Management of Tracheo- or Bronchoesophageal Fistula After Ivor-Lewis Esophagectomy

Background

The development of tracheo- or bronchoesophageal fistula (TBF) after Ivor-Lewis esophagectomy remains to be a rare complication associated with a high mortality rate.

Methods

In this retrospective study, the charts of patients with TBF after esophagectomy were analyzed in terms of individual patient characteristics, esophagotracheal complications, respiratory function, management, and outcome.

Results

Between January 2000 and December 2014, 1204 patients underwent Ivor-Lewis esophagectomy for esophageal cancer; 13 patients (1.1 %) developed a TBF. In all 13 patients, a concomitant leakage of the intrathoracic esophagogastrostomy was evident, either prior to diagnosis of TBF (metachronous TBF) or simultaneously (synchronous TBF). TBF was predominantly located in the left main bronchus (n = 6, 46.1 %) or trachea (n = 5, 38.5 %). Management of TBF included re-thoracotomy (n = 7), interventional endoscopic (n = 10) or bronchoscopic therapy (n = 4). In the majority of patients (n = 8), management consisted of two subsequent treatment modalities. In 3 out of four patients, TBF was successfully treated by endoscopic stenting only. Five patients (38.5 %) died following a septic course with multiple organ failure.

Conclusions

The development of TBF after Ivor-Lewis esophagectomy is always combined with anastomotic leakage of the esophagogastrostomy. Treatment options primarily depend on the vascularization of the gastric conduit, the severity of the concomitant aspiration pneumonia, and the volume of the air leakage.

     

Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses

Background

Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.

Methods

From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.

Results

In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1–78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤10 versus >10 mm (68 vs. 64 %; p = 0.479).

Conclusion

CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.     

Feasibility of esophageal reconstruction using a pedicled jejunum with intrathoracic esophagojejunostomy in the upper mediastinum for esophageal cancer

Objective

An alternative conduit is needed when the gastric tube cannot be used as an esophageal substitute for reconstruction after esophagectomy. We adopted pedicle jejunal reconstruction with intrathoracic anastomosis in the upper mediastinum under such circumstances. The aim of this study was to evaluate the feasibility of this technique.

Methods

Two hundred and ten patients with esophageal cancer underwent esophagectomy and reconstruction from 1998 to 2013. Among them, 6 patients underwent colon interposition (colon group) and 13 underwent jejunum reconstruction (jejunum group) including 8 thoracoscopic anastomosis. The operative results of both groups were compared with those of 191 gastric tube reconstructions (stomach group).

Results

The operative times in the colon and jejunum groups were significantly longer than that in the stomach group (P = 0.001 and P = 0.018, respectively). The colon group showed more operative blood loss and more frequent anastomotic leakage and ischemic stenosis of the conduit than did the stomach group (1605 vs. 530 g, P = 0.007; 50 vs. 12.6 %, P = 0.035; 16.7 vs. 0 %, P = 0.03, respectively). There was no anastomotic leakage, conduit necrosis and mortality in the jejunum group. Ischemic stenosis of the conduit occurred more frequently in jejunum group than in the stomach group (23.1 vs. 0 %, P < 0.001). However, the stenosis could be managed safely with endoscopic treatment. Patient survival in the colon and jejunum groups was consistent with that in the stomach group.

Conclusions

Pedicle jejunal reconstruction with intrathoracic anastomosis can be performed safely under thoracotomy or thoracoscopic surgery when stomach cannot be used as an esophageal substitute after esophagectomy.     

Risk factors for pulmonary complications after esophagectomy for esophageal cancer

Purpose

Pulmonary complications after esophagectomy are still common and are a major cause of mortality. The aim of this study was to clarify the risk factors for the occurrence of pulmonary complications after esophagectomy.

Methods

The clinical courses of 299 patients who underwent elective subtotal esophagectomy with lymph node dissection for esophageal cancer were retrospectively analyzed. Group I included patients who had pulmonary complications (n = 53), and group II included patients who did not (n = 246). The clinicopathological factors, surgical procedures and surgical results were compared between the groups.

Results

The frequency of any pulmonary complication was 17.7 %. Pneumonia (n = 26; 8.7 %) and respiratory failure that needed initial ventilatory support for 48 h or reintubation (n = 16; 5.4 %) were the major morbidities. The results of the logistic regression analysis suggested that smoking with a Brinkman index ≥800, salvage esophagectomy after definitive chemoradiotherapy and the amount of blood loss/body weight were independent factors associated with the occurrence of pulmonary complications.

Conclusion

Pulmonary complications after esophagectomy remain common despite advances in perioperative management. Cases with a history of heavy smoking, preoperative definitive chemoradiotherapy, and high blood loss during surgery require more careful postoperative pulmonary care.     

Compromised visceral circulation does not affect the outcome of colorectal surgery

Purpose

Anastomotic leakage is a serious complication after colorectal surgery, and many risk factors for this problem have so far been identified. The aim of this study was to assess the association between visceral arterial occlusive disease and anastomotic leakage.

Methods

The preoperative abdominal computed tomography scans from all consecutive patients who underwent colorectal surgery with anastomosis in 2010 were retrospectively analyzed.

Results

A total of 242 patients were included, with a median age of 65 years (interquartile range 55–74). Anastomotic leakage occurred in 14 % of cases (n = 34). The mortality rate was 3 % (n = 8). There was no association between atherosclerosis of the visceral or iliac arteries and anastomotic leakage. There was also no association between right-sided or left-sided resections and total occlusion of the superior or inferior mesenteric artery, respectively.

Conclusion

Asymptomatic visceral artery occlusive disease is not a risk factor for anastomotic leakage after colorectal surgery, and additional radiological imaging or percutaneous transluminal angioplasty for occluded visceral vessels is not indicated prior to colorectal surgery.     

Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the use of computed tomography scan versus early endoscopy

Background

Concern over potential injury to the anastomosis has limited the use of early postoperative endoscopy to diagnose conduit ischemia or anastomotic breakdown. Alternatively, a computed tomography (CT) scan has been suggested as a noninvasive means for identifying these complications. This study aimed to compare CT scan with early endoscopy for diagnosing gastric conduit ischemia or anastomotic breakdown after esophagectomy with cervical esophagogastrostomy.

Methods

Between 2000 and 2007, 554 patients underwent an esophagectomy and gastric pull-up with cervical esophagogastrostomy at the University of Southern California. Records were reviewed to identify patients who had undergone endoscopy and CT scan within 24 h of each other during the first three postoperative weeks for suspicion of an ischemic conduit or anastomotic breakdown. The accuracies of CT scan and endoscopy in diagnosing an ischemic conduit were compared.

Results

A total of 76 patients had endoscopy and CT scan for clinical suspicion of conduit ischemia or anastomotic breakdown. Endoscopy was performed without complications in all 76 patients. The postoperative endoscopic findings were normal in 24 of the patients, and none subsequently experienced an ischemic conduit or anastomotic breakdown. Evidence of ischemia was present in 28 patients, 7 of whom had black mucosa throughout the gastric conduit with the anastomosis still intact and required removal of their conduit. The remaining 24 patients had partial or complete anastomotic breakdown. On the CT scan, 23 of the 76 patients showed evidence of conduit ischemia (n = 9) or anastomotic breakdown (n = 14). There was no evidence of ischemia or anastomotic breakdown on CT scan for the 24 patients with normal endoscopy or for 3 of the 7 patients who had their conduit removed for graft necrosis.

Conclusion

A normal CT scan does not rule out the possibility of an ischemic gastric conduit after esophagectomy. Early endoscopy is a safe and accurate method for assessing conduit ischemia.     

Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent

Background

Leaks of the esophagus are associated with a high mortality rate and need to be treated as soon as possible. Therapeutic options are surgical repair or resection or conservative management with cessation of oral intake and antibiotic therapy. We evaluated an alternative approach that uses self-expandable metallic stents (SEMS).

Methods

Between 2002 and 2007, 31 consecutive patients with iatrogenic esophageal perforation (n = 9), intrathoracic anastomotic leak after esophagectomy (n = 16), spontaneous tumor perforation (n = 5), and esophageal ischemia (n = 1) were treated at our institution. All were treated with endoscopic placement of a covered SEMS. Stent removal was performed 4 to 6 weeks after implantation. To exclude continuous esophageal leak after SEMS placement, radiologic examination was performed after stent implantation and removal.

Results

SEMS placement was successful in all patients and a postinterventional esophagogram demonstrated full coverage of the leak in 29 patients (92%). In two patients, complete sealing could not be achieved and they were referred to surgical repair. Stent migration was seen in only one patient (3%). After removal, a second stent with larger diameter was placed and no further complication occurred. Two patients died: one due to myocardial infarction and one due to progressive ischemia of the esophagus and small bowl as a consequence of vascular occlusion. Stent removal was performed within 6 weeks, and all patients had radiologic and endoscopic evidence of esophageal healing.

Conclusions

Implantation of covered SEMS in patients with esophageal leak or perforation is a safe and feasible alternative to operative treatment and can lower the interventional morbidity rate.     

Factors Associated with Postoperative Pulmonary Morbidity After Esophagectomy for Cancer

Background

Most studies analyzing risk factors for pulmonary morbidity date from the early 1990s. Changes in technology and treatment such as minimally invasive esophagectomy (MIE) and neoadjuvant treatment mandate analysis of more contemporary cohorts.

Methods

Predictive factors for overall and specific pulmonary morbidity in 858 patients undergoing esophagectomy between 1998 and 2008 in five Australian university hospitals were analyzed by logistic regression models.

Results

A total of 394 patients underwent open esophagectomy, and 464 patients underwent MIE. A total of 259 patients received neoadjuvant chemoradiotherapy, 139 preoperative chemotherapy alone, and 2 preoperative radiotherapy alone. In-hospital mortality was 3.5%. Smoking and the number of comorbidities were risk factors for overall pulmonary morbidity (odds ratio [OR] 1.47, P = 0.016; OR 1.35, P = 0.001) and pneumonia (OR 2.29, P = 0.002; 1.56, P = 0.005). The risk of respiratory failure was higher in patients with more comorbidities (OR 1.4, P = 0.035). Respiratory comorbidities (OR 3.81, P = 0.017) were strongly predictive of postoperative acute respiratory distress syndrome (ARDS). ARDS (4.51, P = 0.032) or respiratory failure (OR 8.7, P < 0.001), but not anastomotic leak (OR 2.22, P = 0.074), were independent risk factors for death. MIE (OR 0.11, P < 0.001) and thoracic epidural analgesia (OR 0.12, P = 0.003) decreased the risk of respiratory failure. Neoadjuvant treatment was not associated with an increased risk of pulmonary complications.

Conclusions

Preoperative comorbidity and smoking were risk factors for respiratory complications, whereas neoadjuvant treatment was not. MIE and the use of thoracic epidural analgesia decreased the risk of respiratory failure. Respiratory failure and ARDS were the only independent factors associated with an increased risk of in-hospital death, whereas anastomotic leakage was not.     

Surgical Endoscopic Vacuum Therapy for Anastomotic Leakage and Perforation of the Upper Gastrointestinal Tract

Introduction

Emergency operations for perforations and anastomotic leakage of the upper gastrointestinal tract are associated with a high overall morbidity and mortality rate. An endoscopic vacuum therapy (EVT) has been established successfully for anastomotic leakage after rectal resection but only limited data exist for EVT of the upper GI tract.

Methods

We report on a series of nine patients treated with EVT for defects of the upper intestinal tract between March 2011 and May 2012. In four patients, initial endoscopic sponge placement was performed in combination with open surgical revision. Median follow-up was 189 (range, 51?C366) days.

Results

In total, 52 vacuum sponges were placed in upper GI defects of nine patients. Indication for EVT were anastomotic leakage after esophageal resection or gastrectomy (n?=?5) and iatrogenic or spontaneous esophageal perforations (n?=?4). The mean number of sponge insertions was six (range, 1?C13) with a mean changing interval of 3.5?days (range, 2?C5). A successful vacuum therapy for upper intestinal defects was achieved in eight of nine patients (89?%).

Conclusion

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. If necessary the endoscopic procedure can be combined with operative revision for better control of the local septic focus.     

Intrathoracic Anastomotic Leakage after Gastroesophageal Cancer Resection Is Associated with Reduced Long-term Survival

Background

Most likely because of low statistical power, no previous studies have shown any significant association between long-term survival and anastomotic leakage in patients who have undergone gastroesophageal cancer resection.

Material and methods

The present study included, prospectively and consecutively, nationwide collected patients who underwent gastroesophageal cancer resection between 2003 and 2011 in Denmark. The operation was carried out as an Ivor Lewis procedure. Only patients with intrathoracic anastomosis were included in the analysis.

Results

From 2003 to 2011, 1,296 patients underwent gastroesophageal resection, and 128 (9.9 %) of these experienced anastomotic leakage. The overall 5-year survival rates in patients with and without anastomotic leakage were 20 and 35 % (P < 0.0001), respectively. After exclusion of 4 weeks mortality, the 5-year survival rate in patients with leakage was 22 % compared to 36 % in patients without anastomotic leakage (P < 0.001). After exclusion of 8 weeks mortality, the 5-year survival rate was 23 % in patients with leakage and 36 % in those without (P = 0.009). The corresponding median time of survival was 74 versus 128, 87 versus 138, and 95 versus 138 weeks, respectively. The overall hazard ratios of death after anastomotic leakage, unadjusted, and after adjusting for potentially confounding factors, were 1.59 (1.27–1.99) and 1.45 (1.14–1.84). The unadjusted and adjusted odds ratios after exclusion of 4 weeks mortality were 1.51 (1.19–1.90) and 1.41 (1.10–1.81). After exclusion of 8 weeks mortality the odds ratios were 1.38 (1.08–1.77) and 1.32 (1.02–1.71).

Conclusions

This nationwide study confirms that patients experiencing anastomotic leakage after gastroesophageal cancer resection have a significantly lower long-term survival, even following full recovery after the leakage.     

Modified triangulating stapling technique for esophagogastrostomy after esophagectomy for esophageal cancer

Background

Anastomosis performed during esophagectomy for esophageal cancer is usually involves hand-sewn or circular stapled methods. However, these techniques have been reported to be associated with a high frequency of anastomotic complications, including leakage and benign stenosis. Here a novel triangulating stapling technique for esophagogastrostomy after esophagectomy for esophageal cancer and its retrospective investigation are described.

Methods

Forty-eight patients were underwent esophagectomy for esophageal cancer from January 2006 to December 2009 by the same surgeon using the triangulating stapling technique. The short-term outcomes were evaluated retrospectively. This end-to-end anastomosis used three linear staplers in an everted fashion.

Results

Patients comprised 36 men and 12 women with a mean age of 59.4 years. Anastomotic leakage occurred in 4 patients (8.3 %), while anastomotic stenosis was observed in 6 (12.5 %). The average number of endoscopic pneumatic dilatations in patients with anastomotic stenosis was 2.4. The median (range) duration of hospital stay was 40.8 (19–154) days.

Conclusions

Our modified triangulating stapling technique for esophagogastrostomy may be a feasible alternative, resulting in a lower frequency of postoperative anastomotic complications.     

Clinical Outcomes After Unplanned Extubation in a Surgical Intensive Care Population

Background

Clinical outcome after unplanned extubation (UE) in patients admitted to the surgical intensive care unit (SICU) has not been fully investigated. In this study we assessed in-hospital mortality of patients with UE and determined whether UE is a predictor of in-hospital mortality. Finally, we sought to identify predictors of reintubation after UE in mechanically ventilated patients in the SICU.

Methods

Medical charts of patients (n = 4,407) admitted to the SICU between October 2007 and December 2011 were reviewed retrospectively.

Results

Eighty-five episodes of UE occurred in 81 patients. Patients with UE required emergency surgery more frequently and had higher ICU and hospital mortality rates, reintubation rate, and APACHE II scores and longer mechanical ventilation (MV) and ICU stay than patients without UE (P < 0.05 for all associations). Multivariate analysis revealed that reintubation (odds ratio [95 % confidence interval]: 4.14 [2.58–6.67]; P < 0.001), APACHE II scores (1.14 [1.12–1.17]; P < 0.001), emergency surgery (1.73 [1.18–2.53]; P = 0.005), and chronic neurologic disease (2.11 [1.30–3.41]; P = 0.002) were associated with hospital mortality. Reintubation was necessary in 17 patients. On multivariate analysis, a score on the Richmond Agitation–Sedation Scale (RASS, 0.48 [0.31–0.76]; P = 0.001), PaO₂/FiO₂ ratio (0.99 [0.99–1.00]; P = 0.048), and MV duration before UE (1.46 [1.08–1.98]; P = 0.014) were independently associated with reintubation after UE.

Conclusions

Our results indicated that although patients with UE had high in-hospital mortality, UE was not directly associated with in-hospital mortality. Reintubation, chronic neurologic disease, emergency operation, and higher APACHE II score were related to increased in-hospital mortality. A low RASS score, a low PaO₂/FiO₂ ratio, and long MV duration before UE were related to reintubation after UE.     

Effectiveness of a Transanal Tube for the Prevention of Anastomotic Leakage after Rectal Cancer Surgery

Aim

We evaluated the effectiveness and safety of a transanal tube placed for the prevention of anastomotic leakage after rectal surgery.

Methods

Between 2007 and 2011, a total of 243 patients underwent anterior resection using the double stapling technique for rectal cancer at our institution. We excluded 67 patients with diverting stoma and divided the remaining patients into two groups: patients who did not receive a transanal tube and diverting stoma (n = 140; control group) and those who received a transanal tube (n = 36). We compared the rate of anastomotic leakage, evaluated the complications associated with the transanal tube, and analyzed the risk factors for anastomotic leakage.

Results

The following perioperative parameters were significantly different between the two groups as follows (control group vs. transanal tube group): diabetes mellitus (8 [22 %] vs. 12 [8.5 %] patients, respectively; p = 0.03), surgical duration (262 ± 54.1 min [171–457] vs. 233 ± 61.7 min [126–430], respectively; p < 0.01). The postoperative anastomosis leakage appeared significantly different between the two groups (1 [2.7 %] vs. 22 [15.7 %] patients, respectively; p = 0.04). Anastomotic leakage was significantly associated with the distance between the anastomosis line and the anal verge (odds ratio [OR] 8.58; 95 % confidence interval [CI] 1.53–48.0; p = 0.01) and non-use of a transanal tube (OR 11.1; 95 % CI 1.04–118; p = 0.04) in both univariate and multivariate analyses.

Conclusions

Placement of a transanal tube is effective in decreasing the rate of anastomotic leakage after anterior resection using the double stapling technique. However, complications associated with a transanal tube should be carefully considered.     

End-to-End Cervical Esophagogastric Anastomoses Are Associated with a Higher Number of Strictures Compared with End-to-Side Anastomoses

Background

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

Methods

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

Results

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p?=?0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p?=?0.04). Moreover, a median of 11 (7–17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2–8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p?<?0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p?=?0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p?=?0.03 and p?=?0.01, respectively).

Conclusion

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.     

Endoscopic vacuum therapy of anastomotic leakage and iatrogenic perforation in the esophagus

Background

The management of anastomotic leakage and iatrogenic esophageal perforation has shifted over recent decades from aggressive surgery to conservative and, recently, endoscopic therapy alternatives. The authors present their results for endoscopic vacuum therapy used to treat both entities.

Methods

In the authors’ institution, 17 cases of anastomotic leakage and 7 cases of iatrogenic perforation due to interventional endoscopy or rigid panendoscopy with either intraluminal or intracavitary endoscopic vacuum therapy were treated.

Results

In 23 of 24 cases, the endoscopic treatment was successful. The median duration of therapy was 11 days (range, 4–46 days). All 7 cases of iatrogenic perforation and 16 of 17 anastomotic leakage cases were cured after a median therapy duration of 5 and 12 days, respectively.

Conclusions

Endoscopic vacuum therapy is applicable for a wide range of esophageal defects. In the authors’ experience, it has seemed to be the best choice for iatrogenic perforations and has been a potent supplement in the management of anastomotic leakages.     

Assessment of Short-Term Clinical Outcomes following Salvage Esophagectomy for the Treatment of Esophageal Malignancy: Systematic Review and Pooled Analysis

Background

Combined chemoradiotherapy is increasingly being used as definitive treatment for locoregional esophageal malignancy. Patients with residual or recurrent localized cancer are often selectively considered for salvage esophagectomy (SALV). The aim of this pooled analysis was to compare short-term clinical outcomes from SALV following definitive chemoradiotherapy with those from planned esophagectomy following neoadjuvant chemoradiotherapy (NCRS).

Methods

MEDLINE, EMBASE, Cochrane, trial registries, conference proceedings and reference lists were searched for relevant comparative studies. Primary outcome measures were in-hospital mortality, anastomotic leak and pulmonary complications. Secondary outcomes were length of hospital stay, negative (R0) resection margin, and estimated blood loss.

Results

Eight studies comprising 954 patients; 242 (SALV) and 712 (NCRS) were included. SALV was associated with a significantly increased incidence of post-operative mortality (9.50 vs. 4.07 %; pooled odds ratio [POR] = 3.02; p < 0.001), anastomotic leak (23.97 vs. 14.47 %; POR = 1.99; p = 0.005), pulmonary complications (29.75 vs. 16.99 %; POR = 2.12; p < 0.001), and an increased length of hospital stay (weighted mean difference = 8.29 days; 95 % CI 7.08–9.5; p < 0.001). There were no significant differences between the groups in the incidence of negative resection margins or estimated blood loss.

Conclusions

SALV has poorer short-term outcomes when compared with planned esophagectomy following neoadjuvant chemoradiotherapy. Patients and multidisciplinary tumor boards should be made aware of these differences in outcomes and SALV should be reserved for practice in high-volume institutions.     

Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis

Background

Benign anastomotic strictures occur frequently after esophagectomy, and impact on postoperative recovery, nutritional status, and quality of life. This large cohort study explored the incidence of stricture after transthoracic (2- and 3-stage) and transhiatal resections with uniform single-layer sutured anastomotic technique, and aimed to identify independent risk factors.

Methods

Patients undergoing esophagectomy with gastric conduit reconstruction between February 2001 and October 2014 were studied prospectively. Symptomatic anastomotic stricture was defined as dysphagia requiring endoscopic dilatation, and refractory strictures as those requiring >5 dilatations. Multivariable logistic regression was performed to determine factors independently associated with stricture development.

Results

Five-hundred and twenty-four patients, 77 % with adenocarcinoma, underwent esophagectomy [2-stage, n = 328 (62.6 %); 3-stage, n = 129 (23.3 %); transhiatal, n = 74 (14.1 %)], with an overall inhospital mortality rate of 2.7 %. 58.5 % of patients received neoadjuvant therapy [chemotherapy only, n = 119 (22.7 %); chemoradiation, n = 188 (35.9 %)]. Anastomotic stricture developed in 125 patients (24.5 %), was refractory in 20 (3.9 %) and required a median of 2 dilatations (range 1–18). On multivariable analysis, ASA grade (P < 0.05), cervical anastomosis (P < 0.001), and a significant postoperative cardiac event (P < 0.05) were independently associated with stricture risk. Refractory strictures were independently associated with anastomotic leak (P = 0.01) and transhiatal resections (P < 0.001).

Conclusion

Benign anastomotic strictures are common, particularly with cervical reconstruction, and after transhiatal resection. Refractory strictures are rare. Where fitness and oncologic equivalence apply, a thoracic anastomosis provides significant advantages compared with a cervical anastomosis in terms of anastomotic stricture risk.

     

Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer

Background

The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE).

Methods

One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival.

Results

Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027].

Conclusions

MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.     

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

Background

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

Methods

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

Results

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54 %. The overall success in terms of preventing mortality was 96 %.

Conclusion

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.     

Clinical and oncological effects of triplet chemotherapy followed by radical esophagectomy for resectable esophageal cancer associated with unfavorable prognostic factors

Purposes

The purpose of this study was to evaluate the hypothesis that the survival of patients undergoing R0 resection after triplet chemotherapy for resectable esophageal cancer with unfavorable prognostic factors (Category 3) would be similar to that of patients undergoing esophagectomy for esophageal cancer without such factors (Category 1).

Methods

Patients with Category 3 tumors were assigned to receive triplet chemotherapy consisting of 5-fluorouracil, doxorubicin and nedaplatin (FAN) followed by radical esophagectomy. The outcomes of the bimodality treatment for Category 3 patients (n = 25) were compared with those of Category 1 patients (n = 41) in a prospective cohort study.

Results

Grade 3 or higher toxicity developed during chemotherapy in 32 % of the Category 3 patients, with no treatment-related deaths. No significant difference was detected in the surgery-related mortality and morbidity rates between the two groups. The recurrence-free survival was significantly worse in Category 3 than in Category 1 patients (p = 0.002), although the overall survival was not significantly different (p = 0.085) between the two groups in cases of R0 resection (5-year survival rates: 34.4 vs. 66.5 %).

Conclusions

Although FAN chemotherapy followed by radical esophagectomy can be safely performed, this treatment modality may not have sufficient power to cure Category 3 disease.