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Li Y, Zhang D, Zhao D. Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study. World J Surg Oncol 2024; 22:118. [PMID: 38702817 PMCID: PMC11067194 DOI: 10.1186/s12957-024-03400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery. METHODS A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied. RESULTS There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups. CONCLUSIONS Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.
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Affiliation(s)
- Yu Li
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China.
| | - Danjie Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
| | - Danwen Zhao
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
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2
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Nijssen DJ, Joosten JJ, Osterkamp J, van den Elzen RM, de Bruin DM, Svendsen MBS, Dalsgaard MW, Gisbertz SS, Hompes R, Achiam MP, van Berge Henegouwen MI. Quantification of fluorescence angiography for visceral perfusion assessment: measuring agreement between two software algorithms. Surg Endosc 2024; 38:2805-2816. [PMID: 38594365 PMCID: PMC11078848 DOI: 10.1007/s00464-024-10794-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/09/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Indocyanine green fluorescence angiography (ICG-FA) may reduce perfusion-related complications of gastrointestinal anastomosis. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for visceral perfusion assessment between two independently developed quantification software implementations. METHODS This retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analyzed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland-Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations. RESULTS Seventy pre-anastomosis ICG-FA recordings were included in the study. The Bland-Altman analysis indicated a mean relative difference of + 58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < 0.001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively). CONCLUSION This is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.
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Affiliation(s)
- D J Nijssen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J J Joosten
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - J Osterkamp
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - R M van den Elzen
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - D M de Bruin
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
- Amsterdam UMC Location University of Amsterdam, Biomedical Engineering and Physics, Meibergdreef 9, Amsterdam, The Netherlands
| | - M B S Svendsen
- Copenhagen Academy for Medical Education and Simulation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Computer Science, SCIENCE, University of Copenhagen, Copenhagen, Denmark
| | - M W Dalsgaard
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - R Hompes
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, The Netherlands.
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3
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Li C, Song W, Zhang J, Xu Z, Luo Y. A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy. Aging (Albany NY) 2024; 16:7733-7751. [PMID: 38696304 PMCID: PMC11131977 DOI: 10.18632/aging.205780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. METHODS In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. RESULTS Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. CONCLUSIONS This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.
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Affiliation(s)
- Chenglin Li
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Wei Song
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Jialing Zhang
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Zhongneng Xu
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Yonggang Luo
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
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Liu B, Ma H, Liu X, Minervini F, Rao M, Campisi A, Cheng J, Xing W. Effect of sternocleidomastoid flap repair and endoscopic injection of emulsified adipose tissue stromal vascular fraction in the treatment of refractory cervical anastomotic leak contaminating mediastinum. J Thorac Dis 2024; 16:2668-2673. [PMID: 38738227 PMCID: PMC11087614 DOI: 10.21037/jtd-24-442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 04/22/2024] [Indexed: 05/14/2024]
Abstract
Mediastinal infection caused by anastomotic leak is hard to cure, mainly because the poor drainage at the site of mediastinal infection leads to persistent cavity infection, which in turn becomes a refractory mediastinal abscess cavity after minimally invasive esophagectomy (MIE)-McKeown. Herein, we explored sternocleidomastoid (SCM) muscle flaps and emulsified adipose tissue stromal vascular fraction containing adipose-derived stem-cells to address this issue. We studied 10 patients with esophageal cancer who underwent MIE-McKeown + 2-field lymphadenectomy and developed anastomotic and mediastinal leak and received new technology treatment in the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to March 2022. The clinical data and prognosis of the patients were collected and analyzed. A total of 5 patients received this surgery, and no other complications occurred during the perioperative period. Among the 5 patients, 1 patient was partially cured, and 4 patients were completely cured. During the follow-up 3 months postoperatively, all these 5 patients could eat regular food smoothly, and no relapse of leak and mediastinal infection occurred. The new surgical method has achieved good results in the treatment of anastomotic leak. Compared with the traditional thoracotomy, it is a less invasive and feasible surgical approach, which can be used as a supplement to the effective surgical treatment of cervical anastomotic leak contaminating the mediastinum.
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Affiliation(s)
- Baoxing Liu
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Haibo Ma
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Xingyu Liu
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Fabrizio Minervini
- Division of Thoracic Surgery, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Madhuri Rao
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Alessio Campisi
- Department of Thoracic Surgery, University and Hospital Trust-Ospedale Borgo Trento, Verona, Italy
| | - Jiwei Cheng
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
| | - Wenqun Xing
- Department of Thoracic Surgery, the Affiliated Cancer Hospital of Zhengzhou University/Henan Cancer Hospital, Zhengzhou, China
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Seo HW, Jeon YJ, Cho JH, Kim HK, Choi YS, Zo JI, Shim YM. Treatment Patterns and Outcomes of Anastomotic Leakage after Esophagectomy for Esophageal Cancer. J Chest Surg 2024; 57:152-159. [PMID: 38228498 DOI: 10.5090/jcs.23.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/22/2023] [Accepted: 11/21/2023] [Indexed: 01/18/2024] Open
Abstract
Background Anastomotic leakage (AL) following esophagectomy represents a serious complication that often results in prolonged hospitalization and necessitates repeated interventions, including nothing-by-mouth (NPO) restriction, endoscopic vacuum therapy (EVT), or surgical repair. In this study, we evaluated the patterns and outcomes of AL treatment. Methods We retrospectively reviewed the medical records of patients who underwent esophagectomy for esophageal cancer at a single center between 2003 and 2020. Of 3,096 examined cases, 181 patients (5.8%) with AL were included in the study: 114 patients (63%) with cervical anastomosis (CA) and 67 (37%) with intrathoracic anastomosis (TA). Results The incidence of AL was 11.9% in the CA and 3.2% in the TA group (p<0.001). Among patients with CA who developed AL, 87 (76.3%) were managed with NPO, 15 (13.2%) with EVT, and 12 (10.5%) with surgical repair. Over 90% of patients with cervical AL resumed an oral diet by the time of discharge, regardless of treatment method. Among patients with TA and AL, 36 (53.7%) received NPO, 25 (37.7%) underwent EVT, and 6 (9%) required surgery. Of these, 34 patients who were managed with NPO and 19 with EVT could resume an oral diet. However, only 2 patients who underwent surgery resumed an oral diet, and 2 patients required additional EVT. Conclusion Although patients with CA displayed a higher incidence of AL, their rate of successful oral intake exceeded that of those with TA, regardless of treatment method. Among patients exhibiting AL with TA, EVT was more commonly employed than in CA cases, and it appears effective.
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Affiliation(s)
- Hyo Won Seo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hentschel F, Mollenhauer G, Siemssen B, Paasch C, Mantke R, Lüth S. Placing vacuum sponges in esophageal anastomotic leaks - how we do it. Langenbecks Arch Surg 2024; 409:86. [PMID: 38441680 PMCID: PMC10914858 DOI: 10.1007/s00423-024-03272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/24/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.
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Affiliation(s)
- Florian Hentschel
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany.
- Zentrum für Innere Medizin II, Hochschulklinikum Brandenburg der MHB, Hochstr. 29, 14770, Brandenburg an der Havel, Germany.
| | - Götz Mollenhauer
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | | | - Christoph Paasch
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
- Shouldice Hospital, Thornhill, ON, Canada
| | - René Mantke
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
| | - Stefan Lüth
- Brandenburg Medical School (Theodor Fontane), Brandenburg, Germany
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Takahashi M, Toyama H, Takahashi K, Kaiho Y, Ejima Y, Yamauchi M. Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study. BMC Anesthesiol 2024; 24:29. [PMID: 38238681 PMCID: PMC10795296 DOI: 10.1186/s12871-024-02410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.
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Affiliation(s)
- Misaki Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroaki Toyama
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yutaka Ejima
- Department of Surgical Center and Supply, Sterilization, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Xuefen Z, Yuanyuan B, Qin L, Xiaoyang W. Nutritional care in patients undergoing laparoscopic/minimally invasive surgeries for gastrointestinal tumours. Wideochir Inne Tech Maloinwazyjne 2023; 18:625-638. [PMID: 38239578 PMCID: PMC10793145 DOI: 10.5114/wiitm.2023.130468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/24/2023] [Indexed: 01/22/2024] Open
Abstract
The introduction of minimally invasive surgeries for gastrointestinal tumours has been associated with many favourable postoperative outcomes and a reduced impact on nutritional status. The literature review begins by discussing the impact of minimally invasive procedures on the nutritional status of patients with gastrointestinal tumours, followed by indications for enteral nutrition (EN) in this population, including preoperative nutritional support and postoperative nutritional support. The review then examines the evidence that favours the use of EN in this population, including studies demonstrating improved outcomes with preoperative EN and reduced postoperative complications with postoperative EN. It also discusses potential strategies for improving outcomes with EN, such as early initiation of feeding and individualized nutrition plans. Overall, current evidence shows that EN improves outcomes, reduces complications, and enhances the quality of life. However, the optimal timing, composition of EN, and long-term outcomes are still unclear, indicating the need for future investigations.
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Affiliation(s)
- Zhou Xuefen
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Bian Yuanyuan
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Li Qin
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
| | - Wu Xiaoyang
- Department of Gastrointestinal Surgery, Affiliated Kunshan Hospital to Jiangsu University, Suzhou Jiangsu, China
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Hong Z, Cui B, Lu Y, Bai X, Yang N, He X, Wu X, Cheng T, Jin D, Zhao J, Gou Y. Efficacy and Quality of Life with the Modified Versus the Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study. Ann Surg Oncol 2023; 30:8223-8230. [PMID: 37535270 DOI: 10.1245/s10434-023-14033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy and postoperative quality of life for patients with esophageal cancer treated by either the modified or the traditional thoracolaparoscopic McKeown procedure. METHODS This retrospective case-control study included 269 patients with esophageal cancer admitted to three medical centers in China from February 2020 to August 2022. The patients were divided according to surgical method into the layered hand-sewn end-to-end invagination anastomosis group (modified group) and the traditional hand anastomosis group (traditional group). Propensity score-matching (PSM) was used to maintain balance and comparability between the two groups. RESULTS The differences in age and tumor location between the patients in the traditional and modified groups were statistically significant. After PSM, the aforementioned factors were statistically insignificant. After PSM, each group had 101 patients. The modified group showed the greater advantage in terms of postoperative hospital stay (P = 0.036), incidence of anastomotic leak (P = 0.009), and incidence of gastroesophageal reflux (P < 0.001), and the difference was statistically significant. The results of the Quality of Life Questionnaire Core 30 (QLQ-C30) and Quality of Life Questionnaire Oesophageal Cancer Module 18 (QLQ-OES18) scales showed that the modified group also had the advantage over the traditional group in terms of physical function, overall health status, loss of appetite, eating, reflux, obstruction, and loss of appetite scores at the first and third months after surgery. CONCLUSION The modified thoraco-laparoscopic McKeown procedure is a safe and effective surgical approach that can significantly reduce the incidence of postoperative anastomotic leak and gastroesophageal reflux, shorten the postoperative hospital stay, and improve the postoperative quality of life for patients with esophageal cancer.
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Affiliation(s)
- Ziqiang Hong
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Baiqiang Cui
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Yingjie Lu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Xiangdou Bai
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Ning Yang
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoyang He
- Department of Thoracic Surgery, Hebei Province Chest Hospital, Shijiazhuang, China
| | - Xusheng Wu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Cheng
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jing Zhao
- Lanzhou First People's Hospital, Lanzhou, China.
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
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Lee J, Jeon JH, Yoon SH, Shih BCH, Jung W, Hwang Y, Cho S, Kim K, Jheon S. The Optimal Treatment Strategy for Postoperative Anastomotic Leakage After Esophagectomy: a Comparative Analysis Between Endoscopic Vacuum Therapy and Conventional Treatment. J Gastrointest Surg 2023; 27:2899-2906. [PMID: 38040922 DOI: 10.1007/s11605-023-05637-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/18/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage. METHODS A retrospective review of the medical records of patients who underwent esophagectomy with esophagogastrostomy from November 2003 to August 2021 was conducted. Thirty-four patients who developed anastomotic leakage were analyzed according to whether they underwent CT (n = 13) or EVT (n = 21). RESULTS The median time to complete healing was significantly shorter in the EVT group than in the CT group (16 [4-142] days vs. 70 [8-604] days; p = 0.011). The rate of clinical success was higher in the EVT group (90.5%) than in the CT group (66.7%, p = 0.159). A subgroup analysis showed more favorable outcomes for EVT in patients with thoracic leakage, including a higher clinical success rate (p = 0.037), more rapid complete healing (p = 0.004), and shorter hospital stays (p = 0.006). However, the results were not significantly different in patients with cervical leakage. Anastomotic strictures occurred in 3 EVT patients (14.3%) and 5 CT patients (50.0%) (p = 0.044), and the EVT group showed a trend towards improved freedom from anastomotic strictures (p = 0.105). CONCLUSIONS EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.
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Affiliation(s)
- Joonseok Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea.
| | - Seung Hwan Yoon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Beatrice Chia-Hui Shih
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Woohyun Jung
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Yoohwa Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sukki Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
| | - Sanghoon Jheon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-Ro 173 Beon-Gil, Bundang-Gu, Seongnam-Si, Gyeonggi-Do, 13620, Republic of Korea
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11
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Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
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Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
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12
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Pattynama LMD, Pouw RE, Henegouwen MIVB, Daams F, Gisbertz SS, Bergman JJGHM, Eshuis WJ. Endoscopic vacuum therapy for anastomotic leakage after upper gastrointestinal surgery. Endoscopy 2023; 55:1019-1025. [PMID: 37253387 PMCID: PMC10602657 DOI: 10.1055/a-2102-1691] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 05/19/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Recently, endoscopic vacuum therapy (EVT) was introduced as treatment for anastomotic leakage after upper gastrointestinal (GI) surgery. The aim of this study was to describe the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center. METHODS Patients treated with EVT for anastomotic leakage after upper GI surgery were included retrospectively (January 2018-June 2021) and prospectively (June 2021-October 2021). The primary end point was the EVT success rate. Secondary end points included mortality and adverse events. RESULTS 38 patients were included (31 men; mean age 66 years): 27 had undergone an esophagectomy with gastric conduit reconstruction and 11 a total gastrectomy with esophagojejunal anastomosis. EVT was successful in 28 patients (74 %, 95 %CI 57 %-87 %). In 10 patients, EVT failed: deceased owing to radiation pneumonitis (n = 1), EVT-associated complications (n = 2), and defect closure not achieved (n = 7). Mean duration of successful EVT was 33 days, with a median of six EVT-related endoscopies. Median hospital stay was 45 days. CONCLUSION This initial experience with EVT for anastomotic leakage after upper GI surgery demonstrated a success rate of 74 %. EVT is a promising therapy that could prevent further major surgery. More experience with the technique and its indications will likely improve success rates in the future.
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Affiliation(s)
- Lisanne M. D. Pattynama
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Roos E. Pouw
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jacques J. G. H. M. Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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13
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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14
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Latorre-Rodríguez AR, Huang J, Schaheen L, Smith MA, Hashimi S, Bremner RM, Mittal SK. Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience. Langenbecks Arch Surg 2023; 408:397. [PMID: 37831200 DOI: 10.1007/s00423-023-03121-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center. METHODS After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed. RESULTS During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality. CONCLUSION The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.
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Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
| | - Jasmine Huang
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Lara Schaheen
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Samad Hashimi
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Road, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine, Phoenix Regional Campus, Phoenix, AZ, USA.
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15
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Wang W, Xie JB, Yang TB, Huang SJ, Chen BY. Outcomes of early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophageal cancer surgery: a randomized clinical trial. J Cardiothorac Surg 2023; 18:268. [PMID: 37794501 PMCID: PMC10552382 DOI: 10.1186/s13019-023-02370-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND This study aims to investigate the outcomes of patients who received early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy due to esophageal cancer. METHODS A prospective randomized clinical trial was performed between March 2020 and June 2022. Patients who were scheduled for thoracoscopic and laparoscopic esophagectomy due to esophageal cancer were enrolled. Then, these patients were assigned to the control group (traditional postoperative care) and study group (traditional postoperative care with early bronchoscopic sputum aspiration and lavage). The outcomes, which included the length of hospital stay and medical expenses, and postoperative complications, which included pulmonary infection, atelectasis, respiratory dysfunction and anastomotic leakage, were compared between these two groups. RESULTS A total of 106 patients were enrolled for the present study, and 53 patients were assigned for the control and study groups. There were no statistically significant differences in gender, age, and location of the esophageal cancer between the two groups. Furthermore, the length of hospital stay was statistically significantly shorter and the medical expenses were lower during hospitalization in the study group, when compared to the control group (12.3 ± 1.2 vs. 18.8 ± 1.3 days, 5.5 ± 0.9 vs. 7.2 ± 1.2 Chinese Yuan, respectively; all, P < 0.05). Moreover, there were statistically significantly fewer incidences of overall complications in study group, when compared to the control group (20.7% vs.45.2%, P < 0.05). CONCLUSIONS For patients with esophageal cancer, early fiberoptic bronchoscopic sputum aspiration and lavage after thoracoscopic and laparoscopic esophagectomy can shorten the length of hospital stay, and lower the medical expense and incidence of postoperative complications.
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Grants
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
- 2018S3F019 Science and Technology Project of Putian, Fujian, China
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Affiliation(s)
- Wu Wang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China.
| | - Jin-Biao Xie
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Tian-Bao Yang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Shi-Jie Huang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
| | - Bo-Yang Chen
- Department of Cardiothoracic Surgery, Affiliated Hospital of Putian University, Putian, 351100, Fujian, China
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16
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Sun S, Wang Z, Huang C, Li K, Liu X, Fan W, Zhang G, Li X. Different gastric tubes in esophageal reconstruction during esophagectomy. Esophagus 2023; 20:595-604. [PMID: 37490217 PMCID: PMC10495279 DOI: 10.1007/s10388-023-01021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.
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Affiliation(s)
- Shaowu Sun
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Zhulin Wang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Chunyao Huang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Kaiyuan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Xu Liu
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Wenbo Fan
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
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17
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Housman B, Lee DS, Flores R. A narrative review of anastomotic leak in the Ivor Lewis esophagectomy: expected, accepted, but preventable. Transl Cancer Res 2023; 12:2405-2419. [PMID: 37859730 PMCID: PMC10583019 DOI: 10.21037/tcr-23-515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/01/2023] [Indexed: 10/21/2023]
Abstract
Background and Objective Anastomotic leak (AL) remains a common and highly morbid complication after Ivor Lewis Esophagectomy. Leak is associated with increased morbidity, mortality, strictures and even cancer recurrence. Unfortunately, despite advances in surgical technique and perioperative care, the reported frequency of AL has remained largely unchanged. Methods A PubMed search for all English-language articles that discuss Ivor Lewis esophagectomy, AL, risk factors, and outcomes was conducted from 1901 to 2023 prioritizing research from randomized trials that evaluated outcomes from patients undergoing esophagectomy. Key Content and Findings This narrative review will discuss the prevailing literature on AL, risk factors and outcomes with a focus on its relationship to the Ivor Lewis esophagectomy (ILE). In particular, we emphasize that the gastric conduit, as commonly created for most esophagectomy procedures, is inherently vulnerable to ischemia. We will show trends in the literature that have contributed to the high rate of postoperative complications, with a focus on the AL. In addition, we propose that the traditional Ivor Lewis procedure itself is a risk factor for AL. We review a surgical alternative that increases blood supply of the conduit, and is associated with reduced leak, no strictures, and improved surgical outcomes. Conclusions Multiple factors contribute to AL after esophagectomy; including several current surgical practices. We believe that some of them, especially the commonly accepted approach to the gastric conduit, can be modified to optimize tissue perfusion. With further investigation, we may reduce the incidence of short and long-term anastomotic complications and improve surgical outcomes.
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Affiliation(s)
- Brian Housman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA
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18
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Jeon YH, Yun JK, Jeong YH, Gong CS, Lee YS, Kim YH. Surgical outcomes of 500 robot-assisted minimally invasive esophagectomies for esophageal carcinoma. J Thorac Dis 2023; 15:4745-4756. [PMID: 37868885 PMCID: PMC10586984 DOI: 10.21037/jtd-23-637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/04/2023] [Indexed: 10/24/2023]
Abstract
Background In 2003, robot-assisted minimally invasive esophagectomy (RAMIE) was first reported to overcome the technical limitations of minimally invasive esophagectomy. RAMIE requires repeated modifications to set up the robotic system, and sufficient experience is required to gain technical proficiency. This study aimed to identify the learning periods and the outcomes of RAMIE for esophageal carcinoma. Methods We retrospectively reviewed 500 consecutive RAMIE cases for esophageal cancer from December 2008 to February 2021. The learning curve for RAMIE was identified using cumulative sum analysis. Results In a total of 500 RAMIE patients, the Ivor Lewis and McKeown operation were performed in 267 patients (53.4%) and 192 patients (38.4%), respectively. We classified learning periods into the learning phase (first 50 cases), the developing phase (51-150 case), and the stable phase (151-500 case). The rates of vocal cord palsy (42.0% vs. 28.4%) and anastomotic leakage (10.0% vs. 6.4%) were reduced after the learning phase. The mean total operative time (420 vs. 373 min), the mean length of stay (21.6 vs. 16.7 days), and the rate of anastomotic stricture (27.0% vs. 12.4%) were significantly reduced after reaching stable phase. In the stable phase, the proportion of the Ivor Lewis operation (26.0% vs. 67.1%), neoadjuvant chemoradiation therapy (14.0% vs. 25.7%), and bilateral cervical node dissection cases (12.0% vs. 22.0%) were significantly increased. Conclusions Fifty procedures might be needed to achieve early proficiency, and extensive experience of more than 150 procedures is needed for quality stabilization.
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Affiliation(s)
- Yun-Ho Jeon
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Republic of Korea
| | - Jae Kwang Yun
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Ho Jeong
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Chung-Sik Gong
- Division of Stomach Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yoon Se Lee
- Department of Otolaryngology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Division of Thoracic Surgery, Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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19
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Lim ZY, Mohan S, Balasubramaniam S, Ahmed S, Siew CCH, Shelat VG. Indocyanine green dye and its application in gastrointestinal surgery: The future is bright green. World J Gastrointest Surg 2023; 15:1841-1857. [PMID: 37901741 PMCID: PMC10600780 DOI: 10.4240/wjgs.v15.i9.1841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/17/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
Indocyanine green (ICG) is a water-soluble fluorescent dye that is minimally toxic and widely used in gastrointestinal surgery. ICG facilitates anatomical identification of structures (e.g., ureters), assessment of lymph nodes, biliary mapping, organ perfusion and anastomosis assessment, and aids in determining the adequacy of oncological margins. In addition, ICG can be conjugated to artificially created antibodies for tumour markers, such as carcinoembryonic antigen for colorectal, breast, lung, and gastric cancer, prostate-specific antigen for prostate cancer, and cancer antigen 125 for ovarian cancer. Although ICG has shown promising results, the optimization of patient factors, dye factors, equipment, and the method of assessing fluorescence intensity could further enhance its utility. This review summarizes the clinical application of ICG in gastrointestinal surgery and discusses the emergence of novel dyes such as ZW-800 and VM678 that have demonstrated appropriate pharmacokinetic properties and improved target-to-background ratios in animal studies. With the emergence of robotic technology and the increasing reporting of ICG utility, a comprehensive review of clinical application of ICG in gastrointestinal surgery is timely and this review serves that aim.
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Affiliation(s)
- Zavier Yongxuan Lim
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Swetha Mohan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | | | - Saleem Ahmed
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
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20
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Su P, Huang C, Lv H, Zhang Z, Tian Z. Prediction model using risk factors associated with anastomotic leakage after minimally invasive esophagectomy. Pak J Med Sci 2023; 39:1345-1349. [PMID: 37680807 PMCID: PMC10480737 DOI: 10.12669/pjms.39.5.8050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 04/24/2023] [Accepted: 06/26/2023] [Indexed: 09/09/2023] Open
Abstract
Objective To explore the risk factors of anastomotic leakage after minimally invasive esophagectomy (MIE) and to build a prediction model of the probability of postoperative anastomotic leakage. Methods Clinical data of patients undergoing MIE, admitted in the Fourth Hospital of Hebei Medical University from March 2018 to March 2022, were retrospectively selected, and risk factors of anastomotic leakage after MIE were analyzed by univariate and multivariate logistic regression. A prediction nomogram model was established based on the independent risk factors, and its prediction effect was evaluated. Results A total of 308 patients were included. Thirty patients had postoperative anastomotic leakage, with an incidence of 9.74%. Logistic regression analysis showed that age, postoperative delirium, pleural adhesion, postoperative pulmonary complications, high postoperative white blood cell count and low lymphocyte count were risk factors for postoperative anastomotic leakage. A nomograph prediction model was constructed based on these risk factors. The predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The calculated C-index value (Bootstrap method) was 0.9609, indicating that the nomograph prediction model had a good discrimination ability. By drawing the receiver operating characteristic (ROC) curve, we showed that the area under the curve (AUC) of the nomograph prediction model was 0.9609 (95%CI: 0.937-0.985), which indicated a good prediction efficiency of the model. Conclusions The nomograph prediction model based on the independent risk factors of anastomotic leakage after MIE can accurately predict the probability of postoperative anastomotic leakage.
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Affiliation(s)
- Peng Su
- Peng Su, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Chao Huang
- Chao Huang, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Huilai Lv
- Huilai Lv, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Zhen Zhang
- Zhen Zhang, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
| | - Ziqiang Tian
- Ziqiang Tian, Department of Thoracic Fifth, Fourth Hospital of Hebei Medical University, Shijiazhuang 050011, Hebei Province, P.R. China
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21
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Stuart CM, Gergen AK, Byers S, Vigneshwar N, Madsen H, Johnson J, Oase K, Garduno N, Marsh M, Pratap A, Mitchell JD, David EA, Randhawa SK, Meguid RA, McCarter MD, Stewart CL. ASO Author Reflections: Gastric Ischemic Preconditioning Prior to Esophagectomy: Laparoscopic Gastric Ischemic Preconditioning. Ann Surg Oncol 2023; 30:5826-5827. [PMID: 37294387 DOI: 10.1245/s10434-023-13715-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Christina M Stuart
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA.
| | - Anna K Gergen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Sara Byers
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Navin Vigneshwar
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Helen Madsen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Jocelyn Johnson
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Kristen Oase
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Nicole Garduno
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Megan Marsh
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Akshay Pratap
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado School of Medicine, Aurora, USA
| | - John D Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Elizabeth A David
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Simran K Randhawa
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Robert A Meguid
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Martin D McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Camille L Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
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22
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Agarwal L, Dash NR, Pal S, Agarwal A, Madhusudhan KS. Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study. J Gastrointest Cancer 2023; 54:759-767. [PMID: 35965285 DOI: 10.1007/s12029-022-00856-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL. METHODS Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors. RESULTS A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL. CONCLUSION Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.
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Affiliation(s)
- Lokesh Agarwal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Ayushi Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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23
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Çetinkaya Ç, Bilgi Z, Aslan S, Batırel HF. Evolution of a minimally invasive oesophagectomy program - effective complication management is key. Wideochir Inne Tech Maloinwazyjne 2023; 18:481-486. [PMID: 37868276 PMCID: PMC10585459 DOI: 10.5114/wiitm.2023.130326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/19/2023] [Indexed: 10/24/2023] Open
Abstract
Introduction Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures. Aim To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management. Material and methods All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery). Results In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort. Conclusions Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.
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Affiliation(s)
- Çağatay Çetinkaya
- Department of Thoracic Surgery, Uskudar University, School of Medicine, İstanbul, Turkey
| | - Zeynep Bilgi
- Department of Thoracic Surgery, Medeniyet University, School of Medicine, İstanbul, Turkey
| | - Sezer Aslan
- Department of Thoracic Surgery, Sirnak State Hospital, Sirnak, Turkey
| | - Hasan Fevzi Batırel
- Department of Thoracic Surgery, Biruni University, School of Medicine, İstanbul, Turkey
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24
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Scheese D, Alwatari Y, Rustom S, He G, Puig CA, Julliard WA, Shah RD. Chest vs. neck anastomotic leak post esophagectomy for malignancy: rate, predictors, and outcomes. J Thorac Dis 2023; 15:3593-3604. [PMID: 37559658 PMCID: PMC10407498 DOI: 10.21037/jtd-23-37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 05/12/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Anastomotic leak is a major contributor to comorbidity and mortality following esophagectomy. We sought to assess rate and predictors of leak after esophagectomy and compare outcomes of chest versus neck anastomotic leaks. METHODS A retrospective review was performed utilizing National-Surgical-Quality-Improvement-Program data from 2016-2019 for patients undergoing esophagectomy for malignancy. Preoperative characteristics and postoperative outcomes were compared. Patients were classified into two groups: Ivor Lewis esophagectomy [ILE, chest leak (CL)] and transhiatal esophagectomy (THE)/McKeown esophagectomy [ME, neck leak (NL)]. Multivariable regression models were constructed to determine predictors of each type of leak and postoperative complications. RESULTS A total of 1,665 patients underwent esophagectomy with 14.1% reported post-operative leak, 61% of patients underwent ILE while 39% underwent THE or ME. Of patients who underwent ILE, 13.8% had CL with complications including significantly higher length of stay and mortality compared to patients without leak. Independent predictors of CL included: diabetes, hypertension, advanced disease stage, chronic steroid use, and operative time. Ninety-five patients (14.6%) who underwent either THE or ME had NL with similar complications. Diabetes, pre-operative white blood cell (WBC), and operative time were independent predictors for NL. On multivariable regression, CL was associated with greater odds of requiring intervention compared with NL. CONCLUSIONS Post-esophagectomy CL and NL are associated with higher morbidity and mortality. Diabetes and operative time were independent predictors for both leaks while steroid use, hypertension, and advanced disease stage predicted CL. CL was associated with greater odds of needing an intervention, but contrary to conventional wisdom, was not associated with higher morbidity or mortality.
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Affiliation(s)
| | - Yahya Alwatari
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Salem Rustom
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Gene He
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Carlos A. Puig
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Walker A. Julliard
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
| | - Rachit D. Shah
- Virginia Commonwealth University, Section of Thoracic & Foregut Surgery, Department of Surgery, Richmond, VA, USA
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25
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Grantham JP, Hii A, Shenfine J. Combined and intraoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:1485-1500. [PMID: 37555117 PMCID: PMC10405120 DOI: 10.4240/wjgs.v15.i7.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions. AIM To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes. METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness. RESULTS Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness. CONCLUSION Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- Department of General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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26
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Mitchell W, Roser T, Heard J, Logarajah S, Ok J, Jay J, Osman H, Jeyarajah DR. Regional Anesthetic Use in Trans-Hiatal Esophagectomy. Are They Worth Consideration? A Case Series. Local Reg Anesth 2023; 16:99-111. [PMID: 37456592 PMCID: PMC10349603 DOI: 10.2147/lra.s398331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA. Methods This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission. Results The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain. Conclusion The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study's population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy. Trial Registration This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.
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Affiliation(s)
- William Mitchell
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
| | - Thomas Roser
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
| | - Jessica Heard
- Methodist Richardson Medical Center, Richardson, TX, USA
| | | | - John Ok
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - John Jay
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - Houssam Osman
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
| | - D Rohan Jeyarajah
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX, USA
- Methodist Richardson Medical Center, Richardson, TX, USA
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27
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Bartella I, Brunner S, Schiffmann LM, Schiller P, Schmidt T, Fuchs HF, Chon S, Bruns CJ, Schröder W. Clinical utility and applicability of the,Esophagus Complication Consensus Group' (ECCG) classification of anastomotic leakage following hybrid Ivor-Lewis esophagectomy. Langenbecks Arch Surg 2023; 408:258. [PMID: 37391512 DOI: 10.1007/s00423-023-03001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/25/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) remains the leading surgical complication following Ivor-Lewis (IL) esophagectomy. Different treatment options of AL exist but outcome is difficult to compare due to a lack of generally accepted classifications. This retrospective study was conducted to analyze the clinical significance of a recently proposed classification based on the management of AL. PATIENTS AND METHODS A cohort of 954 consecutive patients undergoing hybrid IL esophagectomy (laparoscopy/thoracotomy) was analysed. AL was defined according to the,Esophagus Complication Consensus Group' (ECCG) criteria depending on its treatment: conservative (AL type I), interventional endoscopic (AL type II), and surgical (AL type III). Primary outcome was single or multiple organ failure (Clavien-Dindo IVA/B) associated with AL. RESULTS Overall morbidity was 63.0% and 8.8% (84/954 patients) developed an AL postoperatively. Three patients (3.5%) had an AL type I, 57 patients (67.9%) an AL type II and 24 patients (28.6%) an AL type III. For patients managed surgically, AL was diagnosed significantly earlier (median days: AL type III: 2 vs AL type II: 6, p < 0.001). Associated organ failure (CD IVA/B) was significantly lower for AL type II as compared to AL type III (21.1% versus 45.8%, p < 0.0001). In-hospital mortality was 3.5% for AL type II and 8.3% for AL type III (p = 0.789). There was no difference for re-admission to ICU and overall length of hospital stay. CONCLUSION The proposed ECCG classification is simply to apply and discriminates the post-treatment severity of AL but does not aid to implement a treatment algorithm.
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Affiliation(s)
- Isabel Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Stefanie Brunner
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Petra Schiller
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Seung Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany.
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Medas R, Rodrigues-Pinto E. Technical Review on Endoscopic Treatment Devices for Management of Upper Gastrointestinal Postsurgical Leaks. Gastroenterol Res Pract 2023; 2023:9712555. [PMID: 37342388 PMCID: PMC10279499 DOI: 10.1155/2023/9712555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/20/2022] [Accepted: 11/25/2022] [Indexed: 06/22/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Nowadays, endoscopy is considered the first-line approach for their management, however, there is no definite consensus on the most appropriate therapeutic approach. There is a wide diversity of endoscopic options, from close-cover-divert approaches to active or passive internal drainage approaches. Theoretically, all these options can be used alone or with a multimodality approach, as each of them has different mechanisms of action. The approach to postsurgical leaks should always be tailored to each patient, taking into account the several variables that may influence the final outcome. In this review, we discuss the important developments in endoscopic devices for the treatment of postsurgical leaks. Our discussion specifically focuses on principles and mechanism of action, advantages and disadvantages of each technique, indications, clinical success, and adverse events. An algorithm for endoscopic approach is proposed.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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29
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Grantham JP, Hii A, Shenfine J. Preoperative risk modelling for oesophagectomy: A systematic review. World J Gastrointest Surg 2023; 15:450-470. [PMID: 37032794 PMCID: PMC10080602 DOI: 10.4240/wjgs.v15.i3.450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/09/2023] [Accepted: 02/23/2023] [Indexed: 03/27/2023] Open
Abstract
BACKGROUND Oesophageal cancer is a frequently observed and lethal malignancy worldwide. Surgical resection remains a realistic option for curative intent in the early stages of the disease. However, the decision to undertake oesophagectomy is significant as it exposes the patient to a substantial risk of morbidity and mortality. Therefore, appropriate patient selection, counselling and resource allocation is important. Many tools have been developed to aid surgeons in appropriate decision-making.
AIM To examine all multivariate risk models that use preoperative and intraoperative information and establish which have the most clinical utility.
METHODS A systematic review of the MEDLINE, EMBASE and Cochrane databases was conducted from 2000-2020. The search terms applied were ((Oesophagectomy) AND (Risk OR predict OR model OR score) AND (Outcomes OR complications OR morbidity OR mortality OR length of stay OR anastomotic leak)). The applied inclusion criteria were articles assessing multivariate based tools using exclusively preoperatively available data to predict perioperative patient outcomes following oesophagectomy. The exclusion criteria were publications that described models requiring intra-operative or post-operative data and articles appraising only univariate predictors such as American Society of Anesthesiologists score, cardiopulmonary fitness or pre-operative sarcopenia. Articles that exclusively assessed distant outcomes such as long-term survival were excluded as were publications using cohorts mixed with other surgical procedures. The articles generated from each search were collated, processed and then reported in accordance with PRISMA guidelines. All risk models were appraised for clinical credibility, methodological quality, performance, validation, and clinical effectiveness.
RESULTS The initial search of composite databases yielded 8715 articles which reduced to 5827 following the deduplication process. After title and abstract screening, 197 potentially relevant texts were retrieved for detailed review. Twenty-seven published studies were ultimately included which examined twenty-one multivariate risk models utilising exclusively preoperative data. Most models examined were clinically credible and were constructed with sound methodological quality, but model performance was often insufficient to prognosticate patient outcomes. Three risk models were identified as being promising in predicting perioperative mortality, including the National Quality Improvement Project surgical risk calculator, revised STS score and the Takeuchi model. Two studies predicted perioperative major morbidity, including the predicting postoperative complications score and prognostic nutritional index-multivariate models. Many of these models require external validation and demonstration of clinical effectiveness.
CONCLUSION Whilst there are several promising models in predicting perioperative oesophagectomy outcomes, more research is needed to confirm their validity and demonstrate improved clinical outcomes with the adoption of these models.
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Affiliation(s)
- James Paul Grantham
- Department of General Surgery, Modbury Hospital, Adelaide 5092, South Australia, Australia
| | - Amanda Hii
- Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
| | - Jonathan Shenfine
- General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
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30
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He Z, Liu H, Zhou L, Li Q, Wang L, Zhang D, Xu H, Xu Z. Risk factors and conservative therapy outcomes of anastomotic leakage after gastrectomy: Experience of 3,926 patients from a single gastric surgical unit. Front Oncol 2023; 13:1163463. [PMID: 37007118 PMCID: PMC10050334 DOI: 10.3389/fonc.2023.1163463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 02/28/2023] [Indexed: 03/17/2023] Open
Abstract
BackgroundAnastomotic leakage (AL) after gastrectomy is one of the severest postoperative complications and is related to increasing mortality. In addition, no consensus guidelines about strategies of AL treatment have been established. This large cohort study aimed to inspect the risk factors and efficacy of the conservative treatment for AL in patients with gastric cancer.MethodsWe reviewed the clinicopathological data of 3,926 gastric cancer patients undergoing gastrectomy between 2014 and 2021. Results contained the rate, risk factors, and conservative therapy outcomes of AL.ResultsIn total, 80 patients (2.03%, 80/3,926) were diagnosed with AL, and esophagojejunostomy was the most frequent AL site (73.8%, 59/80). Among them, one patient (2.5%, 1/80) died. Multivariate analysis indicated that low albumin concentration (P = 0.001), presence of diabetes (P = 0.025), laparoscopic method (P < 0.001), total gastrectomy (P = 0.003), and proximal gastrectomy (P = 0.002) were predicting factors for AL. The closure rate for the conservative treatment of AL in the first month after AL diagnosis was 83.54% (66/79), and the median time from leakage diagnosis to the closure of leakage was 17 days (interquartile range 11–26 days). Low level of plasma albumin (P = 0.004) was associated with late leakage closures. In terms of 5-year overall survival, no significant difference was observed between patients with and without AL.ConclusionThe incidence of AL after gastrectomy is associated with low albumin concentration, diabetes, the laparoscopic method, and extent of resection. The conservative treatment is relatively safe and effective for the AL management in patients after gastric cancer surgery.
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Affiliation(s)
- Zhongyuan He
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongda Liu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ling Zhou
- Department of Anesthesiology and Perioperative Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Qingya Li
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Linjun Wang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Diancai Zhang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Xu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zekuan Xu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Zekuan Xu,
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Shafiq A, Azad J, Batool SEZ, Butt UI, Umar M, Syed A, Khattak S. Post-esophagectomy Anastomosis Leak: A 10-Year Experience at a Specialized Center for Cancer Surgeries in Pakistan. Cureus 2023; 15:e34777. [PMID: 36909101 PMCID: PMC10005833 DOI: 10.7759/cureus.34777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/10/2023] Open
Abstract
Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.
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Affiliation(s)
- Ahsan Shafiq
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Junaid Azad
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Shan-E-Zahra Batool
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | | | | | - Aamir Syed
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
| | - Shahid Khattak
- Surgical Oncology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, PAK
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Feenstra ML, Alkemade L, van den Bergh JE, Gisbertz SS, Daams F, van Berge Henegouwen MI, Eshuis WJ. Contrast-Enhanced Radiologic Evaluation of Gastric Conduit Emptying After Esophagectomy. Ann Surg Oncol 2023; 30:563-570. [PMID: 36210402 PMCID: PMC9726779 DOI: 10.1245/s10434-022-12596-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nasogastric tube (NGT) insertion is the standard of care in many hospitals after esophagectomy for gastric conduit decompression. An upper gastrointestinal contrast passage evaluation (UGI-CE) is a diagnostic test to evaluate passage through the gastric conduit. The authors hypothesized that introducing routine UGI-CE after esophagectomy results in earlier removal of the NGT and resumption of oral intake. METHODS This retrospective study evaluated two consecutive series of patients undergoing esophagectomy, one before (control group) and one after the introduction of a routine UGI-CE on postoperative day (POD) 3 or 4 (UGI-CE group). If contrast passage was found on the UGI-CE, the NGT was capped and removed. In the control group, the NGT was routinely capped and removed on day 5 after surgery. The primary outcome was the POD on which oral diet was initiated. The secondary outcomes were the day of NGT removal, NGT reinsertions, postoperative complications, and length of hospital stay. RESULTS Each cohort included 74 patients. In the UGI-CE group, the contrast test was performed on median POD 3.5 (IQR, 3-4). The median day of NGT removal, initiation of clear liquids, and full liquid and solid intake was 1 to 2 days earlier in the UGI-CE group than in the control group (i.e. POD 4, 4, 5, and 6 vs. POD 5, 5, 6.5, and 8; all p < 0.001). The study found no significant differences in NGT reinsertions, pneumonias, anastomotic leakages, or hospital stay. CONCLUSION The routine use of a UGI-CE after esophagectomy led to earlier removal of the NGT and earlier resumption of oral intake.
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Affiliation(s)
- Minke L. Feenstra
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Lily Alkemade
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke E. van den Bergh
- Radiology and Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S. Gisbertz
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Freek Daams
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands ,Department of Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mark I. van Berge Henegouwen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Wietse J. Eshuis
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands ,Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands ,Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome. Cancers (Basel) 2022; 14:cancers14225556. [PMID: 36428649 PMCID: PMC9688292 DOI: 10.3390/cancers14225556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT). METHODS In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies. RESULTS In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches. CONCLUSIONS Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.
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Wagner M, Brandenburg JM, Bodenstedt S, Schulze A, Jenke AC, Stern A, Daum MTJ, Mündermann L, Kolbinger FR, Bhasker N, Schneider G, Krause-Jüttler G, Alwanni H, Fritz-Kebede F, Burgert O, Wilhelm D, Fallert J, Nickel F, Maier-Hein L, Dugas M, Distler M, Weitz J, Müller-Stich BP, Speidel S. Surgomics: personalized prediction of morbidity, mortality and long-term outcome in surgery using machine learning on multimodal data. Surg Endosc 2022; 36:8568-8591. [PMID: 36171451 PMCID: PMC9613751 DOI: 10.1007/s00464-022-09611-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/03/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Personalized medicine requires the integration and analysis of vast amounts of patient data to realize individualized care. With Surgomics, we aim to facilitate personalized therapy recommendations in surgery by integration of intraoperative surgical data and their analysis with machine learning methods to leverage the potential of this data in analogy to Radiomics and Genomics. METHODS We defined Surgomics as the entirety of surgomic features that are process characteristics of a surgical procedure automatically derived from multimodal intraoperative data to quantify processes in the operating room. In a multidisciplinary team we discussed potential data sources like endoscopic videos, vital sign monitoring, medical devices and instruments and respective surgomic features. Subsequently, an online questionnaire was sent to experts from surgery and (computer) science at multiple centers for rating the features' clinical relevance and technical feasibility. RESULTS In total, 52 surgomic features were identified and assigned to eight feature categories. Based on the expert survey (n = 66 participants) the feature category with the highest clinical relevance as rated by surgeons was "surgical skill and quality of performance" for morbidity and mortality (9.0 ± 1.3 on a numerical rating scale from 1 to 10) as well as for long-term (oncological) outcome (8.2 ± 1.8). The feature category with the highest feasibility to be automatically extracted as rated by (computer) scientists was "Instrument" (8.5 ± 1.7). Among the surgomic features ranked as most relevant in their respective category were "intraoperative adverse events", "action performed with instruments", "vital sign monitoring", and "difficulty of surgery". CONCLUSION Surgomics is a promising concept for the analysis of intraoperative data. Surgomics may be used together with preoperative features from clinical data and Radiomics to predict postoperative morbidity, mortality and long-term outcome, as well as to provide tailored feedback for surgeons.
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Affiliation(s)
- Martin Wagner
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- National Center for Tumor Diseases (NCT), Heidelberg, Germany.
| | - Johanna M Brandenburg
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Sebastian Bodenstedt
- Department of Translational Surgical Oncology, National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- Cluster of Excellence "Centre for Tactile Internet with Human-in-the-Loop" (CeTI), Technische Universität Dresden, 01062, Dresden, Germany
| | - André Schulze
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Alexander C Jenke
- Department of Translational Surgical Oncology, National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Antonia Stern
- Corporate Research and Technology, Karl Storz SE & Co KG, Tuttlingen, Germany
| | - Marie T J Daum
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Lars Mündermann
- Corporate Research and Technology, Karl Storz SE & Co KG, Tuttlingen, Germany
| | - Fiona R Kolbinger
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Else Kröner Fresenius Center for Digital Health, Technische Universität Dresden, Dresden, Germany
| | - Nithya Bhasker
- Department of Translational Surgical Oncology, National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
| | - Gerd Schneider
- Institute of Medical Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Grit Krause-Jüttler
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Hisham Alwanni
- Corporate Research and Technology, Karl Storz SE & Co KG, Tuttlingen, Germany
| | - Fleur Fritz-Kebede
- Institute of Medical Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Oliver Burgert
- Research Group Computer Assisted Medicine (CaMed), Reutlingen University, Reutlingen, Germany
| | - Dirk Wilhelm
- Department of Surgery, Faculty of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johannes Fallert
- Corporate Research and Technology, Karl Storz SE & Co KG, Tuttlingen, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Lena Maier-Hein
- Department of Intelligent Medical Systems (IMSY), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Dugas
- Institute of Medical Informatics, Heidelberg University Hospital, Heidelberg, Germany
| | - Marius Distler
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral-, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Helmholtz-Zentrum Dresden - Rossendorf (HZDR), Dresden, Germany
| | - Beat-Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Stefanie Speidel
- Department of Translational Surgical Oncology, National Center for Tumor Diseases (NCT/UCC), Dresden, Germany
- Cluster of Excellence "Centre for Tactile Internet with Human-in-the-Loop" (CeTI), Technische Universität Dresden, 01062, Dresden, Germany
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35
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A novel nomogram predicting the risk of postoperative pneumonia for esophageal cancer patients after minimally invasive esophagectomy. Surg Endosc 2022; 36:8144-8153. [PMID: 35441868 DOI: 10.1007/s00464-022-09249-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/07/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Pneumonia is a common complication after minimally invasive esophagectomy (MIE), which prolongs hospital stay, adding to the cost and increasing the risk to patients' lives. This study aimed to identify risk factors and establish a predictive nomogram for postoperative pneumonia (PP). METHODS This case control study included 609 patients with esophageal cancer who underwent MIE between March 2015 and August 2019 in Cancer Hospital, Chinese Academy of Medical Sciences. We randomly divided the data into training and validation sets in the ratio of 7:3 and performed univariate and multivariate logistic regression analyses to acquire independent risk factors of the training set. We constructed a nomogram based on the independent risk factors. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA) plots were used to evaluate the discrimination of the nomogram. Validation set was applied to confirm the predictive value of the nomogram. RESULTS In the univariate analysis, age, gender, abdominal procedure method, thoracic operative time, duration of chest tube placement, anastomotic leakage, and recurrent laryngeal nerve palsy were found to be correlated with the incidence of PP. In multivariate analysis, all variables except thoracic operative time were found to be independent risk factors for PP. A nomogram was constructed based on these independent risk factors. The C-index of the training and validation sets was 0.769 and 0.734, respectively, and the areas under the curve (AUC) of ROC curves of the training and validation sets were 0.769 and 0.686, respectively. The calibration plots and DCA plots of the training and validation sets showed the accuracy and predictive value of the nomogram. CONCLUSION The nomogram could accurately identify the risk factors for PP. We could predict the occurrence of PP based on this nomogram and take corresponding measures to reduce the incidence of PP.
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36
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Kim JH, Shin JH, Oh JS. Role of interventional radiology in the management of postoperative gastrointestinal leakage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220039] [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: 11/06/2022] Open
Affiliation(s)
- Ji Hoon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Suk Oh
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Xing H, Hu M, Wang Z, Jiang Y. Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis. Front Surg 2022; 9:950108. [PMID: 36386496 PMCID: PMC9649905 DOI: 10.3389/fsurg.2022.950108] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/26/2022] [Indexed: 09/05/2023] Open
Abstract
OBJECTIVE The objective of this article is to assess the rate of anastomotic leak and other perioperative outcomes in patients undergoing esophagectomy with either thoracic or cervical anastomosis. METHODS This meta-analysis was conducted by searching relevant literature studies in Web of Science, Cochrane Library, PubMed, and Embase databases. Articles that included patients undergoing esophagectomy and compared perioperative outcomes of McKeown with Ivor Lewis procedures were included. The primary outcome parameter was anastomotic leak, and secondary outcome parameters were grade ≥2 anastomotic leak, chylothorax, recurrent laryngeal nerve injury, hospital length of stay, intensive care unit (ICU) length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined. RESULTS A total of eight studies, with 3,291 patients (1,857 Ivor Lewis procedure and 1,434 McKeown procedure) were eligible for analysis. Meta-analysis showed that Ivor Lewis procedure was associated with lower rate of anastomosis leak of all grades [risk ratio (RR), 0.67; 95% confidence interval (CI), 0.55-0.82; P = 0.0001], lower rate of recurrent laryngeal nerve injury (RR, 0.14; 95% CI, 0.08-0.25), and shorter length of hospital stay (weighted mean difference, 0.13; 95% CI, 0.04-0.22). Grade ≥2 anastomotic leak, chylothorax, ICU length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined were similar between the two groups. CONCLUSIONS Although all grades of anastomotic leak and recurrent laryngeal nerve injury are higher in the McKeown procedure, this meta-analysis supports similar short-term outcomes and oncological efficacy between Ivor Lewis and McKeown esophagectomy.
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Affiliation(s)
- Huajie Xing
- Department of Thoracic Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Mengyu Hu
- Department of Radiation Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Zhiqiang Wang
- Department of Thoracic Oncology, Chongqing University Cancer Hospital, Chongqing, China
| | - Yuequan Jiang
- Department of Thoracic Oncology, Chongqing University Cancer Hospital, Chongqing, China
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Jin Z, Zhang J, Chen D, Wu S, Xue P, Zhu K, Xu C, Zhu C, Zhang B. Neoadjuvant chemoradiotherapy, chemotherapy, and radiotherapy do not significantly increase the incidence of anastomotic leakage after esophageal cancer surgery: a meta-analysis. Dis Esophagus 2022; 35:6482985. [PMID: 34952537 DOI: 10.1093/dote/doab089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/06/2021] [Indexed: 12/24/2022]
Abstract
This study investigated whether neoadjuvant therapies, such as neoadjuvant chemoradiotherapy (NCRT), neoadjuvant chemotherapy (NCT), and neoadjuvant radiotherapy (NRT), would affect the incidence of anastomotic leakage (AL) after esophageal cancer surgery. Published randomized controlled trials were reviewed, and the incidence of AL after esophageal cancer was statistically analyzed in each study. Meta-analysis was performed using Revman and Stata software. A total of 17 randomized controlled trials with 2874 patients were reviewed showing that, in general, preoperative neoadjuvant therapies were not significant risk factors for AL after esophageal cancer surgery (relative risk [RR] = 0.82, 95% CI = 0.64-1.04). NCRT and NRT did not significantly increase the risk of postoperative AL in patients with esophageal cancer (RR = 0.81, 95% CI = 0.63-1.05; RR = 0.64, 95% CI = 0.14-2.97, respectively). Moreover, NCT has no significant correlation with the occurrence of AL (RR = 1.01, 95% CI = 0.57-1.80). NCRT, NCT, and NRT do not significantly increase the incidence of gastroesophageal AL after esophageal cancer surgery.
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Affiliation(s)
- Zixian Jin
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Jian Zhang
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Dong Chen
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Sikai Wu
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Penglai Xue
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Kanghao Zhu
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, China
| | - Congcong Xu
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Chengchu Zhu
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Bo Zhang
- Key Laboratory of Minimally Invasive Techniques & Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China.,Department of Thoracic Surgery, Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
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Hung PC, Chen HY, Tu YK, Kao YS. A Comparison of Different Types of Esophageal Reconstructions: A Systematic Review and Network Meta-Analysis. J Clin Med 2022; 11:jcm11175025. [PMID: 36078955 PMCID: PMC9457433 DOI: 10.3390/jcm11175025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/26/2022] Open
Abstract
Background: A total esophagectomy with gastric tube reconstruction is the mainstream procedure for esophageal cancer. Colon interposition and free jejunal flap for esophageal reconstruction are the alternative choices when the gastric tube is not available. However, to date, a solution for the high anastomosis leakage rates among these three types of conduits has not been reported. The aim of this network meta-analysis was to investigate the rate of anastomotic leakage (AL) among the three procedures to determine the best esophageal substitute or the future direction for improving the conventional gastric pull-up (GPU). Methods: We searched PubMed, Cochrane, and Embase databases. We included esophageal cancer patients receiving esophagectomy and excluded patients with other cancer. The random effect model was used in this network meta-analysis. The Newcastle–Ottawa Scale (NOS) was used for the quality assessment of studies in the network meta-analysis, and funnel plots were used to evaluate publication bias. The primary outcome is anastomosis leakage; the secondary outcomes are stricture formation, length of hospital stays, and mortality rate. Results: Nine studies involving 1613 patients were included in this network meta-analysis. The trend results indicated the following. Regarding anastomosis leakage, free jejunal flap was the better procedure; regarding stricture formation, colon interposition was the better procedure; regarding mortality rate, free jejunal flap was the better procedure; regarding length of hospital stay, gastric pull-up was the better treatment. Discussion: Overall, if technically accessible, free jejunal flap is a better choice than colon interposition when gastric conduit cannot be used, but further study should be conducted to compare groups with equal supercharged patients. In addition, jejunal flap (JF) cannot replace traditional gastric pull-up (GPU) due to technical complexities, more anastomotic sites, and longer operation times. However, the GPU method with the supercharged procedure would be a possible solution to lower postoperative AL. The limitation of this meta-analysis is that the number of articles included was low; we aim to update the result when new data are available. Funding: None. Registration: N/A.
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Affiliation(s)
- Pang-Chieh Hung
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Hsuan-Yu Chen
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City 235, Taiwan
| | - Yu-Kang Tu
- Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei 106, Taiwan
| | - Yung-Shuo Kao
- Department of Radiation Oncology, China Medical University Hospital, Taichung 404, Taiwan
- Correspondence:
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Seika P, Biebl M, Raakow J, Berndt N, Feldbrügge L, Maurer MM, Dobrindt E, Thuss-Patience P, Pratschke J, Denecke C. The Association between Neoadjuvant Radio-Chemotherapy and Prolonged Healing of Anastomotic Leakage after Esophageal Resection Treated with EndoVAC Therapy. J Clin Med 2022; 11:jcm11164773. [PMID: 36013012 PMCID: PMC9410280 DOI: 10.3390/jcm11164773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 12/24/2022] Open
Abstract
(1) Background: Endoscopic vacuum therapy (EVT) has become the mainstay in the treatment of early anastomotic leakage (AL) after esophageal resection. The effect of nRCT on the efficacy of EVT is currently unknown. (2) Methods: Data of 427 consecutive patients undergoing minimally invasive esophagectomy between 2013 and 2022 were analyzed. A total of 26 patients received EVT for AL after esophagectomy between 2010 and 2021. We compared a cohort of 13 patients after treatment with EVT for anastomotic leakage after neoadjuvant radiochemotherapy (nRCT) with a control group of 13 patients after neoadjuvant chemotherapy (nCT) using inverse propensity score weighting to adjust for baseline characteristics between the groups. EVT therapy was assessed regarding patient survival, treatment failure as defined by a change in treatment to stent/operation, duration of treatment, and secondary complications. Statistical analysis was performed using linear regression analysis. (3) Results: Time to EVT after initial tumor resection did not vary between the groups. The duration of EVT was longer in patients after nRCT (14.69 days vs. 20.85 days, p = 0.002) with significantly more interventions (4.38 vs. 6.85, p = 0.001). The success rate of EVT did not differ between the two groups (nCT n = 8 (61.54%) vs. nCT n = 5 (38.46%), p = 0.628). The rate of operative revision did not vary between the groups. Importantly, no mortality was reported within 30 days and 90 days in both groups. (4) Conclusions: EVT is a valuable tool for the management of AL after esophageal resection in patients after nRCT. While the success rates were comparable, EVT was associated with a significantly longer treatment duration. Anastomotic leakages after nRCT often require prolonged and multimodal treatment strategies while innovative strategies such as prophylactic endoVAC placement or use of a VAC-Stent may be considered.
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Affiliation(s)
- Philippa Seika
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Department of Surgery, Division of Surgical Sciences, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Matthias Biebl
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Jonas Raakow
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Nadja Berndt
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Linda Feldbrügge
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Max Magnus Maurer
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Eva Dobrindt
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Peter Thuss-Patience
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Johann Pratschke
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Christian Denecke
- Chirurgische Klinik, Campus Charité Mitte|Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
- Correspondence:
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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Shen J, Dai S, Li Z, Dai W, Hong J, Huang J, Chen J. Effect of Enteral Immunonutrition in Patients Undergoing Surgery for Gastrointestinal Cancer: An Updated Systematic Review and Meta-Analysis. Front Nutr 2022; 9:941975. [PMID: 35845793 PMCID: PMC9277464 DOI: 10.3389/fnut.2022.941975] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
Background The efficacy of enteral immunonutrition (EIN) in patients undergoing gastrointestinal cancer surgery remains debatable. This meta-analysis aimed to investigate the effectiveness of EIN administration in patients undergoing surgery for gastrointestinal cancer. Methods From January 2000 to January 2022, PubMed, EMBASE, Cochrane Library, and Web of Science were thoroughly searched for randomized controlled trials (RCTs) with EIN versus standard diet or no supplement in patients undergoing surgery for gastrointestinal cancer. Overall complications and infectious complications were the primary outcomes. The secondary results were non-infectious complications, mortality, length of hospital stay, and enteral nutrition-related complications. Results Thirty-five studies reporting 3,692 patients undergoing surgery for gastrointestinal cancer (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer) were included. Compared with the control group, EIN group had a significantly decreased incidence of overall complications (RR = 0.79, p < 0.001). Infectious complications in patients who received EIN were considerably lower than in the control group (RR = 0.66, p < 0.001). Compared to the control group, the incidence of surgical site infection, abdominal abscess, anastomotic leakage, bacteremia, duration of systemic inflammatory response syndrome (SIRS), and duration of antibiotic therapy was significantly lower in the specific infectious complications treated with EIN. Still, there was no significant difference between the two groups with other infectious complications. Moreover, a substantial shortening in the length of hospital stay was shown in EIN group compared with the control group. Still, no significant effect of EIN was demonstrated in non-infectious complicatios and mortality. The enteral nutrition-related complications had no significant difference between two groups. Conclusions EIN is safe and effective in reducing overall complications, infectious complications, and hospital stay in patients undergoing gastrointestinal cancer surgery (including gastric cancer, colorectal cancer, esophageal cancer, periampullary cancer, or pancreatic cancer).
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Affiliation(s)
- Jingyi Shen
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Senjie Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zongze Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wei Dai
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jingjie Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
- *Correspondence: Jingjie Chen
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Fabbi M, van Berge Henegouwen MI, Fumagalli Romario U, Gandini S, Feenstra M, De Pascale S, Gisbertz SS. End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes. Langenbecks Arch Surg 2022; 407:2681-2692. [PMID: 35639136 DOI: 10.1007/s00423-022-02567-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 05/21/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups. METHODS We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications. RESULTS Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups. CONCLUSIONS The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.
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Affiliation(s)
- Manrica Fabbi
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), Milan, Italy.
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Sara Gandini
- Department of Experimental Oncology, European Institute of Oncology (IRCCS), Milan, Italy
| | - Minke Feenstra
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stefano De Pascale
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), Milan, Italy
| | - Suzanne S Gisbertz
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Evaluation of the Use of Inflammatory Biomarkers in the Early Detection of Anastomotic Leakage after Oesophagectomy. Surg Open Sci 2022; 10:12-18. [PMID: 35800711 PMCID: PMC9253454 DOI: 10.1016/j.sopen.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/28/2022] [Accepted: 05/14/2022] [Indexed: 11/21/2022] Open
Abstract
Background Postoperative anastomotic leakage remains a major complication of esophagectomy. The development of a reliable method of early detection of anastomotic leakage can revolutionize the management of esophageal carcinoma. Materials and Methods This is a retrospective data analysis of 147 patients who underwent Ivor–Lewis esophagectomy as a curative attempt to treat distal esophageal carcinoma in our surgery department between 2010 and 2021. C-reactive protein and white blood cell count in postoperative days 1, 3, 5, and 8 were compared in patients with and without anastomotic leakage. The diagnostic accuracy of these tests was challenged against the clinical reference standard represented by computed tomography or upper gastrointestinal endoscopy. Results Twenty-eight patients (19%) developed anastomotic leakage. C-reactive protein values in postoperative day 8 were the only parameter to qualify as a potential clinically helpful test with an area under the receiver operating curve of 0.85 and a P value of less than .01. We calculated the cutoff value for C-reactive protein during postoperative day 8 to be 10.85 mg/dL with specificity and sensitivity of 73.1% and 89.3%, respectively. C-reactive protein showed a positive predictive value of 43.9% and a negative predictive value of 96.7% at this cutoff value. Conclusion An absolute diagnostic value of postoperative estimation of serum inflammatory biomarkers to detect anastomotic leakage could not be proved. Serum C-reactive protein on postoperative day 8 with a cutoff value of 10.85 mg/dL could be used to exclude anastomotic leakage after esophagectomy to serve as one of the discharge criteria of the patients. Anastomotic leakage is a serious and quite common complication after esophagectomy. Early detection of anastomotic leakage is crucial to successful management. Increased inflammatory biomarkers suggest the presence of anastomotic leakage. Increased serum C-reactive protein is a potential detector of anastomotic leakage.
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Gao L, Lu J, Zhang P, Hong ZN, Kang M. Toripalimab combined with docetaxel and cisplatin neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma: a single-center, single-arm clinical trial (ESONICT-2). J Gastrointest Oncol 2022; 13:478-487. [PMID: 35557591 PMCID: PMC9086050 DOI: 10.21037/jgo-22-131] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/03/2022] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND More and more evidence has confirmed the efficacy and safety of immunotherapy drugs, such as camrelizumab and pembrolizumab. There are several phase-I/II studies showing that toripalimab has an acceptable safety profile and promising clinical activity in patients with advanced solid tumors. To further confirm its efficacy and safety, the aim of the study was to evaluate toripalimab combined with docetaxel and cisplatin neoadjuvant therapy for locally advanced esophageal squamous cell carcinoma (ESCC). METHODS This study was an investigator-initiated, open-label, non-randomized, single-arm, single-center phase II trial (registration number: ChiCTR2100052784). The patients eligible for inclusion criteria at Fujian Medical University Union Hospital from October 2019 to October 2020 were included in this study. Patients who were suitable for surgery underwent minimally invasive esophagectomy (MIE) within 4-6 weeks after neoadjuvant therapy. Pathological complete response (pCR) and adverse events (AEs) were the primary end points. Secondary endpoints included R0 resection rate, major pathological response (MPR), interval to surgery, and 30-day complications. RESULTS A total of 20 patients were enrolled from October 2019 to October 2020. All patients successfully completed 2 cycles of neoadjuvant therapy. Treatment-related AEs were common during neoadjuvant therapy, with leucopenia the most frequently occurring AE (4/20, 25%). With respect to immune-related AEs, immune dermatitis occurred in 2 patients, including 1 patient with grade I and 1 patient with grade III. Based on radiologic evaluation, the objective response rate (ORR) was 70% (14/20). Twelve patients underwent McKeown MIE. The pCR rate of the primary tumor was 16.7% (2/12), and the MPR rate of the primary tumor was 5/12 (41.7%). The mean interval to surgery was 33.2 days, and no patients experienced delayed surgery due to treatment-related AEs. Pneumonia was the most common 30-day postoperative complication (3/12, 25%). Anastomotic leakage (AL) only occurred in 1 patient during the hospital stay. There were no treatment- or surgery-related deaths. CONCLUSIONS Based on our results, toripalimab combined with docetaxel and cisplatin as a novel neoadjuvant therapy was safe and effective in locally advanced ESCC.
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Affiliation(s)
- Lei Gao
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Jieming Lu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Peipei Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Zhi-Nuan Hong
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
| | - Mingqiang Kang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fujian Province University, Fuzhou, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Tumor Microbiology, Fujian Medical University, Fuzhou, China
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Tzortzakakis A, Kalarakis G, Huang B, Terezaki E, Koltsakis E, Kechagias A, Tsekrekos A, Rouvelas I. Role of Radiology in the Preoperative Detection of Arterial Calcification and Celiac Trunk Stenosis and Its Association with Anastomotic Leakage Post Esophagectomy, an Up-to-Date Review of the Literature. Cancers (Basel) 2022; 14:cancers14041016. [PMID: 35205764 PMCID: PMC8870074 DOI: 10.3390/cancers14041016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Esophageal cancer is the sixth deadliest among all cancers worldwide. Multimodal treatment, including surgical resection of the esophagus, offers the potential for cure even in advanced cases, but esophagectomy is still associated with serious complications. Among these, anastomotic leakage has the most significant clinical impact, both in terms of prognosis and health-related quality of life. Identifying patients at a high risk for leakage is of great importance in order to modify their treatment and, if possible, avoid this complication. This review aims to study the current literature regarding the role of radiology in detecting potential risk factors associated with anastomotic leakage. The measurement of calcium plaques on the aorta, as well as the detection of narrowing of the celiac trunk and its branches, can be easily assessed by preoperative computed tomography, and can be used to individualize perioperative patient management to effectively reduce the rate of leakage. Abstract Surgical resection of the esophagus remains a critical component of the multimodal treatment of esophageal cancer. Anastomotic leakage (AL) is the most significant complication following esophagectomy, in terms of clinical implications. Identifying risk factors for AL is important for modifying patient management and improving surgical outcomes. This review aims to examine the role of radiological risk factors for AL after esophagectomy, and in particular, arterial calcification and celiac trunk stenosis. Eligible publications prior to 25 August 2021 were retrieved from Medline and Google Scholar using a predefined search algorithm. A total of 68 publications were identified, of which 9 original studies remained for in-depth analysis. The majority of these studies found correlations between calcifications in the aorta, celiac trunk, and right post-celiac arteries and AL following esophagectomy. Some studies suggest celiac trunk stenosis as a more appropriate surrogate. Our up-to-date review highlights the need for automated quantification of aortic calcifications, as well as the degree of celiac trunk stenosis in preoperative computed tomography in patients undergoing esophagectomy, to obtain robust and reproducible measurements that can be used for a definite correlation.
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Affiliation(s)
- Antonios Tzortzakakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, 141 86 Huddinge, Sweden
| | - Georgios Kalarakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Department of Radiology, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
| | - Biying Huang
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of General Surgery, Södertälje Hospital, 152 86 Södertälje, Sweden
| | - Eleni Terezaki
- Department of Emergency Medicine, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - Emmanouil Koltsakis
- Department of Radiology, Karolinska University Hospital, Solna, 171 64 Stockholm, Sweden;
| | - Aristotelis Kechagias
- Department of Digestive Surgery, Kanta-Häme Central Hospital, 13530 Hämeenlinna, Finland;
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
- Correspondence: ; Tel.: +46-70-797-68-14
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Kang H, Ben-David K, Sarosi GA, Thomas RM. Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2022; 26:279-285. [PMID: 35037179 DOI: 10.1007/s11605-021-05219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy. METHODS A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy. RESULTS Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 "asymptomatic radiographic leak tests" (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent "symptomatic radiographic leak tests" (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( -), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0-5.5) and 9.0 days (IQR 6.0-13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively. CONCLUSIONS Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging.
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Affiliation(s)
- Hansol Kang
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - George A Sarosi
- Section of General Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA.,Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA
| | - Ryan M Thomas
- Section of General Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA. .,Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA.
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Yu WQ, Gao HJ, Shi GD, Tang JY, Wang HF, Hu SY, Wei YC. Development and validation of a nomogram to predict anastomotic leakage after esophagectomy for esophageal carcinoma. J Thorac Dis 2021; 13:3549-3565. [PMID: 34277050 PMCID: PMC8264723 DOI: 10.21037/jtd-21-209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/29/2021] [Indexed: 11/20/2022]
Abstract
Background This study aimed to identify variables associated with anastomotic leakage after esophagectomy and established a tool for anastomotic leakage prediction. Methods Twenty-six preoperative and postoperative variables were retrospectively collected from esophageal cancer patients who were treated with radical esophagectomy from January 2018 to June 2020 in the Affiliated Hospital of Qingdao University. SPSS Version 23.0 and Empower Stats software were used for establishing a nomogram after screening relevant variables by univariate and multivariate Logistic regression analyses. The established nomogram was identified by depicting the receiver operating characteristic (ROC) curves and calibration curve, which was verified by 1,000 bootstrap resamples method. Results A total of 604 eligible esophageal cancer patients were included, of which 51 (8.4%) patients had anastomotic leakage. Multivariate Logistic regression analysis showed that smoking, anastomotic location, anastomotic technique, prognostic nutritional index (PNI) and ASA score were independent risks of anastomotic leakage. The area under curve (AUC) of ROC in the established nomogram was 0.764 (95% CI, 0.69–0.83). The internal validation confirmed that the nomogram had a great discrimination ability (AUC =0.766). Depicted calibration curve demonstrated a well-fitted prediction and observation probability. In addition, the decision curve analysis concluded that the newly established nomogram is significant for clinical decision-making. Conclusions This nomogram provided the individual prediction of anastomotic leakage for esophageal cancer patients after surgery, which might benefit treatment results for patients and clinicians, as well as pre-and postoperative intervention strategy-making.
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Affiliation(s)
- Wen-Quan Yu
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hui-Jiang Gao
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Guo-Dong Shi
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Jia-Yu Tang
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hua-Feng Wang
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Shi-Yu Hu
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Yu-Cheng Wei
- Thoracic Surgeon, Department of Thoracic Surgery, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
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Fabbi M, De Pascale S, Ascari F, Petz WL, Fumagalli Romario U. Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes. Updates Surg 2021; 73:1837-1847. [PMID: 33900550 PMCID: PMC8500894 DOI: 10.1007/s13304-021-01054-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/07/2021] [Indexed: 12/05/2022]
Abstract
Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50–1000 ml). The median overall length of stay was 13 (7–64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.
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Affiliation(s)
- Manrica Fabbi
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), 20141, Milan, Italy.
| | - Stefano De Pascale
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), 20141, Milan, Italy
| | - Filippo Ascari
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), 20141, Milan, Italy
| | - Wanda Luisa Petz
- Department of Digestive Surgery, European Institute of Oncology (IRCCS), 20141, Milan, Italy
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Åkesson O, Heyman I, Johansson J, Rissler P, Falkenback D. Early endoscopic assessment after esophagectomy can predict anastomotic complications: a novel scoring system. Surg Endosc 2021; 36:1903-1909. [PMID: 33835253 DOI: 10.1007/s00464-021-08472-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/26/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic leakage after esophagectomy is a serious and demanding complication. Early detection and treatment can probably prevent clinical deterioration of the patient. We have used early endoscopic assessment and a novel endoscopy score to predict anastomotic complications. METHODS 57 patients planned for Ivor Lewis esophagectomy were included. Endoscopy videos were recorded and biopsies were taken from the gastric conduit on day 7 or 8 after esophagectomy. A scoring system based on the endoscopic appearance, the combined endoscopy score (0-6), was developed. Scoring of the videos was done blinded. Patient outcome with regards to anastomotic complications was registered on postoperative day 30 in accordance with the ECCG definitions and compared to histopathology assessment and the combined endoscopy score retrospectively. RESULTS The rate of anastomotic defect (necrosis and leakage, ECCG definitions) was 19%. 7 out of 8 patients with a combined endoscopy score of ≥ 4 developed anastomotic defects. The combined endoscopy score was the only predictor for anastomotic complications. CONCLUSION Prediction of anastomotic complications enables early detection and treatment which often limits the clinical extent of the complication. Early postoperative endoscopy is safe and a relatively simple procedure. The combined endoscopy score is an accurate tool to predict anastomotic complications.
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Affiliation(s)
- Oscar Åkesson
- Department of Surgery, Skåne University Hospital, Lund, Sweden.
- Department of Clinical Sciences, Lund University, Lund, Sweden.
- Department of Surgery, Skåne University Hospital, Getingevägen 4, 222 41, Lund, Sweden.
| | - Isak Heyman
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jan Johansson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Pehr Rissler
- Division of Laboratory Medicine, Department of Pathology, Skåne University Hospital, Lund, Sweden
| | - Dan Falkenback
- Department of Surgery, Skåne University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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