCC patients (hazard ratio [HR], 0.633; 95% confidence interval [CI], 0.499-0.803; P < 0.001). By integrating the prognostic values of NSM and N stage, the authors proposed the new N staging system. The categories defined by the new N staging system were more homogeneous in terms of OS than those defined by the current N system. Moreover, the new N system was shown to be an independent prognostic factor also for thoracic ESCC patients (HR, 1.607; 95% CI, 1.520-1.700; P < 0.001). Overall, the new N system had slightly better homogeneity, discriminatory ability, and monotonicity of gradient than the current N system. CONCLUSIONS This study emphasized the prognostic power of NSM and developed a modified node-staging system to improve the efficiency of the current International Union for Cancer Control (UICC)/American Joint Committee on Cancer (AJCC) N staging system.
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Affiliation(s)
- Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li-Yan Xu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hong Yang
- Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yin Li
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Li
- Department of Thoracic Surgery, Cancer Hospital Chinese Academy of Medical Sciences, Beijing, China
| | - Zhi-Yong Wu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Hua Fu
- Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiao-Dong Yao
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiu-E Xu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jian-Yi Wu
- Department of Oncology Surgery, Shantou Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi-Wei Fan
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.
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Li XK, Xu Y, Cong ZZ, Luo J, Zhou H, Ji SG, Diao YF, Wu WJ, Qiang Y, Qian JJ, Shen Y. Modified Collard versus end-to-side hand-sewn anastomosis for cervical anastomosis after McKeown esophagectomy. Thorac Cancer 2020; 11:2909-2915. [PMID: 32833352 PMCID: PMC7529547 DOI: 10.1111/1759-7714.13630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background According to previously published studies, esophagectomy with modified Collard anastomosis has been reported to have low incidences of anastomotic leak and stricture. However, the optional anastomotic method after esophagectomy is still controversial. We conducted this study to compare the incidence of postoperative anastomotic stricture formation and dysphagia over three years after an esophagectomy with modified Collard anastomosis (MC) or end‐to‐side (ETS) hand‐sewn anastomosis. Meanwhile, the early postoperative anastomotic leakage and other complications, hospital stay and 30‐ and 90‐day mortality were also evaluated. Methods The clinical data of 905 patients undergoing McKeown esophagectomy were retrospectively reviewed. The rate of postoperative stricture formation after three years was demonstrated by stricture‐free survival which is the primary end‐point of this study. The incidence of dysphagia, first time of onset of stricture and number of dilatations were also recorded during follow‐up. Results The incidence of anastomotic leak tended to be higher in the MC group compared with that in the ETS group (13.0% vs. 8.7%, P = 0.064). The rates of anastomotic stricture in the MC group were significantly less than in the ETS group (P = 0.004). The number of dilatations in the MC group were significantly greater than those in the ETS group (2.34 vs. 2.46, P = 0.011). Conclusions A modified Collard cervical esophagogastric anastomosis was associated with lower rates of anastomotic stricture and dysphagia, compared with ETS hand‐sewn anastomosis. However, the modified Collard anastomosis is accompanied by an increased anastomotic leakage rate.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Hai Zhou
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Sai-Guang Ji
- Department of Thoracic Surgery, Nanjing Second Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jian-Jun Qian
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
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11
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Kim HR. Stricture Following Esophageal Reconstruction. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:222-225. [PMID: 32793456 PMCID: PMC7409887 DOI: 10.5090/kjtcs.2020.53.4.222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/08/2020] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
Abstract
Owing to varying clinical definitions of anastomotic stricture following esophageal reconstruction, its reported incidence rate varies from 10% to 56%. Strictures adversely impact patients’ quality of life. Risk factors, such as the anastomosis method, leakage, ischemia, neoadjuvant chemoradiotherapy, and underlying disease have been mentioned, but conflicting information has been reported. Balloon dilation is regarded as a safe and effective treatment method for patients with benign anastomotic strictures. Reoperations are seldom required. The etiology and management of anastomotic strictures are reviewed in this article.
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Affiliation(s)
- Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, University of Ulsan College of Medicine, Seoul, Korea
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Aquino JLBD, Leandro-Merhi VA, Mendonça JA, Mendes EDT, Clairet CDMAV, Reis LO. COMPARATIVE ANALYSIS OF LATE RESULTS OF CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS BY MANUAL AND MECHANICAL SUTURE IN PATIENTS SUBMITTED TO ESOPHAGEAL MUCOSECTOMY THROUGH ADVANCED MEGAESOPHAGUS. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2019; 32:e1462. [PMID: 31859915 PMCID: PMC6918746 DOI: 10.1590/0102-672020190001e1462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/06/2019] [Indexed: 11/30/2022]
Abstract
Background: Among the anastomoses of the gastrointestinal tract, those of the esophagus
are of special interest due to several anatomical or even general
peculiarities. Aim: Evaluate retrospectively the results comparing mechanical vs. manual suture
at cervical esophagogastric anastomosis in megaesophagus treatment. Methods: Were included 92 patients diagnosed with advanced megaesophagus with clinical
conditions to undergo the surgery. All underwent esophageal mucosectomy,
performing anastomosis of the esophagus stump with the gastric tube at the
cervical level. In order to make this anastomosis, the patients were divided
into two groups: group A (n=53) with circular mechanical suture, lateral
end; group B (n=39) with manual suture in two sides, lateral end. In the
postoperative period, an early evaluation was performed, analyzing local and
systemic complications and late (average 5.6 y) analyzing deglutition. Results: Early evaluation: a) dehiscence of esophagogastric anastomosis n=5 (9.4%) in
group A vs. n=9 (23.0%) in group B (p=0.0418); b) stenosis of
esophagogastric anastomosis n=8 (15.1%) in group A vs. n=15 (38.4%) in group
B (p=0.0105.); c) pulmonary infection n=5 (9.4%) in group A vs. n=3 (7.6%)
in group B (p=1.0000.); d) pleural effusion n=5 (9.4%) in group A vs. n=6
(15.4%) in group B (p<0.518). Late evaluation showed that 86.4-96% of the
patients presented the criteria 4 and 5 from SAEED, expressing effective
swallowing mechanisms without showing significant differences among the
groups. Conclusion: Cervical esophagogastric anastomosis by means of mechanical suture is more
proper than the manual with lower incidence of local complications and, in
the long-term evaluation, regular deglutition was acquired in both suture
techniques in equal quality.
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Affiliation(s)
- José Luis Braga de Aquino
- Graduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, SP, Brazil
| | | | - José Alexandre Mendonça
- Graduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, SP, Brazil
| | | | | | - Leonardo Oliveira Reis
- Graduate Program in Health Sciences, Pontifical Catholic University of Campinas, Campinas, SP, Brazil
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Qiu ML, Lin JB, Li X, Luo RG, Liu B, Lin JW. Current state of esophageal cancer surgery in China: a national database analysis. BMC Cancer 2019; 19:1064. [PMID: 31703631 PMCID: PMC6839071 DOI: 10.1186/s12885-019-6191-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 09/23/2019] [Indexed: 12/17/2022] Open
Abstract
Background The present standard of surgical treatment for esophageal cancer is country dependent. The aim of the present study was to investigate the basic aspects of surgical procedures performed for esophageal cancer, and provide information about the present state of esophageal cancer surgery in China. Methods Data were obtained from a database administered by the Chinese Ministry for Health. A total of 542 participating hospitals were divided into seven geographic areas, and 10% of hospitals in each area were randomly chosen for inclusion. All patients with esophageal cancer, who underwent esophagectomy in these participating hospitals from January 1 to December 31, 2015, were included in the present study. The clinical characteristics, stage of tumor at diagnosis, operation summary and outcomes, and histological findings of patients were extracted and analyzed. Results The present study included 11,791 patients, and the average number of patients per hospital was 218. Squamous cell carcinoma was the most common pathological type, while the mid-esophagus was the most common location. Open procedures were performed in 63.8% of patients, while minimally invasive esophagectomy was performed in 36.2% of patients. Multiple approaches to transthoracic esophagectomy were utilized. Two-field lymphadenectomy was the most frequently performed (64.8%), followed by three-field lymphadenectomy (21.8%). Gastric tubes, thoracic duct ligation and postoperative enteral nutrition were implemented to minimize complications. Conclusion The standard operative procedure and detailed technique for esophageal carcinoma surgery is presently being debated in China. This survey provides some basic information about the present state of esophageal cancer surgery countrywide.
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Affiliation(s)
- Ming-Lian Qiu
- Thoracic Surgery Department, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China
| | - Jian-Bo Lin
- Thoracic Surgery Department, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China
| | - Xu Li
- Thoracic Surgery Department, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China.
| | - Rong-Gang Luo
- Thoracic Surgery Department, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China
| | - Bo Liu
- Department of Medical Record Information, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China
| | - Jing-Wei Lin
- Department of Health, Government of Fujian province, Fuzhou City, 350003, China
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Quantitative Assessment of Blood Flow in the Gastric Conduit With Thermal Imaging for Esophageal Reconstruction. Ann Surg 2018; 271:1087-1094. [DOI: 10.1097/sla.0000000000003169] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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15
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Akiyama Y, Iwaya T, Endo F, Shioi Y, Chiba T, Takahara T, Otsuka K, Nitta H, Koeda K, Mizuno M, Kimura Y, Sasaki A. Stability of cervical esophagogastrostomy via hand-sewn anastomosis after esophagectomy for esophageal cancer. Dis Esophagus 2017; 30:1-7. [PMID: 28375439 DOI: 10.1093/dote/dow007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of the present study is to evaluate the outcome of hand-sewn esophagogastric anastomosis during radical esophagectomy for esophageal cancer. The outcomes of 467 consecutive esophageal cancer patients who underwent cervical esophagogastric anastomosis using interrupted and double-layered sutures after radical esophagectomy via right thoracotomy or thoracoscopic surgery were retrospectively reviewed. Anastomotic leakage, including conduit necrosis, occurred in 11 of 467 patients (2.4%); 7 of 11 (63.6%) cases experienced only minor leakage, whereas the other four (36.4%) patients had major leakage that required surgical or radiologic intervention, including two patients of conduit necrosis. Anastomotic leakages were more frequently observed after retrosternal reconstruction compared with the posterior mediastinal route (P < 0.0001). The median time to healing of leakage was 40 days (range: 14-97 days). Two patients (2/467, 0.4%) died in the hospital due to sepsis caused by the leakage and conduit necrosis. Twelve patients (2.6%) developed anastomotic stenosis, which was improved by dilatation in all patients. Hand-sewn cervical esophagogastric anastomosis is a stable and highly safe method of radical esophagectomy for esophageal cancer.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Y Kimura
- Department of Palliative Medicine, Iwate Medical University School of Medicine, Iwate, Japan
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16
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Giugliano DN, Berger AC, Rosato EL, Palazzo F. Total minimally invasive esophagectomy for esophageal cancer: approaches and outcomes. Langenbecks Arch Surg 2016; 401:747-56. [PMID: 27401326 DOI: 10.1007/s00423-016-1469-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/16/2016] [Indexed: 12/23/2022]
Abstract
Since the introduction of minimally invasive esophagectomy 25 years ago, its use has been reported in several high volume centers. With only one published randomized control trial and five meta-analyses comparing its outcomes to open esophagectomy, available level I evidence is very limited. Available technical approaches include total minimally invasive transthoracic (Ivor Lewis or McKeown) or transhiatal esophagectomy; several hybrid options are available with one portion of the procedure completed via an open approach. A review of available level I evidence with focus on total minimally invasive esophagectomy is presented. The old debate regarding the superiority of a transthoracic versus transhiatal approach to esophagectomy may have been settled by minimally invasive esophagectomy as only few centers are reporting on the latter being utilized. The studies with the highest level of evidence available currently show that minimally invasive techniques via a transthoracic approach are associated with less overall morbidity, fewer pulmonary complications, and shorter hospital stays than open esophagectomy. There appears to be no detrimental effect on oncologic outcomes and possibly an added benefit derived by improved lymph node retrieval. Quality of life improvements may also translate into improved survival, but no conclusive evidence exists to support this claim. Robotic and hybrid techniques have also been implemented, but there currently is no evidence showing that these are superior to other minimally invasive techniques.
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Affiliation(s)
- Danica N Giugliano
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Adam C Berger
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA.
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17
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Ghaderi B, Amini S, Maroofi F, Jalali C, Javanmardi M, Roshani D, Abdi M. Adenosine Deaminase Activity in Chronic Lymphocytic Leukemia and Healthy Subjects. IRANIAN JOURNAL OF CANCER PREVENTION 2016; 9:e5069. [PMID: 27703646 PMCID: PMC5038830 DOI: 10.17795/ijcp-5069] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/30/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND B cell chronic lymphocytic leukemia is one of the most frequent hematologic malignancies in the world. Cellular surface CD markers and serum Beta-2-microglobulin may be used as a prognostic tool in CLL patients. OBJECTIVES In the present study we introduce serum adenosine deaminase as a diagnostic marker in CLL. MATERIALS AND METHODS Blood samples were collected from B-CLL and healthy subjects. White blood cell, red blood cell and platelet count and blood Erythrocyte sedimentation rate was recorded and serum Beta-2-microglobulin, Lactate dehydrogenase and total ADA enzyme activity were determined. RESULTS Serum ADA activity was significantly higher in patients group than that of controls. ADA had a significant and direct correlation with B2M, WBC, LDH and ESR. However, there was not any relation between ADA and the stages of disease. Diagnostic cut-off, sensitivity and specificity of the serum ADA test were 27.97 U/L, 91% and 94%, respectively. CONCLUSIONS A higher ADA activity in patients group and its correlation with CLL markers were seen in our study. High diagnostic value of serum ADA in our study suggests that it might be considered as a useful screening tool among the other markers in CLL.
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Affiliation(s)
- Bayazid Ghaderi
- Department of Internal Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, IR Iran
| | - Sabrieh Amini
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
| | - Farzad Maroofi
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
| | - Chiya Jalali
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
| | - Mitra Javanmardi
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
| | - Daem Roshani
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
| | - Mohammad Abdi
- Department of Internal Medicine, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, IR Iran
- Department of Biology, College of Science, Islamic Azad University, Sanandaj, IR Iran
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18
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Mishra PK, Shah H, Gupta N, Varshney V, Patil NS, Jain A, Saluja SS. Stapled versus hand-sewn cervical esophagogastric anastomosis in patients undergoing esophagectomy: A Retrospective Cohort Study. Ann Med Surg (Lond) 2016; 5:118-24. [PMID: 27222711 PMCID: PMC4866531 DOI: 10.1016/j.amsu.2015.12.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/31/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
Introduction Anastomotic leak is one of the main causes of morbidity following esophageal resection for carcinoma of the esophagus and gastroesophageal junction. We compared hand sewn and stapled cervical esophagogastric anastomotic techniques in terms of postoperative complications. Methods All patients who underwent esophagectomy with cervical esophagogastric anastomosis at a single academic center from 2004 to 2014 were included in the study. Both early and late complications were analyzed. Results 153 patients underwent resection for carcinoma of the esophagus and gastroesophageal junction. Of these 140 patients had esophagectomy with cervical esophagogastric anastomosis. 66 patients underwent a hand sewn anastomosis and 74 patients had a side-to-side stapled anastomosis fashioned. Both groups were comparable with respect to preoperative characteristics. There was no difference in the operative blood loss and T and N stage of the disease. The overall morbidity and mortality was 32.8% and 6.4%, respectively. Overall leak rate was 17%. There was no difference in the leak rates among two groups (12 in the hand-sewn group & 12 in the Stapled stapled group; p = 0.82). The rate of anastomotic stricture was significantly higher for the hand sewn group (16.1% vs 4.3%; p = 0.03) at median follow up of 30 months. Conclusion Both hand sewn and stapled anastomotic techniques are equally effective way of performing a cervical esophagogastric anastomosis. However, patients having anastomotic leak develop anastomotic stricture more often in those having hand-sewn anastomosis compared to stapled anastomosis. We analyzed & compared the outcomes of cervical esophagogastric anastomosis between hand sewn and partial side to side stapled technique. Both hand sewn and stapled techniques are equally effective way of performing a cervical esophagogastric anastomosis. Anastomotic leak results in anastomotic stricture more often with hand-sewn anastomosis than stapled.
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Affiliation(s)
- Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Harsh Shah
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Nikhil Gupta
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Vaibhav Varshney
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Nilesh Sadashiv Patil
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Amit Jain
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Sundeep Singh Saluja
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
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Castro PMV, Ribeiro FPG, Rocha ADF, Mazzurana M, Alvarez GA. Hand-sewn versus stapler esophagogastric anastomosis after esophageal ressection: systematic review and meta-analysis. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2015; 27:216-21. [PMID: 25184776 PMCID: PMC4676383 DOI: 10.1590/s0102-67202014000300014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Accepted: 04/22/2014] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Postoperative anastomotic leak and stricture are dramatic events that cause increased morbidity and mortality, for this reason it's important to evaluate which is the best way to perform the anastomosis. AIM To compare the techniques of manual (hand-sewn) and mechanic (stapler) esophagogastric anastomosis after resection of malignant neoplasm of esophagus, as the occurrence of anastomotic leak, anastomotic stricture, blood loss, cardiac and pulmonary complications, mortality and surgical time. METHODS A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) using the combination of descriptors (anastomosis, surgical) and (esophagectomy) was performed. RESULTS Thirteen randomized trials were included, totaling 1778 patients, 889 in the hand-sewn group and 889 in the stapler group. The stapler reduced bleeding (p <0.03) and operating time (p<0.00001) when compared to hand-sewn after esophageal resection. However, stapler increased the risk of anastomotic stricture (NNH=33), pulmonary complications (NNH=12) and mortality (NNH=33). There was no significant difference in relation to anastomotic leak (p=0.76) and cardiac complications (p=0.96). CONCLUSION After resection of esophageal cancer, the use of stapler shown to reduce blood loss and surgical time, but increased the incidence of anastomotic stricture, pulmonary complications and mortality.
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20
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Indocyanine Green Fluorescence Angiography for Quantitative Evaluation of Gastric Tube Perfusion in Patients Undergoing Esophagectomy. J Am Coll Surg 2015. [PMID: 26206660 DOI: 10.1016/j.jamcollsurg.2015.04.022] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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21
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Allum WH, Bonavina L, Cassivi SD, Cuesta MA, Dong ZM, Felix VN, Figueredo E, Gatenby PAC, Haverkamp L, Ibraev MA, Krasna MJ, Lambert R, Langer R, Lewis MPN, Nason KS, Parry K, Preston SR, Ruurda JP, Schaheen LW, Tatum RP, Turkin IN, van der Horst S, van der Peet DL, van der Sluis PC, van Hillegersberg R, Wormald JCR, Wu PC, Zonderhuis BM. Surgical treatments for esophageal cancers. Ann N Y Acad Sci 2015; 1325:242-68. [PMID: 25266029 DOI: 10.1111/nyas.12533] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.
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Affiliation(s)
- William H Allum
- Division of Surgery and Interventional Science, University College London, London, United Kingdom
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22
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Wang Q, He XR, Shi CH, Tian JH, Jiang L, He SL, Yang KH. Hand-Sewn Versus Stapled Esophagogastric Anastomosis in the Neck: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Indian J Surg 2015; 77:133-40. [PMID: 26139968 PMCID: PMC4484531 DOI: 10.1007/s12262-013-0984-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/24/2013] [Indexed: 01/25/2023] Open
Abstract
The application of cervical esophagogastric anastomoses was of great concern. However, between circular stapler (CS) and hand-sewn (HS) methods with anastomosis in the neck, which one has better postoperative effects still puzzles surgeons. This study aims to systematically evaluate the effectiveness, security, practicality, and applicability of CS compared with the HS method for the esophagogastric anastomosis after esophageal resection. A systematic literature search, as well as other additional resources, was performed which was completed in January 2013. The relevant randomized controlled trials (RCTs) about the surgical technique for esophageal resection were included. Trial data was reviewed and extracted independently by two reviewers. The quality of the included studies was assessed by the recommended standards basing on Cochrane handbook 5.1.0, and the data was analyzed via RevMan 5 software (version 5.2.0). Nine studies with 870 patients were included. The results showed that in comparing HS to CS methods with cervical anastomosis, no significant differences were found in the risk of developing anastomotic leakages (relative risk (RR) = 1.30, 95 % confidence intervals (CI) 0.87-1.92, p = 0.20), as well as the anastomosis stricture (RR = 0.97, 95 % CI 0.47-1.99, p = 0.93), postoperative mortality (RR = 0.83, 95 % CI 0.43-1.58, p = 0.57), blood loss (mean difference (MD) = 39.68; 95 % CI -6.97, 86.33; p = 0.10) and operative time (MD = 18.05; 95 % CI -3.22, 39.33; p = 0.10). However, the results also illustrated that the CS methods with cervical anastomosis might be less time-consuming and have shorter hospital stay and higher costs. Based upon this meta-analysis, there were no differences in the postoperative outcomes between HS and CS techniques. And the ideal technique of cervical esophagogastric anastomosis following esophagectomy remains under controversy.
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Affiliation(s)
- Quan Wang
- />Evidence-Based Medicine Center, School of Basic Medical Science, Lanzhou University, Lanzhou, China
- />The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Xi-Ran He
- />Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital & Institute, Beijing, China
| | - Chun-Hu Shi
- />Evidence-Based Medicine Center, School of Basic Medical Science, Lanzhou University, Lanzhou, China
| | - Jin-Hui Tian
- />Evidence-Based Medicine Center, School of Basic Medical Science, Lanzhou University, Lanzhou, China
| | - Lin Jiang
- />The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Sheng-Liang He
- />The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Ke-Hu Yang
- />Evidence-Based Medicine Center, School of Basic Medical Science, Lanzhou University, Lanzhou, China
- />The First Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
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Gaur P, Lyons C, Malik TM, Kim MP, Blackmon SH. Endoluminal Suturing of an Anastomotic Leak. Ann Thorac Surg 2015; 99:1430-2. [DOI: 10.1016/j.athoracsur.2014.01.089] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/13/2014] [Accepted: 01/14/2014] [Indexed: 10/23/2022]
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Liu QX, Min JX, Deng XF, Dai JG. Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis. World J Gastroenterol 2014; 20:17218-17226. [PMID: 25493038 PMCID: PMC4258594 DOI: 10.3748/wjg.v20.i45.17218] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/24/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.
METHODS: A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electronic database search, hand search, and reference search were used to retrieve all randomized controlled trials that compared hand-sewn and mechanical esophagogastric anastomoses.
RESULTS: This study included 15 randomized controlled trials with a total of 2337 patients. The results revealed that there was no significant difference in the incidence of anastomotic leakage between the methods [relative risk (RR) = 0.77, 95% confidence interval (CI): 0.57-1.04; P = 0.09], but a subgroup analysis yielded a significant difference for the sutured layer and year of publication (Ps < 0.05). There was also no significant difference in the incidence of postoperative mortality (RR = 1.52, 95%CI: 0.97-2.40; P = 0.07). However, the anastomotic strictures rate was increased in the stapler group compared with the hand-sewn group (RR = 1.45, 95%CI: 1.11-1.91; P < 0.01) in the end-to-side subgroup, while the incidence of anastomotic strictures was decreased (RR = 0.34, 95%CI: 0.16-0.76; P < 0.01) in the side-to-side subgroup.
CONCLUSION: The stapler reduces the anastomotic leakage rate compared with hand sewing. End-to-side stapling increases the risk of anastomotic strictures, but side-to-side stapling decreases the risk.
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Knight BC, Rice SJ, Devitt PG, Lord A, Game PA, Thompson SK. Proximal anastomosis using the OrVil circular stapler in major upper gastrointestinal surgery. J Gastrointest Surg 2014; 18:1345-9. [PMID: 24553876 DOI: 10.1007/s11605-014-2478-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/28/2014] [Indexed: 01/31/2023]
Abstract
Anastomoses in major upper gastrointestinal surgery can be technically demanding, especially handsewn anastomoses traversing the diaphragmatic hiatus. The OrVil stapler is a unique circular stapler that allows rapid creation of various upper gastrointestinal anastomoses in technically challenging circumstances, particularly if additional proximal clearance is desirable. Little is reported in the literature regarding its outcomes and complication rates. In this 'How I do It' article, we describe our technique and experience with the OrVil in major upper gastrointestinal surgery.
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Affiliation(s)
- Benjamin C Knight
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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26
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Use of oesophageal flap valvuloplasty and wrapping suturing technique in preventing postoperative complications after oesophagectomy for oesophageal cancer. Eur J Surg Oncol 2014; 40:1355-60. [PMID: 24835379 DOI: 10.1016/j.ejso.2014.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/03/2014] [Accepted: 04/01/2014] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Esophagogastrostomy for oesophageal cancer is the standard surgical treatment. However, traditional techniques have been associated with high frequency of anastomotic complications. The purpose of this study is to clarify the superiority of the oesophageal flap valvuloplasty and wrapping suturing technique in preventing postoperative complications after oesophagectomy for oesophageal cancer. METHODS A prospective, randomised study was performed on 394 patients treated for esophageal cancer between January 2006 and December 2010. The trial registry number is ChiCTR-TRC-13003817 in the Chinese Clinical Trial Registry. RESULTS Anastomotic leaks occurred in four patients in group A (2.1%) and in twelve patients in group B (6.2%) with statistically significant (P = 0.038). During the evaluation of benign stricture seven patients were excluded for hospital mortality. Thirty three patients in group A (6.9%) and 25 patients in group B (13.2%) occurred anastomotic stricture respectively (P = 0.044). Furthermore, reflux oesophagitis and Barrett's epithelium were found in 105 patients (55.3%) of group B, and 54 (28.7%) patients in group A (P < 0.001). CONCLUSION The oesophageal flap valvuloplasty and wrapping suturing technique decreased anastomotic leakage incidence and stricture rate thereby decreasing the morbidity and mortality. This procedure also prevented the occurrence of gastroesophageal reflux after esophagectomy.
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Hemming K, Pinkney T, Futaba K, Pennant M, Morton DG, Lilford RJ. A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures. PLoS One 2013; 8:e75132. [PMID: 24116028 PMCID: PMC3792070 DOI: 10.1371/journal.pone.0075132] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/11/2013] [Indexed: 01/09/2023] Open
Abstract
Objective To systematically evaluate the evidence across surgical specialties as to whether staples or sutures better improve patient and provider level outcomes. Design A systematic review of systematic reviews and panoramic meta-analysis of pooled estimates. Results Eleven systematic reviews, including 13,661 observations, met the inclusion criteria. In orthopaedic surgery sutures were found to be preferable, and for appendicial stump sutures were protective against both surgical site infection and post surgical complications. However, staples were protective against leak in ilecolic anastomosis. For all other surgery types the evidence was inconclusive with wider confidence intervals including the possibly of preferential outcomes for surgical site infection or post surgical complication for either staples or sutures. Whilst reviews showed substantial variation in mean differences in operating time (I2 94%) there was clear evidence of a reduction in average operating time across all surgery types. Few reviews reported on length of stay, but the three reviews that did (I2 0%, including 950 observations) showed a non significant reduction in length of stay, but showed evidence of publication bias (P-value for Egger test 0.05). Conclusions Evidence across surgical specialties indicates that wound closure with staples reduces the mean operating time. Despite including several thousand observations, no clear evidence of superiority emerged for either staples or sutures with respect to surgical site infection, post surgical complications, or length of stay.
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Affiliation(s)
- Karla Hemming
- Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, United Kingdom
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28
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Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg 2013; 257:238-48. [PMID: 23001084 DOI: 10.1097/sla.0b013e31826d4723] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection. BACKGROUND DATA Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined. METHODS A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration. RESULTS Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66-1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95-2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16-2.42), and (3) reduced the length of the operation time (mean: -15.3 minutes, range: -28.1 to -2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration. CONCLUSION The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.
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Price TN, Nichols FC, Harmsen WS, Allen MS, Cassivi SD, Wigle DA, Shen KR, Deschamps C. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg 2013; 95:1154-60; discussion 1160-1. [PMID: 23395626 DOI: 10.1016/j.athoracsur.2012.11.045] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 11/19/2012] [Accepted: 11/19/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) (longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques. METHODS From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed. RESULTS There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p=0.01) and LS anastomoses had the lowest risk of stricture (p=0.006). CONCLUSIONS When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation.
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Affiliation(s)
- Theolyn N Price
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Randomized trial comparing side-to-side stapled and hand-sewn esophagogastric anastomosis in neck. J Gastrointest Surg 2012; 16:1287-95. [PMID: 22528571 DOI: 10.1007/s11605-012-1885-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 04/03/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leak from cervical esophagogastric anastomosis (CEGA) following esophagectomy is associated with morbidity and poor functional outcome. To address this issue, we conducted a randomized trial comparing "hand-sewn" with "stapled side-to-side" CEGA. METHODS Of 174 patients who underwent esophageal resection and CEGA between 2004 and 2010, 87 each were randomized to "hand-sewn" and "stapled side-to-side" CEGA [ www.Clinical Trials.gov: NCT00497549]. The primary outcome measure was anastomotic leak rate. The secondary outcome measures included CEGA construction time and occurrence of anastomotic stricture during follow up. RESULTS The overall anastomotic leak rate was 17.2% (major leaks: 8 %). The leak rate was similar among the two groups (hand-sewn: 14/87, stapled: 16/87; p=0.33). The stapled anastomotic technique was faster (25 ±.5 min vs. 27 ± 5.5 min; p=0.02). The overall operative mortality and morbidity rates were 6.3 % and 40.8 %, respectively. At a median follow up of 12 (6-42) months, anastomotic stricture occurred in 24 (14.7 %) patients and was significantly more common in the "hand-sewn" group (17/82 vs. 7/81; p=0.045). CONCLUSION There were no differences in the leak rates and postoperative outcome between the two CEGA techniques. At follow up, anastomotic strictures occurred less frequently following stapled CEGA. The ideal CEGA technique remains elusive.
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Yin G, Xu Q, Chen S, Bai X, Jiang F, Zhang Q, Xu L, Xu W. Fluoroscopically guided three-tube insertion for the treatment of postoperative gastroesophageal anastomotic leakage. Korean J Radiol 2012; 13:182-8. [PMID: 22438685 PMCID: PMC3303901 DOI: 10.3348/kjr.2012.13.2.182] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 09/22/2011] [Indexed: 01/13/2023] Open
Abstract
Objective To retrospectively evaluate the feasibility and effectiveness of three-tube insertion for the treatment of postoperative gastroesophageal anastomotic leakage (GEAL). Materials and Methods From January 2007 to January 2011, 28 cases of postoperative GEAL after an esophagectomy with intrathoracic esophagogastric anastomotic procedures for esophageal and cardiac carcinoma were treated by the insertion of three tubes under fluoroscopic guidance. The three tubes consisted of a drainage tube through the leak, a nasogastric decompression tube, and a nasojejunum feeding tube. The study population consisted of 28 patients (18 males, 10 females) ranging in their ages from 36 to 72 years (mean: 59 years). We evaluated the feasibility of three-tube insertion to facilitate leakage site closure, and the patients' nutritional benefit by checking their serum albumin levels between pre- and post-enteral feeding via the feeding tube. Results The three tubes were successfully placed under fluoroscopic guidance in all twenty-eight patients (100%). The procedure times for the three tube insertion ranged from 30 to 70 minutes (mean time: 45 minutes). In 27 of 28 patients (96%), leakage site closure after three-tube insertion was achieved, while it was not attained in one patient who received stent implantation as a substitute. All patients showed good tolerance of the three-tube insertion in the nasal cavity. The mean time needed for leakage treatment was 21 ± 3.5 days. The serum albumin level change was significant, increasing from pre-enteral feeding (2.5 ± 0.40 g/dL) to post-enteral feeding (3.7 ± 0.51 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from 7 to 60 months (mean: 28 months). Conclusion Based on the results of this study, the insertion of three tubes under fluoroscopic guidance is safe, and also provides effective relief from postesophagectomy GEAL. Moreover, our findings suggest that three-tube insertion may be used as the primary procedure to treat postoperative GEAL.
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Affiliation(s)
- Guowen Yin
- Department of Interventional Radiology, Cancer Institution of Jiangsu Province, Nanjing, China
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Poghosyan T, Gaujoux S, Chirica M, Munoz-Bongrand N, Sarfati E, Cattan P. Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer. J Visc Surg 2011; 148:e327-35. [PMID: 22019835 DOI: 10.1016/j.jviscsurg.2011.09.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.
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Affiliation(s)
- T Poghosyan
- Service de chirurgie générale, digestive et endocrinienne, hôpital Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
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OrVil™-assisted anastomosis in laparoscopic upper gastrointestinal surgery: friend of the laparoscopic surgeon. Surg Endosc 2011; 26:811-7. [PMID: 21993942 DOI: 10.1007/s00464-011-1957-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Accepted: 08/25/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND An increasing number of minimally invasive oesophagogastrectomies (MIOG) are being performed. However, the complexity of the surgical skills required and the steep learning curve have thus far confined the minimally invasive approach to selected tertiary centres. The oesophagogastric and the oesophagojejunal anastomosis can be challenging and often time-consuming. The recently developed transorally inserted anvil (OrVil(™)) is a technique aimed to simplify the anastomotic procedure. The aim of the study was to evaluate the safety, feasibility, and efficacy of OrVil(™)-assisted anastomosis during laparoscopic surgery in a tertiary upper-GI cancer centre. METHODS From July 2008 to July 2010, 53 consecutive patients underwent MIOG for cancer performed by one surgeon at our institution. Thirty patients underwent laparoscopic Ivor-Lewis oesophagectomy (ILO) and 23 patients underwent laparoscopic gastrectomy. Of the latter group, 13 had a total gastrectomy (TG) and 10 had a subtotal gastrectomy (SG). The gastrointestinal anastomosis was checked with intraoperative endoscopy in all cases. RESULTS There were three in-hospital deaths. Median hospital stay was 14 days for oesophagectomies and 11 days for gastrectomies. There were three anastomotic leaks (5.6%), all in the oesophageal group, successfully treated conservatively. Two patients needed conversion to open surgery (3.7%), 3 patients (5.6%) required re-exploration (for bleeding, infected haematoma, and diaphragmatic hernia), and 18 patients (34%) had respiratory complications (pneumonia, pleural effusions, respiratory failure). Four patients developed anastomotic stricture requiring endoscopic balloon dilatation. The average number of lymph nodes harvested was 22 (range = 11-39) and 26 (range = 5-78) for oesophagectomies and gastrectomies, respectively. CONCLUSIONS The principles of a good anastomosis are good vascular supply, must be tension-free, and the use of a high-quality surgical technique. The use of the OrVil(™) in laparoscopic upper-gastrointestinal surgery is safe and does not have an increased complication rate. It is quicker and easier compared to the traditional purse-string technique and it may help to expand the adoption of MIOG surgery.
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End-to-end versus end-to-side esophagogastrostomy after esophageal cancer resection: a prospective randomized study. Ann Surg 2011; 254:226-33. [PMID: 21725230 DOI: 10.1097/sla.0b013e31822676a9] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To compare single-layered hand-sewn cervical end-to-side (ETS) anastomosis with end-to-end (ETE) anastomosis in a prospective randomized fashion. BACKGROUND The preferred organ used for reconstruction after esophagectomy for cancer is the stomach. Previous studies attempted to define the optimal site of anastomosis and anastomotic techniques. However, anastomotic stricture formation and leakage still remain an important clinical problem. METHODS From May 2005 to September 2007, 128 patients (64 in each group) were randomized between ETE and ETS anastomosis after esophagectomy for cancer with gastric tube reconstruction. Routine contrast swallow studies and endoscopy were performed. Anastomotic stricture within 1 year, requiring dilatation, was the primary endpoint. Secondary endpoints were anastomotic leak rate and mortality. RESULTS Ninety-nine men and 29 women underwent esophagectomy and gastric tube reconstruction. Benign stenosis of the anastomosis, for which dilatation was required, occurred more often in the ETE group (40% vs. ETS 18%, P < 0.01) after 1 year of follow-up. The overall (clinical and radiological) anastomotic leak rate was lower in the ETE group (22% vs. ETS 41%, P = 0.04). Patients with an ETE anastomosis suffered less often from pneumonia; 17% versus ETS 44%, P = 0.002 and had subsequently significantly shorter in-hospital stay (15 days vs. 22 days, P = 0.02). In-hospital mortality did not differ between both groups. CONCLUSION ETS anastomosis is associated with a lower anastomotic stricture rate, compared to ETE anastomosis. However, prevention of stricture formation was at high costs with increased anastomotic leakage and longer in-hospital stay. This study is registered with the Dutch Trial Registry and carries the ID number OND1317772.
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Kim T, Yu W, Chung H. Handsewn versus stapled gastroduodenostomy in patients with gastric cancer: long-term follow-up of a randomized clinical trial. World J Surg 2011; 35:1026-9. [PMID: 21424150 DOI: 10.1007/s00268-011-1038-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The role of circular staplers in gastroduodenostomy during subtotal gastrectomy for gastric cancer has not been defined clearly. METHODS A randomized clinical trial included patients with gastric cancer who underwent subtotal gastrectomy with either stapled (99 patients) or handsewn gastroduodenostomy (98 patients). The anastomosis time and postoperative outcomes in the two groups were compared. RESULTS Performance of stapled gastroduodenostomy was significantly quicker than handsewn gastroduodenostomy. There were no significant differences between the groups in postoperative course, morbidity and mortality rates, survival rate, and recurrence pattern. CONCLUSIONS Stapled gastroduodenostomy with a circular stapler can reduce the anastomosis time with relative safety.
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Affiliation(s)
- Taebong Kim
- Department of Surgery, Daegu Veterans Hospital, 748 Dowon-dong, Dalseo-gu, Daegu, 704-802, Korea.
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Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
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Abstract
The leak rates of different gastrointestinal anastomoses vary considerably but despite this there are common and general concepts for diagnosis and management. Early diagnosis and timely consistent therapy must guide management to prevent harm to the patients. Diagnosis of anastomotic leaks is coupled to clinical signs of the patients and should be initiated promptly. Dependent on the localization of the leak, computed tomography with administration of oral or rectal contrast dye and endoscopy are of high diagnostic value. Both procedures guarantee the option of drainage or stenting through interventional drains or stent placement. Only the implementation of uniform definitions of anastomotic leaks enables surgeons to compare and to improve surgical treatment. Over recent years consensus definitions of postoperative complications including bile leak, pancreatic fistula and colorectal leak have been formulated. These definitions are based on a 3-fold increase of bilirubin (bile leak) or amylase levels (pancreatic fistula) in abdominal drainage fluid compared to serum levels or on an intestinal wall defect with communication of the intraluminal and extraluminal compartments (colorectal anastomosis). The definitions each describe three severity grades A-C. A change of clinical management is required in grade B whereas grade C usually requires a re-operation. Comparable consensus definitions for anastomotic leaks following esophagogastrostomy or esophagojejunostomy or following small bowel anastomosis have not been established. The authors strongly recommend implementation of the presented consensus definitions into clinical and academic daily practice.
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Santo MA, Takeda FR, Sallum RAA. Staplers in digestive surgery: technological advancement in surgeons' own hands. ARQUIVOS DE GASTROENTEROLOGIA 2011; 48:1-2. [PMID: 21537533 DOI: 10.1590/s0004-28032011000100001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Markar SR, Karthikesalingam A, Vyas S, Hashemi M, Winslet M. Hand-sewn versus stapled oesophago-gastric anastomosis: systematic review and meta-analysis. J Gastrointest Surg 2011; 15:876-84. [PMID: 21271360 DOI: 10.1007/s11605-011-1426-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/11/2011] [Indexed: 01/31/2023]
Abstract
OBJECTIVE In this meta-analysis, data from relevant randomised controlled trials has been pooled together to gain a consensus in the comparison of outcome following hand-sewn versus stapled oesophago-gastric (OG) anastomoses. METHODS Medline, Embase, Cochrane, trial registries, conference proceedings and reference lists were searched for randomised controlled trials comparing hand-sewn and stapled OG anastomoses. Primary outcome measures were 30-day mortality, anastomotic leakage and stricture. Secondary outcomes were operative time, cardiac complications and pulmonary complications. RESULTS Nine randomised trials were included in this meta-analysis. There was no significant difference between the groups for 30-day mortality (pooled odds ratio = 1.71; 95% CI = 0.822 to 3.56; P = 0.15) and anastomotic leakage (pooled odds ratio = 1.06; 95% CI = 0.62 to 1.80; P = 0.83). There was a significantly increased rate of anastomotic stricture associated with stapled OG anastomosis (pooled odds ratio = 1.76; 95% CI = 1.09 to 2.86; P = 0.02). DISCUSSION Meta-analysis of randomised controlled trials comparing hand-sewn with stapled OG anastomosis demonstrates that a stapled anastomosis is associated with a shorter operative time but with an increased rate of post-operative anastomotic stricture.
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Affiliation(s)
- Sheraz R Markar
- Department of General Surgery, University College London Hospital, 235 Euston Road, London, UK.
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Abstract
INTRODUCTION Esophageal cancer remains a challenging clinical problem, with overall long-term survivorship consistently at a level of approximately 30%. The incidence of esophageal cancer is increasing worldwide, with the most dramatic increase being seen with respect to esophageal adenocarcinoma. DISCUSSION Pretreatment staging accuracy has improved with the utilization of CT and PET scans, as well as endoscopic ultrasound and endoscopic mucosal resection. In an increasing percentage of patients, endoscopic techniques are being utilized in selected patients for the treatment of high-grade dysplasia in Barrett's and intramucosal cancer. Surgery remains the treatment of choice in all appropriate patients with invasive and locoregional esophageal cancer, although multimodality therapy is now used in most patients with stage II or stage III disease. CONCLUSION Outcomes for esophagectomy have been dominated by concerns regarding high mortality and morbidity; however, mortality rates associated with esophageal resection have dramatically decreased, especially in high-volume specialty centers. This manuscript highlights some of the evolutionary issues associated with staging and endoscopic and surgical treatments of Barrett's and esophageal cancer.
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Hu Z, Yin R, Fan X, Zhang Q, Feng C, Yuan F, Chen J, Jiang F, Li N, Xu L. Treatment of intrathoracic anastomotic leak by nose fistula tube drainage after esophagectomy for cancer. Dis Esophagus 2011; 24:100-7. [PMID: 20819102 DOI: 10.1111/j.1442-2050.2010.01102.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal anastomotic leak remains a lethal complication after esophagectomy for cancer. The aim of the present study is to describe an effective new management, nose fistula tube drainage (NFTD), to treat postoperative intrathoracic leaks. From July 2003 to August 2009, 41 of 4132 patients (0.99%) requiring transthoracic esophagectomy for esophageal and cardiac carcinoma had developed an intrathoracic esophageal anastomotic leak in our hospital as well as another three patients with similar conditions from other hospitals, excluding three patients with gastric necrosis (two) and tracheo-esophageal fistula (one); 23 patients were treated by NFTD, and the remaining 18 patients were treated by conventional chest tube drainage (CCTD). Clinical records of these patients were reviewed and analyzed, including the healing of the leak, mortality, and morbidity. In the NFTD group, 4 patients (17.4%) died, 1 patient (4.3%) required reoperation, and 18 patients (78.3%) healed. However, in the CCTD group, 3 patients (16.7%) died, 1 patient (5.5%) required reoperation, and 14 patients (77.8%) healed. As compared with the CCTD group, patients of the NFTD group had a shorter intensive care course (11.95 vs 33.62 days, P= 0.01) and hospital stay (39.74 vs 77.54 days, P= 0.02). Although this novel NFTD management did not significantly decrease mortality when compared with CCTD, it could gain more effective drainage than CCTD and eventually shorten hospital stay.
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Affiliation(s)
- Z Hu
- Department of Surgery, Medical School of Nanjing University, Nanjing, China
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Abstract
BACKGROUND Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development. METHODS A Pubmed search was performed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses. CONCLUSIONS There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.
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Affiliation(s)
- K Schwameis
- Universitätsklinik für Chirurgie, Medizinische Universität Wien, AKH Wien, Österreich
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Affiliation(s)
- Matthew J Schuchert
- Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
OBJECTIVE To identify independent risk factors for development of benign cervical anastomotic strictures in general and specifically for refractory strictures after esophagectomy in a large series of patients. SUMMARY BACKGROUND DATA Benign strictures develop frequently when a cervical anastomosis is performed after esophagectomy, causing burdensome symptoms and poor quality of life. METHODS From 1996 to 2006, all patients in the Academic Medical Center prospective database undergoing esophagectomy with a cervical anastomosis were included. Stricture was defined as dysphagia requiring endoscopic dilation of the anastomosis. Prediction of stricture was assessed using uni- and multivariate logistic regression analysis. Evaluation of risk factors was also performed for refractory strictures (>2 times the median number of dilations in all patients with stricture) in a similar fashion. RESULTS A total of 607 patients underwent potentially curative esophagectomy, with an in-hospital mortality of 2.5%. During follow-up, 253 (41.7%) patients developed a stricture after a median time of 74 days, requiring a median number of 5 dilations. Cardiovascular disease (P = 0.002), gastric tube compared with colonic interposition (P = 0.03), and anastomotic leakage (P = 0.002) were predictive for development of stricture in multivariate analysis. Development of stricture within 90 days after surgery (P = 0.001), chemoradiotherapy (P = 0.02), and anastomotic leakage (P = 0.03) were independent predictors for refractory strictures requiring over 10 dilations. CONCLUSIONS The benign cervical stricture rate after esophagectomy was relatively high. Cardiovascular disease, gastric tube compared with colonic interposition and postoperative anastomotic leakage were independent predictors for development of benign anastomotic stricture. Anastomotic leakage, chemoradiotherapy and early development of stricture were independently associated with the development of refractory strictures, requiring a higher number of dilations. Prevention of anastomotic stricture formation should be focused on prevention of anastomotic leakage.
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Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 2010; 101:527-33. [PMID: 20401920 DOI: 10.1002/jso.21510] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Anastomotic complications are responsible for significant morbidity and mortality following esophagectomy for cancer. Conflicting reports exist regarding the superiority of hand-sewn versus stapled techniques. This systematic review identified eight randomized clinical trials examining this issue. None of the studies reported significant differences in leak rate or early mortality. One study demonstrated a difference in stricture rates, with fewer for hand-sewn anastomoses. There is insufficient evidence to recommend one anastomotic technique over the other.
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Affiliation(s)
- Roger H Kim
- Division of Surgical Oncology, Department of Surgery, Louisiana State University Health Sciences Center in Shreveport, Feist-Weiller Cancer Center, Shreveport, Louisiana 71130-3932, USA.
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Kranzfelder M, Büchler P, Lange K, Friess H. Treatment options for squamous cell cancer of the esophagus: a systematic review of the literature. J Am Coll Surg 2010; 210:351-9. [PMID: 20193900 DOI: 10.1016/j.jamcollsurg.2009.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 12/08/2009] [Accepted: 12/08/2009] [Indexed: 10/19/2022]
Affiliation(s)
- Michael Kranzfelder
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
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Lagarde SM, Vrouenraets BC, Stassen LP, van Lanschot JJB. Evidence-Based Surgical Treatment of Esophageal Cancer: Overview of High-Quality Studies. Ann Thorac Surg 2010; 89:1319-26. [DOI: 10.1016/j.athoracsur.2009.09.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 09/23/2009] [Accepted: 09/28/2009] [Indexed: 10/19/2022]
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Surgery within multimodal therapy concepts for esophageal squamous cell carcinoma (ESCC): the MRI approach and review of the literature. Adv Med Sci 2010; 54:158-69. [PMID: 20022858 DOI: 10.2478/v10039-009-0044-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Radical esophagectomy with lymphadenectomy remains the only curative therapy for patients with resectable esophageal squamous cell cancer (ESCC), however, combined treatment modalities may improve survival. Based upon more than 1300 consecutive esophageal resections, we present our current multidisciplinary ESCC approach with analysis in the context of recently published RCTs. METHODS Subject to tumor staging, patients with resectable ESCC receive either a neoadjuvant radiochemotherapy (uT3N+) or are referred to primary surgery (uT1/2N0). By Medline searches (1997-2009), all published RCTs containing multimodal ESCC therapy concepts were identified and a systematic review was generated. RESULTS From July 2007 to June 2009, 62 patients with ESCC were treated in our department (40 multimodal treatment concept, 21 primary surgery, 1 definite radiochemotherapy). The R0 resection rate was 78%, in hospital mortality 4.8%. 60% of patients showed a good response to neoadjuvant treatment. 18-month follow-up data revealed absence of tumor recurrence in 7 patients (18%). Our approach is aligned to the current published literature including 12 studies in this review. In line with our institutional experience, neodjuvant radiochemotherapy tends to improve overall survival and increases the likelihood of R0 resection. However, postoperative morbidity and mortality rates are increased. Adjuvant treatment failed to demonstrate any improvement in prognosis. For palliation, concurrent radiochemotherapy is the treatment of choice. CONCLUSION The MRI approach can be aligned to the most recent published data. Surgical resection remains the principle treatment for patients with resectable ESCC. Although multimodal therapy concepts tend to improve survival rates, postoperative morbidity and mortality rates are increased.
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Campos GM, Jablons D, Brown LM, Ramirez RM, Rabl C, Theodore P. A safe and reproducible anastomotic technique for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with the trans-oral anvil. Eur J Cardiothorac Surg 2010; 37:1421-6. [PMID: 20153660 DOI: 10.1016/j.ejcts.2010.01.010] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 12/18/2009] [Accepted: 01/05/2010] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES In expert hands, the intrathoracic oesophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardised 25 mm/4.8mm circular-stapled anastomosis using a trans-orally placed anvil. MATERIALS AND METHODS We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis oesophagectomy at a tertiary referral centre. The oesophago-gastric anastomosis was created using a 25-mm anvil (Orvil, Autosuture, Norwalk, CT, USA) passed trans-orally, in a tilted position, and connected to a 90-cm long polyvinyl chloride delivery tube through an opening in the oesophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (end-to-end anastomosis stapler (EEA XL) 25 mm with 4.8-mm staples, Autosuture, Norwalk, CT, USA) inserted into the gastric conduit. Primary outcomes were leak and stricture rates. RESULTS Thirty-seven patients (mean age 65 years) with distal oesophageal adenocarcinoma (n=29), squamous cell cancer (n=5) or high-grade dysplasia in Barrett's oesophagus (n=3) underwent an Ivor Lewis oesophagectomy between October 2007 and August 2009. The abdominal portion was operated laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle-sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis. DISCUSSION The circular-stapled anastomosis with the trans-oral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis oesophagectomy.
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Affiliation(s)
- Guilherme M Campos
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
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Aquino JLBD, Said M, Brandi LA, Oliveira JMVPD, Maziero D, Merhi VL. Tubo gástrico isoperistáltico de grande curvatura gástrica com sutura mecânica no tratamento cirúrgico do câncer de esôfago irressecável. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2009. [DOI: 10.1590/s0102-67202009000300003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
RACIONAL: Frequentemente, o diagnóstico da neoplasia do esôfago é tardio, restando como escolha terapêutica o tratamento paliativo. A transposição de tubo isoperistáltico da grande curvatura gástrica é um dos métodos de eleição que, porém, quando complicado com a deiscência da anastomose, impede a alimentação natural, comprometendo a qualidade de vida. OBJETIVO: Avaliar as complicações da anastomose esofagogástrica cervical com sutura mecânica com o tubo gástrico, em pacientes com câncer de esôfago irressecável. MÉTODO: Vinte e dois pacientes com câncer de esôfago irressecável foram submetidos à transposição do tubo gástrico isoperistáltico. A anastomose com o coto esofágico foi realizada com sutura mecânica circular em nível cervical. Foram avaliadas complicações sistêmicas (cardiopulmonares) e locais (a deiscência e a estenose da anastomose esofagogástrica cervical). RESULTADOS: Dez pacientes (45,5%) apresentaram de uma a três complicações, dos quais seis (27,2%) com complicações sistêmicas: um (4,5%) embolia pulmonar (evoluindo ao óbito), um infarto do miocárdio e quatro (18,2%) com infecção de pulmão (todos com boa evolução com o tratamento clínico. Cinco pacientes tiveram complicações locais: três (13,6%) com deiscência da anastomose e quatro (18,2%) com estenose da anastomose, sendo que dois deles tiveram deiscência prévia. De 20 pacientes avaliados em período de seis a 18 meses, 16 (80%) apresentaram deglutição satisfatória para sólidos e/ou pastosos. CONCLUSÃO: O tubo gástrico isoperistáltico de grande curvatura, com sutura mecânica, parece oferecer melhora significativa da deglutição com qualidade de vida satisfatória e morbimortalidade aceitável.
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