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Song P, Li J, Zhang Q, Gao S. Ultrathin endoscopy versus computed tomography in the detection of anastomotic leak in the early period after esophagectomy. Surg Oncol 2019; 32:30-34. [PMID: 31715559 DOI: 10.1016/j.suronc.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 06/03/2019] [Accepted: 10/28/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Anastomotic leak after esophagectomy is a major postoperative complication that leads to significant mortality. The aim of this study was to evaluate the safety of early postoperative ultrathin endoscopy in detecting anastomotic leaks and compare diagnostic performance of ultrathin endoscopy and computed tomography (CT) scan in identifying anastomotic leak after esophagectomy. MATERIALS AND METHODS A prospective trial of 71 patients undergoing esophagectomy was conducted between January 2016 to December 2017. A contrast CT was performed prior to ultrathin endoscopy on postoperative day 5-7. RESULTS All 71 patients underwent ultrathin endoscopy and CT scan safely without complications. Among the 71 patients, transoral ultrathin endoscopy was performed on 51 patients and 20 patients with hypertension and coronary artery disease received transnasal ultrathin endoscopy. Overall, 14 leaks (20%) were identified. Endoscopy not only correctly identified the 2 patients of false-positive evaluations by CT, but also determined 4 leaks that were missed on CT. In addition, ultrathin endoscopy accurately identified 3 potential leaks based on pathological findings of anastomosis: ischemia and much fibrin coverings. One patient with normal postoperative CT findings showed healthy anastomosis but an ulcer on gastric conduit on endoscopy. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of CT were 71.4% and 96.5%. CONCLUSIONS Ultrathin endoscopy after esophagectomy is safe and provides more accurate and reliable identification of anastomotic leak than CT scan. Ultrathin transnasal endoscopy may be a more appropriate diagnostic test to detect anastomosis for patients with hypertension and coronary artery disease.
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Affiliation(s)
- Peng Song
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jiagen Li
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Qingrui Zhang
- Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, National Cancer Center/ National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Early prediction of complex benign anastomotic stricture after esophagectomy using early postoperative endoscopic findings. Surg Endosc 2019; 34:3460-3469. [DOI: 10.1007/s00464-019-07123-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 09/17/2019] [Indexed: 12/18/2022]
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Abstract
Esophageal surgery has become quite specialized, and both dedicated diagnostic and refined surgical techniques are required to deliver state-of-the-art care. The field has evolved to include endoscopic mucosal resection and radiofrequency ablation for early-stage esophageal cancer and minimally invasive esophagectomy with the reconstruction of a gastric conduit for carefully selected patients with esophageal cancer or those with "end-stage" esophagus from benign diseases. Reoperative esophageal surgery after esophagectomy deserves special mention given that these patients, with improved survival, are presenting years after esophagectomy with functional and anatomic disorders that sometimes require surgical intervention. Different diagnostic modalities are essential for assessing patients and planning surgical treatment. Recognizing early and late postoperative complications on imaging may expedite and improve patient outcomes. Finally, endoscopic management of achalasia with peroral endoscopic myotomy and the use of the LINX device for gastroesophageal reflux disease are highly effective and minimally invasive treatments that may reduce complications, costs, and length of hospital stay.
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Endoscopy after esophagectomy: Safety demonstrated in a porcine model. J Thorac Cardiovasc Surg 2017; 154:1152-1158. [DOI: 10.1016/j.jtcvs.2016.12.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/26/2016] [Accepted: 12/17/2016] [Indexed: 12/19/2022]
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Ding JY. Endoscopy after esophagectomy: Doctors' dilemma. J Thorac Cardiovasc Surg 2017. [PMID: 28647098 DOI: 10.1016/j.jtcvs.2017.05.034] [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: 10/19/2022]
Affiliation(s)
- Jian-Yong Ding
- Department of Thoracic Surgery, The Affiliated Zhongshan Hospital of Fudan University, Shanghai, China.
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Nishikawa K, Fujita T, Yuda M, Yamamoto S, Tanaka Y, Matsumoto A, Tanishima Y, Yano F, Mitsumori N, Yanaga K. Early postoperative endoscopy for targeted management of patients at risks of anastomotic complications after esophagectomy. Surgery 2016; 160:1294-1301. [DOI: 10.1016/j.surg.2016.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 06/17/2016] [Accepted: 06/18/2016] [Indexed: 12/11/2022]
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Jia R, Guo R, Liu G, Yuan X, Dong C, Shan T, Yuan X, Zhang Y, Tai EWT, Feng X, Gao S. Evaluation of combined argon plasma coagulation and Savary Bougienage for the relief of anastomotic-stenosis after esophageal squamous cancer surgery. Dig Surg 2015; 31:415-21. [PMID: 25573021 DOI: 10.1159/000369941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 11/16/2014] [Indexed: 12/10/2022]
Abstract
BACKGROUND Several endoscopic dilation techniques have been reported for treatment of anastomotic-stenosis of esophageal cancer, but the high incidence of dysphagia has remained unchanged. The aim of this study was to compare the effect of Argon Plasma Coagulation (APC) combined with Savary Bougienage (SB) compared to APC alone or SB alone for anastomotic-stenosis after radical operation for squamous cell carcinoma of the esophagus. METHODS Patients with anastomotic-stenosis that was diagnosed for the first time following esophageal squamous cell carcinoma resection surgery were randomly assigned to undergo APC combined with SB, APC alone, or SB alone. Primary endpoints were the dysphagia-free survival (DFS defined as the time from first dilatation of effectively relieved dysphagia to dysphagia relapse expressed in days) after 6 months of follow up. RESULTS A total of 90 patients from the Cancer Institute, First Affiliated Hospital of Henan University of Science and Technology were entered into the study (APC group, n = 30, SB group, n = 30, combination group [APC combined with SB], n = 30). Primary endpoints: 6 months after treatment, DFS of combination group (115.63 days; 95% CI, 105.31-125.95) was significantly longer than the APC alone group (39.53 days; 95% CI, 35.95-43.11, p = 0.000) and the SB alone group (16.93 days; 95% CI, 15.01-18.84, p = 0.000). No severe complications occurred within the three treatment groups. CONCLUSIONS APC combined with SB was a safe and well-tolerated method for relieving dysphagia of esophageal squamous cell cancer patients with anastomotic-stenosis. (Registered with randomized controlled trials, ChiCRT, registration number ChiCTR-TRC-13003757.)
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Affiliation(s)
- Ruinuo Jia
- Cancer Institute, First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
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Sokouti M, Golzari SE, Pezeshkian M, Farahnak MR. The Role of Esophagogastric Anastomotic Technique in DecreasingBenign Stricture Formation in the Surgery of Esophageal Carcinoma. J Cardiovasc Thorac Res 2013; 5:11-6. [PMID: 24251003 DOI: 10.5681/jcvtr.2013.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 03/07/2013] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Postoperative stenosis and dysphagia after esophageal carcinoma resection is the major problem. The aim of this study is to compare two types cervical esophagogastric anastomosis in reduction of stricture formation in esophageal cancer surgery. METHODS The subjects of this study were 223 patients undergoing esophageal carcinoma resection during 1998 to 2007. Twenty two patients were excluded from the study because of recurrent malignancy of anastomosis, mortality and losing in follow up period. Two hundred and one patients remained by the end of study were classified into two groups: 98 patients were treated by routinely transverse hand-sewn cervical esophagogastric anastomosis (group 1); and 103 patients were treated by the proposed oblique hand-sewn esophagogastric anastomotic technique (group 2). All the operations were with high abdominal and left cervical incisions (Transhiatal esophagectomy). All patients of both groups were followed up at least 6-month for detection of anastomotic strictures. RESULTS Postoperative dysphagia occurred in 20 patients of group 1 versus 5 patients of group 2. In working up by rigid esophagoscopy, two patients of group 2 and four patients of group 1 had not true strictures. Anastomotic strictures occurred in 16 cases of group 1, versus 3 cases of group 2. Statistical comparative analysis results of two groups about stricture formation were significant (3% versus 16% P= 0.003). CONCLUSION The oblique hand-sewn esophagogastric anastomostic techniques reduce markedly the rate of stricture formation after esophagectomy.
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Affiliation(s)
- Mohsen Sokouti
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
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10
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Stent for nonmalignant leaks, perforations, and ruptures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2011.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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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 HK, Choi YH, Shim JH, Cho YH, Baek MJ, Sohn YS, Kim HJ. Endoscopic evaluation of the quality of the anastomosis after esophagectomy with gastric tube reconstruction. World J Surg 2009; 32:2010-4. [PMID: 18553190 DOI: 10.1007/s00268-008-9664-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. METHODS A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. RESULTS The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. CONCLUSION Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.
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Affiliation(s)
- Hyun Koo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University Guro Hospital, 97 Guro-Dongkil, Guro-Ku, Seoul 152-703, Korea
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Marjanovic G, Schrag HJ, Fischer E, Hopt UT, Fischer A. Endoscopic bougienage of benign anastomotic strictures in patients after esophageal resection: the effect of the extent of stricture on bougienage results. Dis Esophagus 2008; 21:551-7. [PMID: 18430180 DOI: 10.1111/j.1442-2050.2008.00819.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of our retrospective study was to determine the incidence of benign anastomotic strictures (BAS) in patients after esophageal resection and to examine the influence of the extent of BAS on the results of bougienage therapy. From January 2001 to July 2006, 79 patients at risk of BAS development were included in the study. BAS was diagnosed with a median delay of 8 weeks (4-26) postoperative in 23 patients (29%). A median of 4 bougienage sessions (2-20) was needed for success (success rate 100%). The mean follow-up time was 22 months [range 3-47]. There were no late recurrences of BAS. Five patients had an anastomosis diameter <5.5 mm and 14 patients >5.5 mm. There was no difference in median number of bougienage procedures in these subgroups (4.5 [2-9] vs. 4 [2-20]). Patients who presented with BAS earlier than 6 weeks postoperative had more procedures (median 8 [2-20] vs. 4 [2-9]) than those presenting later. Patients in whom first bougienage was possible to only 16 mm diameter needed more procedures than patients in whom first dilation was possible to more than 16 mm (median 5.5 [3-20] vs. 3 [2-9]). In conclusion, both early BAS development and the diameter of bougienage at first endoscopy, but not the extent of stricture, seem to be predictive factors for longer bougienage therapy. In order to influence the BAS formation early, we now routinely examine every patient after esophageal resection endoscopically in the 6th postoperative week.
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Affiliation(s)
- G Marjanovic
- Department of General and Visceral Surgery, University Hospital of Freiburg, Freiburg, Germany.
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Chang AC, Orringer MB. Management of the cervical esophagogastric anastomotic stricture. Semin Thorac Cardiovasc Surg 2007; 19:66-71. [PMID: 17403460 DOI: 10.1053/j.semtcvs.2006.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2006] [Indexed: 12/28/2022]
Abstract
Esophagogastric anastomotic stricture following esophagectomy with a gastric esophageal substitute can be a vexing problem for the patient and treating physician. We describe the clinical practice at a single center with extensive experience in esophageal surgery for management of this complication.
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Affiliation(s)
- Andrew C Chang
- Section of Thoracic Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109, USA.
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Abstract
Endoscopic closure of gastrointestinal perforations, fistulas, and anastomotic dehiscence is technically feasible. Endoluminal closure of the instrumental perforations of the gastrointestinal tract can be accomplished immediately after the recognition of perforation, while avoiding the delay of arranging surgery and the trauma associated with thoracotomy or laparotomy. In addition, endoscopic closure should be considered in patients with anastomotic dehiscence and chronic fistulas as this may avoid the risk associated with reoperation. The outcome of closure depends on the technical expertise in the proper selection and use of various endoluminal closure options. Training of the endoscopists in the use of this novel technology will enhance the quality of care of our patients.
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Affiliation(s)
- G S Raju
- Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of Internal Medicine, 4.106 McCullough Building, 301 University Boulevard, University of Texas Medical Branch, Galveston, TX 77555-0764, USA.
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Endoscopic Management of Anastomotic Esophageal Leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2006. [DOI: 10.1016/j.tgie.2006.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Unfortunately normal gastrointestinal function after an esophagectomy is rare. Most patients will never eat the way they did before their illness. Most patients require smaller more frequent meals. It is common for patients to loose up to 15% of their body weight from the time of diagnosis through the first 6 months postoperatively, but fortunately this trend levels off after 6 months. Dumping syndrome, delayed gastric emptying, reflux, and dysphagia can all contribute to nutritional deficiency and poor quality of life. There is no one surgical modification to eliminate any one of these complications, but several guidelines can help reduce conduit dysfunction. Most patients seem to benefit from a 5-cm-wide greater-curvature gastric tube brought up through the posterior mediastinum. The gastric-esophageal anastomosis should be placed higher than the level of the azygous vein. Drainage procedures seem to be helpful, especially when using the whole stomach as a conduit. Early erythromycin therapy significantly aids in the function of the gastric conduit. Proton-pump inhibitors are important for improvement of postoperative reflux symptoms and to help prevent Barrett's metaplasia in the esophageal remnant. Single-layer hand-sewn or semi-mechanical anastomoses provide greater cross-sectional area and fewer problems with stricture. When benign strictures occur, early endoscopy and dilation with proton-pump inhibition greatly reduces the morbidity. Patients should be instructed to eat six small meals a day and to remain upright for as long as possible after eating. Simple sugars and fluid at mealtime should be avoided until the function of the conduit is established.
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Affiliation(s)
- Jessica Scott Donington
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA 94305, USA.
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Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic complications following esophagectomy. Semin Thorac Cardiovasc Surg 2004; 16:124-32. [PMID: 15197687 DOI: 10.1053/j.semtcvs.2004.03.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since the first reports of esophageal resection for the treatment of various esophageal diseases and disorders, morbidity related to the anastomosis and the chosen replacement conduit have remained a frequent nemesis, a constant concern, and an ongoing area of research and experimentation. In this review of this key component of esophageal resection, an analysis is presented of the most frequent complications related to the anastomosis and conduit: anastomotic leak, conduit necrosis, and conduit stricture. In each case, a review of the current pertinent literature and experience is reported with a view to providing management recommendations to minimize or prevent occurrences, to improve timely diagnosis and to best treat these complications when they arise.
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Affiliation(s)
- Stephen D Cassivi
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Vij R, Triadafilopoulos G, Owens DK, Kunz P, Sanders GD. Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus. Gastrointest Endosc 2004; 60:739-56. [PMID: 15557950 DOI: 10.1016/s0016-5107(04)02167-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities. METHODS By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer. RESULTS Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%. CONCLUSIONS Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.
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Affiliation(s)
- Rohini Vij
- Division of Gastroenterology and Hepatology, Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University School of Medicine, California, USA
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Briel JW, Tamhankar AP, Hagen JA, DeMeester SR, Johansson J, Choustoulakis E, Peters JH, Bremner CG, DeMeester TR. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004; 198:536-41; discussion 541-2. [PMID: 15051003 DOI: 10.1016/j.jamcollsurg.2003.11.026] [Citation(s) in RCA: 213] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2003] [Accepted: 11/28/2003] [Indexed: 12/13/2022]
Abstract
BACKGROUND Reports of esophageal anastomotic complications often involve more gastric than colonic reconstructions and are incomplete because of fragmented followup by physicians unfamiliar with the surgical procedure. STUDY DESIGN Three hundred ninety-three consecutive esophagectomy patients had prevalence and risk factors determined for graft ischemia and anastomotic leak; 363 of these patients followed for more than 1 month (median 15 months) had prevalence and risk factors determined for anastomotic stricture. RESULTS Conduit ischemia occurred in 36 (9.2%) and anastomotic leak in 43 patients (10.9%). Risk factor for ischemia was comorbid conditions requiring therapy (Odds ratio [OR]: 2.2 [95% CI 1.1-4.3]), and for leak were ischemia (OR: 5.5 [95% CI 2.5-12.1]), neoadjuvant therapy (OR: 2.2 [95% CI 1.1-4.5]), and comorbid conditions (OR: 2.1 [95% CI 1.1-3.9]). A stricture developed in 80 patients (22.0%). Risk factors were ischemia (OR: 4.4 [95% CI 2.0-9.6]), anastomotic leak (OR: 3.8 [95% CI 1.9-7.6]), and increasing preoperative weight (p = 0.022). The prevalence of ischemia was similar after gastric (10.4%) versus colonic (7.4%) reconstruction; leak and stricture were more common (14.3% versus 6.1%, p = 0.013, 31.3% versus 8.7%, p < 0.0001, respectively) and strictures were more severe (11.2% versus 2%, p = 0.001) after gastric pull-up. Patients free of ischemia and leak who developed stricture were more likely to have had a gastric pull-up (25% versus 7%, p < 0.0001). Dilatation was effective treatment in 93% of patients. CONCLUSIONS After esophagectomy 10% of patients will develop conduit ischemia or an anastomotic leak and 22% will develop anastomotic stricture. Anastomotic leak and strictures are more common and the strictures are more severe after gastric pull-up compared with colon interposition. Dilatation is a safe and effective treatment.
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Affiliation(s)
- John W Briel
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033, USA
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Bruce J, Krukowski ZH, Al-Khairy G, Russell EM, Park KG. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg 2001; 88:1157-68. [PMID: 11531861 DOI: 10.1046/j.0007-1323.2001.01829.x] [Citation(s) in RCA: 488] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery. METHODS A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted. RESULTS Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak. CONCLUSION There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.
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Affiliation(s)
- J Bruce
- Department of Public Health, University of Aberdeen, Medical School, Polwarth Building, Aberdeen AB25 2ZD, UK.
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