scholarly journals P-OGC47 Anastomotic stricture after Ivor Lewis Oesophagectomy - An evaluation of incidence, risk factors and treatment

2021 ◽  
Vol 108 (Supplement_9) ◽  
Author(s):  
Renol Koshy ◽  
Joshua Brown ◽  
Jakub Chmelo ◽  
Thomas Watkinson ◽  
Pooja Prasad ◽  
...  
Keyword(s):  
Risk Factors ◽  
Anastomotic Leak ◽  
Anastomotic Stricture ◽  
Multivariable Analysis ◽  
Circular Stapler ◽  
High Volume ◽  
Contributing Factors ◽  
Curative Intent ◽  
Stricture Rate ◽  
Anastomotic Strictures

Abstract Background Anastomotic stricture is a recognised complication after oesophagectomy. It can impact the patient’s quality of life and may require recurrent dilatations. The aim of this study was to evaluate the frequency of benign strictures, contributing factors, and the long-term outcomes of management in patients undergoing oesophagectomy with thoracic anastomosis using a standardised circular stapler technique. Methods All patients who underwent a two-stage transthoracic oesophagectomy with curative intent between January 2010 and December 2019 at this single, high volume centre were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Those with variations to anastomotic technique or those not having a transthoracic anastomosis were excluded to reduce heterogeneity. Patients who developed malignant anastomotic strictures and patients who died in hospital were excluded from the analysis. Benign stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded and analysed. Results Overall, 705 patients were included with 192 (27.2%) developing benign strictures. Refractory strictures occurred in 38 patients (5.4%). One, two, and three dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients respectively. Multivariable analysis identified the occurrence of an anastomotic leak (OR 1.906, 95% CI 1.088-3.341, p = 0.024) and circular stapler size <28mm (OR 1.462, 95% CI 1.033-2.070, p = 0.032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs. 4.7%, OR 3.089, 95% CI 1.349-7.077, p = 0.008). Conclusions This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery for a benign anastomotic stricture. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures. Smaller circular stapler size and anastomotic leak have been identified as independent risk factors for developing a benign anastomotic stricture following oesophagectomy, and these patients should be monitored closely for symptomatology following surgery.

scholarly journals Complications of biliary-enteric anastomoses

2017 ◽  
Vol 99 (3) ◽  
pp. 210-215 ◽  
Author(s):  
RS Kadaba ◽  
KA Bowers ◽  
S Khorsandi ◽  
RR Hutchins ◽  
AT Abraham ◽  
...  
Keyword(s):  
Risk Factors ◽  
Anastomotic Leak ◽  
Anastomotic Stricture ◽  
Multivariable Analysis ◽  
Significant Risk ◽  
Significant Risk Factor ◽  
Late Complications ◽  
Biliary Reconstruction ◽  
Tertiary Referral Centre ◽  
Younger Age

INTRODUCTION Biliary-enteric anastomoses are performed for a range of indications and may result in early and late complications. The aim of this study was to assess the risk factors and management of anastomotic leak and stricture following biliary-enteric anastomosis. METHODS A retrospective analysis of the medical records of patients who underwent biliary-enteric anastomoses in a tertiary referral centre between 2000 and 2010 was performed. RESULTS Four hundred and sixty-two biliary-enteric anastomoses were performed. Of these, 347 (75%) were performed for malignant disease. Roux-en-Y hepaticojejunostomy or choledocho-jejunostomy were performed in 440 (95%) patients. Perioperative 30-day mortality was 6.5% (n=30). Seventeen patients had early bile leaks (3.7%) and 17 had late strictures (3.7%) at a median of 12 months. On univariable logistic regression analysis, younger age was a significant risk factor for biliary anastomotic leak. However, on multivariable analysis only biliary reconstruction following biliary injury (odds ratio [OR]=6.84; p=0.002) and anastomosis above the biliary confluence (OR=4.62; p=0.03) were significant. Younger age and biliary reconstruction following injury appeared to be significant risk factors for biliary strictures but multivariable analysis showed that only younger age was significant. CONCLUSIONS Biliary-enteric anastomoses have a low incidence of early and late complications. Biliary reconstruction following injury and a high anastomosis (above the confluence) are significant risk factors for anastomotic leak. Younger patients are significantly more likely to develop an anastomotic stricture over the longer term.

scholarly journals The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler

2021 ◽  
Author(s):  
E. Tagkalos ◽  
P. C. van der Sluis ◽  
E. Uzun ◽  
F. Berlth ◽  
J. Staubitz ◽  
...  
Keyword(s):  
Anastomotic Stricture ◽  
Circular Stapler ◽  
Median Number ◽  
Stapled Anastomosis ◽  
Esophagogastric Anastomosis ◽  
Ivor Lewis ◽  
Anastomotic Insufficiency ◽  
Ivor Lewis Esophagectomy ◽  
Stricture Rate ◽  
Anastomotic Strictures

Abstract Background For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. Methods Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. Results In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). Conclusion There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

663 QUANTITATIVE PERFUSION ASSESSMENT TO PREDICT ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY

2021 ◽  
Vol 34 (Supplement_1) ◽  
Author(s):  
Yoshitaka Ishikawa ◽  
Christopher Breuler ◽  
Andrew C Chang ◽  
Jules Lin ◽  
Mark B Orringer ◽  
...  
Keyword(s):  
Anastomotic Leak ◽  
Anastomotic Stricture ◽  
Statistical Significance ◽  
Multivariable Analysis ◽  
Gastric Conduit ◽  
Fluorescence Angiography ◽  
Operative Care ◽  
Significant Difference ◽  
Perfusion Assessment ◽  
Mckeown Esophagectomy

Abstract   Impaired gastric conduit perfusion is a risk factor for anastomotic leak after esophagectomy. Most studies evaluating conduit perfusion have been qualitative with limited impact on post-operative care. The aim of this study is to evaluate the feasibility of intraoperative quantitative assessment of gastric conduit perfusion with indocyanine green (ICG) fluorescence angiography as a predictor for cervical esophagogastric anastomotic (CEGA) leak after esophagectomy. Methods ICG fluorescence angiography using the SPY elite® (Stryker, MI, USA) system was performed in patients who had undergone a transhiatal or McKeown esophagectomy CEGA from July 2015 through December 2020. Fluorescence angiography assessed Ingress (dye uptake) and Egress (dye exit). Ingress Index, Ingress Time, Egress Index, and Egress Time at two anatomic landmarks (tip of the conduit, and 5 cm from tip) were calculated from the measured curve of fluorescence (Figure). The collected data between the leak (L) group and the no-leak (NL) group were compared by both univariate and multivariable analyses to analyze risk factors potentially associated with CEGA leak. Results 304 patients were evaluated. There was no significant difference in patients' demographic and post-operative complications between the groups (L n = 73; NL n = 231), except for anastomotic stricture (42.5 vs 9.1%, p < 0.01). 5 cm and Tip Ingress Index were significantly lower in L (35.0 vs 45.1% and 17.4 vs 25.7%, p < 0.01). 5 cm Ingress Time was significantly higher in L (70.6 vs 56.8 sec, p < 0.01). On multivariable analysis, these variables retained statistical significance, suggesting that these three variables can be used to predict future leak. Conclusion This study revealed that gastric conduit perfusion correlates with the incidence of CEGA leak. Intraoperative measurement of gastric conduit perfusion may be predictive for CEGA leak following esophagectomy. These variables can be easily collected intraoperatively with the SPY study and used to make clinical decisions which may avert CEGA leak.

Stenosis of the celiac trunk is associated with anastomotic leak after Ivor–Lewis esophagectomy

2019 ◽  
Vol 32 (7) ◽  
Author(s):  
S Brinkmann ◽  
D H Chang ◽  
K Kuhr ◽  
A H Hoelscher ◽  
J Spiro ◽  
...  
Keyword(s):  
Risk Factors ◽  
Esophageal Cancer ◽  
Anastomotic Leak ◽  
Preoperative Staging ◽  
Multivariable Analysis ◽  
Celiac Trunk ◽  
Ivor Lewis ◽  
Ivor Lewis Esophagectomy ◽  
Significant Difference ◽  
Postoperative Anastomotic Leak

SUMMARY Transthoracic esophagectomy with gastric tube formation is the surgical treatment of choice for esophageal cancer. The surgical reconstruction induces changes of gastric microcirculation, which are recognized as potential risk factors of anastomotic leak. This prospective observational study investigates the association of celiac trunk (TC) stenosis with postoperative anastomotic leak. One hundred fifty-four consecutive patients with esophageal cancer scheduled for Ivor–Lewis esophagectomy were included. Preoperative staging computed tomography (CT) was used to identify TC stenosis. Any narrowing of the lumen due to atherosclerotic changes was classified as stenosis. Percentage of stenotic changes was calculated using the North American Symptomatic Carotid Endarterectomy Trial formula. Multivariable analysis was used to identify possible risk factors for leak. The overall incidence of TC stenosis was 40.9%. Anastomotic leak was identified in 15 patients (9.7%). Incidence of anastomotic leak in patients with stenosis was 19.4% compared to 2.3% in patients without stenosis. Incidence of stenosis in patients with leak was 86.7% (13 of 15 patients) and significantly higher than 38.8% (54 of 139 patients) in patients without leak (P < 0.001). There was a significant difference in median degree of TC stenosis (50.0% vs 39.4%; P = 0.032) in patients with and without leak. In the multivariable model, TC stenosis was an independent risk factor for anastomotic leak (odds ratio: 5.98, 95% CI: 1.58–22.61). TC stenosis is associated with postoperative anastomotic leak after Ivor–Lewis esophagectomy. Routine assessment of TC for possible stenosis is recommended to identify patients at risk.

scholarly journals Outcomes of the Use of Fully Covered Esophageal Self-Expandable Stent in the Management of Colorectal Anastomotic Strictures and Leaks

2014 ◽  
Vol 2014 ◽  
pp. 1-6 ◽  
Author(s):  
Chad J. Cooper ◽  
Angel Morales ◽  
Mohamed O. Othman
Keyword(s):  
Anastomotic Leak ◽  
Clinical Success ◽  
Anastomotic Stricture ◽  
Clinical Success Rate ◽  
Stent Migration ◽  
Metal Stents ◽  
The Novel ◽  
Anastomotic Leaks ◽  
Anastomotic Strictures

Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate.

scholarly journals Performance of the transoral circular stapler for oesophagogastrectomy after induction therapy

2019 ◽  
Vol 29 (6) ◽  
pp. 890-896
Author(s):  
Lily Wang ◽  
Steven Milman ◽  
Thomas Ng
Keyword(s):  
Anastomotic Leak ◽  
Induction Chemotherapy ◽  
Oesophageal Cancer ◽  
Induction Therapy ◽  
Anastomotic Stricture ◽  
Cancer Recurrence ◽  
Circular Stapler ◽  
Median Number ◽  
Increased Risk ◽  
Grade 3

Abstract OBJECTIVES Patients undergoing oesophageal anastomosis may be at an increased risk for leak after induction therapy for oesophageal cancer, with intrathoracic leaks having significant morbidity. The outcomes of utilizing transoral circular stapler for the creation of a thoracic anastomosis have not been well studied in this patient population. METHODS Patients with oesophageal cancer undergoing induction chemotherapy/radiation followed by Ivor Lewis oesophagogastrectomy were evaluated. All thoracic anastomoses were constructed with transoral circular stapler. Primary outcomes evaluated were the rates of anastomotic leak and stricture. RESULTS Over 7 years, 87 consecutive patients were evaluated, among whom 69 (79%) were male. The median age was 63 years, median body mass index (BMI) was 27 kg/m2 and median age-adjusted comorbidity index was 5. Median operative blood loss was 400 ml and median operative time was 300 min. Major complications (grade ≥3) were seen in 19 (22%), including anastomotic leak in 2 (2.3%), both successfully treated with temporary covered metal stent. The median duration of hospital stay was 10 days, and 1 (1.2%) death was reported at 90 days due to cancer recurrence. Stricture occurred in 8 (9.2%), and median time to dilation was 109 days and median number of dilations was 1. Univariable analysis found BMI to be significantly higher in patients with an anastomotic leak versus those without (43 vs 27 kg/m2, P = 0.002). No variables were found to be predictive of anastomotic stricture. CONCLUSIONS The use of the transoral circular stapler for thoracic anastomosis results in a consistent formation of the anastomosis, with low leak and stricture rates in the setting of induction chemotherapy/radiation. Leaks that do occur appear to be amenable to stent therapy.

Buttressing hepaticojejunostomy's with hepatic round ligament flap may be beneficial

2017 ◽  
Vol 89 (4) ◽  
pp. 5-10 ◽  
Author(s):  
Jayant Kumar Banerjee ◽  
Ramanathan Saranga Bharathi ◽  
Pankaj Purushotam Rao
Keyword(s):  
Anastomotic Stricture ◽  
Bile Leak ◽  
Technical Difficulty ◽  
Round Ligament ◽  
Pancreas Carcinoma ◽  
Operative Outcomes ◽  
Stricture Rate ◽  
Anastomotic Strictures ◽  
Head Of The Pancreas

Background: Bile leaks and anastomotic strictures are important complications of hepaticojejunostomy (HJ). Evidence suggests that the use of hepatic round ligament (HRL) to buttress HJ may be beneficial. This study evaluates the feasibility of this approach. Methods: HJs performed over 2 years (Jun 2014- May 2016), with HRL reinforcement, were analyzed. Operative outcomes measured included technical difficulty, blood loss, time necessary for flap harvest, and reinforcement of HJ. The postoperative outcomes measured were the presence of bile leak and anastomotic stricture. Results: Forty-one patients (27 M: 14 F), aged 2-79 years, median age of61 years, underwent HJ with HRL buttress; 27 for periampullary/ head of the pancreas carcinoma; 4 for choledochal cysts; 4 for chronic pancreatitis; 3 for gallbladder carcinoma; 3 for benign biliary stricture. The time for harvesting HRL flaps and buttressing HJ was <10 minutes. No blood was lost during harvesting the flaps. One patient (2.5 %) had grade A leak following radical cholecystectomy, and structures were not observed during a median follow-up of 18 months (6 months to 2years). Conclusion: HRL-based buttressing of HJ can reduce the bile leak and/or stricture rate.

Role of Surgeon Volume in Radical Prostatectomy Outcomes

2003 ◽  
Vol 21 (3) ◽  
pp. 401-405 ◽  
Author(s):  
Jim C. Hu ◽  
Karen F. Gold ◽  
Chris L. Pashos ◽  
Shilpa S. Mehta ◽  
Mark S. Litwin
Keyword(s):  
Radical Prostatectomy ◽  
Length Of Stay ◽  
Anastomotic Stricture ◽  
High Volume ◽  
Parameter Estimate ◽  
Surgeon Volume ◽  
Lengths Of Stay ◽  
Complication Risk ◽  
Anastomotic Strictures ◽  
High Volume Hospital

Purpose: To examine the effect of hospital and surgeon volume on postoperative outcomes and to determine whether hospital or surgeon volume is the stronger predictor. Patients and Methods: Using 1997 to 1998 claims data from a national 5% random sample of Medicare beneficiaries, we identified 2,292 men who underwent radical prostatectomy at 1,210 hospitals by 1,788 surgeons. Hospitals were classified as high (≥ 60 per year) or low (< 60 per year) volume according to radical prostatectomy experience over the 2-year period. Surgeons were classified as high (≥ 40 per year) or low (< 40 per year) volume. Multivariate logistic regression was performed to control for patient demographics and comorbidities when assessing the association of hospital and surgeon volume with in-hospital complications, length of stay, and anastomotic stricture rates. In-hospital complications included cardiac, respiratory, vascular, wound, genitourinary, and miscellaneous surgical and medical conditions. Results: High-volume surgeons had half the complication risk (odds ratio [OR] = 0.53; 95% confidence interval [CI], 0.32 to 0.89) and shorter lengths of stay (4.1 v 5.2 days, P = .03) compared with low-volume surgeons. High-volume hospital patients tended to have fewer anastomotic strictures (OR = 0.72; 95% CI, 0.49 to 1.04). Patient age (≥ 75 years) was associated with more complications (OR = 1.9; 95% CI, 1.39 to 2.70), more anastomotic strictures (OR = 2.2; 95% CI, 1.54 to 3.15), and longer hospital stays (parameter estimate = 2.26; 95% CI, 1.75 to 2.77). Conclusion: Surgeon volume is inversely related to in-hospital complications and length of stay in men undergoing radical prostatectomy. Hospital volume is not significantly associated with outcomes after adjusting for physician volume. Further study is necessary to elucidate the mechanism of the volume-outcome effect.

Risk factors for refractory anastomotic strictures after oesophageal atresia repair: a multicentre study

2018 ◽  
Vol 104 (2) ◽  
pp. 152-157 ◽  
Author(s):  
Floor W T Vergouwe ◽  
John Vlot ◽  
Hanneke IJsselstijn ◽  
Manon C W Spaander ◽  
Joost van Rosmalen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Multicentre Study ◽  
Anastomotic Leakage ◽  
Oesophageal Atresia ◽  
Anastomotic Stricture ◽  
Multivariable Logistic Regression Analysis ◽  
Exclusion Criteria ◽  
Anastomotic Strictures ◽  
End To End

ObjectiveTo determine the incidence of refractory anastomotic strictures after oesophageal atresia (OA) repair and to identify risk factors associated with refractory strictures.MethodsRetrospective national multicentre study in patients with OA born between 1999 and 2013. Exclusion criteria were isolated fistula, inability to obtain oesophageal continuity, death prior to discharge and follow-up <6 months. A refractory oesophageal stricture was defined as an anastomotic stricture requiring ≥5 dilations at maximally 4-week intervals. Risk factors for development of refractory anastomotic strictures after OA repair were identified with multivariable logistic regression analysis.ResultsWe included 454 children (61% male, 7% isolated OA (Gross type A)). End-to-end anastomosis was performed in 436 (96%) children. Anastomotic leakage occurred in 13%. Fifty-eight per cent of children with an end-to-end anastomosis developed an anastomotic stricture, requiring a median of 3 (range 1–34) dilations. Refractory strictures were found in 32/436 (7%) children and required a median of 10 (range 5–34) dilations. Isolated OA (OR 5.7; p=0.012), anastomotic leakage (OR 5.0; p=0.001) and the need for oesophageal dilation ≤28 days after anastomosis (OR 15.9; p<0.001) were risk factors for development of a refractory stricture.ConclusionsThe incidence of refractory strictures of the end-to-end anastomosis in children treated for OA was 7%. Risk factors were isolated OA, anastomotic leakage and the need for oesophageal dilation less than 1 month after OA repair.

scholarly journals Regional disease in head and neck cutaneous squamous cell carcinoma: the role of primary tumor characteristics and number of nodal metastases

2021 ◽  
Author(s):  
Alberto Grammatica ◽  
Michele Tomasoni ◽  
Milena Fior ◽  
Emanuela Ulaj ◽  
Tommaso Gualtieri ◽  
...  
Keyword(s):  
Risk Factors ◽  
Squamous Cell Carcinoma ◽  
Cell Carcinoma ◽  
Head And Neck ◽  
Squamous Cell ◽  
Primary Tumor ◽  
Multivariable Analysis ◽  
Cutaneous Squamous Cell Carcinoma ◽  
Tumor Characteristics ◽  
Curative Intent

Abstract Purpose To identify potential risk factors impacting on overall survival (OS) of patients affected by lymph node metastasis from cutaneous squamous cell carcinoma (cSCC) of the head and neck (HN), with special emphasis on primary tumor characteristics and pattern of nodal recurrence (intraparotid and/or cervical). Methods A bi-institutional retrospective study on consecutive patients affected by cervical and/or intraparotid NM from HN cSCC and surgically treated with curative intent from May 2010 to January 2020 was conducted. OS was considered the outcome of interest. Results The study included 89 patients (M:F = 3.4:1; median age, 78 years; range, 22–99). Among the primary tumor characteristics, the most relevant prognostic factors were diameter ≥ 4 cm (hazard ratio [HR] = 2.56, p = 0.010) and depth of infiltration ≥ 6 mm (HR = 3.54, p = 0.027). Cervical NM was associated with worse OS (HR = 2.09, p = 0.016) compared to purely intraparotid NM (5-year OS: 60.9% vs. 28.1%, p = 0.014). At multivariable analysis, age, immunosuppression, pT3-T4 categories and a high burden of nodal disease (> 2 NM) confirmed to be independent risk factors, whereas adjuvant radiotherapy was independently associated with better outcome. Conclusion This study confirms the association of several independent prognosticators related to the patient, primary tumor, and nodal burden status. Patients with cervical NM should be considered at risk for harboring a higher number of metastatic lymph nodes.

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