Extracorporeal membrane oxygenation support after Ivor-Lewis esophagectomy for esophageal adenocarcinoma (original) (raw)
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Selective management of intrathoracic anastomotic leak after esophagectomy
The Journal of Thoracic and Cardiovascular Surgery, 2005
Objective: We sought to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy. Methods: All patients who had intrathoracic anastomotic leaks after esophagectomy were reviewed. Management and factors affecting outcome were analyzed. Results: From March 1993 through February 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight (6.3%) patients had an anastomotic leak; one refused authorization to review his medical record and was excluded from further analysis. Twenty-four (51.1%) patients had a contained leak. Twenty-seven (57.4%) patients were managed nonoperatively. Twenty (42.6%) patients required surgical intervention that included primary anastomotic repair in 14 patients, reinforcement of the anastomosis with viable tissue in 6 patients, and esophageal diversion in 2 patients. A single reoperation was done in 15 patients, and 5 patients had 2 reoperations. Median hospitalization in the reoperative group was 31 days (range, 15-97 days) and 20 days (range, 10-42 days) in the nonoperative group (P ϭ .0037). Four (8.5%) patients died. Cause of death was sepsis in 2 patients and multiorgan failure and myocardial infarction in 1 patient each. At follow-up (median, 8 months; range, 1-120 months), 10 (58.8%) patients in the reoperative group were eating a normal diet and 5 (29.4%) patients required at least one dilatation compared with 20 (76.9%) patients in the nonoperative group who were eating a normal diet and 9 (34.6%) who required at least one dilatation. A noncontained leak had an adverse effect on long-term survival (P ϭ .04). Conclusion: Intrathoracic anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Contained leaks often can be managed nonoperatively. When surgical management is required, esophagogastric continuity can often be maintained in the majority of patients. Long-term functional results are satisfactory and similar in both the reoperative and nonoperative groups. However, a noncontained leak adversely affected long-term survival.
Outcomes of a novel intrathoracic esophagogastric anastomotic technique
The Journal of Thoracic and Cardiovascular Surgery, 2018
Objectives: Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel ''side-to-side: staple line-on-staple line'' (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide-diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institution's initial 6-year experience. Methods: An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications. Results: There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end-stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P ¼ .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge. Conclusions: We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.
Intrathoracic Anastomotic Leak after Ivor Lewis Esophagectomy: Non-Surgical Management
2016
1 Department of General Surgery, Clinical Emergency Hospital Bucharest, Romania Correspondin author 2 Departament of Gastroenterology, Clinical Emergency Hospital Bucharest, Romania 3 Department of Toxicology, Clinical Emergency Hospital Bucharest, Romania Corresponding author: Dragos Ene Clinical Emergency Hospital, Calea Floreasca nr. 8, Bucharest, Romania. E-mail: dragoshene@yahoo.com Abstract
Anastomotic Complications after Esophagectomy
Digestive Surgery, 2002
Anastomotic complications after esophagectomy continue to be a burden jeopardizing the quality of life and of swallowing. However, incidence, mortality and morbidity of anastomotic complications have substantially decreased in recent years. It seems that this is not so much related to the use of a particular conduit, approach or route for reconstruction, but rather related to refinement in anastomotic techniques and perhaps even more to progress in modern perioperative management. Knowledge of surgical anatomy and meticulous technique are of paramount importance and obviously related to individual expertise. As to the management, most leaks can be treated by conservative measures and reintervention surgery today is rather exceptional. Early endoscopy and dilatation seem to decrease the incidence and severity of anastomotic stenosis.
Diseases of the Esophagus, 2018
Summary Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce the AL rate and postoperative morbidity. Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophagogastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. The endpoints of this study were AL rate and postoperative morbidity. There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien–Dindo grade IIIb) unrelated to anastomotic healing. He underwent open reanastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic h...
A Comprehensive Review of Anastomotic Technique in 432 Esophagectomies
The Annals of Thoracic Surgery, 2013
Background. Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) (longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques. Methods. From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed. Results. There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p ؍ 0.01) and LS anastomoses had the lowest risk of stricture (p ؍ 0.006). Conclusions. When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation.
Diseases of the Esophagus, 2020
Summary Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5–56) with a median number of 3 (range 1–14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The ...
Journal of Visualized Experiments, 2020
We describe a novel esophagogastric anastomotic technique ("side-to-side: staple line-on-staple line", STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution. The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures. There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p<0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients. The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.