Gastric Tube Necrosis Research Articles

Laparoscopic ischemic conditioning prior esophagectomy in selected patients: the ISCON trial.

Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12-18days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45minutes (range: 25-230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2days (range: 2-4days). Esophagectomy was completed in all patients after a median of 14days (range: 12-28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.

Preoperative chemoradiation (CRT) with carboplatin (CBP)/paclitaxel (PCL) (CP) or with 5-fluorouracil (FU)/oxaliplatin (OX) (Fx) for esophageal or junctional cancer: A randomized phase 2 trial.

4015 Background: Preoperative CRT with a FU/platinum regimen has been used for years for esophageal or junctional cancer before the CP regimen became a standard of care following the results of the CROSS study (van Hagen 2012). We aimed at evaluating the complete resection (R0) rate and severe postoperative morbidity rate associated with these 2 neoadjuvant regimens, each being combined with the radiation (RT) regime used in the CROSS trial. Methods: PROTECT is a multicenter, randomized, non-comparative, phase 2 trial (NCT02359968) in patients (pts) with resectable esophageal or Siewert type I-II junctional cancer, stage II (T1-2N1 or T3N0) or stage III (T3N1 or T4anyN) tumors (UICC-7 classification), and ECOG PS ≤2. Following randomization (balanced by ECOG PS 0 vs 1-2, stage II vs III, squamous-cell (SCC) vs adenocarcinoma (ADK), center), pts received CP (AUC2 CBP plus PCL 50mg/m² / week x 5 weeks), or Fx (FU 400 mg/m² bolus Day 1, then FU 1600 mg/m² continuous infusion over 2 days, plus OX 85 mg/m², and Folinic acid 200 mg/m², 2-h infusion, Day 1; 3 cycles every 2 weeks). RT technique was similar in both arms: 3D-conformal as published in the CROSS trial or IMRT (n = 35); total dose of 41.4Gy, 5 fractions of 1.8Gy / week, starting at Day 1 of chemotherapy. Surgery was performed 4 to 8 weeks after completion of CRT through a transthoracic or mini-invasive approach with a two field extended lymphadenectomy. Co-primary endpoints were R0 (failure: R1 or disease progression under CRT), and severe postoperative morbidity rate ≤30 days after surgery (Clavien-Dindo grade ≥ III). Based on a Bryant and Day 2-stage design (p0 = 75% and p1 = 90% for resection; p0 = 45% and p1 = 25% for morbidity; α = 10% and β = 15%), 48 evaluable pts were required by arm. Results: 100/104 pts recruited from 02/2015 to 08/2020, started the study treatment: 50 CP & 50 Fx. Overall, median age = 64 (range, 33-79); 82/100 males; 62 ADK and 38 SCC; 66 esophageal and 34 junctional site; 31 stage II; 68 stage III, 1 Nx. R0 resection was obtained in 46/50 CP pts (92.0%, 95% CI: 80.8-97.8%), and in 42/48 Fx pts (87.5%, 74.8-95.3%); 2 non evaluable pts because of event unrelated to disease progression. Severe postoperative adverse events (AEs) occurred in 34/91 pts who underwent surgery: 21/48 CP (43.8%, 29.5-58.8%) and 13/43 Fx (30.2%, 17.2-46.1%). Severe AEs were respiratory disorders (CP 26%; Fx 26%), esophageal fistula (CP 18%; Fx 6%), infection (CP 5%; Fx 3%), haemorrhage (CP 5%; Fx 0%) and gastric tube necrosis (CP 6%; Fx 3%). 5 pts died from AEs (3 CP, 2 Fx). A TRG1-2 was observed in 29/48 (60.4%, 95% CI: 44.3-74.2%) CP pts, and in 19/43 (44.2%, 29.1-60.1%) Fx pts. Conclusions: When combined to preoperative radiation therapy at 41.4Gy, both regimens (CP and Fx) provided short-term benefit on R0 resection; however, CP is associated with a severe postoperative morbidity rate higher than expected. Clinical trial information: NCT02359968.

McKeown esophagectomy with concomitant median arcuate ligament release in a case of esophageal cancer with celiac artery stenosis

BackgroundThe celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor–Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release.Case presentationA 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter.ConclusionsProphylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.

46 ESOPHAGECTOMY FOR ESOPHAGEAL CANCER TO THE PATIENT ACCOMPANIED WITH PROTEIN C DEFICIENCY

Abstract Protein C deficiency is a rare genetic disease that predisposes to thrombotic disease, which is characterized by tendency to form thrombus due to hypercoagulation. The incidence of protein C deficiency with clinical symptoms has been reported to be estimated at 1 in 20,000. Only a few cases of surgery for gastrointestinal cancer with protein C deficiency have been reported, however, there have been no reports regarding the perioperative management in detail for those patients. Methods We present. We assess perioperative management for the case of esophagectomy for an esophageal cancer accompanied with protein C deficiency. Results A 63-year-old male with protein C deficiency underwent thoracoscopic esophagectomy and digestive reconstruction using gastric tube for thoracic esophageal cancer whose clinical stage was T1bN0M0. On postoperative day 3, his gastric tube was removed due to gastric tube necrosis. Digestive reconstruction using free jejunal graft has been attempted after 140 days from first surgery, however, thrombus formation in the jejunal artery and vein caused the reconstruction to failure. Ten days after this surgery, digestive reconstruction using colon was performed with anticoagulation control by administrating intraoperative heparin. The patient went fine without thrombus formation afterward. Conclusion During digestive reconstruction in patients with conditions predisposing to thrombus formation as typified by protein C deficiency, the perioperative management should be done with careful attention to prevent thrombus formation. In particular, because there is likely to develop necrosis of reconstructed organ due to thrombus formation, the appropriate anticoagulation control such as intraoperative heparin administration is recommended in patients with protein C deficiency.

Esophagectomy for Esophageal Cancer in a Patient with Protein C Deficiency: A Case Report

A 63-year-old man with protein C deficiency underwent thoracoscopic esophagectomy and digestive reconstruction using a gastric tube for thoracic esophageal cancer. On postoperative day 3, the gastric tube was removed because of anastomotic leakage and gastric tube necrosis. Digestive reconstruction using a free jejunal graft was attempted 140 days after the first surgery. However, thrombus formation in the artery and vein of the jejunal graft resulted in a failed reconstruction. Ten days after this surgery, digestive reconstruction using the colon was performed with intraoperative heparin administered for anticoagulation control. The surgery was successful, with no thrombus formation afterward. When performing digestive reconstruction in patients with conditions predisposing to thrombus formation, perioperative management should be completed with careful attention toward preventing thrombus formation. In particular, appropriate anticoagulation control, such as the administration of intraoperative heparin, is recommended in patients with protein C deficiency because necrosis of the reconstructed organ is likely.

P119 SURGICAL OUTCOMES AFTER ESOPHAGECTOMY IN THE ELDERLY POPULATION - A SINGLE CENTER COHORT STUDY

Abstract Aim To evaluate morbidity and mortality after esophagectomy among elderly patients Background & Methods Esophagectomy is associated with significant morbidity1, and with the aging population we are faced with an increasing number of elderly patients eligible for surgery. In this retrospective study we analyzed both minor and major postoperative complications (Clavidien-Dindo II-V), in-hospital and 90-day mortality, and overall survival in all carcinoma patients ≥75 yo undergoing esophagectomy for cancer between 2009 and 2018 at a high-volume center. Results 47 patients underwent esophagectomy during the 10-yr. period, 95,7% either minimally invasively or with a hybrid approach. Median age was 77, and the oldest patient 85 yo. The majority were in otherwise good health, 39 had an ASA score of 1-2, and all but one was ECOG 0. 70% had adenocarcinomas, and 70% received neoadjuvant treatment. 68,1% of the patients suffered some sort of complication. 19 patients (40,4%) had a C-D III-IV complication, 9 of which were pulmonary requiring a median of 5 days in the ICU. Only 4 patients (8,5%) had anastomotic leakage requiring an intervention, 2 were managed endoscopically, 1 early dehiscence was sutured and one required a revision and LD plasty. One patient had non-fatal gastric tube necrosis that was excised. Atrial fibrillation (34%) was the most common but easily managed issue, followed by pulmonary complications (C-D II 5pts /10,6%, C-D III-IV 10 pts / 21,3%). We had 3 re-operations for bowl herniation, and one for bleeding. Our in-hospital and 90-day mortality were 0%, in spite of the high complication rate. 63,8% were discharged home. Mean and median survival times 68,2 mo. and 47 mo., respectively. At time of follow up, 28 patients (59,6%) were still alive. Conclusion Esophagectomy comes with high morbidity, but with acceptable long term results it should be considered for elderly patients otherwise fit for surgery. Our results show that in select cases age is just a number 1. Low DE, Kuppusamy MK, Alderson D, Cecconello I, Chang AC, Darling G, Davies A, D'Journo XB, Gisbertz SS, Griffin SM, Hardwick R, Hoelscher A, et al. Benchmarking Complications Associated with Esophagectomy. Ann Surg 2017;:1.

PS01.241: HYBRID MINIMALLY INVASIVE TECHNIQUE OF OESOPHAGECTOMY FOR OESOPHAGEAL CARCINOMA

Abstract Background Oesophagectomy is challenging procedure involving multiple body cavities. The traditional open procedure being either transthoracic or transhiatal, carries significant morbidity and mortality. There is continuing debate between the two approaches. Minimally invasive oesophagectomy has swung the pendulum towards transthoracic procedure, though it remains a complex and technically demanding procedure. This study was done to assess the feasibility, and benefit of hybrid minimally invasive technique over open technique. Methods Patients of oesophageal cancer were selected from January 2005 to December 20,017. After 2012 open technique was replaced with minimally invasive technique. Open technique included Ivor Lewis, McKeown's or transhiatal. Hybrid minimally invasive technique included laparoscopic gastric mobilisation and thoracic part using small thoracotomy. Anastomosis was done using hand sewn technique. The short term outcome, including postoperative complications were analysed from prospectively collected data. Results One hundred sixty three patients underwent open procedure and 103 patients underwent hybrid minimally invasive esophagectomy. Total operative time was shorter in laparoscopic group (325.6 minutes vs 232.6 minutes, P < 0.05). The number of transfused patients were significantly smaller in laparoscopic group (40.75% vs 13.6%, P < 0.05). The postoperative course without complication was observed in 68.1% and 79.3% in open vs laparoscopic group respectively. Serious complications included myocardial infarction and gastric tube necrosis and bleed. There was no anastomotic leak in chest anastomosis but there was overall 17.3% leak in neck anastomosis, higher in open group 20.8% vs 16.6% in minimally invasive group. Mortality was higher ion open group (5.5% vs 2%, P < 0.05). On multivariate analysis, age more than 60 years, chest complications and cardiovascular comorbidity were associated with increased mortality. Conclusion Hybrid minimally invasive procedure is feasible and safe procedure for patients with oesophageal cancer. it is associated with shorter operative time and less postoperative complications. Even laparoscopic gastric tube mobilisation alone adds to in decreasing the morbidity in esophagectomy. Disclosure All authors have declared no conflicts of interest.

Effect of goal-directed therapy on outcome after esophageal surgery: A quality improvement study.

BackgroundGoal-directed therapy (GDT) can reduce postoperative complications in high-risk surgery patients. It is uncertain whether GDT has the same benefits in patients undergoing esophageal surgery. Goal of this Quality Improvement study was to evaluate the effects of a stroke volume guided GDT on post-operative outcome.Methods and findingsWe compared the postoperative outcome of patients undergoing esophagectomy before (99 patients) and after (100 patients) implementation of GDT. There was no difference in the proportion of patients with a complication (56% vs. 54%, p = 0.82), hospital stay and mortality. The incidence of prolonged ICU stay (>48 hours) was reduced (28% vs. 12, p = .005) in patients treated with GDT. Secondary analysis of complication rate showed a decrease in pneumonia (29 vs. 15%, p = .02), mediastinal abscesses (12 vs. 3%, p = .02), and gastric tube necrosis (5% vs. 0%, p = .03) in patients treated with GDT. Patients in the GDT group received significantly less fluids but received more colloids.ConclusionsThe implementation of GDT during esophagectomy was not associated with reductions in overall morbidity, mortality and hospital length of stay. However, we observed a decrease in pneumonia, mediastinal abscesses, gastric tube necrosis, and ICU length of stay.

Non-inferiority of minimally invasive oesophagectomy: an 8-year retrospective case series.

The trend towards laparoscopic surgery seen in other specialties has not occurred at the same pace in oesophagectomy. This stems from concerns regarding compromised oncological clearance, and complications associated with gastric tube necrosis and anastomotic failure. We present our experience of minimally invasive oesophagectomy (MIO) compared to open and hybrid surgery. We aim to ascertain non-inferiority of MIO by evaluating impact on survival, oncological clearance by resection margin and lymph node harvest and post-operative complications. Data were sourced retrospectively 2008-2015. Three approaches were studied. MIO (3-stage Mckeown), hybrid (2-stage Ivor Lewis, laparoscopy, thoracotomy) and open (2-stage Ivor Lewis). Five-year survival was 54.2%. Surgical approach had no significant impact on survival at any stage of disease (Stage 0/I p=0.98; stage II p=0.2; stage III p=0.76). There was no statistically significant difference in oncological clearance by resection margins between procedures when compared by disease stage (p=0.49). A higher number of nodes were harvested in hybrid [median 27.5 (6-65)] and open surgeries [median 26 (4-54)] than in MIO [median 20 (7-44)] (p>0.01). Numbers of nodes resected did not impact risk of recurrence [recurrence, median 25 (6-54), no recurrence, 26 (4-65)] (p=0.25). Anastomotic strictures (22.4%) and potential leaks (17.9%) were more common in MIO (strictures p>0.01, leaks p=0.08), although associated morbidity was lower. Respiratory complications were less common in MIO (2.9%) versus hybrid (13.3%) (p=0.02). Wound infection and chyle leak were also lower (wound 1.5% MIO 3.5% open, p=0.6; chyle leak 1.5% MIO, 6.7% hybrid, p=0.2). Our results show no negative impact of MIO on survival or oncological clearance. Respiratory and wound complications are lower in MIO, but rates of anastomotic strictures and potential anastomotic leaks are increased. This may be due to the longer length of conduit and subclinical ischaemia at the anastomosis and merits further evaluation.

Usage of “Reversal Penetrating Technique” with Ancillary Trocar in Minimally Invasive Ivor Lewis Esophagectomy

We present a "Reversal Penetrating Technique" (RPT) to perform thoracoscopic esophagogastric anastomosis in Ivor Lewis minimally invasive esophagectomy (MIE). The safety and efficiency of this technique are evaluated. RPT was used in Ivor Lewis MIE for treating patients with distal esophageal cancer. A specific anvil set is inserted into proximal esophagus lumen to allow its prefixed Prolene suture to pierce from the inside out. Then, the suture is pulled until the anvil rod penetrates the esophageal wall. The esophageal stump and anvil placement are completed after the esophagus is transected by a linear stapler. After the circular stapler is docked with the anvil, the intrathoracic anastomosis is performed in a side-to-side manner. Since August 2012, RPT anastomosis was successfully performed in 30 consecutive patients without conversion to other anastomotic techniques or open surgery. No patient experienced anastomotic leak or gastric tube necrosis. No postoperative deaths occurred. No patient complained of remarkable dysphasia during follow-up. Twenty six patients were checked by gastroscopy, no localized recurrence or anastomotic stricture was identified. RPT is less technically challenging as it eliminates the need for sewing and trimming of esophageal remnant. This technique is safe and efficient, and is particularly suited to those who do not have access to the Orvil device when performing Ivor Lewis MIE.

Initial results of robotic esophagectomy for esophageal cancer

IntroductionThere is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. Patients and methodsObservational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. ResultsThirty-two patients, with a mean age of 58 years (34–74), were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218min (190–285). Blood loss was 170ml (40–255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8–50). All the resections were R0 and the median of removed lymph nodes was 16 (2–23). ConclusionsOur results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

Acute necrotic pancreatitis after esophagectomy: a case report

Acute pancreatitis after esophagectomy is a very rare but fatal complication. This case report describes a 74-year-old man diagnosed with cT2N0M0, cStage IB esophageal squamous cell carcinoma (Union for International Cancer Control, seventh edition). On the basis of the patient’s condition, it was decided that he should undergo esophagectomy without thoracotomy. The patient developed pyrexia 3 days after the operation. Chest and abdominal computed tomography revealed severe acute pancreatitis and gastric tube necrosis; therefore, gastrectomy was performed. Subsequent surgical exploration indicated pancreatic necrosis that was diagnosed as acute necrotic pancreatitis. Postoperative management of acute pancreatitis and the general condition of the patient were quite challenging, and rapid deterioration of the respiratory status was observed. The patient experienced multiple organ failure and died 57 days after the second surgery (60 days after the first surgery). This is a report of a patient with acute necrotic pancreatitis after esophagectomy.

Resultados iniciales de la esofaguectomía robótica en el cáncer de esófago

IntroductionThere is scant experience with robot-assisted esophagectomy in cases of esophageal and gastro-esophageal junction cancer. Our aim is to report our current experience. Patients and methodsObservational cohort study of the first 32 patients who underwent minimally invasive esophagectomy for esophageal cancer from September 2011 to June 2014. The gastric tube was created laparoscopically. In the thoracic field, a robot-assisted thoracoscopic approach was performed in the prone position with intrathoracic robotic hand-sewn anastomosis. Patient and tumour characteristics, surgical technique, short-term outcomes (morbidity and mortality) and oncological results (radicality and number of removed nodes) were evaluated. ResultsThirty-two patients, with a mean age of 58 years (34-74) were treated by a totally minimally invasive esophagectomy: robotic laparoscopy and thoracoscopy (11 McKeown and 21 Ivor-Lewis). Twenty-nine received neoadjuvant chemoradiotherapy. There were no conversions to open surgery. Console time was 218minutes (190-285). Blood loss was 170ml (40-255). One patient died from cardiac disease. Nine patients had a major complication (Dindo-Clavien grade II or higher). There was no case of respiratory complication or recurrent laryngeal nerve palsy. Five patients had intrathoracic fistula, 4 radiological and one clinical. Three had chylothorax, 2 cervical fistula and one gastric tube necrosis. The median hospital stay was 12 days (8-50). All the resections were R0 and the median of removed lymph nodes was 16 (2-23). ConclusionsOur results suggest that minimally invasive esophagectomy with robot-assisted thoracoscopy is safe and achieves oncological standards.

Immediate free jejunum transfer for salvage surgery of gastric tube necrosis.

Gastric tube necrosis after esophagus cancer surgery is a rare but critical situation. Salvage reconstruction of the esophagus remains a challenging procedure for head and neck surgeons. Historically, surgeons have employed a two-stage salvage surgery consisting of debridement followed by reconstruction. While this procedure generates good results, the time to restart oral alimentation is long. The present report describes the case of a 62-year-old male who developed gastric tube necrosis 3 days after undergoing surgery for thoracic-cervical esophageal cancer and immediate reconstruction with the retrosternal gastric pullup technique. He was treated with debridement and simultaneous free jejunum transfer 4 days after the primary surgery. He was able to restart oral alimentation 10 days after the salvage surgery. This rapid return to oral alimentation is a major advantage of the one-stage immediate esophagus salvage reconstruction. Another advantage is the ease of the reconstructive procedure: the absence of scarring and prolonged inflammation, which are disadvantages of the two-stage procedure, meant that recipient vessel selection and anastomosis were uncomplicated. The one-step procedure may be particularly useful in cases where the inflammation is discovered early.

A Retrospective Study on Nonmalignant Airway Erosion After Right Transthoracic Subtotal Esophagectomy: Incidence, Diagnosis, Therapy, and Risk Factors

This study investigated the incidence, diagnosis, treatment, and risk factors for nonmalignant airway erosion after subtotal esophagectomy for thoracic esophageal carcinoma. Clinical data from all patients with thoracic esophageal carcinoma who underwent right transthoracic subtotal esophagectomy from 2000 to 2012 at our institution were retrospectively reviewed, and the clinical course and outcome of those who developed airway erosion were investigated in detail. Risk factors for airway erosion were calculated by multivariate analysis. Of 1,091 patients enrolled, 15 patients (1.4%) developed nonmalignant airway erosion, which occurred at postoperative day (POD) 7 to 92 (median, 24). Anastomotic leakage or gastric-tube necrosis was detected prior to airway erosion in 14 cases (93.3%). Endoscopic and surgical therapy was administrated to 3 patients. Airway erosion was cured in 9 patients (60.0%). Five patients died from airway erosion directly (mortality, 33.3%). Alimentary leakage or necrosis (p<0.001), preoperative radiotherapy (p=0.004), and reconstruction through the posterior mediastinal route (p=0.051) were independent risk factors for airway erosion development. Airway erosion is a fatal complication after subtotal esophagectomy. Preoperative radiotherapy dramatically increases the risk of developing airway erosion and reduces the probability of spontaneous healing. Aggressive treatment of alimentary leakage or necrosis and reconstruction through the anterior route help to decrease the risk of airway erosion, especially in high-risk patients.

Gastric tube necrosis following minimally invasive oesophagectomy is a learning curve issue

Gastric tube necrosis following oesophagectomy is thought to have an increased association with a minimally invasive technique. Some suggest gastric ischaemic preconditioning may reduce ischaemic complications. We discuss our series of 155 consecutive minimally invasive oesophagectomies (MIOs), including a number of cases of gastric tube ischaemia, of which 4 (2.6%) developed conduit necrosis. Data were collected prospectively of MIOs carried out by a single surgeon between 2005 and 2011. Cases of gastric tube necrosis were identified. Overall, 155 patients were identified. The inpatient mortality rate was 2.6%. Gastric tube necrosis occurred in four patients (2.6%). An ultrasonic dissector injury to the gastroepiploic arcade had occurred in two cases. In another case, the gastric tube was strangulated in the hiatus. In the remaining case, no clear mechanical cause was identified. All 4 cases occurred within the first 73 cases. The gastric tube necrosis rate of the first 50 cases versus cases 51-155 was 4% and 2% respectively (p=0.5948). The anastomotic leak rate in these two cohorts was 18% and 7% respectively (p=0.0457). There was a significant reduction in overall gastric tube complications from 22% to 10% following the learning curve of the initial 50 cases (p=0.0447). In our series, gastric tube necrosis appears to be a learning curve issue. Prophylactic measures such as ischaemic preconditioning become less relevant as the operating surgeon's experience increases. Instead, meticulous attention to preserving the gastroepiploic arcade, avoidance of tension in the tube and careful positioning of the gastric conduit through an adequately sized hiatus are key factors.

Usefulness of Indocyanine Green Angiography for Evaluation of Blood Supply in a Reconstructed Gastric Tube During Esophagectomy

We report a case of necrosis of a reconstructed gastric tube in a 77-year-old male patient who had undergone esophagectomy. At the time of admission, the patient had active gastric ulcers, but these were resolved by treatment with a proton pump inhibitor. Subtotal esophagectomy with gastric tube reconstruction was performed. Visually, the reconstructed gastric tube appeared to be well perfused with blood. Using indocyanine green (ICG) fluorescence imaging the gastroepiploic vessels were well enhanced and no enhancement was visable 3 to 4 cm from the tip of the gastric tube. Four days after esophagectomy, gastric tube necrosis was confirmed, necessitating a second operation. The necrosis of the gastric tube matched the area that had been shown to lack blood perfusion by ICG angiography imaging. It seems that ICG angiography is useful for the evaluation of perfusion in a reconstructed gastric tube.

Phenylephrine infusion improves blood flow to the stomach during oesophagectomy in the presence of a thoracic epidural analgesia

Gastric tube necrosis is a major cause of mortality after oesophagectomy. The construction of the gastric tube used for oesophageal reconstruction involves a division of several arteries leading to a reduction in the blood supply at the fundus, which is used for the oesophageal anastomosis. This study was undertaken to determine the effect of thoracic epidural anaesthesia and intravenous phenylephrine on haemodynamics and blood flow in the tubularized stomach. Ten patients undergoing an oesophagectomy were prospectively studied. Pulmonary artery catheters were used to measure haemodynamic changes, and laser Doppler flow probes were used to measure gastric blood flow. The effects of an intraoperative thoracic epidural and subsequent intravenous phenylephrine infusion were documented. The administration of a thoracic epidural bolus of bupivacaine 0.25% at 0.1 ml kg resulted in a significant reduction in flux at the anastomotic end of the newly formed gastric tube from a median of 57-41 perfusion units (P = 0.003). A subsequent intravenous phenylephrine infusion titrated to restore mean arterial pressure significantly increased the flux at the anastomotic end from a median of 41-66 perfusion units (P = 0.009). An intravenous phenylephrine infusion can reverse the epidural bolus-induced reduction in blood flow at the anastomotic end of the newly formed gastric tube.

Management of anastomotic leakage-induced tracheobronchial fistula following oesophagectomy: the role of endoscopic stent insertion†

Tracheobronchial fistulas are rare but life-threatening complications after oesophagectomy. Leakage of the oesophagointestinal anastomosis with inflammatory involvement of the tracheobronchial tree is the predominant reason for postoperative fistulization between the airways and the oesophagus or the gastric tube. Successful management is challenging and still controversially discussed. After promising results in the treatment of intrathoracic anastomotic leaks, we adopted endoscopic stent implantation as the primary treatment option in patients with anastomotic leak-induced tracheobronchial fistula. The aim of this study was to investigate the feasibility, the limits and the results of this procedure. Between January 2004 and December 2010, 222 consecutive patients underwent oesophageal resection mainly for oesophageal cancer. An anastomotic leak-induced tracheobronchial fistula was bronchoscopically verified in seven patients. Four patients received endoscopic implantation of either a self-expanding tracheal or oesophageal stent or both as primary treatment. Surgical re-exploration was mandatory in 2 patients because of necrosis of the pulled-up gastric tube or gangrene of the airways. One patient was conservatively managed. Endoscopic stent placement was successfully accomplished in all 4 patients. Two patients received an oesophageal stent, one patient a tracheal stent and one patient both an oesophageal and a tracheal stent. Closure of the fistula was achieved in all cases and 3 patients finally recovered while one died by reason of respiratory failure. In both surgical re-explored patients resection of the gastric tube was performed, and in one patient, because of subtotal gangrene of the right bronchial tree, emergency pneumectomy was also mandatory. Both patients died due to severe sepsis and respiratory failure. The one conservatively treated patient died from severe pneumonia. Treatment of anastomotic leak-induced tracheobronchial fistulas by means of oesophageal and tracheal stent implantation is feasible. If stent insertion is limited by gastric tube necrosis or bronchial gangrene, the prognosis is likely to be fatal.

Gastric tube necrosis following Minimally Invasive Oesophagectomy: the experience of a specialist unit

Gastric tube necrosis following Minimally Invasive Oesophagectomy: the experience of a specialist unit