P-P09 Salvage transgastric necrosectomy as a part of a step-up approach to managing acute necrotising pancreatitis

Abstract Background The use of EUS (endoscopic ultrasound) guided drainage with endoscopic LAMS (lumen apposing metal stent) necrosectomy is an emerging treatment option for walled-off pancreatic necrosis (WOPN) secondary to acute severe pancreatitis. It can delay or remove the need for surgical necrosectomy, which can be associated with high morbidity and mortality. However, the endoscopic approach is not always successful due to a multitude of factors and salvage transgastric necrosectomy can be performed using the tract created by the LAMS to achieve internal drainage and remove necrotic pancreas. Methods We describe our unit’s experience in managing WOPN in two patients. We suggest a treatment pathway of WOPN which includes a step-up approach including salvage transgastric necrosectomy in patients where multiple endoscopic necrosectomies and washouts have failed. Results Two patients, aged 67 and 69, were admitted as intensive care transfers for gallstone and alcohol pancreatitis respectively. They underwent a step-up approach to treat their infected WOPN, starting with the deployment of LAMS and endoscopic necrosectomy. They both showed brief clinical improvement after repeated endoscopic necrosectomy but further imaging showed ongoing large collections that could not be treated endoscopically. Both patients underwent successful transgastric open necrosectomy where necrotic pancreatic tissue was accessed surgically through the already created cyst-gastrostomy. This had the advantage of internal drainage of the collection into the stomach without the need for external surgical drains. Conclusions The emphasis in the treatment of WOPN has shifted to minimally invasive percutaneous or endoscopic drainage modalities. Endoscopically inserted LAMS may not always achieve definitive drainage of the WOPN but should be employed in the first instance as they are associated with reduced morbidity and mortality compared to surgery. Ultimately, open necrosectomy with washout remains the definitive management strategy in the step-up approach. We believe that the trans-gastric open necrosectomy approach can be used successfully in patients where the minimally invasive approach has failed.

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Acute necrotising pancreatitis – early management in the district general hospital and tertiary hepato-pancreatico-biliary unit

Journal of the Intensive Care Society ◽

10.1177/1751143718783605 ◽

2018 ◽

Vol 20 (3) ◽

pp. 263-267

Author(s):

Rajiv P Lahiri ◽

Nariman D Karanjia

Keyword(s):

Acute Pancreatitis ◽

Nutritional Support ◽

Morbidity And Mortality ◽

High Morbidity ◽

Early Management ◽

Surgical Emergency ◽

High Dependency ◽

Necrotising Pancreatitis ◽

Acute Necrotising Pancreatitis ◽

Acute Necrotising

Acute pancreatitis is a common general surgical emergency presentation. Up to 20% of cases are severe and can involve necrosis with high associated morbidity and mortality. It is most commonly due to gallstones and excess alcohol consumption. All patients with acute pancreatitis need to be scored for severity and patients with severe acute pancreatitis should be managed on the high dependency unit. The mainstay of early treatment is supportive, with care to ensure strict fluid balance and optimisation of end organ perfusion. There is no role for early antibiotic use in acute necrotising pancreatitis and antibiotics should only be used in the presence of positive cultures. Nutritional support is vitally important in improving outcomes in necrotising pancreatitis. This should ideally be provided enterally using an naso-jejunal tube if the patient cannot tolerate oral intake. Patients with significant early necrosis, persisting organ dysfunction, infected walled off necrosis requiring intervention or haemorrhagic pancreatitis should be referred to a regional hepato-pancreatico-biliary unit for advice or transfer. Percutaneous and endoscopic necrosectomy has replaced open surgery due to improved outcomes. Acute necrotising pancreatitis remains a complex surgical emergency with high morbidity and mortality that requires a multidisciplinary approach to attain optimum outcomes. The mainstay of treatment is supportive care and nutritional support. Patients with significant pancreatic necrosis or infected collections requiring drainage require input from a tertiary HPB unit to guide management.

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Minimally Invasive Approach to Infected Pancreatic Necrosis

10.1093/med/9780199384075.003.0020 ◽

2017 ◽

Author(s):

Rachel J. Kwon

Keyword(s):

Minimally Invasive ◽

Pancreatic Necrosis ◽

Necrotizing Pancreatitis ◽

Infected Pancreatic Necrosis ◽

Minimally Invasive Approach ◽

Invasive Approach ◽

Open Necrosectomy ◽

Study Intervention ◽

Landmark Study

This chapter provides a summary of a landmark study in abdominal surgery. Does a minimally invasive, “step-up” approach to necrotizing pancreatitis reduce mortality and major complications as compared to open necrosectomy? Starting with that question, it describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case involving a patient with infected pancreatic necrosis.

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Citrobacter freundiicausing pharyngitis and secondary retropharyngeal abscess with intrathoracic extension to the diaphragm: minimally invasive management of a rare case

The Journal of Laryngology & Otology ◽

10.1017/s002221511000054x ◽

2010 ◽

Vol 124 (5) ◽

Cited By ~ 1

Author(s):

A Trinidade ◽

V Sekhawat ◽

Z Andreou ◽

J Meldrum ◽

S Kamat ◽

...

Keyword(s):

Minimally Invasive ◽

Head And Neck ◽

Clinical Course ◽

Retropharyngeal Abscess ◽

Morbidity Rate ◽

Suction Catheter ◽

High Morbidity ◽

Pharyngeal Wall ◽

Invasive Approach ◽

High Morbidity Rate

AbstractIntroduction:Citrobacter freundiiis a rare but potentially aggressive cause of pharyngitis which may progress to retropharyngeal abscess with diaphragmatic extension.Objective:To raise awareness of: (1) citrobacter as a potential cause of head and neck infection, including retropharyngeal abscess; (2) a novel surgical approach to draining such an abscess; and (3) citrobacter's particular biological properties which may affect the clinical course.Method:Case report.Results:The abscess was drained via a minimally invasive posterior pharyngeal wall incision and placement of a suction catheter into the mediastinum through this incision. Residual intrathoracic collections were drained by the cardiothoracic team via percutaneous aspiration. The patient made a full recovery.Conclusion:Early recognition of citrobacter head and neck infections, an awareness of the peculiarities of the clinical course of such infections, and timely surgical intervention can prevent catastrophic outcomes. A minimally invasive approach to mediastinal collections can be considered as a viable alternative to open thoracotomy, which carries a high morbidity rate.

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Minimally Invasive Esophagectomy for Esophageal Cancer: The First Experience from Pakistan

International Journal of Surgical Oncology ◽

10.1155/2014/864705 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5 ◽

Cited By ~ 1

Author(s):

Farrukh Hassan Rizvi ◽

Syed Shahrukh Hassan Rizvi ◽

Aamir Ali Syed ◽

Shahid Khattak ◽

Ali Raza Khan

Keyword(s):

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Disease Free Survival ◽

Transhiatal Esophagectomy ◽

Learning Phase ◽

Morbidity And Mortality ◽

High Morbidity ◽

Continuous Variables ◽

Perioperative Morbidity ◽

Invasive Esophagectomy

Background. Two common procedures for esophageal resection are Ivor Lewis esophagectomy and transhiatal esophagectomy. Both procedures have high morbidity rates of 20–46%. Minimally invasive esophagectomy has been introduced to decrease morbidity. We report initial experience of MIE to determine the morbidity and mortality associated with this procedure during learning phase.Material and Methods. Patients undergoing MIE at our institute from January 2011 to May 2013 were reviewed. Record was kept for any morbidity and mortality. Descriptive statistics were presented as frequencies and continuous variables were presented as median. Survival analysis was performed using Kaplan Meier curves.Results. We performed 51 minimally invasive esophagectomies. Perioperative morbidity was in 16 (31.37%) patients. There were 3 (5.88%) anastomotic leaks. We encountered 1 respiratory complication. Reexploration was required in 3 (5.88%) patients. Median operative time was 375 minutes. Median hospital stay was 10 days. The most frequent long-term morbidity was anastomotic narrowing observed in 5 (9.88%) patients. There were no perioperative mortalities. Our mean overall survival was 37.66 months (95% confidence interval 33.75 to 41.56 months). Mean disease-free survival was 24.43 months (95% CI 21.26 to 27.60 months).Conclusion. Minimally invasive esophagectomy, when performed in the learning phase, has acceptable morbidity and mortality.

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Minimally Invasive Esophagectomy

Cardiac Anesthesia: A Problem-Based Learning Approach ◽

10.1093/med/9780190884512.003.0031 ◽

2019 ◽

pp. 308-318

Author(s):

Brandon Merling ◽

Frank Dupont

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Minimally Invasive Esophagectomy ◽

Anesthetic Management ◽

Pulmonary Complications ◽

Morbidity And Mortality ◽

High Morbidity ◽

Perioperative Morbidity ◽

Invasive Esophagectomy ◽

Common Causes

Esophageal cancer is the eighth most common malignancy worldwide, producing a high morbidity and mortality rate around the globe. Minimally invasive esophagectomy (MIE) is most commonly performed on patients with this devastating disease. Esophagectomy is a high-risk procedure, and perioperative mortality remains around 5%–8%. Because esophageal cancer is associated with chronic alcohol and tobacco use, patients have serious comorbid conditions that affect anesthetic management and perioperative care. Among them, pulmonary complications and anastomotic failure remain the most common causes of perioperative morbidity and mortality. The anesthesiologist managing a patient during MIE must be able to reduce the effect of the patient’s multiple comorbidities intraoperatively while mitigating the factors that lead to adverse postoperative outcomes.

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Outcomes of minimally invasive versus open esophagectomy for esophageal cancer: A single-center case-control study.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.4_suppl.171 ◽

2016 ◽

Vol 34 (4_suppl) ◽

pp. 171-171

Author(s):

Hugo Miguel Teixeira Ferraz Dos Santos Sousa ◽

Márcio Mesquita ◽

Marisa Aral ◽

José Costa-Maia

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Postoperative Morbidity ◽

Case Control Study ◽

Case Control ◽

Morbidity And Mortality ◽

Initial Population ◽

Invasive Approach ◽

Open Esophagectomy ◽

Control Study

171 Background: Esophagectomy is a major surgery associated with significant morbidity and mortality. There is growing evidence in literature that the minimally invasive approach in esophagectomy (MIE) may decrease morbidity. The aim of this study was the comparative analysis of the outcomes between MIE and open esophagectomy (OE) for esophageal cancer. Methods: Analysis (case-control study) of a prospective database with esophageal cancer cases submitted to curative intent surgery, between May 2006 and October 2014, in an Upper GI Surgery Unit. For this analysis, cases of non-resectional surgery were excluded. Results: From the initial population (n = 79), 65 cases (Group A: 24 MIE - 13 totally MIE and 11 hybrid MIE; Group B: 41 OE, including 5 cases of conversion from MIE) were included. Both groups were matched for gender, age, comorbidities, BMI, tumor location and histology, staging (cT and cN), neoadjuvant therapy and type of surgery. The presence of postoperative morbidity was 37,5% in MIE vs 61% in OE (p = 0,058), with a rate of respiratory complications of 16,7% and 22%, respectively (p = ns). Statistically significant differences were seen in Clavien classification of postoperative morbidity (p = 0,018) and in postoperative mortality (MIE 0% vs OE 22%, p = 0,021). Conclusions: The results of this case-control study provide further evidence for the feasibility and possible improvements in the postoperative morbidity and mortality of MIE, when performed in differentiated centers.

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P54 INCIDENCE AND OUTCOME OF HIATAL HERNIA AFTER OESOPHAGECTOMY: COMPARISON OF TRADITIONAL OPEN AND MINIMALLY INVASIVE APPROACH

Diseases of the Esophagus ◽

10.1093/dote/doz092.54 ◽

2019 ◽

Vol 32 (Supplement_2) ◽

Author(s):

Sanberg Ljungdalh Jonas ◽

Markus Stilling Nicolaj ◽

Patrick Ainsworth Alan ◽

Hareskov Larsen Michael

Keyword(s):

Minimally Invasive ◽

Hiatal Hernia ◽

Malignant Disease ◽

University Hospital ◽

Morbidity Rate ◽

High Morbidity ◽

Electronic Patient Records ◽

Invasive Approach ◽

High Morbidity Rate

Abstract Aim The primary aim of this retrospective study is to evaluate the incidence of symptomatic and asymptomatic hiatal hernia (HH) in patients who have undergone intended curative open or minimally invasive oesophagectomy (MIO) for cancer of the oesophagus in a high-volume surgical centre. The secondary aim is to describe the treatment and outcome after HH treatment. Background & Methods MIO for the treatment of oesophageal cancer has emerged as an alternative to traditional open oesophagectomy without compromising disease free or overall survival1. HH of abdominal viscera other than the gastric conduit is an infrequent but potentially life-threatening complication following oesophagectomy. HH may present with grievous complications, such as severe respiratory failure, intestinal ischemia with perforation, bowel obstruction, and strangulation leading to emergency surgery2,3. Surgical repair of these HHs is associated with a high morbidity rate and in the emergent setting even a high mortality4. In meta-analysis, the pooled incidence of symptomatic HH after MIO was 4.5 %, compared to a pooled incidence of 1.0 % after open oesophagectomy5. However, studies on the subject, often do not describe whether patients are asymptomatic or simply have not been examined for the existence of HH. The actual HH incidence may therefore be underestimated and may be more sufficiently reported when including patient material with comprehensive follow-up. This retrospective cohort study includes all patients (n≈455) who have undergone curative intended resection for malignant disease in the oesophagus at The Department of Surgery, Odense University Hospital, from 1th January 2012 – 31th December 2018. Patient demography, perioperative data including surgical approach and follow-up, including occurrence and treatment of hiatal hernia, mortality and recurrence of malignant disease will be extracted from complete electronic patient records. Follow-up ranges from 6-84 months. Primary outcome is occurrence of hiatal hernia after oesophagectomy determined by CT-scan or during surgery. Results As of abstract deadline for ESDE 2019, we have only just received permission for the study from The Danish Patient Safety Authority and can unfortunately not present our results yet. However, we expect that results are ready for presentation at ESDE 2019 and hope for your understanding.

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Intraoperative High-Resolution Anoscopy: A Minimally Invasive Approach in the Treatment of Patients with Bowen's Disease and Results in a Private Practice Setting

The American Surgeon ◽

10.1177/000313480707301219 ◽

2007 ◽

Vol 73 (12) ◽

pp. 1279-1283 ◽

Cited By ~ 1

Author(s):

Alice P. Chung ◽

David B. Rosenfeld

Keyword(s):

High Resolution ◽

Minimally Invasive ◽

Pap Smear ◽

Community Setting ◽

Intraepithelial Neoplasia ◽

Patient Characteristics ◽

Hiv Positive ◽

High Morbidity ◽

Invasive Approach ◽

Hiv Negative

Anal intraepithelial neoplasia III (AIN III) is a risk factor for anal cancer with poor curative results and high morbidity. High-resolution anoscopy (HRA) is a minimally invasive means of identifying and treating AIN III early. We retrospectively reviewed HRA in the treatment of AIN III in a community setting. From January 2002 through November 2005, 76 patients with AIN III diagnosed by anal Pap smear, colposcopy, or biopsy underwent HRA for diagnosis and treatment. Twenty-one patients with AIN III on initial HRA underwent follow-up HRA for reassessment and treatment at 6 months. Recurrence/persistence of disease was recorded and compared with patient characteristics. Of 21 patients with repeat HRA, four were HIV-negative and 17 were HIV-positive. Twelve of 21 (57%) had intraanal recurrence/persistence; nine of 21 (43%) had no AIN III. Eleven (92%) with recurrence were HIV-positive; one (8%) was HIV-negative. Three (75%) HIV-negative patients had no recurrence/persistence; one of four (25%) had recurrence; and 11 of 17 (65%) HIV-positive patients had persistence of disease. HRA is an alternative tool to treat AIN III and can be performed in a community setting yielding results comparable to the university setting. As the prevalence of AIN III increases, it will be more important for community surgeons to treat AIN III with HRA.

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Emergent Minimally Invasive Esophagogastrectomy

Case Reports in Surgery ◽

10.1155/2017/4308628 ◽

2017 ◽

Vol 2017 ◽

pp. 1-3

Author(s):

Thomas Fabian ◽

Dorothy Chiaravalle ◽

Jeremiah Martin

Keyword(s):

Minimally Invasive ◽

Esophageal Perforation ◽

Minimally Invasive Esophagectomy ◽

Definitive Treatment ◽

High Morbidity ◽

Invasive Approach ◽

Invasive Esophagectomy ◽

Extended Care ◽

Surgical Evaluation ◽

Iatrogenic Esophageal Perforation

Introduction. Esophageal perforation in the setting of a malignancy carries a high morbidity and mortality. We describe our management of such a patient using minimally invasive approach.Methods. An 83-year-old female presented with an iatrogenic esophageal perforation during the workup of dysphagia. She was referred for surgical evaluation immediately after the event which occurred in the endoscopy suite. Minimally invasive esophagectomy was chosen to provide definitive treatment for both her malignancy and esophageal perforation.Results. Following an uncomplicated operative course, she was eventually discharged to extended care for rehabilitation and remains alive four years after her resection.Conclusion. Although traditional open techniques are the accepted gold standard of treatment for esophageal perforation, minimally invasive esophagectomy plays an important role in experienced hands and may be offered to such patients.

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