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Morikawa K, Tanishima Y, Igarashi T, Ohki Y, Takahashi K, Kurogochi T, Yano F, Ojiri H. Evaluation of the Usefulness of Contrast-Enhanced Computed Tomography for the Early Detection of Anastomotic Leakage After Esophagectomy. J Comput Assist Tomogr 2024; 48:719-726. [PMID: 38346793 DOI: 10.1097/rct.0000000000001595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
OBJECTIVE Anastomotic leakage is one of the most severe complications after esophagectomy. However, a diagnostic gold standard for anastomotic leakage has not been established yet. This retrospective cohort study aimed to evaluate the potential use of routine postoperative contrast-enhanced computed tomography findings as an early predictor of anastomotic leakage in patients who underwent esophagectomy for esophageal cancer. METHODS This study included 75 patients who underwent Mckeown esophagectomy, of whom 22 developed anastomotic leakage after surgery. The computed tomography findings for this patient cohort were categorized into 3 grades based on mural enhancement patterns observed at the anastomotic site. Both semiquantitative and quantitative analyses were performed, and the interobserver agreement between the 2 experienced radiologists was assessed. RESULTS It was found that poor enhancement in both the early and portal venous phases (grade 2) had a robust association with the occurrence of anastomotic leakage. The computed tomography enhancement ratio that is used to estimate wall degeneration and ischemia was significantly higher in patients with anastomotic leakage. CONCLUSIONS Routine postoperative contrast-enhanced computed tomography could be beneficial for the early detection of anastomotic leakage, even in asymptomatic patients, after esophagectomy.
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Affiliation(s)
| | - Yuichiro Tanishima
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | - Keita Takahashi
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Kurogochi
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Division of Gastrointestinal Surgery, Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan
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Lemmens J, Klarenbeek B, Verstegen M, van Workum F, Hannink G, Ubels S, Rosman C. Performance of a consensus-based algorithm for diagnosing anastomotic leak after minimally invasive esophagectomy for esophageal cancer. Dis Esophagus 2023; 36:doad016. [PMID: 36988007 PMCID: PMC10543373 DOI: 10.1093/dote/doad016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/17/2023] [Indexed: 03/30/2023]
Abstract
Anastomotic leak (AL) is a common and severe complication after esophagectomy. This study aimed to assess the performance of a consensus-based algorithm for diagnosing AL after minimally invasive esophagectomy. This study used data of the ICAN trial, a multicenter randomized clinical trial comparing cervical and intrathoracic anastomosis, in which a predefined diagnostic algorithm was used to guide diagnosing AL. The algorithm identified patients suspected of AL based on clinical signs, blood C-reactive protein (cut-off value 200 mg/L), and/or drain amylase (cut-off value 200 IU/L). Suspicion of AL prompted evaluation with contrast swallow computed tomography and/or endoscopy to confirm AL. Primary outcome measure was algorithm performance in terms of sensitivity, specificity, and positive and negative predictive values (PPV, NPV), respectively. AL was defined according to the definition of the Esophagectomy Complications Consensus Group. 245 patients were included, and 125 (51%) patients were suspected of AL. The algorithm had a sensitivity of 62% (95% confidence interval [CI]: 46-75), a specificity of 97% (95% CI: 89-100), and a PPV and NPV of 94% (95% CI: 79-99) and 77% (95% CI: 66-86), respectively, on initial assessment. Repeated assessment in 19 patients with persisting suspicion of AL despite negative or inconclusive initial assessment had a sensitivity of 100% (95% CI: 77-100). The algorithm showed poor performance because the low sensitivity indicates the inability of the algorithm to confirm AL on initial assessment. Repeated assessment using the algorithm was needed to confirm remaining leaks.
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Affiliation(s)
- Jobbe Lemmens
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bastiaan Klarenbeek
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Moniek Verstegen
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frans van Workum
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Gerjon Hannink
- Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sander Ubels
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Drefs M, Schardey J, von Ehrlich-Treuenstätt V, Wirth U, Burian M, Zimmermann P, Werner J, Kühn F. Endoscopic Treatment Options for Gastrointestinal Leaks. Visc Med 2022; 38:311-321. [PMID: 37970585 PMCID: PMC10642546 DOI: 10.1159/000526759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients. Methods We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
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Postoperative Leckagen im Gastrointestinaltrakt – Diagnostik und Therapie. DER GASTROENTEROLOGE 2022; 17:47-56. [PMID: 35035584 PMCID: PMC8744584 DOI: 10.1007/s11377-021-00584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/17/2022]
Abstract
Postoperative Leckagen nach Ösophagus‑, Magen- oder Kolon- bzw. Rektumchirurgie stellen schwerwiegende chirurgische Komplikationen mit einer hohen Morbidität und Mortalität dar. Leckagen werden zumeist durch eine Kombination aus klinischer Beobachtung, Infektionsparametern sowie endoskopischen und schnittbildgebenden Verfahren diagnostiziert. Die Therapie ist bei intraperitonealen Leckagen chirurgisch, bei retroperitonealen bzw. mediastinalen Leckagen in einem interdisziplinären Setting überwiegend interventionell endoskopisch. Hier stehen der Defektverschluss durch die Abdichtung mittels selbstexpandierender gecoverter Stents mit gleichzeitiger externer extraluminaler Drainage sowie der Defektverschluss mit simultaner innerer Drainage und endoskopischer Unterdrucktherapie als vorrangige Methoden zur Verfügung.
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Veziant J, Gaillard M, Barat M, Dohan A, Barret M, Manceau G, Karoui M, Bonnet S, Fuks D, Soyer P. Imaging of postoperative complications following Ivor-Lewis esophagectomy. Diagn Interv Imaging 2021; 103:67-78. [PMID: 34654670 DOI: 10.1016/j.diii.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/21/2021] [Indexed: 02/08/2023]
Abstract
Postoperative imaging plays a key role in the identification of complications after Ivor-Lewis esophagectomy (ILE). Careful analysis of imaging examinations can help identify the cause of the presenting symptoms and the mechanism of the complication. The complex surgical procedure used in ILE results in anatomical changes that make imaging interpretation challenging for many radiologists. The purpose of this review was to make radiologists more familiar with the imaging findings of normal anatomical changes and those of complications following ILE to enable accurate evaluation of patients with an altered postoperative course. Anastomotic leak, gastric conduit necrosis and pleuropulmonary complications are the most serious complications after ILE. Computed tomography used in conjunction with oral administration of contrast material is the preferred diagnostic tool, although it conveys limited sensitivity for the diagnosis of anastomotic fistula. In combination with early endoscopic assessment, it can also help early recognition of complications and appropriate therapeutic management.
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Affiliation(s)
- Julie Veziant
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Martin Gaillard
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Anthony Dohan
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
| | - Maximilien Barret
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology and Digestive Oncology, Hôpital Cochin, APHP.Centre, 75014 Paris, France
| | - Gilles Manceau
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Mehdi Karoui
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, APHP.Centre, 75015 Paris, France
| | - Stéphane Bonnet
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Hôpital Cochin, APHP.Centre, 75014 Paris, France; Université de Paris, Faculté de Médecine, 75006 Paris, France
| | - Philippe Soyer
- Université de Paris, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, APHP.Centre, 75014, Paris, France
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