1
|
Barchi A, Massimino L, Mandarino FV, Vespa E, Sinagra E, Almolla O, Passaretti S, Fasulo E, Parigi TL, Cagliani S, Spanò S, Ungaro F, Danese S. Microbiota profiling in esophageal diseases: Novel insights into molecular staining and clinical outcomes. Comput Struct Biotechnol J 2024; 23:626-637. [PMID: 38274997 PMCID: PMC10808859 DOI: 10.1016/j.csbj.2023.12.026] [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: 08/22/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/27/2024] Open
Abstract
Gut microbiota is recognized nowadays as one of the key players in the development of several gastro-intestinal diseases. The first studies focused mainly on healthy subjects with staining of main bacterial species via culture-based techniques. Subsequently, lots of studies tried to focus on principal esophageal disease enlarged the knowledge on esophageal microbial environment and its role in pathogenesis. Gastro Esophageal Reflux Disease (GERD), the most widespread esophageal condition, seems related to a certain degree of mucosal inflammation, via interleukin (IL) 8 potentially enhanced by bacterial components, lipopolysaccharide (LPS) above all. Gram- bacteria, producing LPS), such as Campylobacter genus, have been found associated with GERD. Barrett esophagus (BE) seems characterized by a Gram- and microaerophils-shaped microbiota. Esophageal cancer (EC) development leads to an overturn in the esophageal environment with the shift from an oral-like microbiome to a prevalently low-abundant and low-diverse Gram--shaped microbiome. Although underinvestigated, also changes in the esophageal microbiome are associated with rare chronic inflammatory or neuropathic disease pathogenesis. The paucity of knowledge about the microbiota-driven mechanisms in esophageal disease pathogenesis is mainly due to the scarce sensitivity of sequencing technology and culture methods applied so far to study commensals in the esophagus. However, the recent advances in molecular techniques, especially with the advent of non-culture-based genomic sequencing tools and the implementation of multi-omics approaches, have revolutionized the microbiome field, with promises of implementing the current knowledge, discovering more mechanisms underneath, and giving insights into the development of novel therapies aimed to re-establish the microbial equilibrium for ameliorating esophageal diseases..
Collapse
Affiliation(s)
- Alberto Barchi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Luca Massimino
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Edoardo Vespa
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Cefalù, Italy
| | - Omar Almolla
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Sandro Passaretti
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Ernesto Fasulo
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Tommaso Lorenzo Parigi
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Stefania Cagliani
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| | - Salvatore Spanò
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Federica Ungaro
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silvio Danese
- Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Faculty of Medicine, Milan, Italy
| |
Collapse
|
2
|
Maher A, De Coppi P, Blackburn S, Loukogeorgakis S, Eaton S, Cross K, Giuliani S, Curry J, Mullassery D. Short and Medium Term Outcomes of Open and Laparoscopic Assisted Oesophageal Replacement Procedures. J Pediatr Surg 2024; 59:192-196. [PMID: 38016850 DOI: 10.1016/j.jpedsurg.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 10/10/2023] [Indexed: 11/30/2023]
Abstract
AIM OF THE STUDY We describe the short- and medium-term outcomes following open and laparoscopic assisted oesophageal replacement surgery in a single tertiary paediatric surgical centre. METHODS A retrospective review (institutional audit approval no. 3213) on patients who underwent open or laparoscopic-assisted oesophageal replacement (OAR vs. LAR) at our centre between 2002 and 2021 was completed. Data collected (demographics, early complications, stricture formation, need for oesophageal dilatations, and mortality) were analysed using GraphPad Prism v 9.50 and are presented as median (IQR). RESULTS 71 children (37 male) had oesophageal replacement surgery at a median age of 2.3 years (IQR 4.7 years). 51 were LAR (6 conversions). Replacement conduit was stomach (n = 67), colon (n = 3), or jejunum (n = 1). Most gastric transpositions had a pyloroplasty (46/67) or pyloromyotomy (14/67). Most common pathology was oesophageal atresia (n = 50 including 2 failed transpositions), caustic injury (n = 19 including 3 due to button battery), stricture of unknown cause (n = 1), and megaoesophagus (n = 1). There were 2 (2.8 %) early postoperative deaths at 2 days (major vessel thrombosis), 1 month (systemic sepsis), and one death at 5 years in the community. The rate of postoperative complications were comparable across LAR and OAR including anastomotic leak, pleural effusions, or early strictures. More patients with caustic pathology needed dilatations (60 % vs 30 % in OA, p = 0.05). CONCLUSIONS Outcomes of open and laparoscopic-assisted oesophageal replacement procedures are comparable in the short and medium term. Anastomotic stricture is higher in those with caustic injury. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Ahmed Maher
- Great Ormond Street Hospital for Children, London, United Kingdom; Assiut University, Assiut, Egypt
| | - Paolo De Coppi
- Great Ormond Street Hospital for Children, London, United Kingdom; UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Simon Blackburn
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | - Simon Eaton
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Kate Cross
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Stefano Giuliani
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Joe Curry
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | |
Collapse
|
3
|
Hajibandeh S, Hajibandeh S, McKenna M, Jones W, Healy P, Witherspoon J, Blackshaw G, Lewis W, Foliaki A, Abdelrahman T. Effect of intraoperative botulinum toxin injection on delayed gastric emptying and need for endoscopic pyloric intervention following esophagectomy: a systematic review, meta-analysis, and meta-regression analysis. Dis Esophagus 2023; 36:doad053. [PMID: 37539558 DOI: 10.1093/dote/doad053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/31/2023] [Indexed: 08/05/2023]
Abstract
The aim of this study was to evaluate the effect of intraoperative botulinum toxin (BT) injection on delayed gastric emptying (DGE) and need for endoscopic pyloric intervention (NEPI) following esophagectomy. In compliance with Preferred Reporting Items for Systematic reviews and Meta-Analyses statement standards, a systematic review of studies reporting the outcomes of intraoperative BT injection in patients undergoing esophagectomy for esophageal cancer was conducted. Proportion meta-analysis model was constructed to quantify the risk of the outcomes and direct comparison meta-analysis model was constructed to compare the outcomes between BT injection and no BT injection or surgical pyloroplasty. Meta-regression was modeled to evaluate the effect of variations in different covariates among the individual studies on overall summary proportions. Nine studies enrolling 1070 patients were included. Pooled analyses showed that the risks of DGE and NEPI following intraoperative BT injection were 13.3% (95% confidence interval [CI]: 7.9-18.6%) and 15.2% (95% CI: 7.9-22.5%), respectively. There was no difference between BT injection and no BT injection in terms of DGE (odds ratio [OR]: 0.57, 95% CI: 0.20-1.61, P = 0.29) and NEPI (OR: 1.73, 95% CI: 0.42-7.12, P = 0.45). Moreover, BT injection was comparable to pyloroplasty in terms of DGE (OR: 0.85, 95% CI: 0.35-2.08, P = 0.73) and NEPI (OR: 8.20, 95% CI: 0.63-105.90, P = 0.11). Meta-regression suggested that male gender was negatively associated with the risk of DGE (coefficient: -0.007, P = 0.003). In conclusion, level 2 evidence suggests that intraoperative BT injection may not improve the risk of DGE and NEPI in patients undergoing esophagectomy. The risk of DGE seems to be higher in females and in early postoperative period. High quality randomized controlled trials with robust statistical power are required for definite conclusions. The results of the current study can be used for hypothesis synthesis and power analysis in future prospective trials.
Collapse
Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Matthew McKenna
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - William Jones
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Paul Healy
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Jolene Witherspoon
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Guy Blackshaw
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Wyn Lewis
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Antonio Foliaki
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | - Tarig Abdelrahman
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| |
Collapse
|
4
|
Horváth ÖP, Pavlovics G, Cseke L, Vereczkei A, Papp A. Dysphagia After Esophageal Replacement and Its Treatment. Dysphagia 2023; 38:1323-1332. [PMID: 36719515 PMCID: PMC10471736 DOI: 10.1007/s00455-023-10557-2] [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: 09/02/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.
Collapse
Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary.
| | - Gábor Pavlovics
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - László Cseke
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Papp
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| |
Collapse
|
5
|
Okada N, Kinoshita Y, Nishihara S, Kurotaki T, Sato A, Kimura K, Kushiya H, Umemoto K, Furukawa S, Yamabuki T, Takada M, Kato K, Ambo Y, Nakamura F. PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy: study protocol for the PYNI-GAREREO phase III randomized controlled trial. Trials 2023; 24:412. [PMID: 37337238 DOI: 10.1186/s13063-023-07435-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 06/05/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying. METHODS The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively. DISCUSSION We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty. TRIAL REGISTRATION UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346 .
Collapse
Affiliation(s)
- Naoya Okada
- Department of Surgery and Center of Esophageal Diseases, Teine Keijinkai Hospital, 1-40 Maeda, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan.
| | - Yoshihiro Kinoshita
- Department of Surgery and Center of Esophageal Diseases, Teine Keijinkai Hospital, 1-40 Maeda, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan.
| | - Shoji Nishihara
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Takuma Kurotaki
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Aya Sato
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Kotaro Kimura
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Hiroki Kushiya
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Kazufumi Umemoto
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Shotaro Furukawa
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Takumi Yamabuki
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Minoru Takada
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Kentaro Kato
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Yoshiyasu Ambo
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Fumitaka Nakamura
- Department of Surgery, Teine Keijinkai Hospital, 1-40 Maeda1-12, Teine-Ku, Sapporo, Hokkaido, 006-8555, Japan
| |
Collapse
|
6
|
Arkle T, Sivarajan S, Kulasegaran S, Penney N, Kumar B. Long-term patient-focussed outcomes remain under-evaluated in reviews of pyloric drainage procedures in oesophagectomy. Langenbecks Arch Surg 2023; 408:116. [PMID: 36881164 DOI: 10.1007/s00423-023-02847-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/18/2023] [Indexed: 03/08/2023]
Affiliation(s)
- T Arkle
- Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK.
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK.
| | - S Sivarajan
- Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - S Kulasegaran
- Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - N Penney
- Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
| | - B Kumar
- Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, NR4 7UY, UK
- Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK
| |
Collapse
|
7
|
Bolger JC, Lau H, Yeung JC, Darling GE. Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients. Dis Esophagus 2023; 36:6694033. [PMID: 36073933 DOI: 10.1093/dote/doac061] [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: 03/10/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 12/11/2022]
Abstract
Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65 years, P = 0.6), pathological stage (P = 0.10) or ASA status (P = 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P = 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P = 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.
Collapse
Affiliation(s)
- Jarlath C Bolger
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Harry Lau
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada
| | - Jonathan C Yeung
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University Health Network, Toronto, ON, Canada.,Department of Surgery, Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
8
|
Kinoshita H, Shimoike N, Nishizaki D, Hida K, Tsunoda S, Obama K, Watanabe N. Routine decompression by nasogastric tube after oesophagectomy for oesophageal cancer. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2023; 2023:CD014751. [PMCID: PMC9933613 DOI: 10.1002/14651858.cd014751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the effects of routine nasogastric decompression as compared to no nasogastric decompression after oesophagectomy. In the case of routine decompression, we will also aim to assess the effects of early versus late removal of the nasogastric tube.
Collapse
Affiliation(s)
| | | | - Norihiro Shimoike
- Department of SurgeryKyoto University Graduate School of MedicineKyotoJapan
| | | | - Koya Hida
- Department of SurgeryKyoto University HospitalKyotoJapan
| | | | - Kazutaka Obama
- Department of SurgeryKyoto University HospitalKyotoJapan
| | - Norio Watanabe
- Department of Health Promotion and Human BehaviorKyoto University School of Public HealthKyotoJapan
| |
Collapse
|
9
|
Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis. J Gastrointest Surg 2023; 27:823-835. [PMID: 36650418 DOI: 10.1007/s11605-022-05573-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy. METHODS PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality. RESULTS There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I2 = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I2 = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I2 = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I2 = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I2 = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I2 = 0%) between the pyloric drainage and no intervention groups. CONCLUSIONS Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.
Collapse
|
10
|
Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:3287-3295. [PMID: 36163378 DOI: 10.1007/s00423-022-02685-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure. METHODS A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention. RESULTS Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29). CONCLUSION Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.
Collapse
|
11
|
Assessment of pyloric sphincter physiology after Ivor-Lewis esophagectomy using an endoluminal functional lumen imaging probe. Surg Endosc 2022:10.1007/s00464-022-09714-9. [DOI: 10.1007/s00464-022-09714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/11/2022] [Indexed: 12/04/2022]
Abstract
Abstract
Objective of the study
The most common functional complication after Ivor-Lewis esophagectomy is the delayed emptying of the gastric conduit (DGCE) for which several diagnostic tools are available, e.g. chest X-ray, upper esophagogastroduodenoscopy (EGD) and water-soluble contrast radiogram. However, none of these diagnostic tools evaluate the pylorus itself. Our study demonstrates the successful measurement of pyloric distensibility in patients with DGCE after esophagectomy and in those without it.
Methods and procedures
Between May 2021 and October 2021, we performed a retrospective single-centre study of all patients who had an oncological Ivor-Lewis esophagectomy and underwent our post-surgery follow-up programme with surveillance endoscopies and computed tomography scans. EndoFlip™ was used to perform measurements of the pylorus under endoscopic control, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling.
Results
We included 70 patients, and EndoFlip™ measurement was feasible in all patients. Successful application of EndoFlip™ was achieved in all interventions (n = 70, 100%). 51 patients showed a normal postoperative course, whereas 19 patients suffered from DGCE. Distensibility proved to be smaller in patients with symptoms of DGCE compared to asymptomatic patients. For 40 ml, 45 ml and 50 ml, the mean distensibility was 6.4 vs 10.1, 5.7 vs 7.9 and 4.5 vs 6.3 mm2/mmHg. The differences were significant for all three balloon fillings. No severe EndoFlip™ treatment-related adverse events occurred.
Conclusion
Measurement with EndoFlip™ is a safe and technically feasible endoscopic option for measuring the distensibility of the pylorus. Our study shows that the distensibility in asymptomatic patients after esophagectomy is significantly higher than that in patients suffering from DGCE. However, more studies need to be conducted to demonstrate the general use of EndoFlip™ measurement of the pylorus after esophagectomy.
Collapse
|
12
|
Endoscopic Intrapyloric Botulinum Toxin Injection with Pyloric Balloon Dilation for Symptoms of Delayed Gastric Emptying after Distal Esophagectomy for Esophageal Cancer: A 10-Year Experience. Cancers (Basel) 2022; 14:cancers14235743. [PMID: 36497224 PMCID: PMC9737592 DOI: 10.3390/cancers14235743] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022] Open
Abstract
Patients with esophageal cancer undergoing esophagectomy have an improved survival over time, however adverse events associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related complication which can decreased quality of life by causing debilitating gastrointestinal symptoms and malnutrition. The aim of our study was to evaluate the effect of endoscopic intrapyloric botulinum (BT) injection in combination with pyloric balloon dilation in patients with DGE following distal esophagectomy at our tertiary cancer center. Patients with a prior history of distal esophagectomy who had also undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study. One hundred units of BT were injected endoscopically into the pylorus in four quadrants using an injection needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12−20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed. A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. The patients underwent the procedures at a median of 22 months (range, 1−108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times (>2). Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. Eighteen patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) showed no improvement, whereas in two (10%) patients responses were not available. In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex, possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results.
Collapse
|
13
|
Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
14
|
Singh P, Gossage J, Markar S, Pucher PH, Wickham A, Weblin J, Chidambaram S, Bull A, Pickering O, Mythen M, Maynard N, Grocott M, Underwood T. Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/Perioperative Quality Initiative (POQI) consensus statement on intraoperative and postoperative interventions to reduce pulmonary complications after oesophagectomy. Br J Surg 2022; 109:1096-1106. [PMID: 36001582 PMCID: PMC10364741 DOI: 10.1093/bjs/znac193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/09/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Pulmonary complications are the most common morbidity after oesophagectomy, contributing to mortality and prolonged postoperative recovery, and have a negative impact on health-related quality of life. A variety of single or bundled interventions in the perioperative setting have been developed to reduce the incidence of pulmonary complications. Significant variation in practice exists across the UK. The aim of this modified Delphi consensus was to deliver clear evidence-based consensus recommendations regarding intraoperative and postoperative care that may reduce pulmonary complications after oesophagectomy. METHODS With input from a multidisciplinary group of 23 experts in the perioperative management of patients undergoing surgery for oesophageal cancer, a modified Delphi method was employed. Following an initial systematic review of relevant literature, a range of anaesthetic, surgical, and postoperative care interventions were identified. These were then discussed during a two-part virtual conference. Recommendation statements were drafted, refined, and agreed by all attendees. The level of evidence supporting each statement was considered. RESULTS Consensus was reached on 12 statements on topics including operative approach, pyloric drainage strategies, intraoperative fluid and ventilation strategies, perioperative analgesia, postoperative feeding plans, and physiotherapy interventions. Seven additional questions concerning the perioperative management of patients undergoing oesophagectomy were highlighted to guide future research. CONCLUSION Clear consensus recommendations regarding intraoperative and postoperative interventions that may reduce pulmonary complications after oesophagectomy are presented.
Collapse
Affiliation(s)
- Pritam Singh
- Department of General Surgery, Royal Surrey NHS Foundation Trust, Surrey, UK
| | - James Gossage
- Department of Upper Gastrointestinal Surgery, Guy’s and St Thomas’ Hospitals NHS Trust, London, UK
| | - Sheraz Markar
- Department of Upper Gastrointestinal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Department of Molecular Medicine and Surgery, Karolinska Institute, Solna, Sweden
| | - Philip H Pucher
- Department of Upper Gastrointestinal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Alex Wickham
- Department of Anaesthesia, Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Weblin
- Department of Physiotherapy, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Alexander Bull
- Department of Upper Gastrointestinal Surgery, Guy’s and St Thomas’ Hospitals NHS Trust, London, UK
| | - Oliver Pickering
- School of Cancer Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | - Monty Mythen
- Centre for Anaesthesia, Critical Care and Pain Management, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nick Maynard
- Department of Upper Gastrointestinal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mike Grocott
- NIHR Southampton Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tim Underwood
- School of Cancer Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| |
Collapse
|
15
|
Wolf S, Anthuber M. [Functional advantages of double tract reconstruction after esophagectomy]. CHIRURGIE (HEIDELBERG, GERMANY) 2022; 93:993-994. [PMID: 36036854 DOI: 10.1007/s00104-022-01714-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 06/15/2023]
Affiliation(s)
| | - M Anthuber
- Klinik für Allgemein‑, Viszeral- Transplantationschirurgie, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| |
Collapse
|
16
|
Wu Y, XuWu, Zhang J, Li X, Liu N, Li J, Chen X, Wei L. Effect of modified esophagectomy perioperative technique resection for patients with locally advanced esophageal cancer (tumor length > 8 cm): initial experience in 45 cases. J Cardiothorac Surg 2022; 17:226. [PMID: 36056357 PMCID: PMC9438225 DOI: 10.1186/s13019-022-01942-3] [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: 11/30/2021] [Accepted: 08/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients with locally advanced esophageal cancer with a lesion length greater than 8 cm (LCWEC) are prone to high mortality in a short time due to esophagotracheal fistula (ETF) and esophagoaortic fistula (EAF). We tried to explore a safe salvage surgical method during the perioperative period to maximize the resection of the tumor on the premise of safety and reconstruction of the alimentary tract to avoid early death due to ETF and EAF. Methods From December 2007 to November 2018, forty-five LCWEC patients were treated using the modified Wu’s esophagectomy. Patient features, surgical techniques, postoperative complications, and pathology outcomes were analyzed. Results The average length of the tumors was 12.5 cm (range 8.1–22.5 cm), and the average transverse tumor diameter was 5.8 cm (range 4.5–7.8 cm). No complications like anastomotic leakage, anastomotic stenosis, chylothorax, delayed gastric emptying, vocal cord paralysis, dumping syndrome, and reflux were detected. The 30-day and in-hospital mortality rates were 0%. Complete (R0) resection was achieved in 38 (84.4%) cases. The resection margin rate of positive anastomosis was 0%. Until the death of the patients, no feeding failure due to gastrointestinal obstruction and early death due to ETF or EAF occurrence. During follow-up, the median time to death was 17.2 months for patients treated with surgery alone and 32 months for patients treated with postoperative multimodal treatment. Conclusion The modified Wu’s esophagectomy is a safe and feasible salvage surgical method for LCWEC resection.
Collapse
Affiliation(s)
- Yunfei Wu
- Department of Thoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - XuWu
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China.
| | - Junhua Zhang
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Xiang Li
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Nanbo Liu
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Jun Li
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Xuyuan Chen
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Lichun Wei
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| |
Collapse
|
17
|
Nienhüser H, Heger P, Crnovrsanin N, Schaible A, Sisic L, Fuchs HF, Berlth F, Grimminger PP, Nickel F, Billeter AT, Probst P, Müller-Stich BP, Schmidt T. Mechanical stretching and chemical pyloroplasty to prevent delayed gastric emptying after esophageal cancer resection-a meta-analysis and review of the literature. Dis Esophagus 2022; 35:6530222. [PMID: 35178557 DOI: 10.1093/dote/doac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/09/2022] [Accepted: 01/28/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) occurs in up to 40% of patients after esophageal resection and prolongs recovery and hospital stay. Surgically pyloroplasty does not effectively prevent DGE. Recently published methods include injection of botulinum toxin (botox) in the pylorus and mechanical interventions as preoperative endoscopic dilatation of the pylorus. The aim of this study was to investigate the efficacy of those methods with respect to the newly published Consensus definition of DGE. METHODS A systematic literature search using CENTRAL, Medline, and Web of Science was performed to identify studies that described pre- or intraoperative botox injection or mechanical stretching methods of the pylorus in patients undergoing esophageal resection. Frequency of DGE, anastomotic leakage rates, and length of hospital stay were analyzed. Outcome data were pooled as odd's ratio (OR) or mean difference using a random-effects model. Risk of bias was assessed using the Robins-I tool for non-randomized trials. RESULTS Out of 391 articles seven retrospective studies described patients that underwent preventive botulinum toxin injection and four studies described preventive mechanical stretching of the pylorus. DGE was not affected by injection of botox (OR 0.87, 95% confidence interval [CI] 0.37-2.03, P = 0.75), whereas mechanical stretching resulted in significant reduction of DGE (OR 0.26, 95% CI 0.14-0.5, P < 0.0001). CONCLUSION Mechanical stretching of the pylorus, but not injection of botox reduces DGE after esophageal cancer resection. A newly developed consensus definition should be used before the conduction of a large-scale randomized-controlled trial.
Collapse
Affiliation(s)
- Henrik Nienhüser
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Heger
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Nerma Crnovrsanin
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Leila Sisic
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans F Fuchs
- Department of General, Visceral-, Tumor and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center Mainz, Mainz, Germany
| | - Felix Nickel
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral- and Transplant Surgery, University Hospital Heidelberg, Heidelberg, Germany.,Department of General, Visceral-, Tumor and Transplant Surgery, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
18
|
Comment on the Article, “Randomized Comparison of Gastric Tube Reconstruction With and Without Duodenal Diversion Plus Roux-en-Y Anastomosis After Esophagectomy“. Ann Surg 2022; 276:e67-e68. [DOI: 10.1097/sla.0000000000004617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
19
|
Santucci NR, Kemme S, El-Chammas KI, Chidambaram M, Mathur M, Castillo D, Sun Q, Fei L, Kaul A. Outcomes of combined pyloric botulinum toxin injection and balloon dilation in dyspepsia with and without delayed gastric emptying. Saudi J Gastroenterol 2022; 28:268-275. [PMID: 35083974 PMCID: PMC9408736 DOI: 10.4103/sjg.sjg_493_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pyloric botulinum toxin injection has improved symptoms in children with delayed gastric emptying. We aimed to determine the clinical response to combined endoscopic intra-pyloric botulinum toxin injection and pyloric balloon dilation (IPBT-BD) in patients with dyspepsia. Methods Electronic medical records were reviewed to gather demographic data, symptoms, and follow-up on patients with dyspepsia. Cases were defined as those who underwent IPBT-BD in addition to their ongoing management. Controls received pharmacotherapy, behavioral intervention, or dietary management alone. Clinical response was defined as no change, partial, or complete improvement in symptoms within 12 months. Propensity score matching based on age, gender, and symptom duration was used to pair cases and controls. Results In total, 79 cases and 83 controls were identified. After propensity matching, 63 patients were included in each group. The mean age for cases was 14.5 ± 3.9y; 62% were females and 98% were Caucasian. Further, 83% of 46 cases and 94% of 49 controls who had scintigraphy scans showed delayed gastric emptying. After matching, 76% of cases showed partial or complete improvement compared with 49% controls within 12 months (P = 0.004). Younger children tended to respond more favorably to the procedure (P = 0.08). Conclusions In our propensity-matched analysis, combined IPBT-BD in addition to pharmacotherapy, behavioral, or dietary management clearly showed a benefit over these modalities alone. This favorable response lasted up to 12 months.
Collapse
Affiliation(s)
- Neha R Santucci
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Sarah Kemme
- Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Denver, CO, United States of America
| | - Khalil I El-Chammas
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Maneesh Chidambaram
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Manav Mathur
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Daniel Castillo
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Qin Sun
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Lin Fei
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Ajay Kaul
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| |
Collapse
|
20
|
Abdelrahman M, Ariyarathenam A, Berrisford R, Humphreys L, Sanders G, Wheatley T, Chan DSY. Systematic review and meta-analysis of the influence of prophylactic pyloric balloon dilatation in the prevention of early delayed gastric emptying after oesophagectomy. Dis Esophagus 2022; 35:6363055. [PMID: 34476470 DOI: 10.1093/dote/doab062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/03/2021] [Accepted: 08/16/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Early delayed gastric emptying (DGE) occurs in up to 50% of patients following oesophagectomy, which can contribute to increased anastomotic leak and respiratory infection rates. Although the treatment of DGE in the form of pyloric balloon dilatation (PBD) post-operatively is well established, there is no consensus on the optimal approach in the prevention of DGE. The aim of this review was to determine the efficacy of prophylactic PBD in the prevention of DGE following oesophagectomy. METHOD PubMed, MEDLINE and the Cochrane Library (January 1990 to April 2021) were searched for studies reporting the outcomes of prophylactic PBD in patients who underwent oesophagectomy. The primary outcome measure was the rate of DGE. Secondary outcome measures include anastomotic leak rate and length of hospital stay. RESULTS Three studies with a total of 203 patients [mean age 63 (26-82) years, 162 males (79.8%)] were analyzed. PBD with a 20-mm balloon was performed in 165 patients (46 patients had PBD and botox therapy) compared with 38 patients who had either no intervention or botox alone (14 patients). The pooled rates of early DGE [16.27%, 95% CI (12.29-20.24) vs. 39.02% (38.87-39.17) (P < 0.001)] and anastomotic leak [8.55%, 95% CI (8.51-8.59) vs. 12.23% (12.16-12.31), P < 0.001] were significantly lower in the PBD group. CONCLUSION Prophylactic PBD with a 20-mm balloon significantly reduced the rates of early delayed gastric emptying and anastomotic leak following oesophagectomy.
Collapse
Affiliation(s)
| | | | | | - Lee Humphreys
- Department of Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - Grant Sanders
- Department of Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - Tim Wheatley
- Department of Upper GI Surgery, Derriford Hospital, Plymouth, UK
| | - David S Y Chan
- Department of Upper GI Surgery, Derriford Hospital, Plymouth, UK
| |
Collapse
|
21
|
Bull A, Pucher PH, Maynard N, Underwood TJ, Lagergren J, Gossage JA. Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1033-1038. [PMID: 34840008 DOI: 10.1016/j.ejso.2021.11.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/14/2021] [Accepted: 11/20/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over 1500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation. MATERIAL AND METHODS An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data. RESULTS Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions. CONCLUSIONS Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.
Collapse
Affiliation(s)
- Alexander Bull
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London, UK
| | - Philip H Pucher
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London, UK; Department of General Surgery, Queen Alexandra Hospital, Portsmouth University Hospital NHS Trust, Portsmouth, UK
| | - Nick Maynard
- Department of General Surgery, Oxford University Hospital NHS Foundation Trust, Oxford, UK
| | - Tim J Underwood
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, UK
| | - Jesper Lagergren
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London, UK; School of Cancer and Pharmaceutical Sciences, King's College London, London, UK; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - James A Gossage
- Department of General Surgery, Guy's and St Thomas' NHS Trust, London, UK; School of Cancer and Pharmaceutical Sciences, King's College London, London, UK; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| |
Collapse
|
22
|
Daroudi R, Nahvijou A, Arab M, Faramarzi A, Kalaghchi B, Sari AA, Javan-Noughabi J. A cost-effectiveness modeling study of treatment interventions for stage I to III esophageal squamous cell carcinoma. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2022; 20:16. [PMID: 35366919 PMCID: PMC8976992 DOI: 10.1186/s12962-022-00352-5] [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: 08/25/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
Background Esophageal cancer causes considerable costs for health systems. Appropriate treatment options for patients with esophageal squamous cell carcinoma (ESCC) can reduce medical costs and provide more improved outcomes for health systems and patients. This study evaluates the cost-effectiveness of treatment interventions for patients with ESCC according to the Iranian health system. Material and methods A five-state Markov model with a 15-year time horizon was performed to evaluate the cost-effectiveness of treatment interventions based on stage for ESCC patients. Costs ($US 2021) and outcomes were calculated from the Iranian health system, with a discount rate of 3%. One-way sensitivity analyses were performed to assess the potential effects of uncertain variables on the model results. Results In stage I, the Endoscopic Mucosal Resection (EMR) treatment yielded the lowest total costs and highest total QALY for a total of $1473 per QALY, making it the dominant strategy compared with esophagectomy and EMR followed by ablation. In stages II and III, chemoradiotherapy (CRT) followed by surgery dominated esophagectomy. CRT followed by surgery was also cost-effective with an incremental cost-effectiveness ratio (ICER) of $2172.8 per QALY compared to CRT. Conclusion From the Iranian health system’s perspective, EMR was the dominant strategy versus esophagectomy and EMR followed by ablation for ESCC patients in stage I. The CRT followed by surgery was a cost-effective intervention compared to CRT and esophagectomy in stages II and III. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-022-00352-5.
Collapse
|
23
|
Tham JC, Pournaras DJ, Alcocer B, Forbes R, Ariyarathenam AV, Humphreys ML, Berrisford RG, Wheatley TJ, Chan D, Sanders G, Lewis SJ. Gut hormones profile after an Ivor Lewis gastro-esophagectomy and its relationship to delayed gastric emptying. Dis Esophagus 2022; 35:6544855. [PMID: 35265988 PMCID: PMC9742676 DOI: 10.1093/dote/doac008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 01/03/2022] [Accepted: 02/02/2022] [Indexed: 12/15/2022]
Abstract
Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established.
Collapse
Affiliation(s)
- Ji Chung Tham
- Address correspondence to: Mr Ji Chung Tham MBChB, MSc, FRCS, C/O Mr Grant Sanders, Level 7, Peninsula Oesophago-Gastric Centre, Derriford Hospital, Plymouth PL6 8DH, UK. Tel: +44(0)1752430011; Fax: +44(0)1752517576;
| | - Dimitri J Pournaras
- Department of Upper Gastrointestinal Surgery, North Bristol NHS Trust, Bristol, UK
| | - Bruno Alcocer
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Rosie Forbes
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | | | - Martyn L Humphreys
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | | | - Tim J Wheatley
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - David Chan
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Grant Sanders
- Peninsula Oesophago-Gastric Centre, University Hospital Plymouth, Plymouth, UK
| | - Stephen J Lewis
- Department of Gastroenterology, University Hospital Plymouth, Plymouth, UK
| |
Collapse
|
24
|
Double tract-like gastric tube reconstruction decreases the incidences of delayed gastric emptying and bile reflux after esophagectomy: results of a pilot study of an experimental technique. Langenbecks Arch Surg 2022; 407:1431-1439. [DOI: 10.1007/s00423-022-02461-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
|
25
|
Babic B, Schiffmann LM, Fuchs HF, Mueller DT, Schmidt T, Mallmann C, Mielke L, Frebel A, Schiller P, Bludau M, Chon SH, Schroeder W, Bruns CJ. There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy. Surg Endosc 2022; 36:6777-6783. [PMID: 34981236 PMCID: PMC9402722 DOI: 10.1007/s00464-021-08962-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 12/12/2021] [Indexed: 10/29/2022]
Abstract
INTRODUCTION Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. PATIENTS AND METHODS 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. RESULTS 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. CONCLUSION Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.
Collapse
Affiliation(s)
- Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Lars Mortimer Schiffmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Dolores Thea Mueller
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Christoph Mallmann
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Laura Mielke
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Antonia Frebel
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Petra Schiller
- Faculty of Medicine, Institute of Medical Statistics and Computational Biology, University of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Wolfgang Schroeder
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| |
Collapse
|
26
|
Mertens A, Gooszen J, Fockens P, Voermans R, Gisbertz S, Bredenoord A, van Berge Henegouwen MI. Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation. Dig Surg 2022; 38:337-342. [PMID: 34727541 PMCID: PMC8820434 DOI: 10.1159/000519785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/26/2021] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. METHODS Between 2015 and 2018, patients with delayed gastric emptying 8-10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. RESULTS Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9-15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. CONCLUSION Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.
Collapse
Affiliation(s)
- Alexander Mertens
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands,Robotics and Mechatronics, University of Twente, Enschede, The Netherlands,*Alexander Mertens,
| | - Jan Gooszen
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Rogier Voermans
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Suzanne Gisbertz
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Arjan Bredenoord
- Department of Gastroenterology & Hepatology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam Gastroenterology & Metabolism, Amsterdam, The Netherlands
| | - Mark Ivo van Berge Henegouwen
- Department of Surgery, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands,**Mark Ivo Van Berge Henegouwen,
| |
Collapse
|
27
|
Mei LX, Wang YY, Tan X, Chen Y, Dai L, Chen MW. Is it necessary to routinely perform feeding jejunostomy at the time of esophagectomy? A systematic review and meta-analysis. Dis Esophagus 2021; 34:6245102. [PMID: 33884417 DOI: 10.1093/dote/doab017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/25/2021] [Accepted: 01/30/2021] [Indexed: 12/11/2022]
Abstract
Feeding jejunostomy (FJ) is a routine procedure at the time of esophagectomy in some centers. With the widespread popularization of enhanced recovery after surgery, the necessity of FJ has been increasingly questioned. This study aims to analyze the differences in safety and effectiveness between with (FJ group) or without (no-FJ group) performing FJ at the time of esophagectomy. PubMed, Embase, Web of Science, and Cochrane Library were comprehensively searched for relevant studies, including randomized controlled trials and cohort studies. The primary outcome was the length of hospital stay (LOS). Secondary outcomes were overall postoperative complications, postoperative pneumonia, intestinal obstruction, and weight loss at 3 and 6 months after esophagectomy. Weighted mean differences (WMD) and odds ratios (OR) were calculated for statistical analysis. About 12 studies comprising 2,173 patients were included. The FJ group had a longer LOS (WMD = 2.05, P = 0.01) and a higher incidence of intestinal obstruction (OR = 11.67, P < 0.001) than the no-FJ group. The incidence of overall postoperative complications (OR = 1.24, P = 0.31) and postoperative pneumonia (OR = 1.43, P = 0.13) were not significantly different, nor the weight loss at 3 months (WMD = 0.58, P = 0.24) and 6 months (P > 0.05) after esophagectomy. Current evidence suggests that routinely performing FJ at the time of esophagectomy appears not to generate better postoperative outcomes. FJ may need to be performed selectively rather than routinely. More studies are required to further verify.
Collapse
Affiliation(s)
- Li-Xiang Mei
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong-Yong Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiang Tan
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yong Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lei Dai
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ming-Wu Chen
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| |
Collapse
|
28
|
Carr RA, Harrington C, Stella C, Glauner D, Kenny E, Russo LM, Garrity MJ, Bains MS, Sihag S, Jones DR, Molena D. Early implementation of a perioperative nutrition support pathway for patients undergoing esophagectomy for esophageal cancer. Cancer Med 2021; 11:592-601. [PMID: 34935304 PMCID: PMC8817095 DOI: 10.1002/cam4.4360] [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: 03/04/2021] [Revised: 09/09/2021] [Accepted: 09/12/2021] [Indexed: 11/11/2022] Open
Abstract
Background Unintentional weight loss and malnutrition are associated with poorer prognosis in patients with cancer. Risk of cancer‐associated malnutrition is highest among patients with esophageal cancer (EC) and has been repeatedly shown to be an independent risk factor for worse survival in these patients. Implementation of nutrition protocols may reduce postoperative weight loss and enhance recovery in these patients. Methods We retrospectively identified all patients who underwent Ivor Lewis esophagectomy for EC from January 2015 to August 2019 from a prospectively collected institutional database. Patients who underwent surgery after the implementation of this protocol (September 2017–August 2019) were compared with patients who underwent resection before protocol implementation (January 2015–July 2017). Patients undergoing surgery during the month of protocol initiation were excluded. Results Of the 404 patients included in our study, 217 were in the preprotocol group, and 187 were in the postprotocol group. Compared with the preprotocol group, there were significant reductions in length of hospital stay (p < 0.001), time to diet initiation (p < 0.001), time to feeding tube removal (p = 0.012), and postoperative weight loss (p = 0.002) in the postprotocol group. There was no significant difference in the incidence of postoperative complications, 30‐day readmission, or mortality rates between groups. Conclusions Results of the present study suggest a standardized perioperative nutrition protocol may prevent unintentional weight loss and improve postoperative outcomes in patients with EC undergoing resection.
Collapse
Affiliation(s)
- Rebecca A Carr
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Caitlin Harrington
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Christina Stella
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Diana Glauner
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Erin Kenny
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lianne M Russo
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Meghan J Garrity
- Department of Food and Nutrition Services, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Manjit S Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - David R Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| |
Collapse
|
29
|
D'Journo XB, Fourdrain A, Boulate D. Gastric conduit obstruction after oesophagectomy: a comprehensive approach for surgical revision. Eur J Cardiothorac Surg 2021; 60:1277-1278. [PMID: 34347047 DOI: 10.1093/ejcts/ezab356] [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: 11/13/2022] Open
Affiliation(s)
- Xavier Benoit D'Journo
- Aix-Marseille University, CNRS, INSERM, CRCM, AP-HM, North Hospital, Department of Thoracic Surgery, Chemin des Bourrely, Marseille, France
| | - Alex Fourdrain
- Aix-Marseille University, CNRS, INSERM, CRCM, AP-HM, North Hospital, Department of Thoracic Surgery, Chemin des Bourrely, Marseille, France
| | - David Boulate
- Aix-Marseille University, CNRS, INSERM, CRCM, AP-HM, North Hospital, Department of Thoracic Surgery, Chemin des Bourrely, Marseille, France
| |
Collapse
|
30
|
Functional syndromes and symptom-orientated aftercare after esophagectomy. Langenbecks Arch Surg 2021; 406:2249-2261. [PMID: 34036407 PMCID: PMC8578083 DOI: 10.1007/s00423-021-02203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/16/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.
Collapse
|
31
|
Endoscopic pyloromyotomy in minimally invasive esophagectomy: a novel approach. Surg Endosc 2021; 36:2341-2348. [PMID: 33948713 DOI: 10.1007/s00464-021-08511-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pyloric drainage procedures, namely pyloromyotomy or pyloroplasty, have long been considered an integral aspect of esophagectomy. However, the requirement of pyloric drainage in the era of minimally invasive esophagectomy (MIE) has been brought into question. This is in part because of the technical challenges of performing the pyloric drainage laparoscopically, leading many surgical teams to explore other options or to abandon this procedure entirely. We have developed a novel, technically facile, endoscopic approach to pyloromyotomy, and sought to assess the efficacy of this new approach compared to the standard surgical pyloromyotomy. METHODS Patients who underwent MIE for cancer from 01/2010 to 12/2019 were identified from a prospectively maintained institutional database and were divided into two groups according to the pyloric drainage procedure: endoscopic or surgical pyloric drainage. 30-day outcomes (complications, length of stay, readmissions) and pyloric drainage-related outcomes [conduit distension/width, nasogastric tube (NGT) duration and re-insertion, gastric stasis] were compared between groups. RESULTS 94 patients were identified of these 52 patients underwent endoscopic PM and 42 patients underwent surgical PM. The groups were similar with respect to age, gender and comorbidities. There were more Ivor-Lewis esophagectomies in the endoscopic PM group than the surgical PM group [45 (86%), 15 (36%) p < 0.001]. There was no significant difference in the rate of complications and readmissions. Gastric stasis requiring NGT re-insertion was rare in the endoscopic PM group and did not differ significantly from the surgical PM group (1.9-4.7% p = 0.58). CONCLUSIONS Endoscopic pyloromyotomy using a novel approach is a safe, quick and reproducible technique with comparable results to a surgical PM in the setting of MIE.
Collapse
|
32
|
Antonowicz S, Reddy S, Sgromo B. Gastrointestinal side effects of upper gastrointestinal cancer surgery. Best Pract Res Clin Gastroenterol 2020; 48-49:101706. [PMID: 33317793 DOI: 10.1016/j.bpg.2020.101706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/21/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
In this chapter, we describe the gastrointestinal side effects of oesophagectomy, gastrectomy and pancreaticoduodenectomy for cancer, with a focus on long-term functional impairments and their management. Improvements in upper gastrointestinal cancer surgery have led to a growing group of long-term survivors. The invasive nature of these surgeries profoundly alters the upper gastrointestinal anatomy, with lasting implications for long-term function, and how these impairments may be treated. Successfully maintaining a high quality of survivorship requires multidisciplinary approach, with survivorship care plans focused on function as much as the detection of recurrence.
Collapse
Affiliation(s)
- S Antonowicz
- Oxford Oesophago Gastric Centre, Oxford University Hospitals NHS Trust, UK
| | - S Reddy
- Hepatobiliary and Pancreatic Unit, Oxford University Hospitals NHS Trust, UK
| | - B Sgromo
- Oxford Oesophago Gastric Centre, Oxford University Hospitals NHS Trust, UK.
| |
Collapse
|
33
|
Lieber J, Schmidt A, Kumpf M, Fideler F, Schäfer JF, Kirschner HJ, Fuchs J. Functional outcome after laparoscopic assisted gastric transposition including pyloric dilatation in long-gap esophageal atresia. J Pediatr Surg 2020; 55:2335-2341. [PMID: 32646666 DOI: 10.1016/j.jpedsurg.2020.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 04/21/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND/PURPOSE Among the options for esophageal replacement in long-gap esophageal atresia (LGEA), gastric transposition (GT) is accessible for an endoscopic approach. Here we report a novel technique and functional results after laparoscopic-assisted gastric transposition (LAGT), including pyloric dilatation in patients with LGEA. METHODS Retrospective analysis of 14 children undergoing LAGT. Surgical steps included the release of the gastrostomy, transumbilical ante-situ section of the stomach including pyloric balloon-dilation, and laparoscopically controlled transhiatal retromediastinal blunt dissection followed by LAGT for cervical anastomosis to the proximal esophagus. RESULTS The median age at LAGT was 110 days (33-327 days), bodyweight 5.3 kg (3.1-8.3 kg). Operation time was 255 min (180-436 min); one conversion was necessary. The duration of ventilation was 4 days (1-14 days). Postpyloric feeding was started after 2 days, and oral feeding after 13 days. Complications were recurrent pleural effusion or pneumothorax and transient Horner syndrome or transient incomplete paresis of the recurrence nerve. After a median follow-up of 60 months (13-240 months), all children have a patent upper GI tract, show weight gain, and are fed without delayed gastric emptying, dumping, or reflux. Severe (n = 1) or mild (n = 2) anastomotic or pyloric (n = 5) stenosis was resolved with endoscopic dilatations. CONCLUSIONS Functional outcome after LAGT in patients with LGEA is good. The laparoscopic retromediastinal dissection preserves thoracal structures and increases patients' safety. The technique of pyloric dilatation might also prevent dumping syndrome. TYPE OF STUDY Case Series with no Comparison Group. LEVEL OF EVIDENCE Level IV.
Collapse
Affiliation(s)
- Justus Lieber
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany.
| | - Andreas Schmidt
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany
| | - Matthias Kumpf
- Department of Pediatric Cardiology, Pulmonology, and Intensive Care Medicine, University Children's Hospital, Tübingen, Germany
| | - Frank Fideler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany
| | - Jürgen F Schäfer
- Department of Diagnostic Radiology, University Hospital, Tübingen, Germany
| | - Hans-Joachim Kirschner
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany
| | - Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tübingen, Germany
| |
Collapse
|
34
|
De Pasqual CA, Weindelmayer J, Gobbi L, Alberti L, Veltri A, Giacopuzzi S, de Manzoni G. Effect of Pyloroplasty on Gastric Conduit Emptying and Patients' Quality of Life After Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2020; 31:692-697. [PMID: 32898448 DOI: 10.1089/lap.2020.0595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Delayed gastric emptying (DGE) is a common complication after esophagectomy with gastric tube reconstruction. It is still unclear whether a pyloric drainage procedure might reduce the risk of DGE. Methods: We identified in our database all patients subjected to Ivor Lewis esophagectomy after neoadjuvant chemoradiotherapy in the period 2000-2012. In the period 2000-2009, we performed a routine pyloroplasty (pyloroplasty group, PP group, 15 patients), after 2009 we did not perform any type of pyloric drainage procedure (nonpyloroplasty group, NPP group, 11 patients). We compared the groups with subjective questionnaires to assess the perceived quality of life (QoL) (QLQ-C30 and OES-18) and with objective test to study the gastric tube emptying (timed barium swallow test, scintigraphy, 24 hours' pH-metry). Results: No difference was observed in questionnaires QLC-C30 and OES-18 scores: 73% of patients in PP group and 63% in NPP group scored their overall QoL as good to excellent (QLC-C30). We did not report difference in timed barium swallow test results and in scintigraphy results. Twenty-four-hour pH-metry results showed in PP group a nonsignificant higher number of acid reflux episodes (NPP group 23.2 ± 9.5 versus PP group 41.3 ± 10.7, P = .29) and a longer time with pH <4 (NPP group 0.89% ± 1.6% versus PP group 3.1% ± 2.1%, P = .24). Conclusions: In our series, pyloroplasty was not associated with improved long-term QoL nor with better gastric conduit emptying. Further studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Carlo Alberto De Pasqual
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Jacopo Weindelmayer
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Laura Gobbi
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Luca Alberti
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Alessandro Veltri
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Simone Giacopuzzi
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| | - Giovanni de Manzoni
- Division of General and Upper GI Surgery, Department of Surgery, University of Verona, Verona, Italy
| |
Collapse
|
35
|
Kim D. The Optimal Pyloric Procedure: A Collective Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:233-241. [PMID: 32793458 PMCID: PMC7409877 DOI: 10.5090/kjtcs.2020.53.4.233] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 01/04/2023]
Abstract
Vagal damage and subsequent pyloric denervation inevitably occur during esophagectomy, potentially leading to delayed gastric emptying (DGE). The choice of an optimal pyloric procedure to overcome DGE is important, as such procedures can lead to prolonged surgery, shortening of the conduit, disruption of the blood supply, and gastric dumping/bile reflux. This study investigated various pyloric methods and analyzed comparative studies in order to determine the optimal pyloric procedure. Surgical procedures for the pylorus include pyloromyotomy, pyloroplasty, or digital fracture. Botulinum toxin injection, endoscopic balloon dilatation, and erythromycin are non-surgical procedures. The scope, technique, and effects of these procedures are changing due to advances in minimally invasive surgery and postoperative interventions. Some comparative studies have shown that pyloric procedures are helpful for DGE, while others have argued that it is difficult to reach an objective conclusion because of the variety of definitions of DGE and evaluation methods. In conclusion, recent advances in interventional technology and minimally invasive surgery have led to questions regarding the practice of pyloric procedures. However, many clinicians still perform them and they are at least somewhat effective. To provide guidance on the optimal pyloric procedure, DGE should first be defined clearly, and a large-scale study with an objective evaluation method will then be required.
Collapse
Affiliation(s)
- Dohun Kim
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| |
Collapse
|
36
|
Yang HC, Choi JH, Kim MS, Lee JM. Delayed Gastric Emptying after Esophagectomy: Management and Prevention. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:226-232. [PMID: 32793457 PMCID: PMC7409889 DOI: 10.5090/kjtcs.2020.53.4.226] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 11/16/2022]
Abstract
The quality of life associated with eating is becoming an increasingly significant problem for patients who undergo esophagectomy as a result of the improved survival rate after esophageal cancer surgery. Delayed gastric emptying (DGE) is a common complication after esophagectomy. Although several strategies have been proposed for the management and prevention of DGE, no clear consensus exists. The purpose of this review is to present a brief overview of DGE and to help clinicians choose the most appropriate treatment through an analysis of DGE by cause. Furthermore, we would like to suggest some tips to prevent DGE based on our experience.
Collapse
Affiliation(s)
- Hee Chul Yang
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jin Ho Choi
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Moon Soo Kim
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jong Mog Lee
- Center for Lung Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| |
Collapse
|
37
|
Abstract
Esophagectomy is a major operation whereby intraoperative technique and postoperative care must be optimal. Even in expert hands, the complication rate is as high as 59%. Here the authors discuss the role of surgical adjuncts, including enteral access, nasogastric decompression, pyloric drainage procedures, and anastomotic buttressing as adjuncts to esophagectomy and whether they reduce perioperative complications.
Collapse
Affiliation(s)
- Ammara A Watkins
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA
| | - Jennifer L Wilson
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, W/D 201, Boston, MA 02215, USA.
| |
Collapse
|
38
|
Hasan IS, Mahajan N, Viehman J, Allen MS, Cassivi SD, Lee MK, Nichols FC, Pierson K, Reisenauer JS, Shen RK, Wigle DA, Blackmon SH. Predictors of Patient-Reported Reflux After Esophagectomy. Ann Thorac Surg 2020; 110:1160-1166. [PMID: 32454018 DOI: 10.1016/j.athoracsur.2020.03.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. METHODS A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). RESULTS Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P = .02) and in patients who did not undergo perioperative chemoradiation (P = .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. CONCLUSIONS The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.
Collapse
Affiliation(s)
- Irsa S Hasan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita Mahajan
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jason Viehman
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Mark S Allen
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Stephen D Cassivi
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Minji K Lee
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karlyn Pierson
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Janani S Reisenauer
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert K Shen
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Department of Surgery, Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
39
|
Desprez C, Melchior C, Wuestenberghs F, Huet E, Zalar A, Jacques J, Leroi AM, Gourcerol G. Pyloric distensibility measurement after gastric surgery: Which surgeries are associated with pylorospasm? Neurogastroenterol Motil 2020; 32:e13790. [PMID: 31916346 DOI: 10.1111/nmo.13790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 12/13/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND STUDY AIMS History of gastric surgery is found in 10% of patients with gastroparesis, and vagal lesion is often suspected to be the cause of pylorospasm. Recently, pyloric distensibility measurement using the EndoFLIP® system showed that pylorospasm was present in 30%-50% of gastroparetic patients. Our objective was to assess whether pylorospasm, diagnosed using EndoFLIP® system was observed in three different types of gastric surgeries: antireflux surgery, sleeve gastrectomy, and esophagectomy. PATIENTS AND METHODS Pyloric distensibility and pressure were measured using the EndoFLIP® system in 43 patients from two centers (18 antireflux surgery, 16 sleeve gastrectomy, and nine esophagectomy) with dyspeptic symptoms after gastric surgery, and in 21 healthy volunteers. Altered pyloric distensibility was defined as distensibility below 10 mm2 /mm Hg as previously reported. RESULTS Compared to healthy volunteers (distensibility: 25.2 ± 2.4 mm2 /mm Hg; pressure: 9.7 ± 4.4 mm Hg), pyloric distensibility was decreased in 61.1% of patients in the antireflux surgery group (14.5 ± 3.4 mm2 /mm Hg; P < .01) and 75.0% of patients in the esophagectomy group (10.8 ± 2.1 mm2 /mm Hg; P < .05), while pyloric pressure was only increased in the antireflux surgery group (18.9 ± 2.2 mm Hg; P < .01). Pyloric distensibility and pressure were similar in healthy volunteers and in sleeve gastrectomy (distensibility: 20.3 ± 3.8 mm2 /mm Hg; pressure: 15.8 ± 1.6 mm Hg) groups, with decreased pyloric distensibility affecting 18.7% of sleeve gastrectomy patients. CONCLUSION Antireflux surgery and esophagectomy were associated with pylorospasm although pylorospasm was not found in all patients. Sleeve gastrectomy was not associated with altered pyloric distensibility nor altered pyloric pressure.
Collapse
Affiliation(s)
- Charlotte Desprez
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Fabien Wuestenberghs
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Emmanuel Huet
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Digestive Surgery Department, Rouen University Hospital, Rouen, France
| | - Alberto Zalar
- Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Hepatogastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
| |
Collapse
|
40
|
Awad ZT, Abbas S, Puri R, Dalton B, Chesire DJ. Minimally Invasive Ivor Lewis Esophagectomy (MILE): technique and outcomes of 100 consecutive cases. Surg Endosc 2020; 34:3243-3255. [DOI: 10.1007/s00464-020-07529-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023]
|
41
|
Konradsson M, van Berge Henegouwen MI, Bruns C, Chaudry MA, Cheong E, Cuesta MA, Darling GE, Gisbertz SS, Griffin SM, Gutschow CA, van Hillegersberg R, Hofstetter W, Hölscher AH, Kitagawa Y, van Lanschot JJB, Lindblad M, Ferri LE, Low DE, Luyer MDP, Ndegwa N, Mercer S, Moorthy K, Morse CR, Nafteux P, Nieuwehuijzen GAP, Pattyn P, Rosman C, Ruurda JP, Räsänen J, Schneider PM, Schröder W, Sgromo B, Van Veer H, Wijnhoven BPL, Nilsson M. Diagnostic criteria and symptom grading for delayed gastric conduit emptying after esophagectomy for cancer: international expert consensus based on a modified Delphi process. Dis Esophagus 2019; 33:5585602. [PMID: 31608938 PMCID: PMC7150655 DOI: 10.1093/dote/doz074] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/25/2019] [Accepted: 07/14/2019] [Indexed: 12/11/2022]
Abstract
Delayed gastric conduit emptying (DGCE) after esophagectomy for cancer is associated with adverse outcomes and troubling symptoms. Widely accepted diagnostic criteria and a symptom grading tool for DGCE are missing. This hampers the interpretation and comparison of studies. A modified Delphi process, using repeated web-based questionnaires, combined with live interim group discussions was conducted by 33 experts within the field, from Europe, North America, and Asia. DGCE was divided into early DGCE if present within 14 days of surgery and late if present later than 14 days after surgery. The final criteria for early DGCE, accepted by 25 of 27 (93%) experts, were as follows: >500 mL diurnal nasogastric tube output measured on the morning of postoperative day 5 or later or >100% increased gastric tube width on frontal chest x-ray projection together with the presence of an air-fluid level. The final criteria for late DGCE accepted by 89% of the experts were as follows: the patient should have 'quite a bit' or 'very much' of at least two of the following symptoms; early satiety/fullness, vomiting, nausea, regurgitation or inability to meet caloric need by oral intake and delayed contrast passage on upper gastrointestinal water-soluble contrast radiogram or on timed barium swallow. A symptom grading tool for late DGCE was constructed grading each symptom as: 'not at all', 'a little', 'quite a bit', or 'very much', generating 0, 1, 2, or 3 points, respectively. For the five symptoms retained in the diagnostic criteria for late DGCE, the minimum score would be 0, and the maximum score would be 15. The final symptom grading tool for late DGCE was accepted by 27 of 31 (87%) experts. For the first time, diagnostic criteria for early and late DGCE and a symptom grading tool for late DGCE are available, based on an international expert consensus process.
Collapse
Affiliation(s)
- M Konradsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Gastroenterology, Landspitali National University Hospital, Reykjavik, Iceland,Address correspondence to: Magnus Konradsson, MD, Department of Clinical Science, Investigation and Technology (CLINTEC), Karolinska Institutet, 14186 Stockholm, Sweden.
| | - M I van Berge Henegouwen
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - C Bruns
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - M A Chaudry
- Department of Surgery, Royal Marsden Hospital, London, UK
| | - E Cheong
- Norfolk and Norwich University Hospital, Norwich, UK
| | - M A Cuesta
- Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, Netherlands
| | - G E Darling
- Department of Surgery, Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Canada
| | - S S Gisbertz
- Amsterdam UMC, location AMC, University of Amsterdam, Department of Surgery, Cancer Center Amsterdam
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - C A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | | | - W Hofstetter
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - A H Hölscher
- Centre for Esophageal and Gastric Surgery, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
| | - Y Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - J J B van Lanschot
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Lindblad
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - L E Ferri
- Department of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - D E Low
- Virginia Mason Medical Center, Seattle, WA, USA
| | - M D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, The Netherlands
| | - N Ndegwa
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
| | - S Mercer
- Queen Alexandra Hospital Portsmouth, United Kingdom
| | - K Moorthy
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - C R Morse
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | | | - P Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - C Rosman
- Department of surgery, Radboud university center Nijmegen, The Netherlands
| | - J P Ruurda
- Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - J Räsänen
- Department of General, Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - P M Schneider
- The Center for Visceral, Thoracic and Specialized Tumor Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - W Schröder
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
| | - B Sgromo
- Oxford University Hospitals, Oxford, UK
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases, Metabolism and Aging, KU Leuven, Belgium
| | - B P L Wijnhoven
- Department of Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - M Nilsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden,Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
42
|
Strong AT, Landreneau JP, Cline M, Kroh MD, Rodriguez JH, Ponsky JL, El-Hayek K. Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis. J Gastrointest Surg 2019; 23:1095-1103. [PMID: 30809781 DOI: 10.1007/s11605-018-04088-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. METHODS Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. RESULTS During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. CONCLUSION POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.
Collapse
Affiliation(s)
- Andrew T Strong
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Joshua P Landreneau
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael Cline
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew D Kroh
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - John H Rodriguez
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey L Ponsky
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Kevin El-Hayek
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. .,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
| |
Collapse
|
43
|
Hadzijusufovic E, Tagkalos E, Neumann H, Babic B, Heinrich S, Lang H, Grimminger PP. Preoperative endoscopic pyloric balloon dilatation decreases the rate of delayed gastric emptying after Ivor-Lewis esophagectomy. Dis Esophagus 2019; 32:5223194. [PMID: 30508077 DOI: 10.1093/dote/doy097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/26/2018] [Accepted: 09/12/2018] [Indexed: 12/11/2022]
Abstract
Delayed gastric emptying (DGE) after Ivor-Lewis esophagectomy occurs postoperatively in up to 50% of the patients. This pyloric dysfunction can lead to severe secondary complications postoperatively such as early aspiration, pneumonia or may even have an impact on anastomotic healing and therefore leakage. Early detection of DGE is essential to prevent further complications. The common treatment postoperatively is endoscopic pyloric balloon dilatation (EPBD) after symptoms already occurred. In our work, we analyzed patients who received a preoperative EPBD during the routine restaging endoscopy and compared those patients to a control group to analyze if preoperative EPBD may prevent postoperative DGE and secondary additional complications. We performed a single-center retrospective analysis of 115 patients who received an Ivor-Lewis esophagectomy by the same surgeon between June 2015 and October 2017. Out of these 115 patients, 91 (79.1%) patients received EPBD preoperatively during the staging/restaging endoscopy (PDG, pyloric dilatation group). In 24 (20.9%) patients, preoperative EPBD was not performed due to stenotic esophageal tumors or logistic reasons (NDG, non-pyloric dilatation group). Data of the PDG and NDG group were compared regarding the rate of postoperative DGE as well as DGE and EPBD related complications. In total, 21 (18.3%) patients developed pyloric dysfunction requiring a total of 27 EPBD during follow-up. There were 12 (13.2%) patients in the PDG and 9 (37.5%) patients in the NDG (p = 0.014), respectively. DGE-related complications such as anastomotic leaks (p = 0.466), pulmonary complications (p = 0.466) and longer median hospital stay (p = 0.685) were more frequent in the NDG group; however this difference did not reach statistical significance. The success rate for postoperative EPBD with 20-mm balloons was lower (58.5%) compared to the usage of 30-mm balloons (93.3%). All pre- and postoperative EPBD were performed without any complications. Preoperative EPBD is feasible, safe and can be combined with restating endoscopy. It seems that preoperative EPBD reduces the incidence of DGE and can prevent the need for early postoperative endoscopic interventions. Our recommendation is therefore to perform an EPBD preoperatively when possible to reduce postoperative complications to a minimum. For postoperative EPBD, we recommend the use of the 30-mm balloon due to lower redilatation rates.
Collapse
Affiliation(s)
- E Hadzijusufovic
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - E Tagkalos
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - H Neumann
- Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - B Babic
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - S Heinrich
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - H Lang
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - P P Grimminger
- Department of General-, Visceral-, and Transplant Surgery, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| |
Collapse
|
44
|
Tham JC, Nixon M, Ariyarathenam AV, Humphreys L, Berrisford R, Wheatley T, Sanders G. Intraoperative pyloric botulinum toxin injection during Ivor-Lewis gastroesophagectomy to prevent delayed gastric emptying. Dis Esophagus 2019; 32:5250777. [PMID: 30561584 DOI: 10.1093/dote/doy112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 09/28/2018] [Accepted: 10/24/2018] [Indexed: 12/11/2022]
Abstract
Delayed gastric emptying (DGE) is a common morbidity that affects 10%-50% of Ivor-Lewis gastroesophagectomy (ILGO) patients. DGE management is variable with no gold standard prevention or treatment. We conducted a study to assess the effectiveness of intraoperative pyloric botulinum toxin injection in preventing DGE. All patients undergoing an ILGO for curative intent, semi-mechanical anastomosis, and enhanced recovery between 1st December 2011 and 30th June 2017 were included. Patients with pyloroplasties were excluded and botulinum toxin was routinely given from the 2nd April 2016. We compared botulinum toxin injection (BOTOX) against no intervention (NONE) for patient demographics, adjuvant therapy, surgical approach, DGE incidence, length of stay (LOS), and complications. Additionally, we compared pneumonia risk, anastomotic leak rate, and LOS in DGE versus non-DGE patients. DGE was defined using nasogastric tube input/output differences and chest X-ray appearance according to an algorithm adopted in our unit, which were retrospectively applied. There were 228 patients: 65 (28.5%) received botulinum toxin and 163 (71.5%) received no intervention. One hundred twenty-four (54.4%) operations were performed laparoscopically, of which 11 (4.8%) were converted to open procedures, and 104 (45.6%) were open operations. DGE incidence was 11 (16.9%) in BOTOX and 29 (17.8%) in NONE, P = 0.13. Medical management was required in 14 of 228 (6.1%) cases: 3 (4.6%) in BOTOX and 11 (4.8%) in NONE. Pyloric dilatation was required in 26 of 228 (11.4%): 8 of 65 (12.3%) in the BOTOX and 18 of 163 (11.0%) in NONE. There were no significant differences between groups and requirement for intervention, P = 0.881. Overall median LOS was 10 (6.0-75.0) days: 9 (7.0-75.0) in BOTOX and 10 (6.0-70.0) in NONE, P = 0.516. In non-DGE versus DGE patients, median LOS was 9 (6-57) versus 14 (7-75) days (P < 0.0001), pneumonia incidence of 27.7% versus 30.0% (P = 0.478), and anastomotic leak rate of 2.1% versus 10.0% (P = 0.014). Overall leak rate was 3.5%. Overall complication rate was 67.1%, including minor/mild complications. There were 43 of 65 (66.2%) in BOTOX and 110 of 163 (67.5%) in NONE, P = 0.482. In-hospital mortality was 1 (0.44%), 30-day mortality was 2 (0.88%), 90-day mortality was 5 (2.2%), and there were no 30-day readmissions. Intraoperative pyloric botulinum toxin injections were ineffective in preventing DGE (BOTOX vs. NONE: 16.9% vs. 17.8%) or reducing postoperative complications. DGE was relatively common (17.5%) with 11.4% of patients requiring postoperative balloon dilatation. DGE also resulted in prolonged LOS (increase from 9 to 14 days) and significant increase in leak rate from 2.1% to 10.0%. A better understanding of DGE will guide assessment, investigation, and management of the condition.
Collapse
Affiliation(s)
- J C Tham
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - M Nixon
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - A V Ariyarathenam
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - L Humphreys
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - R Berrisford
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - T Wheatley
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| | - G Sanders
- Peninsula Oesophago-gastric Centre, University Hospitals Plymouth NHS Trust, united Kingdom
| |
Collapse
|
45
|
Grimminger PP, Fuchs HF. [Minimally invasive and robotic-assisted surgical management of upper gastrointestinal cancer]. Chirurg 2019; 88:1017-1023. [PMID: 29026937 DOI: 10.1007/s00104-017-0522-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Total minimally invasive upper gastrointestinal resections are currently mainly performed in centers. The advantages include reduction of operative trauma, magnified enlargement of the operation field and the resulting improvement in operative precision. Robotic-assisted minimally invasive esophagectomy (RAMIE) and laparoscopic/thoracoscopic minimally invasive esophagectomy (MIE) are currently the most commonly performed strategies for esophageal cancer. Laparoscopic (MIG) and robotic-assisted gastrectomy (RAG) are the equivalent procedures for gastric cancer. Due to the relatively low number of reported cases, no definitive statement regarding superiority of these procedures compared to standard open or hybrid procedures can be made; however, there is mounting evidence from high-volume centers in which these procedures are routinely performed that there might be an advantage regarding perioperative morbidity. All of the four procedures described are provided at our high-volume centers in a standardized manner and we are convinced of the benefits of these minimally invasive techniques with respect to morbidity compared to open and hybrid techniques. The additional costs of this technology have to be off-set against a possible reduction of morbidity, reduced cost for personnel and new operative options, such as real-time fluoroscopy.
Collapse
Affiliation(s)
- P P Grimminger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Johannes Gutenberg Universität Mainz, Mainz, Deutschland
| | - H F Fuchs
- Klinik und Poliklinik für Allgemein‑, Viszeral- und Tumorchirurgie, Universität zu Köln, Kerpener Str. 62, Köln, Deutschland.
| |
Collapse
|
46
|
Abstract
With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.
Collapse
Affiliation(s)
- Magnus Konradsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
47
|
Abstract
Delayed gastric conduit emptying (DGE) is a common complication after esophagectomy. Currently, pyloric interventions are the major prevention and treatment for DGE. In this review, we attempt to evaluate the clinical effect and safety of different pyloric interventions in esophagectomy patients. Moreover, other important management of DGE, including size of esophageal substitute, erythromycin and nasogastric tube (NGT) will also be discussed.
Collapse
Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University, Guangzhou 510080, China
| |
Collapse
|
48
|
Nobel T, Tan KS, Barbetta A, Adusumilli P, Bains M, Bott M, Jones D, Molena D. Does pyloric drainage have a role in the era of minimally invasive esophagectomy? Surg Endosc 2018; 33:3218-3227. [PMID: 30535543 DOI: 10.1007/s00464-018-06607-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/28/2018] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pyloric drainage during minimally invasive esophagectomy (MIE) may be more technically challenging than with an open approach. Alternatives to classic surgical drainage have increased in popularity; however, data are lacking to demonstrate whether one technique is superior in MIE. The purpose of this study was to compare post-operative outcomes after MIE between different pyloric drainage methods. METHODS We performed a retrospective review of a prospectively maintained database of patients undergoing MIE at a single academic institution. Patients were divided into three groups for analysis: no drainage, intrapyloric Botulinum Toxin injection, and surgical drainage (pyloroplasty or pyloromyotomy). The primary outcome was any complication within 90 days of surgery; secondary outcomes included reported symptoms and need for pyloric dilation at 6 and 12 months post-operatively. Comparisons among groups were conducted using the Kruskal Wallis and Chi Square tests. RESULTS There were 283 MIE performed between 2011 and 2017; of these, 126 (45%) had drainage (53 Botulinum injection and 73 surgical). No significant difference in the rate of post-operative complications, pneumonia, or anastomotic leak was observed between groups. At 6 and 12 months, patients that received Botulinum injection and surgical drainage had significantly more symptoms than no drainage (p < 0.0001) and higher need for pyloric dilation at 6 months (p = 0.007). CONCLUSIONS Pyloric drainage was not significantly associated with lower post-operative complications or long-term symptoms. While Botulinum injection appears safe post-operatively, it was associated with increased morbidity long-term. Pyloric drainage in MIE may be unnecessary.
Collapse
Affiliation(s)
- Tamar Nobel
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Kay See Tan
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Arianna Barbetta
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Prasad Adusumilli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Manjit Bains
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew Bott
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniela Molena
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| |
Collapse
|
49
|
Boshier PR, Adam ME, Doran S, Muthuswamy K, Hanna GB. Effects of intraoperative pyloric stretch procedure on outcomes after esophagectomy. Dis Esophagus 2018; 31:5018658. [PMID: 29846516 DOI: 10.1093/dote/doy038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Various methods have been described to aid pyloric drainage in patients undergoing esophagectomy with gastric reconstruction. These techniques are intended to prevent delayed gastric empting following esophagectomy that can be associated with early morbidity and long-term functional complaints. The current study aims to review the safety and efficacy of a pyloric stretch procedure performed at the time of esophagectomy. To achieve this, a retrospective review of 100 consecutive patients undergoing esophagectomy during the period 2011-2016 was performed. Until May 2013, no patients received intraoperative pyloric intervention. After May 2013, all patients (N = 50) underwent intraoperative pyloric stretch procedure that involved bidirectional mechanical dilatation of the pylorus. Postoperative outcomes including result of routine oral contrast swallow and early morbidity were evaluated. Intraoperative pyloric stretching was performed safely and without local complications in all patients. Delayed gastric emptying was observed significantly less frequently in patients who received intraoperative pyloric stretching (48% vs. 22%, P = 0.006). No significant differences were observed in postoperative outcomes. When considering all patients as a single cohort, the presence of delayed gastric emptying was associated with significantly higher rates of postoperative pneumonia (71% vs. 45%, P = 0.010), cardiac complications (57% vs. 25%, P = 0.001) as well as longer hospital say (12 vs. 15 days, P < 0.001) and delay to free oral fluid intake (7 vs. 9 days, < 0.001). Binary logistic regression identified age and postoperative delayed gastric emptying as independent risk factors for postoperative pneumonia. In conclusion, this study has demonstrated the safety and efficacy an intraoperative pyloric stretch procedure for the prevention of delayed gastric emptying following esophagectomy.
Collapse
Affiliation(s)
- P R Boshier
- Department of Surgery and Cancer, Imperial College London, UK
| | - M E Adam
- Department of Surgery and Cancer, Imperial College London, UK
| | - S Doran
- Department of Surgery and Cancer, Imperial College London, UK
| | - K Muthuswamy
- Department of Surgery and Cancer, Imperial College London, UK
| | - G B Hanna
- Department of Surgery and Cancer, Imperial College London, UK
| |
Collapse
|
50
|
Marchese S, Qureshi YA, Hafiz SP, Dawas K, Turner P, Mughal MM, Mohammadi B. Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study. J Gastrointest Surg 2018; 22:1319-1324. [PMID: 29667092 DOI: 10.1007/s11605-018-3759-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/24/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus. METHODS A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment. RESULTS Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively). CONCLUSION We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.
Collapse
Affiliation(s)
- Salvatore Marchese
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Yassar A Qureshi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Shazia P Hafiz
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - Khaled Dawas
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Paul Turner
- Upper Gastrointestinal Service, Royal Preston Hospital, Lancashire Teaching Hospitals, Preston, UK
| | - M Muntzer Mughal
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK
| | - Borzoueh Mohammadi
- Department of Oesophago-Gastric Surgery, University College Hospital, University College London Hospitals, 250 Euston Road, London, NW1 2PG, UK.
| |
Collapse
|