Tube Reconstruction Research Articles

718 DIFFERENCES BETWEEN INTRACORPOREAL AND EXTRACORPOREAL GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY: IS THERE A BETTER WAY?

Abstract Introduction Esophagectomy remains good option to curative intent for esophageal carcinoma. However, quality of life for post-operative symptoms such as reflux, gastric emptying delayed and dysphagia is on debate. Some studies advocate relations between those symptoms to gastric tube conformation and discrepancies between intra and extracorporeal gastric tube construction. We aimed to analyze differences between both methods. Methods During 2014–2020, patients underwent to esophagectomy by thoracoscopic approach with cervical anastomosis (McKeown procedure). The abdominal part was performed by totally laparoscopic (group A) or hybrid (group B) hand-assisted gastric tubulization. Clinical parameters, symptoms of reflux, gastric tube evaluated by tomography, post-operative endoscopic findings were assessed and compared between groups. Multivariable analysis was performed. Results 36 group A and 56 group B, 55 (59.7%) were squamous cell carcinoma and 60 (66.6%) did neoadjuvant chemoradiotherapy. Mean follow-up was 32 months. Group A had more gastric tube diameter (p < 0.001), alimentary stasis (p < 0.001), redundant conformation (p < 0.05) and distant from axial central point of the thorax (p < 0.05); all evaluated by tomography. And also, more symptoms of reflux and gastric empty delay by reflux symptoms index (RSI) (p < 0.001); and numbers of esophagitis grade B and C by upper endoscopy (p < 0.01). After multivariable analysis, intracorporeal (p < 0.001) and diameter more than 4.2 cm (p < 0.01) was related to worst RSI. Conclusion The intracorporeal gastric tube reconstruction may lead wider gastric tube conformation, which might be related to gastric empty delay, resulting in intense reflux symptoms confirmed by upper endoscopy.

851 TRANSHIATAL ESOPHAGECTOMY: A SELECTIVE ROLE IN THE CURATIVE APPROACH TO ESOPHAGEAL CANCER

Abstract Surgery remains central to the curative management of esophageal cancer. At this Center, based on evidence from the literature, transthoracic en bloc surgery (TTE) is standard, however transhiatal esophagectomy (THE) is considered for predicted early stage junctional (AEG) tumors, multifocal in situ cancer, or where age or respiratory co-morbidity suggests a high risk with TTE. This audit reports this experience over 19 years. Methods Data was acquired from our prospectively maintained database. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction cancer (cT1-4aN0-3 M0) from 2000 to 2018 were included. THE was compared with TTE for operative complications (ECCG-defined), and proxy markers of oncologic quality. Results 933 patients were included, 166 (18%) THE and 767 (82%) TTE. The median (range) age was 62(22–83) vs 67(36–86) in TTE and THE, with 43(6%) and 40(24%) over 75 respectively (p < 0.01). There were significantly (p < 0.01) more early tumors in the THE (58%) vs the TTE group(11%). 23% were > ASA 3 in THE vs 12% TTE (p < 0.01). Postoperative pulmonary complications (PPCs) were 11% and 18.3% in THE and TTE cohorts, respectively(p 0.03). In-hospital mortality was 1.2%vs3.4% in THE vs TTE (p = 0.21). Five-year survival was 67% and 40% in THE vs TTE, respectively. Conclusion These data are consistent with the safe and effective use of THE in selected cases. Notably, favourable major pulmonary morbidity and mortality rates for a higher risk cohort. We suggest that this approach may still be relevant in defined scenarios in an increasingly minimally invasive era.

303 LONG-TERM SURVIVAL AND PULMONARY COMPLICATIONS IN MEDIASTINOSCOPIC ESOPHAGECTOMY

Abstract The radical esophagectomy for esophageal cancer is an invasive therapy due to a long one-lung ventilation. The mediastinoscopic esophagectomy in consideration of pulmonary complications became eligible for Japanese health insurance. Methods Radical esophagectomies (R0/1, gastric tube reconstruction) by thoracotomy/thoracoscopy (groupT) or mediastinoscopy (groupM) were performed for 118/58 or 225 patients with esophageal cancer. The long-term therapeutic results of mediastinoscopic radical esophagectomy are investigated. Results In clinicopathological features, younger and lower PS patients, neoadjuvant chemotherapy, advanced cases, or R1 resection were more frequent in groupT (p < 0.01). Pulmonary complication was not significantly different in both groups (15.5 vs 11.0%, p = 0.19), whereas the any complications, including the recurrent nerve paralysis, were significantly frequent in groupM. The 5-years overall survival was better in group M (53.0% vs 68.2%, p = 0.04), but it may be because of the difference of cancer progression. In the subgroup analysis, the overall survival rate was similar in each clinical stage. The survival of patients with pulmonary complication was significantly worse in groupT. Conclusion The survival of patients underwent trans-mediastinoscopic radical esophagectomy was not different from that with conventional esophagectomy. The influence of pulmonary complications on survival may be lower in mediastinoscopic esophagectomy.

477 MINIMALLY INVASIVE MEDIASTINOSCOPIC IVOR-LEWIS ESOPHAGECTOMY WITH CERVICAL ANASTOMOSIS FOR ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA PATIENT UNDER INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING

Abstract In early 2000s, cervical anastomosis after esophagectomy was associated with a higher rate of recurrent nerve trauma than thoracic anastomosis. Recently, new technologies have been developed that reduce surgical complications. Mediastinoscopic esophagectomy is reportedly less invasive and allows faster recovery than thoracoscopic esophagectomy. Intraoperative nerve monitoring (IONM) prevents recurrent laryngeal nerve (RNL) palsy. We present the case of minimally invasive mediastinoscopic Ivor-Lewis Esophagectomy (MMIE) under IONM performed on an elderly esophagogastric junction (EGJ) adenocarcinoma patient. Methods An 84-year old man was consulted for adenocarcinoma of GEJ without lymphnode metastasis. Despite his advanced age, he had no comorbidities. We planned to perform MMIE under IONM. The procedure started with a patient lithotomy, and three trocars plus small incision were made in the upper abdomen. Celiac lymphadenectomy was performed. Subsequently, a 35 mm incision was made in the left side of the neck and a monitor was attached to left vagus nerve. Three trocars were placed with single incision surgical devices and pneumomediastinum was noticed. Mediastinoscopic esophagectomy was performed. Gastric tube reconstruction via mediastinum with cervical anastomosis was performed. Results The operation was successful. Total operation time was 393 minutes, with an estimated blood loss of 5 mL. There were no intraoperative and postoperative complications, and no RLN palsy occurred. Conclusion MMIE with cervical anastomosis under IONM is safe and less invasive especially for the respiratory system as a thoracotomy is unnecessary. Video https://www.dropbox.com/s/9yqkzg3pm619pf6/%E7%B8%A6%E9%9A%94%E9%8F%A12%E5%88%8656%E7%A7%92.mp4?dl=0.

Fibrin/fibrinogen Degradation Products Are Associated With Tumor Stage and Prognosis in Patients Undergoing Resection of Esophageal Cancer.

To investigate the significance of preoperative fibrin/fibrinogen degradation products (FDP) in patients with esophageal cancer (EC), we examined the association between the preoperative FDP level and clinicopathological features in patients with EC who underwent McKeown esophagectomy with gastric tube reconstruction without neoadjuvant therapy. Ninety patients with EC who underwent surgery between 2006 and 2014 were included in this study. We investigated the association of FDP levels with clinicopathological features and prognosis. Multivariate analysis revealed increased FDP level and pathological tumor depth to be independent prognostic factors for overall survival (OS) (p=0.008 and p=0.002, respectively). In addition, FDP levels were significantly positively associated with more advanced pathological TNM stage as a continuous variable (p for trend=0.002). The preoperative FDP level was associated with a poor prognosis and was an independent prognostic factor for the OS of EC patients who underwent esophagectomy. Furthermore, the tumor stage-related increase in FDP indicated that a high FDP level is associated with tumor progression in patients with EC.

Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series

Background One cause of anastomotic leakage after radical esophagectomy is blood flow insufficiency at the cervical anastomosis site. . Methods Eighteen patients, who underwent radical esophagectomy with gastric tube reconstruction, were studied. The regional tissue oxygen saturation (rSO2) was measured at the tip (point pre 0) and 2, 4, and 6 cm on the distal side of the tip (point pre 1, pre 2, and pre 3, respectively) before the gastric tube was raised to the cervical site through the retrosternal route. After that, rSO2 was measured at the tip, 2 and 4 cm on the distal side of the tip (points post 0, post 1, and post 2), the actual anastomotic site (point AN), and the chest skin as an indicator of whole-body oxygenation. The relationship between rSO2 scores and the rate of anastomotic leakage was determined. Results The mean rSO2 at pre 0, pre 1, pre 2, and pre 3 were 48.9%, 52.3%, 54.8%, and 56.9%, respectively (p < 0.05). The mean rSO2 at post 0, post 1, and post 2 were 47.8%, 50.5%, and 52.3%, respectively, and the rSO2 at point AN was 52.1%. Anastomotic leakage was found in 6 patients. The rSO2 at points pre 0, pre 1, and pre 2, post 0 and point AN were significantly lower in patients with anastomosis leakage than those without (p < 0.05). Conclusion Tissue oxygen saturation monitoring was a useful indicator of blood flow insufficiency in the gastric tube during radical esophagectomy.

Proximal gastrectomy with gastric tube reconstruction or jejunal interposition reconstruction in upper-third gastric cancer: which offers better short-term surgical outcomes?

ObjectiveProximal gastrectomy acts as a function-preserving operation for upper-third gastric cancer. The aim of this study was to compare the short-term surgical outcomes between proximal gastrectomy with gastric tube reconstruction and proximal gastrectomy with jejunal interposition reconstruction in upper-third gastric cancer.MethodsA retrospective review of 301 patients who underwent proximal gastrectomy with jejunal interposition (JI) or gastric tube (GT) at Harbin Medical University Cancer Hospital between June 2007 and December 2016 was performed. The Gastrointestinal Symptom Rating Scale (GSRS) and Visick grade were used to evaluate postgastrectomy syndromes. Gastrointestinal fiberoscopy was used to evaluate the prevalence and severity of reflux esophagitis based on the Los Angeles (LA) classification system.ResultsThe JI group had a longer operation time than the GT group (220 ± 52 vs 182 ± 50 min), but no significant difference in blood loss was noted. Compared to the GT group, the Visick grade and GSRS score were significantly higher. Reflux esophagitis was significantly increased in the GT group compared with the JI group.ConclusionProximal gastrectomy is well tolerated with excellent short-term outcomes in patients with upper-third gastric cancer. Compared with GT construction, JI construction has clear functional advantages and may provide better quality of life for patients with upper-third gastric cancer.

Primary malignant melanoma of the esophagus successfully treated with nivolumab: a case report

IntroductionPrimary malignant melanoma of the esophagus is a rare and aggressive disease that tends to have a poor response to chemotherapies. Previous studies have indicated that currently available treatment for primary malignant melanoma of the esophagus is insufficient. Here, we describe a case of recurrent primary malignant melanoma of the esophagus successfully treated with the immune checkpoint inhibitor nivolumab.Case presentationAn 81-year-old Japanese female presented with a 3-month history of dysphagia. She was medicated for hypertension and sarcoidosis. The patient had no past history of cutaneous, ocular, or other-site melanomas. An esophagoscopy identified a 30-mm giant tumor in the lower esophagus, at a site 30 cm from the incisors. Enhanced computed tomography revealed wall thickening measuring 30 mm in size at the middle-third of the intrathoracic esophagus, with no significant lymph node infiltration or distant metastasis. Esophageal biopsy showed proliferation of large round tumor cells and melanophages. On the basis of these findings, the patient was diagnosed with esophageal malignant melanoma and underwent esophagectomy and lymph node dissection with gastric tube reconstruction. Although the pathological diagnosis was primary malignant melanoma of the esophagus, the patient presented with multiple lymph node and bone metastases 4 months after surgery. Subsequently, treatment with nivolumab 240 mg every 2 weeks was administered as the first-line treatment. Diffusion-weighted imaging with background body signal suppression following eight courses of nivolumab revealed that the multiple lymph node and bone metastases were markedly reduced. The patient received 30 courses of nivolumab and has maintained the partial response. No severe adverse events related to the immunotherapy were recorded.ConclusionThe current study suggests that nivolumab may be a viable option for patients with metastatic primary malignant melanoma of the esophagus. Additional evidence from future clinical trials and research is necessary to fully validate these findings.

The evaluation of the gastric tube blood flow by indocyanine green fluorescence angiography during esophagectomy: a multicenter prospective study.

We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting. We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90s (preferably within 60s). The enhancement time and the incidence of anastomotic leakage were compared. In all cases, anastomosis was made at the site enhanced within 90s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60s (p = 0.09). Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.

The effect of early oral feeding after subtotal esophagectomy with immediate esophageal reconstruction on patients’ nutritional status: randomized single-center study

BACKGROUND: The efficiency of early oral feeding in the postoperative period is well known. Though doctors still prefer other types of nutritional support after esophagectomy with immediate gastric tube reconstruction in the esophagus surgery.&#x0D; AIMS: To compare the efficacy, safety and nutritional status of patients after esophagectomy with gastric tube reconstruction while beginning of oral and full parenteral nutrition in the early postoperative period.&#x0D; MATERIALS AND METHODS: Weve conducted prospective single-center randomized study. Subtotal esophagectomy with immediate gastric tube reconstruction was performed to 60 patients. In the postoperative period we evaluated the results of treatment, the frequency and severity of complications, anthropometric and laboratory indicators of the nutritional status before the operation on the first, third and sixth postoperative days.&#x0D; RESULTS: Patients without high risk of malnutrition were randomly divided in 2 groups: main group (n=30) starting early oral feeding on the first postoperative day and control group (n=30) that remained nil by mouth and got parenteral feeding within 4 postoperative days. The patients of early oral feeding group had statistically significant earlier gas discharge(2 vs 4 postoperative days, р=0.000042) and stool appearance (3 vs 5 postoperative days, р=0.000004). There was a tendency towards a decrease in the duration of postoperative hospitalization in early oral feeding group (8 vs 9 postoperative days, р=0.13). Early oral feeding did not affect on frequency (46.6% vs 53.3%, р=0.66) and character of postoperative complications. After evaluation of the parameters of nutritional status we found statistically significant decrease of prealbumin level on the third postoperative day in early oral feeding group (0.17 vs 0.2, р=0.03) of due to inability to compensate daily calorie needs in the first days after the operation. On the sixth postoperative day prealbumin became the same in both groups. There were no other significant differences between the groups.&#x0D; CONCLUSIONS: Early oral feeding after esophagectomy with immediate gastric tube reconstruction is safe. Early oral feeding doesnt increase the frequency of anastomotic insufficiency and other complications. The decrease of prealbumin on the third postoperative day was noted in early oral feeding group while evaluating nutritional status.

Effectiveness of the Gerdq Questionnaire for Diagnosing Gastroesophageal Reflux Disease After Esophagectomy for Esophageal Cancer.

Gastroesophageal reflux disease (GERD) is a common complication after esophagectomy with gastric tube reconstruction. The GerdQ questionnaire was developed for diagnosing GERD in primary care patients. Its effectiveness in patients after esophagectomy remains unknown. In this study, we evaluated the usefulness of the GerdQ questionnaire for diagnosing GERD after esophagectomy for esophageal cancer. A total of 124 patients with esophageal cancer underwent right transthoracic esophagectomy with gastric tube reconstruction between January 2010 and December 2016. Esophagogastroduodenoscopy and 24-hour esophageal pH-metry were performed at 1 month, 1 year, and 2 years postoperatively. The GerdQ questionnaire was administered at the same postoperative time points. We assessed any correlation between the GerdQ scores and the endoscopy and pH-metry findings. The incidence rates of GERD at 1 month, 1 year and 2 years post-surgery were 31.6%, 46.9%, and 49.2%, respectively. The GerdQ questionnaire showed 77% sensitivity and 56% specificity for diagnosing GERD at 2 years after esophagectomy when the cutoff point was 7. However, the optimal cutoff points were different at each postoperative time, and the scores showed some imbalance between sensitivity and specificity. Regurgitation may be a useful indicator, as the frequency of regurgitation was significantly higher in patients with GERD than in patients without GERD at 1 year (P = 0.046) and 2 years postoperatively (P = 0.048). The GerdQ questionnaire is not a useful diagnostic tool for GERD in patients who have undergone esophagectomy for esophageal cancer.

Clinical outcomes of gastric tube reconstruction following laparoscopic proximal gastrectomy for early gastric cancer in the upper third of the stomach: experience with 100 consecutive cases.

Gastric tube reconstruction is a form of esophagogastrostomy performed after laparoscopic proximal gastrectomy (LPG). It is a simple and safe technique, but it may cause reflux esophagitis (RE) and impair postsurgical QOL. For several years, we have developed the gastric tube reconstruction and performed it on more than 100 patients. This study aimed to determine whether gastric tube reconstruction can be a feasible choice after LPG in regard to surgical safety and postoperative nutritional status. The subjects consisted of 171 patients who underwent LPG (n = 102) or laparoscopic total gastrectomy (LTG) (n = 69). We compared the two groups in terms of surgical outcomes, incidence rate of RE, and nutritional status including postoperative weight loss and hemoglobin levels. There were no significant differences with regard to the surgical duration and blood loss between the two groups. The incidence of RE was not significantly higher with LPG than with LTG (16.7% vs. 10.1%, respectively; P = 0.07). Later than 2 years and 6 months after surgery, the body weight percentage of preoperative body weight in the LPG group was significantly higher than that in the LTG group. Hemoglobin and ferritin levels in the LPG group were significantly higher than those in the LTG group, later than one after surgery. The overall survival rates were similar between the two groups (5-year survival rates: 97.1% vs. 94.2% in the LPG and LTG groups, respectively; P = 0.69). Gastric tube reconstruction after LPG is simple and had better outcomes than LTG in terms of postoperative nutritional status.

Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process.

In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology. The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed. Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice. This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.

Reviving Matrix for Nerve Reconstruction in Rabbit Model of Chronic Peripheral Nerve Injury With Massive Loss Defect.

Background and Aims: The aim of this study was to investigate the innovative guiding regenerative gel (GRG) and antigliotic GRG (AGRG) fillings for nerve conduits, prepared with Food and Drug Administration (FDA)-approved agents and expected to provide an alternative to autologous nerve graft and to enable reconnection of massive nerve gaps in a rabbit model of chronic peripheral nerve injury with massive loss defect that simulates the human condition of chronic injury with a large gap.Methods: The components and dosimetry for GRG and AGRG formulations were investigated in vitro on nerve cell culture and in vivo on 10-mm reconstructed sciatic nerves of 72 rats using different concentrations of agents and completed on a rabbit model of delayed (chronic) complete peripheral nerve injury with a 25-mm gap. Forty rabbits underwent delayed (9 weeks after complete injury of the tibial portion of the sciatic nerve) nerve tube reconstruction of a gap that is 25 mm long. GRG and AGRG groups were compared with autologous and empty tube reconstructed groups. Rats and rabbits underwent electrophysiological and histochemical assessments (19 weeks for rats and 40 weeks for rabbits).Results: Application of AGRG showed a significant increase of about 78% in neurite length per cell and was shown to have the most promising effect on neuronal outgrowth, with total number of neurites increasing by 4-fold. The electrophysiological follow-up showed that AGRG treatment is most promising for the reconstruction of the tibial portion of the sciatic nerve with a critical gap of 25 mm. The beneficial effect of AGRG was found when compared with the autologous nerve graft reconstruction. Thirty-one weeks post the second surgery (delayed reconstruction), histochemical observation showed significant regeneration after using AGRG neurogel, compared with the empty tube, and succeeded in significantly regenerating the nerve, as well as the autologous nerve graft, which was almost similar to a healthy nerve.Conclusion: We demonstrate that in the model of delayed peripheral nerve repair with massive loss defect, the application of AGRG led to a stronger nerve recovery and can be an alternative to autologous nerve graft.

Laparoscopic real-time vessel navigation using indocyanine green fluorescence during laparoscopy-assisted gastric tube reconstruction: First experience.

A considerable percentage of morbidity and mortality after oesophagectomy is due to leakage of oesophagogastrostomy, which is mainly caused by ischaemia of the gastric tube. Therefore, we performed laparoscopic real-time vessel navigation (LRTVN) using indocyanine green fluorescence (ICG) during laparoscopy-assisted gastric tube reconstruction (LAGR) to evaluate gastric tube blood flow and avoid vascular injury. This study included five oesophageal cancer patients who underwent video-assisted thoracoscopic oesophagectomy and LAGR. We confirmed the presence of the left gastroepiploic artery (LGEA) in all cases, and no findings such as post-operative gastric tube ischaemia were observed. In all cases, no vascular injury was observed, and the vascularization of LGEA was confirmed. This report is the first to consider the usefulness of LRTVN using ICG during LAGR. LRTVN using ICG during LAGR was considered to be useful for evaluating gastric tube blood flow and avoiding vascular injury around the splenic hiatus.

Early oral feeding after subtotal esophagectomy with immediate esophageal reconstruction as a component of ERAS protocol. A prospective randomized study

Introduction. Despite increasing trends toward the early initiation of oral feeding after gastrointestinal surgeries, current evidence about feeding patients after esophagectomy (EE) with gastric tube reconstruction has not been convincing. The further research is needed. The present clinical trial aimed to compare the clinical outcomes of early oral feeding (EOF) with late oral feeding following EE with gastric conduit reconstruction. Objectives. To improve the results of treatment of patients after EE with gastric tube reconstruction by choosing the method of nutritional support in the postoperative period. Materials and methods. Forty patients undergoing esophagectomy with gastric conduit reconstruction enrolled in this prospective randomized controlled trial, and were randomly assigned to a group starting EOF on the first postoperative day (POD) and another group that remained nil by mouth and got parenteral feeding until the 5 POD. The clinical and surgical outcomes were compared between the two groups. Results. Comparing the treatment results of both groups, we did not find a statistically significant difference in the number of patients with postoperative complications in the main and control groups. The patients of EOF group had statistically significant earlier gas discharge-2 vs 4 (3–5.5) POD (p = 0.001) and the appearance of stool — 3 (2–3) vs 4 (2–4.5) POD (p = 0.0002). Early activisation and nutrition support, the absence of intestinal paresis allowed us to note a tendency to reduction of the total time of postoperative hospital stay — 7 (6.5–8.5) vs 8 (7–9) POD (p = 0.1). Conclusions. Early oral nutrition in patients who have undergone EE with gastric conduit reconstruction is safe and effective. However, its use in routine practice is possible only if surgical safety is observed and within the framework of a perioperative support program that includes all the components of ERAS protocol.

Clinical Experience of Enteral Feeding Catheter Placement via the Diaphragm During Esophagectomy and Gastric Tube Reconstruction via the Posterior Mediastinal Route

Clinical Experience of Enteral Feeding Catheter Placement via the Diaphragm During Esophagectomy and Gastric Tube Reconstruction via the Posterior Mediastinal Route

Anomalous left coronary artery from the pulmonary artery repair outcomes: Preoperative mitral regurgitation persists in the follow-up.

This study aims to present the midterm outcomes of surgical correction of the anomalous left coronary artery from the pulmonary artery (ALCAPA) with a focus on mitral regurgitation (MR). Medical records of 36 ALCAPA patients who underwent surgery in a single center were retrospectively reviewed. There were one (2.7%) neonate, 19 (52.7%) infants, 15 (41.6%) children, and 1 (2.7%) adult patient operated. Coronary reimplantation, tube reconstruction, and coronary artery bypass surgery techniques were performed in 29 (80.5%), 6 (16.6%), and 1 (2.7%) patient, respectively. Sixteen (44.4%) patients had a low ejection fraction and 13 (36.1%) patients had at least moderate MR preoperatively. None of our patients underwent a concomitant mitral surgery during the initial repair. Three and two patients died in the early and late postoperative period, respectively. Two patients underwent reoperation due to MR and pulmonary stenosis, separately. Preoperative MR was the only factor associated with at least moderate MR at the final follow-up (p < .01) and the presence of preoperative moderate or over-moderate MR estimated at least moderate MR at the final follow-up with 100% sensitivity and 80% specificity. Although the mitral valve was not repaired in the first operation, the reoperation rate is low. However, a moderate or higher preoperative MR predicted MR at the last follow-up. Performing annuloplasty in such patients can be a strategy to be researched.

Direct Stimulation of Neural Placode and Nerve Roots in Open Myelomeningocele: The Efficacy of Neural Tube Reconstruction

Introduction: Intraoperative electrophysiological studies are increasingly used in spinal surgery. However, its use in myelomeningocele (MMC) surgery is still not widespread. The aim of this study was to present our experience in neural placode (NP) and nerve root stimulations in newborns with open MMC. Methods: Eight newborns underwent surgical treatment for thoracolumbar and lumbosacral MMCs. Intraoperative neuromonitoring including free-running electromyography and stimulation of NP, nerve roots, and spinal cord were performed in all cases. Stimulation sites and intensities and distal response’s amplitudes and latencies were recorded. Results: Five patients had thoracolumbar and 3 patients had lumbosacral MMC. Two patients had no movements at the lower extremities while the other had some movements. No response on the lower extremities was obtained in only 1 patient. Responses from the nerve root stimulations were more robust and significant than the placode stimulations. Conclusions: It is clear that the NP and nerve roots originating from the placode are mostly functional and should be preserved during the surgery. Intraoperative neuromonitoring and direct stimulation should be performed during the MMC repair in order to obtain a better neurological outcome.

The Association of Textbook Outcome and Long-Term Survival After Esophagectomy for Esophageal Cancer

Esophagectomy is the key component of curative esophageal cancer treatment. Textbook outcome is a composite measure describing an optimal perioperative course, including variables related to radical resection, including at least 15 lymph nodes, and an uncomplicated postoperative course without hospital readmission. This study assessed clinicopathologic predictors of textbook outcome and the association of textbook outcome with survival in 2 tertiary referral centers. All patients with esophageal cancer who underwent esophagectomy with gastric tube reconstruction and curative intent between 2007 and 2016 were included. Patients with carcinoma in situ and patients undergoing a salvage or nonelective procedure were excluded. The primary end point was the association of textbook outcome of esophageal cancer surgery with long-term survival. Secondary end points were clinicopathologic predictors of textbook outcome. In total, 1065 patients were included, of whom 327 achieved textbook outcome (30.7%). Squamous cell carcinoma (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.39 to 0.80), hybrid approach (OR, 0.30; 95% CI, 0.10 to 0.89), and American Society of Anesthesiologists (ASA) class II or higher predicted worse textbook rates (ASA class II: OR, 0.33, 95% CI, 0.22 to 0.49; ASA class III or IV: OR, 0.68; 95% CI, 0.48 to 0.96), whereas neoadjuvant therapy predicted a better textbook rate (OR, 1.58; 95% CI, 1.08 to 2.31). Superior overall (hazard ratio, 0.77; 95% CI, 0.64 to 0.93) and disease-free survival (hazard ratio, 0.80; 95% CI, 0.67 to 0.96) were observed in the textbook outcome group. Achieved textbook outcome was associated with better overall and disease-free survival, thus illustrating the association of improved short-term outcomes and long-term survival and the importance of pursuing textbook outcome.