1
|
Chen C, Xu SJ, Zhang ZF, You CX, Luo YF, Chen RQ, Chen SC. Severe postoperative complications after minimally invasive esophagectomy reduce the long-term prognosis of well-immunonutrition patients with locally advanced esophageal squamous cell carcinoma. Ann Med 2025; 57:2440622. [PMID: 39673205 DOI: 10.1080/07853890.2024.2440622] [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: 05/23/2024] [Revised: 08/17/2024] [Accepted: 08/19/2024] [Indexed: 12/16/2024] Open
Abstract
BACKGROUND While severe postoperative complications (SPCs) impact cancer prognosis, their effect on locally advanced esophageal squamous cell carcinoma (ESCC) patients with varying immunonutritional statuses after minimally invasive esophagectomy (MIE) is unclear. METHODS This retrospective study analyzed 442 patients with locally advanced ESCC who underwent MIE, investigating the relationship between SPCs and survival based on preoperative immunonutritional status, determined by the prognostic nutritional index (PNI). Nomograms were developed for patients with preserved immunonutritional status using Cox regression, and their performance was assessed. RESULTS Of the patients, 102 (23.1%) experienced SPCs after MIE. Five-year overall survival (OS) and disease-free survival (DFS) were significantly different between SPCs and non-SPCs groups (p < 0.001). In the preserved immunonutritional group, SPCs significantly reduced 5-year OS (p = 0.008) and DFS (p = 0.011), but not in the poor immunonutritional group (OS p = 0.152, DFS p = 0.098). Multivariate Cox regression identified SPCs as an independent risk factor for OS (HR = 1.653, p = 0.013) and DFS (HR = 1.476, p = 0.039). A nomogram for predicting OS and DFS in preserved immunonutritional patients demonstrated excellent performance. CONCLUSIONS SPCs significantly affect prognosis in ESCC patients with preserved immunonutritional status after MIE. Nomograms based on SPCs can predict OS and DFS in these patients.
Collapse
Affiliation(s)
- Chao Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Shao-Jun Xu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Zhi-Fan Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Cheng-Xiong You
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Yun-Fan Luo
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Rui-Qin Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Shu-Chen Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian Province, China
- Fujian Provincial Key Laboratory of Cardiothoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| |
Collapse
|
2
|
Thammineedi SR, Patnaik SC, Reddy P, Saksena AR, Shukla S, Schissel ME, Smith LM, Are C, Nusrath S. Indocyanine Green Fluorescence Angiography Versus Visual Assessment for Assessing Perfusion of Gastric Conduit and Esophageal Stump in Post Esophagectomy Patients: A Pilot Randomized Controlled Study. J Surg Oncol 2025. [PMID: 40365846 DOI: 10.1002/jso.28145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2025] [Accepted: 02/25/2025] [Indexed: 05/15/2025]
Abstract
BACKGROUND AND OBJECTIVE Anastomotic leak (AL) is a serious complication following esophagectomy and is often linked to poor perfusion of the gastric conduit (GC) and esophageal stump (EC). The aim of this study is to compare the efficacy of intraoperative Indocyanine green fluorescence angiography (ICG-FA) versus visual assessment VA) to assess perfusion status and its impact on the rate of AL. METHODS Fifty-eight esophageal or gastroesophageal junction carcinoma patients were randomized to ICG-FA (28) and VA (30) groups. Perfusion status was assessed with VA alone in the VA group and with VA followed by ICG-FA in the ICG-FA group. RESULTS The ICG-FA group had a lower leak rate of 4% when compared to 27% in the VA group (p = 0.03). ICG-FA identified nine cases where VA misjudged the GC tip vascularity, thereby avoiding unnecessary resections. ICG-FA necessitated revision of the GC tip in one case missed by VA and also identified poor perfusion of ES tip in three cases mandating revision which were deemed well-perfused by VA. CONCLUSION ICG-FA demonstrated superiority over VA in assessing perfusion adequacy of the GC and ES, which resulted in a statistically significant decrease in the rate of anastomotic leaks.
Collapse
Affiliation(s)
- Subramanyeshwar Rao Thammineedi
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Sujit Chyau Patnaik
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Pratap Reddy
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Ajesh Raj Saksena
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Srijan Shukla
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Makayla E Schissel
- Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
| | - Lynette M Smith
- Department of Biostatistics, University of Nebraska Medical Center, College of Public Health, Nebraska Medical Center, Omaha, USA
| | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, USA
| | - Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| |
Collapse
|
3
|
Zhao Z, Huang W, Fu Y, Ji W, Xu J, Chen F, Chen Z, Huang Z. Comparative analysis of cis-cutting and retro-cutting techniques in gastric tube fabrication for preventing postoperative anastomotic leakage after esophagectomy. Surgery 2025; 181:109124. [PMID: 39884217 DOI: 10.1016/j.surg.2024.109124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Revised: 11/13/2024] [Accepted: 12/25/2024] [Indexed: 02/01/2025]
Abstract
OBJECTIVE The construction of a gastric-tube-substitute esophagus is a common method for digestive tract reconstruction after esophagectomy. However, the incidence of postoperative anastomotic leakage remains high. This study aims to compare the effectiveness of 2 gastric tube fabrication methods-cis-cutting and retro-cutting-in reducing postoperative anastomotic leakage. METHODS We retrospectively analyzed 253 patients who underwent McKeown radical esophagectomy for esophageal cancer at the Second Affiliated Hospital of Fujian Medical University from February 2021 to February 2024. Patients were divided into cis-cut (n = 126) and retro-cut (n = 127) groups on the basis of the surgical technique used. The incidence of anastomotic leakage was compared, and logistic regression was used to identify risk factors. RESULTS Anastomotic leakage (16.7%, 21/126 vs 3.9%, 5/127; P < .001) and stricture (28.6%, 36/126 vs 15%, 19/127; P = .009) rates were lower in the retro-cut group than the cis-cut group. Multivariable analysis identified the gastric tube fabrication method in the cis-cut group as an independent risk factor (odds ratio, 3.390; 95% confidence interval, 1.147-10.018; P = .027) for postoperative anastomotic leakage. CONCLUSION Retro-cut gastric tube fabrication significantly reduces the incidence of anastomotic leakage and anastomotic stricture, suggesting its suitability as a standard technique for esophageal reconstruction.
Collapse
Affiliation(s)
- Zhihuang Zhao
- The Second Clinical College of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Wenbo Huang
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - YuXiang Fu
- The Second Clinical College of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Wei Ji
- The Second Clinical College of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Jie Xu
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Feng Chen
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Zhiyao Chen
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - ZhiJun Huang
- Department of Gastrointestinal and Esophageal Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China.
| |
Collapse
|
4
|
Zeng C, Zhang X, Jia B, Hu Y, Lin P, Fu J, Long H, Rong T, Su X. ASO Author Reflections: Anastomotic Leaks as a Surrogate of Biologic Vulnerability in Esophageal Squamous Cell Carcinoma Survival. Ann Surg Oncol 2025:10.1245/s10434-025-17307-8. [PMID: 40281260 DOI: 10.1245/s10434-025-17307-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2025] [Accepted: 03/22/2025] [Indexed: 04/29/2025]
Affiliation(s)
- Chufeng Zeng
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xu Zhang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Bei Jia
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Yi Hu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Tiehua Rong
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xiaodong Su
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China.
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China.
| |
Collapse
|
5
|
Zeng C, Zhang X, Jia B, Hu Y, Lin P, Fu J, Long H, Rong T, Su X. Impact of Anastomotic Leaks on Long-Term Survival in Patients with Esophageal Squamous Cell Carcinoma Following McKeown Esophagectomy: A Propensity Score-Matched Analysis. Ann Surg Oncol 2025:10.1245/s10434-025-17206-y. [PMID: 40198529 DOI: 10.1245/s10434-025-17206-y] [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: 10/08/2024] [Accepted: 03/03/2025] [Indexed: 04/10/2025]
Abstract
BACKGROUND The impact of anastomotic leak (AL) on the long-term survival of patients with esophageal squamous cell carcinoma (ESCC) remains unclear. This study investigated whether AL influences the long-term survival of patients with ESCC following McKeown esophagectomy. PATIENTS AND METHODS An original database was queried to identify patients with ESCC who underwent McKeown esophagectomy between 2012 and 2020 at a high-volume cancer center. Overall survival (OS) and disease-free survival (DFS) were compared using Kaplan-Meier (KM) curves. Cox regression analysis was used for multivariate analysis. Propensity score matching (PSM) was used to adjust for the confounding factors. RESULTS A total of 1614 patients were included, of whom 16.9% developed AL. In patients without neoadjuvant therapy, for patients with and without AL, the 5-year OS was 55.8% and 62.0%, and the 5-year DFS was 48.7% and 59.1%, respectively (OS: p = 0.37, DFS: p = 0.046). In the neoadjuvant cohort, for patients with and without AL, the 5-year OS was 57.9% and 63.2%, and the 5-year DFS was 55.4% and 58.8%, respectively (OS: p = 0.48, DFS: p = 0.78). Moreover, AL significantly increased the risk of distant recurrence in patients without neoadjuvant therapy (p = 0.023). CONCLUSIONS These findings suggest that AL negatively influences DFS in patients without neoadjuvant therapy, but does not significantly affect long-term survival in patients receiving neoadjuvant treatment. Intensive treatment and follow-up plan should be considered when patients without neoadjuvant therapy.
Collapse
Affiliation(s)
- Chufeng Zeng
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xu Zhang
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Bei Jia
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Yi Hu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Peng Lin
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Hao Long
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Tiehua Rong
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China
| | - Xiaodong Su
- Department of Thoracic Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, People's Republic of China.
- Guangdong Esophageal Cancer Institute, Guangzhou, People's Republic of China.
- State Key Laboratory of Oncology in Southern China and Collaborative Innovation Center for Cancer Medicine, Guangzhou, People's Republic of China.
| |
Collapse
|
6
|
Weber MC, Jorek N, Neumann PA, Bachmann J, Dimpel R, Martignoni M, Feith M, Friess H, Novotny A, Berlet M, Reim D. Incidence and treatment of anastomotic leakage after esophagectomy in German acute care hospitals: a retrospective cohort study. Int J Surg 2025; 111:2953-2961. [PMID: 39878167 DOI: 10.1097/js9.0000000000002274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Accepted: 01/09/2025] [Indexed: 01/31/2025]
Abstract
BACKGROUND Anastomotic leakage (AL) is a major concern following esophagectomy due to the associated morbidity and mortality. The impact of hospital volume on postoperative outcomes after esophagectomy has previously been reported. The aim of this study was to analyze the current trends in postoperative anastomotic leakage and associated failure-to-rescue after esophagectomy in relation to hospital volume in German acute care hospitals using real-world data from the German Diagnosis-Related Groups (G-DRG) database. MATERIALS AND METHODS A retrospective secondary data analysis of the G-DRG database was performed for all in-hospital cases of patients undergoing esophagectomy from 2013 to 2021. AL and in-house mortality rates were assessed in relation to hospital case volume and endoscopic treatment modalities. RESULTS The study included 32 335 cases. The mean reported AL rate was 17.1% with a mean failure-to-rescue rate of 18.9%. AL rates did not differ between hospitals with an annual case-volume ≤ 25 procedures/year vs. >25 procedures/year (16.8% vs. 17.6%, OR 1.06, P = 0.07). However, in high-volume centers (> 25 procedures/year), in-hospital mortality for cases with AL (failure-to-rescue) was lower compared to medium-volume (10-25 cases/year) and low-volume (1-9 cases/year) centers (14.2% vs. 21.5% vs. 25.1%). The use of endoscopic vacuum therapy (EVT) increased over time, reaching 58.1% of AL cases in 2021 compared to 14.2% in 2013, while the use of self-expanding metal stents (SEMS) decreased from 37.0% in 2013 to 9.3% in 2021. CONCLUSIONS AL rates after esophagectomy remain high. In-house mortality is significantly lower in high-volume hospitals highlighting the importance to consider improvements in centralization of procedures. Further efforts are needed to reduce AL rates and improve outcomes after esophagectomy.
Collapse
Affiliation(s)
- Marie-Christin Weber
- Department of Surgery, Technical University of Munich, TUM School of Medicine and Health, TUM University Hospital, Klinikum rechts der Isar, Munich, Germany
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Axtell AL, Angeles C, McCarthy DP, Maloney JD, Leverson GE, DeCamp MM. Anastomotic Leak After Esophagectomy: Analysis of the STS General Thoracic Surgery Database. Ann Thorac Surg 2025; 119:796-804. [PMID: 39864771 DOI: 10.1016/j.athoracsur.2024.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Revised: 12/10/2024] [Accepted: 12/30/2024] [Indexed: 01/28/2025]
Abstract
BACKGROUND Anastomotic leak after esophagectomy is a major cause of morbidity and mortality. We sought to identify the prevalence of anastomotic leak, stratified by operative approach and disease etiology, as well as risk factors for leak. METHODS A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted on patients who underwent esophagectomy with gastric reconstruction between 2009 and 2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop an anastomotic leak. Multivariable mixed effects logistic regression models identified risk factors for leak. RESULTS Of 18,419 patients, 3416 (19%) developed an anastomotic leak. Patients who leaked had more comorbidities, including obesity and diabetes. There was no difference in leak based on disease etiology (P = .435.) Patients with anastomotic leak had increased 30-day mortality (7% vs 4%, P < .001), reoperation (58% vs 10%, P < .001), and longer lengths of stay (18 vs 10 days, P < .001). On multivariable analysis, obesity (odds ratio [OR], 1.27; 95% CI, 1.16-1.38; P < .001), diabetes (OR, 1.14; 95% CI, 1.04-1.25; P = .006), and smoking (OR, 1.26; 95% CI, 1.15-1.37; P < .001) were independently predictive of anastomotic leak. Compared with an open 2-field, a transhiatal (OR, 1.35; 95% CI, 1.17-1.55; P < .001) or 3-field esophagectomy (OR, 1.46; 95% CI, 1.25-1.70; P < .001) was more likely to leak. A robotic approach was associated with an increased risk of leak (OR, 1.28; 95% CI, 1.03-1.08; P < .001), however lost significance in a modern subgroup from 2018-2021. CONCLUSIONS Obesity, diabetes, smoking, pulmonary hypertension, and a cervical anastomosis are risk factors for anastomotic leak regardless of disease etiology. These important clinical risk factors identify an opportunity for modifiable risk reduction with aggressive medical optimization perioperatively.
Collapse
Affiliation(s)
- Andrea L Axtell
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Clara Angeles
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - James D Maloney
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| |
Collapse
|
8
|
Kitadani J, Hayata K, Goda T, Tominaga S, Fukuda N, Nakai T, Nagano S, Ojima T, Shimokawa T, Kawai M. Whole stomach versus narrow gastric tube reconstruction after esophagectomy for esophageal cancer (ATHLETE trial): study protocol for a randomized controlled trial. Trials 2025; 26:111. [PMID: 40155976 PMCID: PMC11954340 DOI: 10.1186/s13063-025-08823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 03/21/2025] [Indexed: 04/01/2025] Open
Abstract
BACKGROUND There are two types of methods of creating a gastric conduit after esophagectomy for patients with esophageal cancer: narrow gastric tube reconstruction or whole stomach reconstruction. Whole stomach reconstruction with good blood perfusion was reported in a prospective cohort study to be safe and that it has the possibility to prevent anastomotic leakage (AL). We therefore planned a randomized controlled phase III study to investigate the superiority of whole stomach reconstruction over narrow gastric tube reconstruction after esophagectomy for esophageal cancer. METHODS This is a single center, two-arm, open-label, randomized phase III trial. We calculated that 65 patients in each arm of this study and total study population of 130 patients are required according to our historical data on narrow gastric tube reconstruction and prospective data on whole stomach reconstruction. In the narrow gastric tube group, a 3.5-cm-wide gastric tube is made along the greater curvature of the stomach using linear staplers. Otherwise, in the whole stomach group, after the lymphadenectomy of the lesser curvature and No.2, the stomach is cut just below the esophagogastric junction using a linear stapler. The primary endpoint of this study is the incidence of AL. Secondary endpoints are the occurrence rate of anastomotic stenosis, the occurrence rate of pneumonia, the occurrence rate of all postoperative complications, the occurrence rate of reflux esophagitis, quality of life evaluation by EORTC QLQ-C30 and EORTC OES-18, nutritional evaluation, the amount of blood loss, postoperative hospital stays, and blood flow evaluation. Complications are evaluated using the Clavien-Dindo classification (version 2.0), and those of grade II or higher are considered to be postoperative complications. DISCUSSION If the optimal method for creating a gastric conduit after esophagectomy is clarified, it may be possible to contribute to improving short-term and long-term surgical outcomes for patients undergoing surgery for esophageal cancer. TRIAL REGISTRATION The protocol of ATHLETE trial was registered in the UMIN Clinical Trials Registry as UMIN000050677 ( http://www.umin.ac.jp/ctr/index.htm ). Date of registration: March 26, 2023. Date of first participant enrollment: March 27, 2023.
Collapse
Affiliation(s)
- Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan.
| | - Keiji Hayata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Taro Goda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Shinta Tominaga
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Naoki Fukuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Tomoki Nakai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Shotaro Nagano
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, 811-1 Kimiidera, Wakayama, Japan
| |
Collapse
|
9
|
Huang JS, Yang LT, Zhu JF, Zhong QH, Guo FL, Zhang ZY, Lin JB. Prediction of esophagogastric anastomotic leakage by nomogram combined with preoperative nutritional status and clinical factors: a retrospective study of 775 patients. Perioper Med (Lond) 2025; 14:36. [PMID: 40133981 PMCID: PMC11934493 DOI: 10.1186/s13741-024-00487-4] [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: 05/15/2024] [Accepted: 12/25/2024] [Indexed: 03/27/2025] Open
Abstract
AIM The purpose was to explore the independent risk factors for esophagogastric anastomotic leakage (EGAL) and establish a nomogram. METHODS Patients who underwent esophagectomy were enrolled and randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The differences between the two groups of factors were analyzed by difference analysis, and multivariate regression analysis was subsequently performed. A nomogram was established, and the feasibility of the nomogram was verified by analyzing the discrimination, calibration, and decision curves. RESULTS A total of 775 patients were enrolled, including 532 in the training cohort and 223 in the validation cohort. Multivariate regression analysis revealed that age, smoking history, drinking history, nutritional indicators, and anastomotic location were independent risk factors. In terms of discrimination, in the training group, the area under the curve was 0.757 (P = 0.025). In the calibration curve, the curves and fitting lines before and after correction in the training group and the validation group were basically the same. The results of the Hosmer-Lemeshow test showed that the chi-square value of the training cohort was 5.48 (P = 0.791). In the decision curve analysis of the training set, when the threshold probability was in the range of 5-63%, the net benefit of patients was greater than that of the two extreme curves. CONCLUSION Preoperative malnutrition is an independent risk factor for EGAL. A diagnostic model, developed on age, anastomotic location, smoking status, and drinking history, was a reliable noninvasive tool to timely predict the occurrence of AL.
Collapse
Affiliation(s)
- Jiang-Shan Huang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Li-Tao Yang
- Department of Thoracic Surgery, Baoji Traditional Chinese Medicine Hospital, Baoji, Shaanxi, China
| | - Jia-Fu Zhu
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Qi-Hong Zhong
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Fei-Long Guo
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhen-Yang Zhang
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jiang-Bo Lin
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, China.
| |
Collapse
|
10
|
Yang Y, Han C, Xing X, Qin Z, Wang Q, Lan L, Zhu H. Effects of Postoperative Complications on Overall Survival Following Esophagectomy: A Meta-Analysis Using the Restricted Mean Survival Time Analysis. Thorac Cancer 2025; 16:e70011. [PMID: 39924333 PMCID: PMC11807705 DOI: 10.1111/1759-7714.70011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2024] [Revised: 01/22/2025] [Accepted: 01/24/2025] [Indexed: 02/11/2025] Open
Abstract
OBJECTIVE This study aims to conduct a comprehensive meta-analysis of the effects of postoperative complications (PCs) on survival following esophagectomy using the restricted mean survival time (RMST) analysis. METHODS A systematic literature search was performed in PubMed, Embase, Web of Science, Cochrane, and Medline, including articles published up to July 2024. Data were reconstructed from Kaplan-Meier curves, and the difference in RMST (RMSTD) and the RMST/restricted mean time loss (RMTL) ratios were calculated to examine the effects of PCs on overall survival. RESULTS A total of 12 articles, including 7925 patients, met the inclusion criteria. RMSTD estimates indicate that patients with overall PCs survived an average of 0.04 years shorter (RMSTD = -0.04, 95% CI: -0.06, -0.03) than those without PCs at the 1-year follow-up and 0.39 years shorter (RMSTD = -0.39, 95% CI: -0.55, -0.22) at the 5-year follow-up. Patients with anastomotic leaks survived an average of 0.34 years shorter (RMSTD = -0.34, 95% CI: -0.49, -0.19), and patients with pulmonary complications survived an average of 0.63 years shorter (RMSTD = -0.63, 95% CI: -0.81, -0.45) at the 5-year follow-up. Additionally, RMTL ratios were estimated to be 1.21 (95% CI: 1.12, 1.31) for overall PCs, 1.19 (95% CI: 1.11, 1.28) for anastomotic leaks, and 1.53 (95% CI: 1.36, 1.73) for pulmonary complications at the 5-year follow-up, respectively. CONCLUSIONS Our findings quantified the annual negative impact of PCs of esophageal cancer on overall patient survival following esophagectomy. Increased efforts are needed to enhance prevention, early screening, and timely treatment for complications, particularly for patients with pulmonary complications.
Collapse
Affiliation(s)
- Yongbo Yang
- First Department of Thoracic SurgeryPeking University Cancer Hospital and InstituteBeijingChina
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of EducationPeking University Cancer Hospital and InstituteBeijingChina
| | - Chunyang Han
- The First Clinical SchoolHuazhong University of Science and TechnologyWuhanHubeiChina
| | - Xing Xing
- School of Public HealthPeking UniversityBeijingChina
| | - Zhen Qin
- School of Public HealthPeking UniversityBeijingChina
| | - Qianning Wang
- School of Public HealthPeking UniversityBeijingChina
| | - Lu Lan
- School of Public HealthPeking UniversityBeijingChina
| | - He Zhu
- School of Public HealthPeking UniversityBeijingChina
| |
Collapse
|
11
|
Okumura T, Miwa T, Murotani K, Numata Y, Watanabe T, Hashimoto I, Kamiyama K, Tazawa K, Yamagishi F, Fujii T. Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis. Dis Esophagus 2025; 38:doae100. [PMID: 39537214 DOI: 10.1093/dote/doae100] [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: 09/23/2024] [Revised: 10/23/2024] [Accepted: 11/01/2024] [Indexed: 11/16/2024]
Abstract
One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.
Collapse
Affiliation(s)
- Tomoyuki Okumura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
- Office for Human Research Ethics, Faculty of Education and Research Promotion, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Takeshi Miwa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Kenta Murotani
- Biostatistics Center, Kurume University, Fukuoka City, Japan
| | - Yoshihisa Numata
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Isaya Hashimoto
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| | - Koki Kamiyama
- Department of Surgery, Tomei Atsugi Hospital, Atsugi City, Japan
| | - Kenichi Tazawa
- Department of Surgery, Tomei Atsugi Hospital, Atsugi City, Japan
| | | | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, Toyama City, Japan
| |
Collapse
|
12
|
Markar S, Mariette C, Bonnetain F, Lundell L, Rosati R, de Manzoni G, Bonavina L, Tucker O, Plum P, D'Journo XB, Van Daele D, Cogill G, Santi S, Farran L, Iranzo V, Pera M, Veziant J, Piessen G. Immunonutrition to improve the quality of life of upper gastrointestinal cancer patients undergoing neoadjuvant treatment prior to surgery (NEOIMMUNE): double-blind randomized controlled multicenter clinical trial. Dis Esophagus 2025; 38:doae113. [PMID: 39863958 DOI: 10.1093/dote/doae113] [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: 10/31/2023] [Revised: 09/21/2024] [Accepted: 11/29/2024] [Indexed: 01/27/2025]
Abstract
BACKGROUND Malnutrition is common with esophagogastric cancers and is associated with negative outcomes. We aimed to evaluate if immunonutrition during neoadjuvant treatment improves patient's health-related quality of life (HRQOL) and reduces postoperative morbidity and toxicities during neoadjuvant treatment. METHODS A multicenter double-blind randomized controlled trial (RCT) was undertaken. Included patients had untreated nonmetastatic esophagogastric tumor, aged 18 ≥ years with a life expectancy of >3 months. The study was powered for 80% power to detect a clinically relevant difference in EORTC-QLQC30 with standard deviation of 15 between groups. Primary end point was the quality of life as measured by the global health status at 30 days after surgery. An intention-to-treat analysis was employed. RESULTS The study was terminated at the interim analysis stage. About 300 patients were randomized: 149 to the IMPACT group and 151 to the control-formula group. Patient groups were well-balanced in terms of age, sex, body mass index, WHO performance status, and clinical tumor stage. Analysis of the primary end point for the study of global health status at 30-day postoperatively failed to show any significant differences between the groups (55.4 ± 18.6 [IMPACT] vs. 55.9 ± 19.8 [control]; P = 0.345). No significant differences between the groups were detected in the majority of domains from EORTC QLQC30 and OG25 tools after neoadjuvant therapy and 30 days postoperatively. Finally, no significant differences were seen between groups in neoadjuvant therapy or postoperative complications, or tumor response. CONCLUSION The results of this multicenter double-blind RCT fail to demonstrate any HRQOL benefits to the utilization of immunonutrition during neoadjuvant therapy in patients with esophagogastric cancer.
Collapse
Affiliation(s)
- Sheraz Markar
- Nuffield Department of Surgery, University of Oxford, Oxford, UK
| | - Christophe Mariette
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
| | - Frank Bonnetain
- Methodology and Quality of Life Unit in Cancer, INSERM UMR 1098, University Hospital of Besançon, Besançon, France
| | - Lars Lundell
- Department of Clinical Sciences Intervention and Technology, Karolinska institutet, Stockholm, Sweden
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, San Raffaele Scientific Institute, Vita e Salute University, Milan, Italy
| | | | - Luigi Bonavina
- Division of General Surgery IRCCS Policlinico San Donato, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Olga Tucker
- Department of Surgery, University of Birmingham, Birmingham, UK
| | - Patrick Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Cologne, Germany
| | - Xavier Benoit D'Journo
- Department of Thoracic Surgery, Hôpital Nord, Aix-Marseille Université, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Daniel Van Daele
- Department of Gastro-enterology, Centre Hospitalier Universitaire de Liège, Liège, Belgium
| | - Geoff Cogill
- Department of Oncology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Stefano Santi
- Esophageal Surgery Unit, Gastroenterology Department, Regional Referral Center for Diagnosis and Treatment of Diseases of Esophagus, "Nuovos. Chiara" Hospital, Pisa, Italy
| | - Leandres Farran
- Digestive Surgery Department, Hospital Universitari de Bellvitge, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Vega Iranzo
- Medical Oncology Department, Hospital General Universitario de Valencia, Valencia, Spain
| | - Manuel Pera
- Sección de Cirugía Gastrointestinal, Servicio de Cirugía, Hospital Universitario del Mar, Institut Hospital del Mar d'Investigacións Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julie Veziant
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- Univ. Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, Chu Lille, Lille, France
- Univ. Lille, CNRS, Inserm, Chu Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
| |
Collapse
|
13
|
Loske G, Müller J, Schulze W, Riefel B, Reeh M, Müller CT. Endoscopic negative-pressure treatment : From management of complications to pre-emptive active reflux drainage in abdomino-thoracic esophageal resection-A new safety concept for esophageal surgery. CHIRURGIE (HEIDELBERG, GERMANY) 2025; 96:48-59. [PMID: 38085297 PMCID: PMC11729085 DOI: 10.1007/s00104-023-01996-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 01/14/2025]
Abstract
INTRODUCTION Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients. MATERIALS AND METHODS For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (-125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated. RESULTS During the observation period (2017-2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4-21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis. CONCLUSIONS Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.
Collapse
Affiliation(s)
- Gunnar Loske
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany.
| | - Johannes Müller
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany
| | - Wolfgang Schulze
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany
| | - Burkhard Riefel
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany
| | - Matthias Reeh
- Clinic for General, Visceral, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Germany
| | | |
Collapse
|
14
|
Jorek N, Weber MC, Kasajima A, Reischl S, Jefferies B, Feith M, Dimpel R, Reim D, Friess H, Novotny A, Neumann PA. Configuration of anastomotic doughnuts of stapled anastomoses in upper gastrointestinal surgery is associated with anastomotic leakage. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:109460. [PMID: 39577075 DOI: 10.1016/j.ejso.2024.109460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 10/03/2024] [Accepted: 11/13/2024] [Indexed: 11/24/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate whether the configuration of anastomotic doughnuts from upper gastrointestinal surgeries was associated with anastomotic leakage (AL). BACKGROUND AL is a severe postoperative complication after upper gastrointestinal cancer surgeries. AL is associated with an increase in overall and cancer-related morbidity and mortality in patients with esophageal and gastric cancer. New intraoperative biomarkers are needed to predict the risk of AL to implement early preventive measures. MATERIALS AND METHODS Anastomotic doughnuts from 102 patients undergoing surgery for esophageal or gastric cancer using circular staplers were examined. The minimal and maximal height and width of the anastomotic doughnuts were measured and correlated with the postoperative AL rate. RESULTS The AL rate in our study collective was 15,7 %. The minimal width (Wmin) of the oral and aboral anastomotic doughnuts was significantly lower in patients with AL compared to patients without AL (p = 0.002 and p = 0.041 respectively). The Wmin of the esophageal anastomotic doughnut was an independent risk factor for AL in the multivariable analysis (p = 0.034). Negative predictive values for the measurements of anastomotic doughnuts (Wmin) with regard to the risk of AL were higher than for the commonly used postoperative biomarker C-reactive protein. CONCLUSION Minimal anastomotic doughnut width was statistically significantly associated with AL. Thus, not only the evaluation of the completeness of the anastomotic doughnuts but also intraoperative measurements could be used to predict the risk of AL to initiate early preventive measures to prevent the development of AL and/or reduce AL-associated morbidity.
Collapse
Affiliation(s)
- Nicolas Jorek
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Marie-Christin Weber
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany.
| | - Atsuko Kasajima
- Institute of Pathology, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Stefan Reischl
- Institute for Diagnostic and Interventional Radiology, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Benedict Jefferies
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Marcus Feith
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Rebekka Dimpel
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Daniel Reim
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Alexander Novotny
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, Technical University of Munich (TUM), TUM School of Medicine and Health, TUM University Hospital, Munich, Germany
| |
Collapse
|
15
|
Herzberg J, Strate T, Passlack L, Guraya SY, Honarpisheh H. Effect of Preoperative Body Composition on Postoperative Anastomotic Leakage in Oncological Ivor Lewis Esophagectomy-A Retrospective Cohort Study. Cancers (Basel) 2024; 16:4217. [PMID: 39766116 PMCID: PMC11726741 DOI: 10.3390/cancers16244217] [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: 11/04/2024] [Revised: 12/03/2024] [Accepted: 12/13/2024] [Indexed: 01/15/2025] Open
Abstract
BACKGROUND Surgery for esophageal cancer has an associated high rate of postoperative complications such as anastomotic leakage (AL) and fistulas. Pre-operative sarcopenia as a loss of skeletal muscle mass and function is identified as a potential prognostic factor in determining the outcomes of oncological surgical resections for esophageal cancers. In this study, we evaluated the impact of body composition on postoperative complications in esophageal cancer surgery. METHODS In this cohort study, we analyzed patients' body composition at the level of the third lumbar vertebra on CT scans before Ivor Lewis resections for esophageal cancers between January 2015 and December 2022. Patients with a skeletal muscle index (SMI) ≤ 38.5 cm2/m2 in women and ≤52.4 cm2/m2 in men were classified as sarcopenic. Postoperative complications were categorized following the Dindo-Clavien classification and included AL, postoperative pneumonia, length of hospital stay, and failure-to-rescue which were compared between the sarcopenic and non-sarcopenic patients. RESULTS From a group of 111 patients with Ivor Lewis esophagectomy, 70 patients (63.1%) were classified as sarcopenic based on the SMI and the previously published gender-specific cut-off values. AL occurred at 12.6% (5.6% in adenocarcinoma). Within the whole cohort, patients with AL had a significantly low SMI of 43.487 ± 8.088 vs. 48.668 ± 7.514; p = 0.012. Additionally, the SMI showed a negative correlation to the length of postoperative hospital stay (r = -0.204; p = 0.032; N = 111). The failure-to-rescue rate was higher in the group of sarcopenic patients (12.8% vs. 8%). CONCLUSIONS Our data showed a correlation between SMI and AL. This effect could not be seen in gender-specific SMI. This study showed a lower failure-to-rescue rate in non-sarcopenic patients after Ivor Lewis esophagectomy. These findings underscore the crucial role of determining the preoperative nutritional and body composition status as measured by the preoperative CT scans.
Collapse
Affiliation(s)
- Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, 21465 Reinbek, Germany
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, 21465 Reinbek, Germany
| | - Leon Passlack
- Department of Internal Medicine, Krankenhaus Reinbek St. Adolf-Stift, 21465 Reinbek, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah P.O. Box 27272, United Arab Emirates
| | - Human Honarpisheh
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, 21465 Reinbek, Germany
| |
Collapse
|
16
|
Kitadani J, Hayata K, Goda T, Tominaga S, Fukuda N, Nakai T, Nagano S, Ojima T, Kawai M. Risk Reduction of Severe Anastomotic Leakage by Evaluation of Blood Perfusion Using Indocyanine Green After Minimally Invasive Esophagectomy Followed by Narrow Gastric Tube Reconstruction. Surg Laparosc Endosc Percutan Tech 2024; 34:619-624. [PMID: 39632426 DOI: 10.1097/sle.0000000000001331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 09/24/2024] [Indexed: 12/07/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) is a major complication after esophagectomy and gastric tube reconstruction. This retrospective study aims to reveal the factors in prevention of AL and in reduction of its severity. METHODS Enrolled in this study were the 183 patients diagnosed with esophageal cancer who underwent minimally invasive esophagectomy followed by narrow gastric tube reconstruction at Wakayama Medical University Hospital between January 2018 and March 2023. Evaluation of blood perfusion using indocyanine green began in September 2020. RESULTS AL occurred in 42 patients (22%) and did not occur in 141 patients (78%). Patient characteristics were not significantly different between patients with and without AL. Evaluation of blood perfusion of the gastric tube was performed in 69 of the 183 patients (37.7%), and after its introduction the rates of AL decreased from 28.0% to 14.4%. Blood perfusion was less evaluated in the AL group than in the non-AL group (23.8% vs. 41.8%, P=0.034). Multivariate analysis demonstrated that non-evaluation of blood perfusion using indocyanine green (odds=3.115) was an independent risk factor for AL. For the patients with AL, active interventions (eg, tube insertion into the gastric tube through the nose or fistula, embolization of cyanoacrylate) were performed significantly more often in the group without evaluation of blood perfusion than in the group with evaluation. Without evaluation of blood perfusion, there was significantly longer time from onset to resumption of diet and significantly longer postoperative hospital stays. CONCLUSIONS Evaluation of qualitative blood perfusion can lead to both risk reduction and prevention of severe AL after narrow gastric tube reconstruction for esophageal cancer.
Collapse
Affiliation(s)
- Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Takahashi N, Okamura A, Kuriyama K, Terayama M, Tamura M, Kanamori J, Imamura Y, Watanabe M. Early Postoperative Serum Lactate Levels Predict Anastomotic Leakage After Minimally Invasive Esophagectomy. Ann Surg Oncol 2024:10.1245/s10434-024-16534-9. [PMID: 39550483 DOI: 10.1245/s10434-024-16534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2024] [Accepted: 10/30/2024] [Indexed: 11/18/2024]
Abstract
BACKGROUND Anastomotic leakage (AL) is a major complication after esophagectomy for esophageal cancer, and the significance of elevated postoperative lactate levels in the occurrence of AL is unclear. PATIENTS AND METHODS We evaluated 583 patients who underwent minimally invasive esophagectomy for esophageal cancer. Serum lactate levels were measured immediately after esophagectomy and in the morning on postoperative days (POD) 1, 2, 3, and 4. We also evaluated the factors associated with AL using multivariable logistic regression analysis. RESULTS AL occurred in 8.9% (n = 52) of patients, and the median onset of AL was POD10 (interquartile range: 7-13). The lactate levels immediately after esophagectomy through POD3 were significantly higher in patients with AL than in those without AL. A further multivariable logistic regression analysis showed that elevated lactate level on POD2 was an independent predictor of the occurrence of AL (odds ratio 11.9; 95% confidence interval: 4.04-17.3; P < 0.001). Severe AL was significantly more frequent in the higher lactate patients (P < 0.001). Furthermore, in patients with AL with higher lactate, the onset tended to be earlier (P = 0.054), and the treatment duration of AL was significantly longer compared with those with lower lactate (P = 0.037). CONCLUSIONS AL was significantly associated with elevated postoperative lactate levels. Elevated lactate levels on POD2 could be significant predictor of AL development after esophagectomy.
Collapse
Affiliation(s)
- Naoki Takahashi
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Kengo Kuriyama
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayoshi Terayama
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masahiro Tamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| |
Collapse
|
18
|
Markar SR, Sgromo B, Evans R, Griffiths EA, Alfieri R, Castoro C, Gronnier C, Gutschow CA, Piessen G, Capovilla G, Grimminger PP, Low DE, Gossage J, Gisbertz SS, Ruurda J, van Hillegersberg R, D'journo XB, Phillips AW, Rosati R, Hanna GB, Maynard N, Hofstetter W, Ferri L, Berge Henegouwen MI, Owen R. The Prognostic Impact of Minimally Invasive Esophagectomy on Survival After Esophagectomy Following a Delayed Interval After Chemoradiotherapy: A Secondary Analysis of the DICE Study. Ann Surg 2024; 280:650-658. [PMID: 38904105 DOI: 10.1097/sla.0000000000006411] [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: 06/22/2024]
Abstract
OBJECTIVE To evaluate prognostic differences between minimally invasive esophagectomy (MIE) and open esophagectomy (OE) in patients with surgery after a prolonged interval (>12 wk) following chemoradiotherapy (CRT). BACKGROUND Previously, we established that a prolonged interval after CRT before esophagectomy was associated with poorer long-term survival. METHODS This was an international multicenter cohort study involving 17 tertiary centers, including patients who received CRT followed by surgery between 2010 and 2020. Patients undergoing MIE were defined as thoracoscopic and laparoscopic approaches. RESULTS A total of 428 patients (145 MIE and 283 OE) had surgery between 12 weeks and 2 years after CRT. Significant differences were observed in American Society of Anesthesiologists grade, radiation dose, clinical T stage, and histologic subtype. There were no significant differences between the groups in age, sex, body mass index, pathologic T or N stage, resection margin status, tumor location, surgical technique, or 90-day mortality. Survival analysis showed MIE was associated with improved survival in univariate ( P =0.014), multivariate analysis after adjustment for smoking, T and N stage, and histology (HR=1.69; 95% CI: 1.14-2.5) and propensity-matched analysis ( P =0.02). Further subgroup analyses by radiation dose and interval after CRT showed survival advantage for MIE in 40 to 50 Gy dose groups (HR=1.9; 95% CI: 1.2-3.0) and in patients having surgery within 6 months of CRT (HR=1.6; 95% CI: 1.1-2.2). CONCLUSIONS MIE was associated with improved overall survival compared with OE in patients with a prolonged interval from CRT to surgery. The mechanism for this observed improvement in survival remains unknown, with potential hypotheses including a reduction in complications and improved functional recovery after MIE.
Collapse
Affiliation(s)
- Sheraz R Markar
- Department of Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
- Nuffield Department of Surgery, University of Oxford, UK
| | - Bruno Sgromo
- Department of Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard Evans
- Department of Surgery, Birmingham University Hospitals NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Ewen A Griffiths
- Department of Surgery, Birmingham University Hospitals NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Rita Alfieri
- General Gastric and Esophagus Surgery Unit, Humanitas Research Hospital, Italy
- Oncological Surgery Unit, Veneto Institute of Oncology, IOV - IRCCS, Padua, Italy
| | - Carlo Castoro
- General Gastric and Esophagus Surgery Unit, Humanitas Research Hospital, Italy
| | - Caroline Gronnier
- Esophageal and Endocrine Surgery Unit, Digestive Surgery Department, Centre Magellan, CHU de Bordeaux, France
| | - Christian A Gutschow
- Department of Visceral Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Guillaume Piessen
- Department of Digestive and General Surgery, University Hospital Claude Huriez, Lille, Cedex, France
| | - Giovanni Capovilla
- Department of Surgery, University Medical Centre, Johannes Gutenberg University Mainz. Mainz, Germany
| | - Peter P Grimminger
- Department of Surgery, University Medical Centre, Johannes Gutenberg University Mainz. Mainz, Germany
| | - Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Hospital & Seattle Medical Center, Seattle, WA
| | - James Gossage
- Department of Surgery, Guy's and St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Jelle Ruurda
- Department of Upper Gastrointestinal Surgery, University Medical Center Utrecht, The Netherlands
| | | | - Xavier Benoit D'journo
- Department of Thoracic Surgery, Diseases of the Esophagus & Lung Transplantations. Chemin des Bourrely, North Hospital, Marseille, France
| | - Alexander W Phillips
- Northern Esophago-Gastric Unit, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
| | - Ricardo Rosati
- Department of GI Surgery, San Raffaele Hospital, Milan, Italy
| | - George B Hanna
- Academic Surgical Unit, Department of Surgery and Cancer, Imperial College London, St Mary's Hospital, London, UK
| | - Nick Maynard
- Department of Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | | | - Lorenzo Ferri
- Departments of Surgery and Oncology, McGill University, Montreal General Hospital, Montreal, QC, Canada
| | - Mark I Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Richard Owen
- Department of Surgery, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
- The Ludwig Institute for Cancer Research, University of Oxford, Old Road Campus Research Building Roosevelt Drive, Oxford, UK
| |
Collapse
|
19
|
Hauge T, Dretvik T, Johnson E, Mala T. Treatment of anastomotic leakage following Ivor Lewis esophagectomy-10 year experience from a Nordic center. Dis Esophagus 2024; 37:doae040. [PMID: 38745429 PMCID: PMC11360862 DOI: 10.1093/dote/doae040] [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: 10/29/2023] [Revised: 04/13/2024] [Accepted: 04/26/2024] [Indexed: 05/16/2024]
Abstract
Anastomotic leakage (AL) is a dreaded complication following esophageal resection. No clear consensus exist for the optimal handling of this severe complication. The aim of this study was to describe the treatment outcome following AL. We conducted a retrospective cross-sectional study including all patients with AL operated with Ivor Lewis esophagectomy from 2010 to 2021 at Oslo University Hospital, Norway. 74/526 (14%) patients had AL. Patient outcomes were analyzed and categorized according to main AL treatment strategy; stent (54%), endoscopic vacuum therapy and stent (EVT + stent) (19%), nasogastric tube and antibiotics (conservative) (16%), EVT (8%) and by other endoscopic means (other) (3%). One patient had surgical debridement of the chest cavity. In 66 patients (89%), the perforation healed after median 27 (range: 4-174) days. Airway fistulation was observed in 11 patients (15%). Leak severity (ECCG) was associated with development of airway fistula (P = 0.03). The median hospital and intensive care unit stays were 30 (range: 12-285) and 9 (range: 0-60) days. The 90-days mortality among patients with AL was 5% and at follow up, 13% of all deaths were related to AL. AL closure rates were comparable across the groups, but longer in the EVT + stent group (55 days vs. 29.5 days, P = 0.04). Thirty-two percent developed a symptomatic anastomotic stricture within 12 months. Conclusion: The majority of AL can be treated endoscopically with preservation of the conduit and the anastomosis. We observed a high number of AL-associated airway fistulas.
Collapse
Affiliation(s)
- Tobias Hauge
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Thomas Dretvik
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
| | - Egil Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Ullevål, Norway
- Institute of Clinical Medicine, University of Oslo, Norway
| |
Collapse
|
20
|
Sozzi A, Bona D, Yeow M, Habeeb TAAM, Bonitta G, Manara M, Sangiorgio G, Biondi A, Bonavina L, Aiolfi A. Does Indocyanine Green Utilization during Esophagectomy Prevent Anastomotic Leaks? Systematic Review and Meta-Analysis. J Clin Med 2024; 13:4899. [PMID: 39201041 PMCID: PMC11355508 DOI: 10.3390/jcm13164899] [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: 07/04/2024] [Revised: 08/06/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Indocyanine Green (ICG) is a promising technique for the assessment of gastric conduit and anastomosis perfusion during esophagectomy. ICG integration may be helpful in minimizing the risk of anastomotic leak (AL). Literature evidence is sparse, while the real effect of ICG assessment on AL minimization remains unsolved. The aim of this systematic review and meta-analysis was to compare short-term outcomes between ICG-guided and non-ICG-guided (nICG) esophagogastric anastomosis during esophagectomy for cancer. Materials and Methods: PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried up to 25 April 2024. Studies that reported short-term outcomes for ICG versus non-ICG-guided (nICG) anastomosis in patients undergoing esophagectomy were considered. Primary outcome was AL. Risk ratio (RR) and standardized mean difference (SMD) were utilized as effect size measures, whereas to assess relative inference we used 95% confidence intervals (95% CI). Results: Overall, 1399 patients (11 observational studies) were included. Overall, 576 (41.2%) underwent ICG gastric conduit assessment. The patients' ages ranged from 22 to 91 years, with 73% being male. The cumulative incidence of AL was 10.4% for ICG and 15.4% for nICG. Compared to nICG, ICG utilization was related to a reduced risk for postoperative AL (RR 0.48; 95% CI 0.23-0.99; p = 0.05). No differences were found in terms of pulmonary complications (RR 0.83), operative time (SMD -0.47), hospital length of stay (SMD -0.16), or 90-day mortality (RR 1.70). Conclusions: Our study seems to indicate a potential impact of ICG in reducing post-esophagectomy AL. However, because of limitations in the design of the included studies, allocation/reporting bias, variable definitions of AL, and heterogeneity in ICG use, caution is required to avoid potential overestimation of the ICG effect.
Collapse
Affiliation(s)
- Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Marcus Yeow
- Department of Surgery, National University Hospital, National University Health System, 1E, Kent Ridge Road, NUHS Tower Block, Level 8, Singapore 119228, Singapore;
| | - Tamer A. A. M. Habeeb
- Department of General Surgery, Faculty of Medicine, Zagazig University, Zagazig 7120001, Egypt;
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| | - Giuseppe Sangiorgio
- Department of General Surgery and Medical Surgical Specialties, Surgical Division, G. Rodolico Hospital, University of Catania, 95131 Catania, Italy; (G.S.); (A.B.)
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, Surgical Division, G. Rodolico Hospital, University of Catania, 95131 Catania, Italy; (G.S.); (A.B.)
| | - Luigi Bonavina
- I.R.C.C.S. Policlinico San Donato, Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, 20097 Milan, Italy;
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Department of Biomedical Science for Health, Division of General Surgery, University of Milan, 20122 Milano, Italy; (A.S.); (D.B.); (G.B.); (M.M.)
| |
Collapse
|
21
|
Xu Y, Chow R, Murdy K, Mahsin M, Chandereng T, Sinha R, Lee-Ying R, Abedin T, Cheung WY, Thanh NX, Lee SL. Definitive Chemoradiotherapy versus Trimodality Therapy for Locally Advanced Esophageal Adenocarcinoma: A Multi-Institutional Retrospective Cohort Study. Cancers (Basel) 2024; 16:2850. [PMID: 39199621 PMCID: PMC11353245 DOI: 10.3390/cancers16162850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 08/09/2024] [Accepted: 08/12/2024] [Indexed: 09/01/2024] Open
Abstract
The optimal management of patients with locally advanced esophageal adenocarcinoma is unclear. Neoadjuvant chemoradiotherapy followed by esophagectomy (trimodality therapy) is supported as a standard of care, but definitive chemoradiotherapy is frequently given in practice to patients who may have been surgical candidates. This multi-institutional retrospective cohort study compared the outcomes of consecutive patients diagnosed with stage II to IVA esophageal adenocarcinoma between 2004 and 2018 who planned to undergo trimodality therapy or definitive chemoradiotherapy. A total of 493 patients were included, of whom 435 intended to undergo trimodality therapy and 56 intended to undergo definitive chemoradiotherapy. After a median follow-up of 7.3 years, trimodality therapy was associated with a lower risk of locoregional failure (5-year risk, 30.5% vs. 61.3%; HR, 0.39; 95% CI, 0.24-0.62; p<0.001) but not distant metastases (5-year risk, 58.2% vs. 53.9%; HR, 1.21; 95% CI, 0.77-1.91; p=0.40). There were no differences in overall survival (HR, 0.78; 95% CI, 0.56-1.09; p=0.14) or cancer-specific survival (HR, 0.83; 95% CI, 0.57-1.21; p=0.33). Findings were consistent on propensity score-matched sensitivity analyses. In conclusion, trimodality therapy was associated with a lower risk of locoregional failure, but this did not translate into a significantly lower risk of distant failure or improved survival. Further studies are required to accurately estimate the trade-offs between the two treatment strategies.
Collapse
Affiliation(s)
- Yang Xu
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (Y.X.)
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Ronald Chow
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Kyle Murdy
- Faculty of Law, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Md Mahsin
- Precision Oncology Hub, Arnie Charbonneau Cancer Institute, Calgary, AB T2N 4Z6, Canada;
| | | | - Rishi Sinha
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (Y.X.)
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Richard Lee-Ying
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (Y.X.)
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Tasnima Abedin
- Clinical Research Unit, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada
| | - Winson Y. Cheung
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (Y.X.)
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Nguyen X. Thanh
- Strategic Clinical Networks, Alberta Health Services, Calgary, AB T5J 3E4, Canada
- School of Public Health, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Sangjune Laurence Lee
- Department of Oncology, Tom Baker Cancer Centre, Calgary, AB T2N 4N2, Canada; (Y.X.)
- Department of Oncology, University of Calgary, Calgary, AB T2N 1N4, Canada
| |
Collapse
|
22
|
Ascari F, De Pascale S, Rosati R, Giacopuzzi S, Puccetti F, Weindelmayer J, Cusin S, Leone B, Fumagalli Romario U. Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2). J Gastrointest Surg 2024; 28:1072-1077. [PMID: 38705367 DOI: 10.1016/j.gassur.2024.04.024] [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: 03/12/2024] [Revised: 04/23/2024] [Accepted: 04/27/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. METHODS Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. RESULTS A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. CONCLUSION The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.
Collapse
Affiliation(s)
- Filippo Ascari
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Stefano De Pascale
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Riccardo Rosati
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Simone Giacopuzzi
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Francesco Puccetti
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Jacopo Weindelmayer
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Sofia Cusin
- Division of Gastrointestinal Surgery, Ospedale San Raffaele, Istituti di Ricovero e Cura a Carattere Scientifico, Vita-Salute San Raffaele University, Milan, Italy
| | - Barbara Leone
- Division of General and Upper Gastrointestinal Surgery, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Uberto Fumagalli Romario
- Division of Digestive Surgery, Istituto Europeo di Oncologia, Istituti di Ricovero e Cura a Carattere Scientifico, Milan, Italy.
| |
Collapse
|
23
|
Palleiko BA, Dickson KM, Crawford A, Shafique S, Emmerick I, Uy K, Maxfield MW, Lou F. Preoperative risk factors for anastomotic leak after esophagectomy with gastric reconstruction: A 6-year national surgical quality improvement (NSQIP) database analysis. Surgery 2024; 176:93-99. [PMID: 38719700 DOI: 10.1016/j.surg.2024.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/26/2024] [Accepted: 03/21/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Anastomotic leak is a serious complication after esophagectomy that has been associated with worse outcomes. However, identifying patients at increased risk for anastomotic leak remains challenging. METHODS Patients were included from the 2016 to 2021 National Surgical Quality Improvement Project database who underwent elective esophagectomy with gastric reconstruction for cancer. A multivariable logistic regression model was used to identify risk factors associated with anastomotic leak. RESULTS A total of 4,331 patients were included in the study, of whom 647 patients experienced anastomotic leak (14.9%). Multivariable logistic regression revealed higher odds of anastomotic leak with smoking (adjusted odds ratio 1.24, confidence interval 1.02-1.51, P = .031), modified frailty index-5 score of 1 (adjusted odds ratio 1.44, confidence interval 1.19-1.75, P = .002) or 2 (adjusted odds ratio 1.52, confidence interval 1.19-1.94, P = .000), and a McKeown esophagectomy (adjusted odds ratio 1.44, confidence interval 1.16-1.80, P = .001). Each 1,000/μL increase in white blood cell count was associated with a 7% increase in odds of anastomotic leak (adjusted odds ratio 1.07, confidence interval 1.03-1.10, P = .0005). Higher platelet counts were slightly protective, and each 10,000/ μL increase in platelet count was associated with 2% reduced odds of anastomotic leak (adjusted odds ratio 0.98, confidence interval 0.97-0.99, P = .001). CONCLUSION In this study, smoking status, frailty index, white blood cell count, McKeown esophagectomy, and platelet counts were all associated with the occurrence of anastomotic leak. These results can help to inform surgeons and patients of the true risk of developing anastomotic leak and potentially improve outcomes by providing evidence to improve preoperative characteristics, such as frailty.
Collapse
Affiliation(s)
- Benjamin A Palleiko
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA.
| | - Kevin M Dickson
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Allison Crawford
- Department of Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Samih Shafique
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Isabel Emmerick
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Karl Uy
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Mark W Maxfield
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| | - Feiran Lou
- Department of Surgery, Division of Thoracic Surgery, University of Massachusetts Chan Medical School, Worcester, MA
| |
Collapse
|
24
|
Hedberg J, Sundbom M, Edholm D, Aahlin EK, Szabo E, Lindberg F, Johnsen G, Førland DT, Johansson J, Kauppila JH, Svendsen LB, Nilsson M, Lindblad M, Lagergren P, Larsen MH, Åkesson O, Löfdahl P, Mala T, Achiam MP. Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial. Dis Esophagus 2024; 37:doae010. [PMID: 38366900 PMCID: PMC11144291 DOI: 10.1093/dote/doae010] [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: 10/16/2023] [Revised: 01/11/2024] [Accepted: 01/29/2024] [Indexed: 02/18/2024]
Abstract
Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.
Collapse
Affiliation(s)
- Jakob Hedberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - David Edholm
- Department of Surgery in Linköping and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Eirik Kjus Aahlin
- Department of GI and HPB Surgery, Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
- Department of GI and HPB Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | - Eva Szabo
- Department of Surgery, Örebro University, Örebro, Sweden
| | - Fredrik Lindberg
- Department of Surgical and Perioperative Sciences Surgery, Umeå University, Umeå, Sweden
| | - Gjermund Johnsen
- Department of Gastrointestinal Surgery, Norwegian University of Science and Technology, Trondheim, Norway
| | - Dag Tidemann Førland
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Jan Johansson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Joonas H Kauppila
- Department of Surgery, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Lars Bo Svendsen
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholn, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | - Oscar Åkesson
- Department of Surgery, Skane University Hospital, Lund, Sweden
| | - Per Löfdahl
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tom Mala
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
25
|
Li Y, Zhang D, Zhao D. Feasibility of utilizing mediastinal drains alone following esophageal cancer surgery: a retrospective study. World J Surg Oncol 2024; 22:118. [PMID: 38702817 PMCID: PMC11067194 DOI: 10.1186/s12957-024-03400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND It was typically necessary to place a closed thoracic drainage tube for drainage following esophageal cancer surgery. Recently, the extra use of thoracic mediastinal drainage after esophageal cancer surgery had also become more common. However, it had not yet been determined whether mediastinal drains could be used alone following esophageal cancer surgery. METHODS A total of 134 patients who underwent esophageal cancer surgery in our department between June 2020 and June 2023 were retrospectively analyzed. Among them, 34 patients received closed thoracic drainage (CTD), 58 patients received closed thoracic drainage combined with mediastinal drainage (CTD-MD), while 42 patients received postoperative mediastinal drainage (MD). The general condition, incidence of postoperative pulmonary complications, postoperative NRS score, and postoperative anastomotic leakage were compared. The Mann-Whitney U tests, Welch's t tests, one-way ANOVA, chi-square tests and Fisher's exact tests were applied. RESULTS There was no significant difference in the incidence of postoperative hyperthermia, peak leukocytes, total drainage, hospitalization days and postoperative pulmonary complications between MD group and the other two groups. Interestingly, patients in the MD group experienced significantly lower postoperative pain compared to the other two groups. Additionally, abnormal postoperative drainage fluid could be detected early in this group. Furthermore, there was no significant change in the incidence of postoperative anastomotic leakage and the mortality rate of patients after the occurrence of anastomotic leakage in the MD group compared with the other two groups. CONCLUSIONS Using mediastinal drain alone following esophageal cancer surgery was equally safe. Furthermore, it could substantially decrease postoperative pain, potentially replacing the closed thoracic drain in clinical practice.
Collapse
Affiliation(s)
- Yu Li
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China.
| | - Danjie Zhang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
| | - Danwen Zhao
- Department of Thoracic Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, No. 157#, The West 5th Road, Xi'an, 710004, Shaanxi, China
| |
Collapse
|
26
|
Li C, Song W, Zhang J, Xu Z, Luo Y. A real-world study was conducted to develop a nomogram that predicts the occurrence of anastomotic leakage in patients with esophageal cancer following esophagectomy. Aging (Albany NY) 2024; 16:7733-7751. [PMID: 38696304 PMCID: PMC11131977 DOI: 10.18632/aging.205780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/13/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND The incidence of anastomotic leakage (AL) following esophagectomy is regarded as a noteworthy complication. There is a need for biomarkers to facilitate early diagnosis of AL in high-risk esophageal cancer (EC) patients, thereby minimizing its morbidity and mortality. We assessed the predictive abilities of inflammatory biomarkers for AL in patients after esophagectomy. METHODS In order to ascertain the predictive efficacy of biomarkers for AL, Receiver Operating Characteristic (ROC) curves were generated. Furthermore, univariate, LASSO, and multivariate logistic regression analyses were conducted to discern the risk factors associated with AL. Based on these identified risk factors, a diagnostic nomogram model was formulated and subsequently assessed for its predictive performance. RESULTS Among the 438 patients diagnosed with EC, a total of 25 patients encountered AL. Notably, elevated levels of interleukin-6 (IL-6), IL-10, C-reactive protein (CRP), and procalcitonin (PCT) were observed in the AL group as compared to the non-AL group, demonstrating statistical significance. Particularly, IL-6 exhibited the highest predictive capacity for early postoperative AL, exhibiting a sensitivity of 92.00% and specificity of 61.02% at a cut-off value of 132.13 pg/ml. Univariate, LASSO, and multivariate logistic regression analyses revealed that fasting blood glucose ≥7.0mmol/L and heightened levels of IL-10, IL-6, CRP, and PCT were associated with an augmented risk of AL. Consequently, a nomogram model was formulated based on the results of multivariate logistic analyses. The diagnostic nomogram model displayed a robust discriminatory ability in predicting AL, as indicated by a C-Index value of 0.940. Moreover, the decision curve analysis provided further evidence supporting the clinical utility of this diagnostic nomogram model. CONCLUSIONS This predictive instrument can serve as a valuable resource for clinicians, empowering them to make informed clinical judgments aimed at averting the onset of AL.
Collapse
Affiliation(s)
- Chenglin Li
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Wei Song
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Jialing Zhang
- Department of Gastroenterology, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Zhongneng Xu
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| | - Yonggang Luo
- Department of Cardiothoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, Jiangsu 223300, China
| |
Collapse
|
27
|
Van Daele E, Vanommeslaeghe H, Peirsman L, Van Nieuwenhove Y, Ceelen W, Pattyn P. Early postoperative systemic inflammatory response as predictor of anastomotic leakage after esophagectomy: a systematic review and meta-analysis. J Gastrointest Surg 2024; 28:757-765. [PMID: 38704210 DOI: 10.1016/j.gassur.2024.02.003] [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: 01/10/2024] [Revised: 01/22/2024] [Accepted: 02/03/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND AND PURPOSE Postesophagectomy anastomotic leakage occurs in up to 16% of patients and is the main cause of morbidity and mortality. The leak severity is determined by the extent of contamination and the degree of sepsis, both of which are related to the time from onset to treatment. Early prediction based on inflammatory biomarkers such as C-reactive protein (CRP) levels, white blood cell counts, albumin levels, and combined Noble-Underwood (NUn) scores can guide early management. This review aimed to determine the diagnostic accuracy of these biomarkers. METHODS This study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the PROSPERO (International Prospective Register of Systematic Reviews) database. Two reviewers independently conducted searches across PubMed, MEDLINE, Web of Science, and Embase. Sources of bias were assessed, and a meta-analysis was performed. RESULTS Data from 5348 patients were analyzed, and 13% experienced leakage. The diagnostic accuracy of the serum biomarkers was analyzed, and pooled cutoff values were identified. CRP levels were found to have good diagnostic accuracy on days 2 to 5. The best discrimination was identified on day 2 for a cutoff value < 222 mg/L (area under the curve = 0.824, sensitivity = 81%, specificity = 88%, positive predictive value = 38.6%, and negative predictive value = 98%). A NUn score of >10 on day 4 correlated with poor diagnostic accuracy. CONCLUSION The NUn score failed to achieve adequate accuracy. CRP seems to be the only valuable biomarker and is a negative predictor of postesophagectomy leakage. Patients with a CRP concentration of <222 mg/L on day 2 are unlikely to develop a leak, and patients can safely proceed through their enhanced recovery after surgery protocol. Patients with a CRP concentration of <127 mg/L on day 5 can be safely discharged when clinically possible.
Collapse
Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium.
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Louise Peirsman
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
28
|
Pera M. Anastomotic leak in colorectal cancer surgery: Short term outcomes have long term consequences. Cir Esp 2024; 102:185-187. [PMID: 38430959 DOI: 10.1016/j.cireng.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Miguel Pera
- Department of General and Digestive Surgery, Institute of Digestive and Metabolic Diseases (ICMDM), August Pi i Sunyer Biomedical Research Intitute (IDIBAPS), Hospital Clínic Barcelona, University of Barcelona, Spain.
| |
Collapse
|
29
|
He X, Mao T, Peng L, Wang S, Deng T, He W. Redefining Esophagectomy: The Manual Layered Insertion Method That May Reduce Anastomotic Leakage. J Surg Res 2024; 296:182-188. [PMID: 38277955 DOI: 10.1016/j.jss.2023.12.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 11/30/2023] [Accepted: 12/27/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Anastomotic leakage post-esophagectomy remains a significant challenge. Despite the use of both mechanical and manual anastomosis, leakage rates remain high. This study evaluated the effectiveness of the manual layered insertion anastomosis technique in addressing this issue. METHODS A retrospective analysis was conducted on patients who underwent this technique from September 2020 to December 2021. The process involved thoracoscopic release of the esophagus, mediastinal lymph node dissection, laparoscopic stomach release, and its transformation into a tube. The latter was then guided to the neck for anastomosis. The posterior anastomotic wall was reshaped in the neck first for optimal insertion, followed by layered suturing with the gastric conduit. The anterior wall was subsequently sutured and repositioned into the chest. RESULTS The study included 56 patients (51 men, five women, mean age 65.4 y), with nine having undergone neoadjuvant therapy. All received minimally invasive esophagectomy. Average intraoperative blood loss was 79.8 mL, operation time averaged 331 min, and feeding resumed after an average of 6.3 d. No anastomotic leakages were reported, with reduced incidences of anastomotic stenosis and gastric acid reflux compared to previous studies. CONCLUSIONS The manual layered insertion anastomosis technique may reduce anastomotic leakage and associated complications, improving the efficacy of esophagectomy, which may improve postoperative results and patient quality of life, suggesting the method's potential suitability for wider clinical application.
Collapse
Affiliation(s)
- Xuedong He
- Department of Thoracic Surgery, The People's Hospital of Jianyang City, Jianyang, Sichuan, China
| | - Tianqin Mao
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Cancer Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Lin Peng
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Cancer Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, Sichuan, China
| | - Shiping Wang
- Department of Thoracic Surgery, The People's Hospital of Jianyang City, Jianyang, Sichuan, China
| | - Tao Deng
- Department of Thoracic Surgery, The People's Hospital of Jianyang City, Jianyang, Sichuan, China
| | - Wenwu He
- Department of Thoracic Surgery, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, Cancer Hospital Affiliated to University of Electronic Science and Technology of China, Chengdu, Sichuan, China.
| |
Collapse
|
30
|
Nevins EJ, Chmelo J, Prasad P, Brown J, Phillips AW. Long-term survival is not affected by severity of complications following esophagectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108232. [PMID: 38430703 DOI: 10.1016/j.ejso.2024.108232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/09/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Outcomes following esophagectomy for esophageal cancer have continued to improve over the last 30 years. Post-operative complications impact upon peri-operative and short-term survival but the effect on long-term survival remains debated. This study aims to investigate the effect of post-operative complications on long-term survival following esophagectomy. MATERIALS AND METHODS All patients who underwent an esophagectomy between January 2010 and January 2019 were included from a single high-volume center. Data was collected contemporaneously. Patients were separated into three groups; those who experienced no, or very minor complications (Clavien-Dindo 0 or 1), minor complications (Clavien-Dindo 2), and major complications (Clavien-Dindo 3-4), at 30 days. To correct for short-term mortality effects, those who died during the index hospital admission were excluded. Overall survival was analyzed using Kaplan-Meier and log rank testing. RESULTS The study cohort comprised 721 patients. There were 42.4% (306/721), 29.5% (213/721) and 25.7% (185/721) in the Clavien-Dindo 0-1, Clavien-Dindo 2, and Clavien-Dindo 3-4 group respectively. Seventeen patients (2.4%) died during their index hospital admission and were therefore excluded. There was no significant difference between median survival across the 3 groups (50, 57 and 52 months). Across all 3 groups, overall long-term survival rates were equivalent at 1 (87.5%, 84.9%, 83.2%), 3 (59.7%, 59.6%, 54.2%), and 5 years (43.9%, 48.9%, 45.7%) (p = 0.806). The only factors independently associated with survival in this cohort, were male gender, Charlson comorbidity index, and overall pathological stage of disease. CONCLUSION Long-term survival is not affected by peri-operative complications, irrespective of severity, following esophagectomy. Further study into the long-term quality of life is required.
Collapse
Affiliation(s)
- Edward J Nevins
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Jakub Chmelo
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Pooja Prasad
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Joshua Brown
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK; School of Medical Education, Newcastle University, Newcastle Upon Tyne, UK.
| |
Collapse
|
31
|
Abou Chaar MK, Godin A, Saddoughi SA, Harmsen WM, Lee MK, Yost KJ, Blackmon SH. Patients Struggle With Severe Symptoms Even After Surviving Esophagectomy for Esophageal Cancer. ANNALS OF THORACIC SURGERY SHORT REPORTS 2024; 2:98-102. [PMID: 39790283 PMCID: PMC11708654 DOI: 10.1016/j.atssr.2023.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 01/12/2025]
Abstract
Background This prospective study was conducted to determine postesophagectomy symptom severity of esophageal cancer survivors with use of the Upper Digestive Disease (UDD) questionnaire. Methods A prospective trial included adult esophagectomy patients diagnosed with primary esophageal carcinoma at a single institution from 2000 to 2011. Those who remained alive in 2015 to 2021 were enrolled. Comparison was made between sequential questionnaires. Results From a prospective registry of 895 patients with esophagectomy for esophageal cancer, 297 (33%) long-term survivors were identified. Of those, 93 (31%) had recent contact data and 66 (71%) consented and completed the UDD questionnaire. Most participants, 77% (51), were men with a mean age of 57 (±7) years. The mean time from esophagectomy was 12 (8-20) years. The 66 enrolled patients completed 127 UDD questionnaires. A total of 27 (41%) completed at least 2 questionnaires. Poor performance was recorded in the 5 domains as follows: reflux, 19 patients (29%); pain, 3 patients (5%); dysphagia, 0 patients; gastrointestinal dumping, 31 patients (47%); and generalized dumping, 17 patients (26%). Between the first and second questionnaires, dysphagia had the most noticeable improvement in domain score (23/27 [85%]), and reflux had the most regression in domain score (7/27 [26%]). Conclusions Patient-reported outcome data are an integral part of esophageal cancer survivorship care. Having a standardized tool that would enhance research and standardize care pathway symptom management is needed.
Collapse
Affiliation(s)
- Mohamad K. Abou Chaar
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anny Godin
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sahar A. Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Minji K. Lee
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Kathleen J. Yost
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Shanda H. Blackmon
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Center for Digital Health, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
32
|
Aiolfi A, Bona D, Bonitta G, Bonavina L. Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis. Ann Surg 2024; 279:410-418. [PMID: 37830253 DOI: 10.1097/sla.0000000000006124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.
Collapse
Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, University of Milan, IRCCS Policlinico San Donato, Milan, Italy
| |
Collapse
|
33
|
Liu Y, Zhou J, Gu Y, Hu W, Lin H, Shang Q, Zhang H, Yang Y, Yuan Y, Chen L. Will synchronous esophageal and lung resection increase the incidence of anastomotic leaks? A multicenter retrospective study. Int J Surg 2024; 110:1653-1662. [PMID: 38181122 PMCID: PMC10942245 DOI: 10.1097/js9.0000000000001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2024] [Accepted: 12/11/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, the authors retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study. METHODS Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a four-center prospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score-matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted. RESULTS Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio propensity score-matched EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly ( P =0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic>wedge resection, P =0.016) and site of resected lobe (upper>middle/low lobe; P =0.027), and a nomogram was established to predict the occurrence of leaks accurately (area under the curve=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group ( P =0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS ( P =0.027). CONCLUSION Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.
Collapse
Affiliation(s)
- Yixin Liu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Jianfeng Zhou
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yimin Gu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, Shangjin Nanfu hospital of Chengdu
| | - Weipeng Hu
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, Sanya People’s Hospital
| | - Haonan Lin
- Department of Thoracic Surgery, West China Hospital of Sichuan University
- Department of Thoracic Surgery, West China Tianfu Hospital, Sichuan, People’s Republic of China
| | - Qixin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Hanlu Zhang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yushang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Yong Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| | - Longqi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University
| |
Collapse
|
34
|
Chen C, Ding C, He Y, Guo X. High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy. Eur J Cardiothorac Surg 2024; 65:ezae050. [PMID: 38341665 DOI: 10.1093/ejcts/ezae050] [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: 10/10/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy. METHODS A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching. RESULTS After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002). CONCLUSIONS For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.
Collapse
Affiliation(s)
- Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital Affiliated with Fudan University, Shanghai, China
| | - Chengzhi Ding
- Department of Thoracic Surgery, Henan Provincial People's Hospital; Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yi He
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xufeng Guo
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
35
|
Rayman S, Ross S, Sucandy I, Mikhail K, Christodoulou M, Pattilachan T, Rosemurgy A. The effects of smoking history on robotic transhiatal esophagectomy patient outcomes. J Robot Surg 2024; 18:76. [PMID: 38353887 DOI: 10.1007/s11701-024-01829-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/14/2024] [Indexed: 02/16/2024]
Abstract
Esophageal resection for the treatment of esophageal cancer generally entails high rates of morbidity and mortality. Patients with a smoking history have increased post-operative complications following esophagectomy. This study was undertaken to determine how smoking or a history of smoking can affect perioperative outcomes and morbidity following robotic transhiatal esophagectomy. 75 patients were prospectively followed and divided; 44 patients actively smoking or with a history of significant smoking were classified as 'smokers', while the other 31 patients were classified as 'non-smokers'. Significance was determined at a p-value of ≤ 0.05 and data are presented as median (mean ± SD). 'Smokers' averaged 70(70 ± 7.8) years, 89% male, with 82% undergoing neoadjuvant therapy. 'Nonsmokers' averaged 68(69 ± 7.8) years, 74% male, and 74% receiving neoadjuvant therapy. BMI and ASA class showed no significant difference between the cohorts. 'Smokers' had an operative time of 341(343 ± 91.0) minutes and a blood loss of 150(191 ± 140.0) mL; 'nonsmokers' had 291(298 ± 65.9) minutes and 100(140 ± 120.9) mL, respectively (p = 0.02 for operative time). Tumor size and AJCC staging were similar for both cohorts. No significant differences were noted in postoperative complications, Clavien-Dindo score ≥ III, in-hospital mortality, length of stay, or 30-day readmissions. Survival rates were comparable. Hospital costs for 'smokers' were $33,131(41,091 ± 23,465.17) and $34,896 (62,154 ± 65,839.53) for 'nonsmokers' (p = 0.05). Profit/loss was $-23,155 (- 15,137 ± 35,819.29) for smokers and $-23,720 (- 16,716 ± 50,864.64) for nonsmokers. Current or past 'smokers' had longer operative times and lower costs following robotic transhiatal esophagectomy, with no significant difference in postoperative complications or survival compared to 'non-smokers'.
Collapse
Affiliation(s)
- Shlomi Rayman
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
- Department of General Surgery, Assuta Ashdod Public Hospital, Ashdod, Israel
- Affiliated with the Faculty of Health and Science, Ben-Gurion University, Beer-Sheba, Israel
| | - Sharona Ross
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA.
| | - Iswanto Sucandy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Katherine Mikhail
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Maria Christodoulou
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Tara Pattilachan
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- Digestive Health Institute, AdventHealth Tampa, 3000 Medical Park Drive, Suite#500, Tampa, FL, 33613, USA
| |
Collapse
|
36
|
Fujita T, Sato K, Fujiwara N, Kajiyama D, Shigeno T, Daiko H. A novel imaging technology to assess tissue oxygen saturation and its correlation with indocyanine green in the gastric conduit during thoracic esophagectomy. Surgery 2024; 175:360-367. [PMID: 38001012 DOI: 10.1016/j.surg.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/17/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Anastomotic leakage in esophagectomy is a serious complication, and assessing blood perfusion in the conduit can help minimize this risk. Indocyanine green is the most widely used method to assess tissue blood flow; however, this technique has disadvantages. Evaluating tissue oxygen saturation in the gastric conduit during thoracic esophagectomy compared with indocyanine green blood perfusion assessment addresses these disadvantages and can be performed easily and repeatedly. METHODS This was a prospective study of patients with esophageal cancer who underwent thoracic esophagectomy. Intraoperative tissue oxygen saturation and indocyanine green measurements were obtained to determine the anastomotic site and to compare the correlation between the 2 methods. Tissue oxygen saturation and indocyanine green values were obtained at the tip of the gastric conduit, the demarcation line indicating visible perfusion, and the end of the right gastroepiploic artery. RESULTS Fifty-seven patients were enrolled in this study; 3 developed anastomotic leakage, and all 3 underwent robotic thoracic surgery. The tissue oxygen saturation value decreased gradually toward the tip of the conduit, as did congestion, and was significantly decreased at the tip compared with the value at the demarcation line (P = .001). Mean tissue oxygen saturation differed significantly between the leakage and no-leakage groups at the anastomosis site (P = .04). We found a negative correlation between tissue oxygen saturation and indocyanine green values at the end of the right gastroepiploic artery (r = -0.361; P = .03). CONCLUSION Tissue oxygen saturation imaging was useful in determining the anastomotic site and addressed the disadvantages associated with indocyanine green.
Collapse
Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan.
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Naoto Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Daisuke Kajiyama
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Takashi Shigeno
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| |
Collapse
|
37
|
Sano A, Sohda M, Hosoi N, Tateno K, Watanabe T, Nakazawa N, Shioi I, Shibasaki Y, Okada T, Osone K, Shiraishi T, Sakai M, Ogawa H, Okabe H, Shirabe K, Saeki H. A Novel Method for Thoracoscopic Overlap Esophagogastric Reconstruction With Pleural Closure following Minimally Invasive Ivor-Lewis Esophagectomy for Esophagogastric Junction Cancer. Surg Laparosc Endosc Percutan Tech 2024; 34:108-112. [PMID: 38091490 DOI: 10.1097/sle.0000000000001250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 11/09/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy is a technically demanding surgical technique that can result in serious intrathoracic infections when anastomotic leakage occurs. Herein, we report a novel side-overlap esophagogastric anastomosis with pleural closure for esophagogastric junction cancer. METHODS The 3 key points of our novel technique were the following: (1) overlap esophagogastric anastomosis and closure of the entry hole were all performed using a linear stapler; (2) the pleura was closed to separate the anastomotic site from the thoracic cavity; and (3) the mediastinal drain was inserted transhiatally from the abdominal cavity. RESULTS This modified anastomosis procedure was performed on 8 consecutive patients at our institution. The median overall/thoracoscopic operating time and estimated blood loss were 652.5/241.5 min and 89 mL, respectively. No mortality or serious postoperative complications occurred, and the median postoperative hospital stay was 22 days (range, 17 to 37 d). CONCLUSION This novel thoracoscopic overlap esophagogastric reconstruction procedure with pleural closure is safe and feasible.
Collapse
Affiliation(s)
- Akihiko Sano
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Makoto Sohda
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nobuhiro Hosoi
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kohei Tateno
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takayoshi Watanabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Nobuhiro Nakazawa
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Ikuma Shioi
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yuta Shibasaki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takuhisa Okada
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Katsuya Osone
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Takuya Shiraishi
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Makoto Sakai
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroomi Ogawa
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroshi Okabe
- Department of Gastroenterological Surgery, New Tokyo Hospital, Chiba, Japan
| | - Ken Shirabe
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroshi Saeki
- Department of General Surgical Science, Gunma University Graduate School of Medicine, Gunma, Japan
| |
Collapse
|
38
|
Van Daele E, Vanommeslaeghe H, Decostere F, Beckers Perletti L, Beel E, Van Nieuwenhove Y, Ceelen W, Pattyn P. Systemic Inflammatory Response and the Noble and Underwood (NUn) Score as Early Predictors of Anastomotic Leakage after Esophageal Reconstructive Surgery. J Clin Med 2024; 13:826. [PMID: 38337519 PMCID: PMC10856250 DOI: 10.3390/jcm13030826] [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: 01/02/2024] [Revised: 01/24/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Anastomotic leakage (AL) remains the main cause of post-esophagectomy morbidity and mortality. Early detection can avoid sepsis and reduce morbidity and mortality. This study evaluates the diagnostic accuracy of the Nun score and its components as early detectors of AL. This single-center observational cohort study included all esophagectomies from 2010 to 2020. C-reactive protein (CRP), albumin (Alb), and white cell count (WCC) were analyzed and NUn scores were calculated. The area under the curve statistic (AUC) was used to assess their predictive accuracy. A total of 74 of the 668 patients (11%) developed an AL. CRP and the NUn-score proved to be good diagnostic accuracy tests on postoperative day (POD) 2 (CRP AUC: 0.859; NUn score AUC: 0.869) and POD 4 (CRP AUC: 0.924; NUn score AUC: 0.948). A 182 mg/L CRP cut-off on POD 4 yielded a 87% sensitivity, 88% specificity, a negative predictive value (NPV) of 98%, and a positive predictive value (PPV) of 47.7%. A NUn score cut-off > 10 resulted in 92% sensitivity, 95% specificity, 99% NPV, and 68% PPV. Albumin and WCC have limited value in the detection of post-esophagectomy AL. Elevated CRP and a high NUn score on POD 4 provide high accuracy in predicting AL after esophageal cancer surgery. Their high negative predictive value allows to select patients who can safely proceed with enhanced recovery protocols.
Collapse
Affiliation(s)
- Elke Van Daele
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Hanne Vanommeslaeghe
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
| | - Flo Decostere
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Louise Beckers Perletti
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Esther Beel
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Yves Van Nieuwenhove
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Wim Ceelen
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| | - Piet Pattyn
- Department of Gastrointestinal Surgery, Ghent University Hospital, C. Heymanslaan 10, B-9000 Ghent, Belgium (W.C.)
- Faculty of Medicine, Ghent University, C. Heymanslaan 10, B-9000 Ghent, Belgium; (F.D.); (L.B.P.); (E.B.)
| |
Collapse
|
39
|
Alanazi KO, Alshammari FA, Alanazi AS, Alrashidi MO, Alrashidi AO, Aldhafeeri YA, Alanazi TH, Alkahtani AS, Alrakhimi AS, Albathali HA. Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e50370. [PMID: 38222119 PMCID: PMC10784652 DOI: 10.7759/cureus.50370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/11/2023] [Indexed: 01/16/2024] Open
Abstract
Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.
Collapse
Affiliation(s)
- Khalid O Alanazi
- Department of General Surgery, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Ali Obaid Alrashidi
- Department of Family Medicine, Al-Shifa Primary Health Care Centre, Hafar al-Batin, SAU
| | - Yousif A Aldhafeeri
- Department of Internal Medicine, King Khalid General Hospital, Hafar al-Batin, SAU
| | | | | | | | - Hamdan A Albathali
- Department of Family Medicine, Al-Nozha Primary Health Care Centre, Hafar al-Batin, SAU
| |
Collapse
|
40
|
Hong Z, Cui B, Lu Y, Bai X, Yang N, He X, Wu X, Cheng T, Jin D, Zhao J, Gou Y. Efficacy and Quality of Life with the Modified Versus the Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study. Ann Surg Oncol 2023; 30:8223-8230. [PMID: 37535270 DOI: 10.1245/s10434-023-14033-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy and postoperative quality of life for patients with esophageal cancer treated by either the modified or the traditional thoracolaparoscopic McKeown procedure. METHODS This retrospective case-control study included 269 patients with esophageal cancer admitted to three medical centers in China from February 2020 to August 2022. The patients were divided according to surgical method into the layered hand-sewn end-to-end invagination anastomosis group (modified group) and the traditional hand anastomosis group (traditional group). Propensity score-matching (PSM) was used to maintain balance and comparability between the two groups. RESULTS The differences in age and tumor location between the patients in the traditional and modified groups were statistically significant. After PSM, the aforementioned factors were statistically insignificant. After PSM, each group had 101 patients. The modified group showed the greater advantage in terms of postoperative hospital stay (P = 0.036), incidence of anastomotic leak (P = 0.009), and incidence of gastroesophageal reflux (P < 0.001), and the difference was statistically significant. The results of the Quality of Life Questionnaire Core 30 (QLQ-C30) and Quality of Life Questionnaire Oesophageal Cancer Module 18 (QLQ-OES18) scales showed that the modified group also had the advantage over the traditional group in terms of physical function, overall health status, loss of appetite, eating, reflux, obstruction, and loss of appetite scores at the first and third months after surgery. CONCLUSION The modified thoraco-laparoscopic McKeown procedure is a safe and effective surgical approach that can significantly reduce the incidence of postoperative anastomotic leak and gastroesophageal reflux, shorten the postoperative hospital stay, and improve the postoperative quality of life for patients with esophageal cancer.
Collapse
Affiliation(s)
- Ziqiang Hong
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Baiqiang Cui
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Yingjie Lu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Xiangdou Bai
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Ning Yang
- Department of Thoracic Surgery, Second Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoyang He
- Department of Thoracic Surgery, Hebei Province Chest Hospital, Shijiazhuang, China
| | - Xusheng Wu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Cheng
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Jing Zhao
- Lanzhou First People's Hospital, Lanzhou, China.
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
| |
Collapse
|
41
|
Loske G, Müller J, Schulze W, Riefel B, Reeh M, Müller CT. [Endoscopic negative pressure treatment : From management of complications to pre-emptive active reflux drainage in abdominothoracic esophageal resection-A new safety concept for esophageal surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:1022-1033. [PMID: 37882839 PMCID: PMC10689535 DOI: 10.1007/s00104-023-01970-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Early postoperative reflux (PR) can compromise anastomotic healing after Ivor Lewis esophagectomy (ILE) and poses a risk for aspiration. Anastomotic insufficiency is the most threatening surgical complication. We present the protective method of pre-emptive active reflux drainage (PARD) with simultaneous enteral feeding. We report our experience with this new safety concept in esophageal surgery in a cohort of 43 patients. MATERIALS AND METHODS For PARD we use a double lumen open porous film drainage (dOFD). To create the dOFD, the gastric tube of a Trelumina probe (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore drainage film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over a length of 25 cm. The dOFD is endoscopically inserted into the tubular stomach intraoperatively after completion of the anastomosis. Continuous negative pressure is applied with an electronic pump (-125 mm Hg). The PR is continuously aspirated completely and the stomach and anastomotic region are decompressed. At the same time, nutrition is delivered via an integrated intestinal tube. Depending on the results of the endoscopic control after 5 days, PARD is either continued or terminated. RESULTS During the observation period (2017-2023), PARD was used in all patients (n = 43) with ILE. The healing rate under PARD was 100% and healing was observed in all anastomoses. No additional endoscopic procedures or surgical revisions of the anastomoses were required. The median duration of PARD was 8 days (range 4-21). We observed problems in the healing of the anastomosis in 20 of 43 patients (47%) for whom we defined endoscopic criteria for at-risk anastomosis. CONCLUSIONS Our results suggest that PARD has a strong protective effect on anastomotic healing and may reduce the risk of anastomotic insufficiency. The integrated feeding tube of the dOFD allows early postoperative enteral feeding while simultaneously applying negative pressure. PARD appears to prevent the negative consequences of impaired anastomotic healing.
Collapse
Affiliation(s)
- Gunnar Loske
- Klinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Deutschland.
| | - Johannes Müller
- Klinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Wolfgang Schulze
- Klinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Burkhard Riefel
- Klinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Deutschland
| | - Matthias Reeh
- Klinik für Allgemein‑, Viszeral‑, Thorax- und Gefäßchirurgie, Katholisches Marienkrankenhaus Hamburg, Alfredstr. 9, 22087, Hamburg, Deutschland
| | | |
Collapse
|
42
|
Ri M, Tzortzakakis A, Sotirova I, Tsekrekos A, Klevebro F, Lindblad M, Nilsson M, Rouvelas I. CRP as an early indicator for anastomotic leakage after esophagectomy for cancer: a single tertiary gastro-esophageal center study. Langenbecks Arch Surg 2023; 408:436. [PMID: 37964057 PMCID: PMC10645624 DOI: 10.1007/s00423-023-03176-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
PURPOSE To determine the relationship between postoperative C-reactive protein (CRP) as an early indicator of anastomotic leakage (AL) after esophagectomy for esophageal cancer. METHODS We reviewed patients diagnosed with esophageal or esophagogastric junctional cancer who underwent esophagectomy between 2006 and 2022 at the Karolinska University Hospital, Stockholm, Sweden. Multivariable logistic regression models estimated relative risk for AL by calculating the odds ratio (OR) with a 95% confidence interval (CI). The cut-off values for CRP were based on the maximum Youden's index using receiver operating characteristic curve analysis. RESULTS In total, 612 patients were included, with 464 (75.8%) in the non-AL (N-AL) group and 148 (24.2%) in the AL group. Preoperative body mass index and the proportion of patients with the American Society of Anesthesiologists physical status classification 3 were significantly higher in the AL group than in the N-AL group. The median day of AL occurrence was the postoperative day (POD) 8. Trends in CRP levels from POD 2 to 3 and POD 3 to 4 were significantly higher in the AL than in the N-AL group. An increase in CRP of ≥ 4.65% on POD 2 to 3 was an independent risk factor for AL with the highest OR of 3.67 (95% CI 1.66-8.38, p = 0.001) in patients with CRP levels on POD 2 above 211 mg/L. CONCLUSION Early changes in postoperative CRP levels may help to detect AL early following esophageal cancer surgery.
Collapse
Affiliation(s)
- Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Ira Sotirova
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Department of Surgery, Umeå University Hospital, Umeå, Sweden
| | - Andrianos Tsekrekos
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Klevebro
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Lindblad
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Hälsovägen 13, 141 57, Huddinge, Stockholm, Sweden.
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
43
|
Bîrlă R, Hoara P, Achim F, Dinca V, Ciuc D, Constantinoiu S, Constantin A. Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives. World J Gastrointest Oncol 2023; 15:1675-1690. [PMID: 37969407 PMCID: PMC10631441 DOI: 10.4251/wjgo.v15.i10.1675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/04/2023] [Accepted: 09/22/2023] [Indexed: 10/10/2023] Open
Abstract
Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.
Collapse
Affiliation(s)
- Rodica Bîrlă
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Petre Hoara
- Department of General Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest 020021, Romania
| | - Florin Achim
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Valeriu Dinca
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Diana Ciuc
- Faculty of Medicine, “Titu Maiorescu” University, Bucharest 031593, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| | - Adrian Constantin
- Department of General Surgery, Carol Davila University, Bucharest 011172, Romania
| |
Collapse
|
44
|
Cengiz M, Odemis B, Durak MB. Endoscopic treatment of esophagogastric and esophagojejunal anastomotic leaks: A single tertiary center experience. Medicine (Baltimore) 2023; 102:e35582. [PMID: 37832055 PMCID: PMC10578745 DOI: 10.1097/md.0000000000035582] [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: 05/01/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Anastomotic leakage in esophagogastric and esophagojejunal anastomoses after esophagectomy/gastrectomy is a severe complication with a high mortality rate. We aimed to evaluate the technical and clinical success and outcomes of endoscopic placement of fully covered self-expanding metallic stents (FCSEMSs) for treating anastomotic leaks that develop after cancer surgery. All consecutive patients treated at the Gastroenterology Department, Ankara City Hospital, Ankara, Turkey, who underwent endoscopic FCSEMSs for leaks of esophagogastric or esophagojejunal anastomosis between February 2015 and December 2021 were included in the study. We analyzed the data on leak characteristics, technical success, clinical success, stent-related complications, and mortality to investigate the clinical efficacy and safety of endoscopically implanted FCSEMSs. A total of 24 patients, 12 of whom were male were included in the study. The median age of the patients was 60 years (min-max: 38-84). Nineteen patients underwent esophagojejunal anastomosis, and 5 patients underwent esophagogastric anastomosis. The median stent follow-up time was 68.8 (26-190) days, and the median hospital stay was 62.7 (24-145) days. Complications related to stent placement were observed in of 50%. The most common complication was stent migration, occurring at a frequency of 37.5%. The median follow-up period time was 11.4 (2-37) months. While the clinical success rate was 87.5%, 3 patients died. Endoscopic placement of FCSEMSs is a relatively safe and beneficial treatment for esophagojejunal and esophagogastric anastomotic leaks.
Collapse
Affiliation(s)
- Mustafa Cengiz
- Gulhane Research and Training Hospital, Department of Gastroenterology, Etlik, Ankara, Turkey
| | - Bulent Odemis
- Ankara City Hospital, Department of Gastroenterology, Ankara, Turkey
| | | |
Collapse
|
45
|
Geraedts TCM, Weijs TJ, Berkelmans GHK, Fransen LFC, Kouwenhoven EA, van Det MJ, Nilsson M, Lagarde SM, van Hillegersberg R, Markar SR, Nieuwenhuijzen GAP, Luyer MDP. Long-Term Survival Associated with Direct Oral Feeding Following Minimally Invasive Esophagectomy: Results from a Randomized Controlled Trial (NUTRIENT II). Cancers (Basel) 2023; 15:4856. [PMID: 37835550 PMCID: PMC10571988 DOI: 10.3390/cancers15194856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/27/2023] [Accepted: 10/01/2023] [Indexed: 10/15/2023] Open
Abstract
Advancements in perioperative care have improved postoperative morbidity and recovery after esophagectomy. The direct start of oral intake can also enhance short-term outcomes following minimally invasive Ivor Lewis esophagectomy (MIE-IL). Subsequently, short-term outcomes may affect long-term survival. This planned sub-study of the NUTRIENT II trial, a multicenter randomized controlled trial, investigated the long-term survival of direct versus delayed oral feeding following MIE-IL. The outcomes included 3- and 5-year overall survival (OS) and disease-free survival (DFS), and the influence of complications and caloric intake on OS. After excluding cases of 90-day mortality, 145 participants were analyzed. Of these, 63 patients (43.4%) received direct oral feeding. At 3 years, OS was significantly better in the direct oral feeding group (p = 0.027), but not at 5 years (p = 0.115). Moreover, 5-year DFS was significantly better in the direct oral feeding group (p = 0.047) and a trend towards improved DFS was shown at 3 years (p = 0.079). Postoperative complications and caloric intake on day 5 did not impact OS. The results of this study show a tendency of improved 3-year OS and 5-year DFS, suggesting a potential long-term survival benefit in patients receiving direct oral feeding after esophagectomy. However, the findings should be further explored in larger future trials.
Collapse
Affiliation(s)
- Tessa C. M. Geraedts
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Teus J. Weijs
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Gijs H. K. Berkelmans
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Laura F. C. Fransen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Ewout A. Kouwenhoven
- Department of Surgery, ZGT Hospital Group Twente, 7609 PP Almelo, The Netherlands; (E.A.K.); (M.J.v.D.)
| | - Marc J. van Det
- Department of Surgery, ZGT Hospital Group Twente, 7609 PP Almelo, The Netherlands; (E.A.K.); (M.J.v.D.)
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, 141-86 Stockholm, Sweden;
- Department of Upper Abdominal Diseases, Karolinska University Hospital, 171-77 Stockholm, Sweden
| | - Sjoerd M. Lagarde
- Department of Surgery, Eramus Medical Center, 3015 CN Rotterdam, The Netherlands;
| | | | - Sheraz R. Markar
- Nuffield Department of Surgery, University of Oxford, Oxford OX3 9DU, UK;
| | - Grard A. P. Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| | - Misha D. P. Luyer
- Department of Surgery, Catharina Hospital, 5623 EJ Eindhoven, The Netherlands; (T.C.M.G.); (T.J.W.); (G.A.P.N.)
| |
Collapse
|
46
|
Sugita S, Miyata K, Shimizu D, Ebata T, Yokoyama Y. A risk scoring system for early diagnosis of anastomotic leakage after subtotal esophagectomy for esophageal cancer. Jpn J Clin Oncol 2023; 53:936-941. [PMID: 37370213 DOI: 10.1093/jjco/hyad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most critical postoperative complications after subtotal esophagectomy in patients with esophageal cancer. This study attempted to develop an optimal scoring system for stratifying the risk for AL. METHODS The study included 171 patients who underwent subtotal esophagectomy for esophageal cancer followed by esophagogastrostomy in the cervical region from January 2011 to April 2021 at Nagoya University Hospital. AL was defined by radiologic or endoscopic evidence of anastomotic breakdown using some modalities. A risk scoring system for an early diagnosis of AL was established using factors determined in the multivariate analysis. A score was calculated for each patient, and the patients were classified into three categories according to the risk for AL: low-, intermediate- and high-risk. The trend of the risk for AL among the categories was evaluated. RESULTS Twenty-nine patients (17%) developed AL. Multivariate analysis demonstrated that sinistrous gross features of drain fluid (P < 0.001; odds ratio (OR), 10.2), radiologic air bubble sign (P < 0.001; OR, 15.0) and the level of drain amylase ≥280 U/L on postoperative Day 7 (P < 0.001; OR, 9.0) were significantly associated with AL. According to the matching number of the above three risk factors and categorization into three risk groups, the incidence of AL was 6.1% (8/131) in the low-risk group, 45.5% (15/33) in the intermediate-risk group and 85.7% (6/7) in the high-risk group (area under curve, 0.81; 95% confidence interval, 0.72-0.90). CONCLUSIONS The present AL-risk scoring system may be useful in postoperative patient care after subtotal esophagectomy.
Collapse
Affiliation(s)
- Shizuki Sugita
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazushi Miyata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daisuke Shimizu
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Preoperative Medicine, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| |
Collapse
|
47
|
Stuart CM, Dyas AR, Byers S, Velopulos C, Randhawa S, David EA, Pritap A, Stewart CL, Mitchell JD, McCarter MD, Meguid RA. Social vulnerability is associated with increased postoperative morbidity following esophagectomy. J Thorac Cardiovasc Surg 2023; 166:1254-1261. [PMID: 37119966 DOI: 10.1016/j.jtcvs.2023.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/28/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES The effect of a patient's Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy. METHODS This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016 to 2022. Patients were grouped into low-SVI (<75%ile) and high-SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the 2 groups. Multivariable logistic regression was used to control for covariates. RESULTS Of 149 patients identified who underwent esophagectomy, 27 (18.1%) were in the high-SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% vs 4.9%, P = .029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a postoperative complication (66.7% vs 36.9%, P = .005) and had greater rates of postoperative pneumonia (25.9% vs 6.6%, P = .007), jejunal feeding-tube complications (14.8% vs 3.3%, P = .036), and unplanned intensive care unit readmission (29.6% vs 12.3%, P = .037). In addition, patients with high SVI had a longer postoperative hospital length of stay (13 vs 10 days, P = .017). There were no differences in mortality rates. These findings persisted on multivariable analysis. CONCLUSIONS Patients with high SVI have greater rates of postoperative morbidity following esophagectomy. The effect of SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.
Collapse
Affiliation(s)
- Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo.
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Sara Byers
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
| | - Catherine Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Simran Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Elizabeth A David
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Akshay Pritap
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
| |
Collapse
|
48
|
Zheng F, Yang J, Zhang J, Li J, Fang W, Chen M. Efficacy and complications of single-port thoracoscopic minimally invasive esophagectomy in esophageal squamous cell carcinoma: a single-center experience. Sci Rep 2023; 13:16325. [PMID: 37770495 PMCID: PMC10539285 DOI: 10.1038/s41598-023-41772-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/31/2023] [Indexed: 09/30/2023] Open
Abstract
The traditional surgical technique for esophageal cancer is mainly open esophagectomy. With the innovation of surgical instruments, it is necessary to re-optimize the minimally invasive surgery. Therefore, single-port thoracoscopic minimally invasive esophagectomy (SPTE) is an important direction of development. This study retrospectively analyzed 202 patients with esophageal squamous cell carcinoma undergoing SPTE. Surgical variables and postoperative complications were further evaluated. All procedures were performed using SPTE. The number of patients who received R0 resection was 201 (99.5%). The total number of resected lymph nodes during the whole operation was on average 32.01 ± 12.15, and the mean number of positive lymph nodes was 1.56 ± 2.51. In 170 cases (84.2%), intraoperative blood loss did not exceed 100 ml (ml), while 1 case had postoperative bleeding. Only 1 patient (0.5%) required reoperation after surgery. Postoperative complications included 42 cases of pneumonia (20.8%), 9 cases of anastomotic leak (4.5%), 7 cases of pleural effusion (3.8%), and 1 case (0.5%) of both pleural hemorrhage and acute gastrointestinal hemorrhagic ulcer. Besides, we also recorded the time to remove the drain tube, which averaged 9.13 ± 5.31 days. In our study, we confirmed that the application of SPTE in clinical practice is feasible, and that the postoperative complications are at a low level.
Collapse
Affiliation(s)
- Fei Zheng
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China
| | - Jun Yang
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China
| | - Jiulong Zhang
- Department of Thoracic Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China
| | - Jiancheng Li
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China
| | - Weimin Fang
- Department of Thoracic Surgery, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China.
| | - Mingqiu Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Rd. Jin'an District, Fuzhou, 350014, Fujian Province, People's Republic of China.
| |
Collapse
|
49
|
Kitadani J, Ojima T, Hayata K, Goda T, Takeuchi A, Tominaga S, Fukuda N, Nakai T, Yamaue H, Kawai M. Neoadjuvant Triplet Chemotherapy with Docetaxel, Cisplatin plus 5-Fluorouracil versus Docetaxel, Cisplatin plus S-1 for Advanced Esophageal Squamous cell Carcinoma: Propensity Score Matched Analysis. Oncology 2023; 102:228-238. [PMID: 37708864 DOI: 10.1159/000533790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/19/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION This study examines whether neoadjuvant docetaxel, cisplatin plus S-1 (DCS) therapy is superior to docetaxel, cisplatin plus 5-fluorouracil (DCF) therapy for resectable advanced esophageal squamous cell carcinoma (ESCC). METHODS Patients diagnosed with resectable advanced ESCC at our hospital between January 2010 and December 2019 underwent either neoadjuvant DCF therapy or DCS therapy, followed by radical esophagectomy. Prior to August 2014, we usually used neoadjuvant DCF therapy; we then completely transitioned to using neoadjuvant DCS therapy. RESULTS A total of 144 patients received one of these triplet regimens as neoadjuvant chemotherapy: DCF therapy to 67 patients and DCS therapy to 77 patients. After propensity score matching, 55 patients in each group were selected as matched cohorts. There was no significant difference between the groups in complete response (DCF = 7.3%, DCS = 9.1%) or in partial response (DCF = 45.4%, DCS = 52.7%). The pathological response rate was 23.8% for grade 2 and 18.2% for grade 3 in the DCF group, compared with 30.9% and 14.5% in the DCS group. Independent predictive factors for recurrence-free survival were poor clinical response and pathological response ≤1b. Independent prognostic factors for overall survival were poor clinical response, anastomotic leakage, and pathological response ≤1b. Duration of hospital stays in the DCS group was significantly shorter than those of the DCF group (6.0 vs. 15.0 days, p < 0.001). Expenses of drug and hospitalization for the neoadjuvant chemotherapy in the DCS group were also significantly lower than those of the DCF group (265.7 vs. 550.3 USD, p < 0.001). CONCLUSIONS Neoadjuvant DCS therapy for resectable advanced ESCC did not result in significantly higher clinical and pathological response than neoadjuvant DCF therapy. However, neoadjuvant DCS therapy for resectable ESCC required comparatively shorter hospital stays and incurred lower costs, making it an attractive therapeutic option.
Collapse
Affiliation(s)
- Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Keiji Hayata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Taro Goda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Akihiro Takeuchi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinta Tominaga
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Naoki Fukuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Tomoki Nakai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| |
Collapse
|
50
|
Aiolfi A, Griffiths EA, Sozzi A, Manara M, Bonitta G, Bonavina L, Bona D. Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination. Ann Surg Oncol 2023; 30:5564-5572. [PMID: 37210447 DOI: 10.1245/s10434-023-13670-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. RESULTS Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31). CONCLUSIONS This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.
Collapse
Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luigi Bonavina
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy
| |
Collapse
|