Post-esophagectomy Patients Research Articles

Post-esophagectomy patients presenting for general anesthesia induction: a survey of practice among US anesthesiologists (PESO-GAIN-S)

Post-esophagectomy patients presenting for general anesthesia induction: a survey of practice among US anesthesiologists (PESO-GAIN-S)

Controversies in the management of the pylorus among patients undergoing robotic-assisted minimally invasive esophagectomy

Bilateral truncal vagotomies are intrinsic to nearly all esophagectomies, rendering patients susceptible to delayed gastric emptying. The question of whether, how, and when to perform pyloric drainage is essential and remains controversial in the era of robotic-assisted minimally invasive esophagectomy. While a variety of pyloric intervention techniques have been described, selective endoscopic pyloromyotomy for post-esophagectomy patients with durable signs of delayed gastric emptying is an attractive option, given its low morbidity rate, particularly its low incidence of dumping.

Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients.

Per-oral plication of the (neo)esophagus (POPE) is an endoscopic procedure used to improve emptying of the defunctionalized esophagus or gastric conduit, with the hope of improving symptoms andquality of life. As this procedure has only been performed in the United States for the past 4years, safety and efficacy have not been well established. This is a retrospective case series for patients who underwent POPE from a single institution between 2019 and 2023. Data collected included demographics, preoperative diagnoses and treatments, imaging, endoscopic data,operative intervention, 90-day complications, andresponse to treatment. Quality of life and patient satisfaction data were collected by phone survey. Seventeen cases were identified, encompassing 13 primary procedures and 4 repeat POPEs (re-POPE). Eight patients had end-stage achalasia and 5 had impaired gastric emptying after esophagectomy with gastric conduits. Median age was 65years and median ASA was 3, with 38.5% female patients. POPE was performed with 2-6 plication sutures in an average of 75min. The majority of patients discharged home the same day. For the 17 procedures, there were 4 complications. Two patients required antibiotics for pneumonia, while 4 required procedural intervention. There were no deaths. Preoperative symptoms improved or resolved at initial follow up in 82.3% of patients. Four patients experienced symptom recurrence and required re-POPE, 1 with achalasia and 3 with gastric conduits. Although all achalasia patients had an "end-stage esophagus," none have required esophagectomy since the introduction of POPE. POPE is an endoscopicprocedure that is efficacious in relieving emptying difficulties for the end-stage esophagus andgastric conduit. It may obviate the need for esophagectomy or conduit replacement. Also, it can be repeated in select patients. While the risk profile of complications is favorable compared to alternative operations, patients with gastric conduits are at higher risk.

459. DIAPHRAGMATIC RELAXING INCISION IN THE REPAIR OF DIAPHRAGMATIC HERNIA FOLLOWING OESOPHAGECTOMY: A RETROSPECTIVE STUDY

Abstract Background After oesophagectomy diaphragmatic hernia (DH) is a well-known long-term complication. Approximating the crura around the tubular stomach is often challenging, especially in cases with a wide hiatus. This study evaluates a surgical technique involving a relaxing incision. Methods This retrospective study included all post-oesophagectomy patients from 2016 to 2023 who underwent repair for diaphragmatic hernia. Primary outcome measures included incidence over time, postoperative complications, recurrence of DH, surgical technique, and length of hospital stay. Results 13 patients were included, the relaxing incision was 12 times located on the left side and once on the right. All patients experienced symptoms and 81.3% of the patients were males. The median diameter of the hernia was 70 mm (range 65-100 mm), and the median of the surgical duration was 155 minutes. Complications occurred in 2 patients (2 times transient dysphagia). One recurrence was observed 13 months postoperatively, requiring reintervention. The median hospitalization length was 6 days, with 30.8% needing readmission. In Table 1 additional outcomes and characteristics are presented. Conclusion As far as known, this is the largest series of patients post-oesophagectomy in whom DH was repaired using a diaphragmatic relaxation incision. The relaxation incision proves to be a safe method for achieving an effective cruraplasty. It is essential for experienced laparoscopic surgeons to be aware of this technique when managing post-oesophagectomy patients.

713 The Role of Enteral Feed Composition on Chyle Leak Prevalence and Severity in Post-Oesophagectomy Patients

Abstract Aim Chyle leak presents as an uncommon yet significant complication for post-oesophagectomy patients. This study aims to evaluate the role of enteral feed in the prevalence and severity of chyle leaks post-oesophagectomy. Method We identified 334 patients who underwent an open or minimally invasive oesophagectomy for oesophageal cancer at a single institution between 2015-2022. The prevalence, classification (ECCG scale) and respective management of chyle leaks were retrospectively recorded. Patients who had significant post-operative complications and did not start enteral feed on post-operative day 1 were excluded from the study. Results The median age at operation was 68 (31-82), of which 82% comprised of males. In patients who were started on Nutrison standard feed (high energy or high protein), 22% of patients developed a chyle leak (ECCG IA – IIB). In contrast, in patients who were initially started on Nutrison high energy and high protein feed (HEHP), 11% developed a chyle leak (ECCG IA-IIA). All cases were initially managed conservatively (ECCG I) with a success rate of 81%, before escalating to parenteral nutrition. Moreover, patients with a chyle leak demonstrated an increased length of stay (14.4±7.4 days) in comparison to patients without a chyle leak (12.3±8.7 days; p = 0.03). Conclusions The heterogenous management of post-oesophagectomy patients is heavily influenced by centre and surgeon-specific preferences. This study suggests a potential correlation between enteral feed composition and its role in preventing and minimizing chyle leaks following an oesophagectomy. Further prospective, multicentre studies are required to elucidate an optimal nutritional approach in managing post-oesophagectomy patients.

Gastrocardiac Fistula as a Complication of Prior Bariatric Surgery.

Gastrocardiac fistula is a rare, typically fatal, diagnosis which has been reported infrequently in post-esophagectomy patients and, to a much lesser extent, patients with history of Roux-en-Y gastric bypass. This case describes a patient with a history of an eroded adjustable gastric band and subsequent removal with conversion to Roux-en-Y gastric bypass that initially presented with an upper gastrointestinal bleed. She was found to have a transdiaphragmatic fistula between the gastric lumen and left ventricle.

Colloid gastric emptying with SPECT-CT after oesophagectomy.

Scintigraphic analysis of gastric motility uses the rate of gastric emptying by measuring radioactivity remaining in the stomach at pre-defined points in time. It helps to assess unresolved symptoms of functional gastrointestinal disorders such as gastroparesis. Delayed gastric emptying can occur in post-oesophagectomy patients. Squamous cell carcinoma of the esophagus is a common indication for oesophagectomy. In such patients presenting with post-prandial symptoms of bloating, nausea or vomiting, colloid scintigraphy can play a vital role in evaluation of their symptoms. We present an interesting image of a post-oesophagectomy patient with persistent gastric dilatation suspected of delayed gastric emptying.

Experiences of Post Esophagectomy Patients Admitted in Lady Reading Hospital Peshawar Pakistan

Patients having esophageal cancer can experience psychological, emotional, physical, social, financial and spiritual changes following surgery. Exploration of such challenges, particularly from the Patient’s perspective has been limited in Pakistan. Objective: To explore the experiences of post-esophagectomy patients admitted in Lady Reading Hospital Peshawar Pakistan. Methods: A qualitative phenomenological study was conducted on ten patients having esophagectomy admitted at Lady Reading Hospital Peshawar. Participants were selected through None Probability purposive sampling technique. Permission was taken from concerned departments as well as from participants before data collection. An interview topic guide was used for Face-to-face individual, in-depth interviews. Audio recorded, transcribed, and analyzed through thematic analysis. Results: Five major themes were constructed i.e., Physical changes, psychological effects, social issues and support, financial issues, acceptance, and adjustment to a new changed way of life. Conclusions: Post-esophagectomy patients need full support in adjustment to their physical, psychological, emotional, social, financial, and spiritual aspects of life. Family, friends, and society could be an effective channel in this regard. Government should provide medical and financial support to such patients for their treatment as well as for their rehabilitation.

Clinical effect of home enteral tube feeding supplementation on nutritional status after esophagectomy with retrosternal gastric tube reconstruction.

Body weight loss and poor nutritional status are frequently observed after esophageal cancer surgery. The aim of this study was to pilot an investigation on the impact of home enteral tube feeding supplementation (HES) for up to 3months after esophageal cancer surgery. We retrospectively reviewed consecutive 67 esophageal cancer patients who underwent esophagectomy with gastric tube reconstruction. We started HES from April 2017. The patients were divided into 2 groups. Among 67 patients, 40 patients underwent HES between April 2017 and November 2020 (HES group). Other 27 patients who underwent esophagectomy between January 2012 and March 2017 were not administered HES (C group). Thereafter, multiple factors concerning patient nutritional status at long-term follow-up were evaluated. The baseline characteristics were balanced between the two groups. There were no significant differences in nutritional status scores before esophagectomy. The percentage weight loss was less in the HES group compared with the C group both at 3months and 1year after surgery: 7.3% (-7.6 to 15.2), 7.7% (-4 to 13.9) in the HES group and 10.6% (-3.6 to 29.1), 10.8% (-5.8 to 20.0) in C group (P < 0.05, P < 0.05). In the patients with anastomotic stenosis, the percentage weight loss was less in the HES group compared with the C group: 7.2% (2.0-14.9) and 14.6% (6.2-29.1), P < 0.05. HES may improve early weight loss in postesophagectomy patients.

Nutritional Evaluation by Nurses and Physical Recovery of Malnourished Patients after Esophagectomy

Following an esophagectomy, nurses’ patient nutrition observations are important for physical recovery and quality of life. The study proposed to identify the factors associated with physical recovery among esophageal cancer patients after surgery based on nurses’ observations and nutritional evaluations. Data were collected from the nursing records of 21 esophagectomy patients. The data included patients’ rate of weight loss, body mass index (BMI), energy intake, and postoperative complications. Patients were divided into two groups according to their weight loss rate: <8% and ≥8%. Patient outcomes were compared between the two groups. There was no difference in average BMI before or after surgery between the two groups. There was no difference in albumin levels during hospitalization; however, after esophagectomy, energy intake at discharge was insufficient in both groups. The ≥8% weight loss may be facilitated, or at least confounded, by the presence of recurrent nerve paralysis and aspiration pneumonia. Thus, the nursing records typically identified the need to check for recurrent laryngeal nerve palsy and aspiration pneumonia in conjunction with nutritional assessment to enhance patients’ physical recovery. When weight loss was significant, nurses provided oral intake support with the NST, and patients maintained oral intake levels similar to the group with weight loss under 8%. In order to better support physical recovery among malnourished, post esophagectomy patients, nurses need to monitor for signs of recurrent nerve palsy and aspiration pneumonia in addition to nutritional intake.

Gastrocardiac Fistula as a Complication of Prior Bariatric Surgery.

Gastrocardiac fistula is a rare, typically fatal, diagnosis which has been reported infrequently in post-esophagectomy patients and, to a much lesser extent, patients with history of Roux-en-Y gastric bypass. This case describes a patient with a history of an eroded adjustable gastric band and subsequent removal with conversion to Roux-en-Y gastric bypass that initially presented with an upper gastrointestinal bleed. She was found to have a transdiaphragmatic fistula between the gastric lumen and left ventricle.

705 SIGNIFICANCE OF CLEAR CIRCUMFERENTIAL RESECTION MARGIN IN ESOPHAGEAL CANCER

Abstract Circumferential resection margins (CRM) of an esophagectomy specimen for oesophageal cancer is a key prognostic factor of overall survival (OS). This retrospective study aims to compare OS of post-esophagectomy patients with CRM of &amp;gt;1 mm (R0) and &amp;lt; 1 mm (R1) with further subgroup analysis of locally advanced T3R0 vs T3R1 resection. Methods A total of 110 esophagectomies conducted between 2010 and 2020 were analysed. We recorded R stage based on pathological CRM &amp;gt;1 mm (R0) or &amp;lt; 1 mm (R1). OS was calculated from the day of surgery to day of death or otherwise censored. All patients underwent multimodal therapy including chemotherapy and similar pre-surgical and post-surgical management. 58 of these patients with pT3 stage esophageal cancer (EC) were selected and compared. Statistical analysis was carried out using SPSS. Results Of 110 patients, 78 (71.5%) patients had a R0 resection. Mean OS in R0 resections was 73 months (6 years) compared to 25.2 months (2 years) in R1 resection (p = 0.001). 58 of the 110 patients were pathological stage T3(pT3) despite downstaging with chemotherapy showing the burden of advanced disease. In patients with stage pT3 (n = 58), 32 patients were R0 resections, and 26 patients had R1 resections. Mean OS in T3R0 resections was 51.5 months compared to 28.5 months in T3R1 resection. OS comparison is significant (p = 0.011). Conclusion This study emphasizes the importance of clear CRM in all patients and especially in locally advanced pT3/T4a esophageal cancer in achieving long term survival. Techniques used to ensure a clear CRM such multimodality therapy combined with surgical radical resection concepts such as mesoesophagectomy should be employed.

1511CIMmH, an mHealth Comprehensive Intervention Model for esophageal cancer patients: A Multi-center RCT Protocol

Abstract Background Post-esophagectomy patients often experience a clinically relevant deterioration of quality of life after esophagectomy due to malnutrition, impaired exercise capacity, and psychological problems. The widespread use of mobile health (mHealth) has been increasingly promising for interdisciplinary healthcare givers to deliver efficient and potential cost-effective interventions in cancer patients. However, comprehensive interventions delivered by mHealth with a rigorous design of randomized controlled trial in post-esophagectomy patients were scarce. Methods This study developed the first comprehensive intervention model by mHealth with a parallel RCT design, providing nutrition, physical exercise, and psychological support for post-esophagectomy patients. A total of 120 patients will be randomized into the intervention group or the control group receiving treatment as usual. Participants in the intervention group will receive the 3-month intervention of the CIMmH program via the enhanced WeChat platform and by specialists (offline). The online program includes nutrition guidelines, physical exercise instructions, and psychological courses. All participants will be assessed at baseline, 1, and 3 months after esophagectomy. The primary outcomes are health-related QOL, weight, and physical fitness measured by 6-minute walking distance. Secondary outcomes include nutritional biomarkers, body composition, strength, interleukin-6, depressive symptoms, anxiety, and coping. Discussion This study is among the first efforts to innovatively develop a comprehensive intervention program to prompt rehabilitation in post-esophagectomy patients. Once proven effective, CIMmH could be integrated into the management of post-esophagectomy patients. Key messages Esophageal cancer, QOL, Nutrition, Physical exercise, Psychological support, mHealth

Laparoscopic management of isolated metachronous adrenal metastases in a patient with esophageal cancer: a case report

BackgroundThe presence of isolated metachronous adrenal metastasis in patients with esophageal cancer is rare. There is significant controversy regarding the management of such patients. Adrenal metastasectomy has been shown to be of benefit in some reports. Minimally invasive approach, although the gold standard for adrenalectomy, has not been used commonly in a postesophagectomy setting owing to the anticipated technical difficulties. We describe one such case wherein this approach helped in early recovery and long-term survival.Case presentationA 59-year-old male of Asian ethnicity presented with an isolated left adrenal nodule, 3 years after an Ivor Lewis esophagectomy for a lower esophageal adenocarcinoma. The biopsy of the nodule was suggestive of metastatic adenocarcinoma. The patient underwent laparoscopic excision of the left adrenal gland.ConclusionAdrenal metastasectomy, in postesophagectomy patients can provide good oncological control. Laparoscopic approach, though technically challenging, can provide results equivalent to those of open surgery, albeit with less morbidity.

Supplemental enteral tube feeding nutrition after hospital discharge of esophageal cancer patients who have undergone esophagectomy

BackgroundAfter undergoing esophagectomy to treat esophageal cancer, there are changes in the normal intake patterns in most patients, with more than half found to have an inadequate oral intake at the time of their hospital discharge. However, the use of home supplemental enteral tube feeding nutrition after hospital discharge in esophagectomy patients has yet to be established. The aim of this study was to evaluate the feasibility of 90-day home supplemental enteral tube feeding nutrition in esophagectomy patients.MethodsThis single-center, prospective, and single-arm study evaluated the feasibility of using supplemental tube feeding nutrition intervention for 90 days in esophageal cancer patients who have undergone esophagectomy.ResultsThis study enrolled 24 post-esophagectomy patients between February 2015 and September 2016. Twenty patients were administered 70% or more of the planned nutrient, with 83% of the patients completing the nutritional intervention procedure. There were no grade 3/4 adverse events observed, with a mean body weight change of − 7.6 ± 6.0%.ConclusionsOur results showed that routine use of 90-day home supplemental enteral tube feeding nutrition after hospital discharge for esophagectomy patients was both feasible and acceptable.Trial registrationUMIN000016286.

Role of Procalcitonin in the Early Detection of Anastomotic Leaks After Esophagectomy

1.1. Background: Anastomotic leaks are devastating complications after esophagectomy, and early diagnosis is crucial. We sought to assess the association between procalcitonin levels and anastomotic leaks in post esophagectomy patients. 1.2. Methods: Procalcitonin (PCT) levels were prospectively collected on patients undergoing esophagectomy within our hospital system between postoperative days 1 and 11. All patients were evaluated for an anastomotic leak between postoperative day 4 and 9. The sensitivity, specificity, negative, and positive predictive values based on procalcitonin level were calculated. 1.3. Results: A total of 30 esophagectomies were performed between August 2016 and June 2019. Anastomotic leaks were radiographically confirmed in five patients. ROC analysissuggested a procalcitonin cut-off level of ≤0.335 ng/mL, which resulted in a sensitivity of 80%, specificity of 68%, positive predictive value of 33%, and negative predictive value of 94%. In subset analysis of 8 patients with leukocytosis and fever, a procalcitonin level of ≤0.335 ng/mL had a sensitivity of 100%, specificity of 50%, positive predictive value of 40%, and negative predictive value of 100%. 1.4. Conclusion: Our analysisshowsthat a procalcitonin level ≤0.335 ng/ mL has a high negative predictive value in post esophagectomy patients even in the setting of fever and leukocytosis. Page -01 World Journal of Clinical Surgery Open Access Abbreviations: AL - Anastomotic Leak; CT - Computer Tomography; EGD - Esophago-Gastro-Duodenoscopy; F - Fahrenheit; NPV - Negative predictive value; PCT – Procalcitonin; PPV - Positive Predictive Value; WBC - White blood cell

Adaptive and Maladaptive Coping Mechanisms Used by Patients With Esophageal Cancer After Esophagectomy

BackgroundEsophagectomy patients have high rates of postoperative complications. Maladaptive coping mechanisms such as smoking, alcoholism, and obesity-related reflux are risk factors for esophageal cancer and could affect recovery after surgery. In this study, coping mechanisms used among postesophagectomy patients were identified and maladaptive mechanisms correlated with smoking, alcohol use, or BMI. Materials and methodsPatients who received an esophagectomy from 2017 to 2018 at an academic medical center were surveyed using the validated Brief Coping Orientation to Problems Experienced, which includes 14 coping mechanisms (both adaptive and maladaptive) using a 4-point Likert scale. A Fischer's exact and chi-square was performed to measure the significance of difference between groups. ResultsThere was a 67.2% response rate (43/64). 61.3% (27/43) were obese. Sixty-three percent (62.8%, 27/43) had at least 10 pack-years smoking tobacco history; average smoking tobacco usage was 27 pack-years. 30.2% (13/43) had alcohol use. All 14 coping strategies were used by at least one patient. Twenty patients used only adaptive coping strategies, with acceptance being the most used (100%, 20/20 patients). Twenty-three patients used at least one maladaptive coping strategy, with self-distraction being the most used (91.3%, 21/23). All patients used some adaptive coping. There was a significant difference in mean number of coping strategies between groups (P-value <0.0001). Patients with maladaptive coping also demonstrated greater rates of active coping and humor (P < 0.05). There was no correlation between maladaptive coping and smoking, alcohol use, or increased BMI. ConclusionsMost postesophagectomy patients use at least one maladaptive coping strategy; however, history of smoking, alcohol use, or obesity does not predict maladaptive coping in the postesophagectomy period.

77 CUTOFF VALUE OF SERUM C-REACTIVE PROTEIN ON THE FIFTH POSTOPERATIVE DAY IS EFFECTIVE TO RULE OUT ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY

Abstract Anastomotic leakage is one of most severe complications after esophagectomy. There is no consensus on the best method of identification of such complications. Serum C-reactive protein measurement on postoperative day 5 (POD) has been reported to be reliable to rule-out leakage. Methods We prospectively assessed the medical records of consecutive post-esophagectomy patients from January 2019 to January 2020. We analyzed serum CRP and complete blood cell counts from the day before surgery to the POD5. A CRP level ≤ 150 mg/l at POD5 was considered sufficient to start oral feeding. In contrast a CRP level &amp;gt; 150 mg/l at POD5 lead to a computed tomography (CT) with oral contrast to rule-out the presence of an anastomotic leakage. Anastomotic leakage was classified according to ECCG classification. Sensibility, sensitivity, positive and negative predictive value of CRP were calculated. Results Over a 12-month period, 52 patients were included (Figure 1). Measurement of CRP on POD5 was ≤150 mg/l in 34 (64%) patients (32 without fistula and 2 with fistula diagnosed after POD5) and &amp;gt; 150 mg/L in 18 (36%) patients (8 without fistula and 10 with fistula). Twelve (23%) patients developed anastomotic fistula. The cutoff value of CRP ≤150 mg/l on the POD5 was associated with sensitivity 83%, specificity 80%, positive predictive value 56% and negative predictive value 94%. The CRP protocol allowed to avoid 30/52 (57%) unnecessary postoperative CT-scan. Conclusion On the basis of a high negative predictive value, a CRP level at POD5 ≤ 150 mg/l can be effective to eliminate an anastomotic leakage and to start oral feeding without any further exams. This information is useful in the context of ERAS protocols to reduce hospital discharge and decrease hospital costs.

Airway Management in Patients With a History of Esophagectomy: A Case Series

Esophagectomy is a highly invasive surgery, and it often is accompanied by various postoperative complications. With increases in the rate and length of patient survival in postoperative esophagectomy patients, the number of said patients receiving subsequent surgeries is increasing. However, airway management in post-esophagectomy patients is yet to be researched widely. This study used anesthesia records from the Kitakyushu Municipal Medical Center to examine airway conditions and complications in patients who had undergone 1 or more additional surgeries following an esophagectomy. Case series. Single center in Japan. Forty-one post-esophagectomy patients from August 2010 to July 2019. None. Forty-one post-esophagectomy patients underwent 58 surgeries. Two of the cases (3%) involved retrosternal reconstruction, and in each, reflux from the gastric conduit was observed during tracheal intubation. The author determined that, in both cases, the gastric conduit was located laterally to the trachea, was sandwiched between both lungs, and was located ventrally to the oral cavity. There were no cases ofaspiration. The possibility of aspiration-especially in cases of retrosternal reconstruction-should be considered in post-esophagectomy patients. Based on computed tomography findings, rapid- sequence induction with head-up position is recommended. Conversely, lung ventilation (inflation) and routine cricoid pressure may be less effective or, in some patients, even harmful.

Yeast Infections after Esophagectomy: A Retrospective Analysis

Esophageal malignancy is a disease with poor prognosis. Curative therapy incorporates surgery and is burdensome with high rates of infection morbidity and mortality. The role of yeast as causative organisms of post-esophagectomy infections is poorly defined. Consequently, the benefits of specific antifungal prophylactic therapy in improving patient outcome are unclear. Therefore, this study aimed at investigating the incidence of yeast infections at the University Medical Center Groningen among 565 post-esophagectomy patients between 1991 and 2017. The results show that 7.3% of the patients developed a yeast infection after esophageal resection with significantly increased incidence among patients suffering from diabetes mellitus. For patients with yeast infections, higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, more frequent intensive care unit readmissions, prolonged hospital stays and higher mortality rates were observed. One-year survival was significantly lower for patients with a yeast infection, as well as diabetes mellitus and yeast-positive pleural effusion. We conclude that the incidence of yeast infections following esophagectomy is considerable, and that patients with diabetes mellitus are at increased risk. Furthermore, yeast infections are associated with higher complication rates and mortality. These observations encourage further prospective investigations on the possible benefits of antifungal prophylactic therapy for esophagectomy patients.