PS01.204: ANASTOMOTIC LEAKS AFTER IVOR-LEWIS ESOPHAGECTOMY: INDOCYANINE GREEN NEAR-INFRERED ANGIOGRAPHY FOR GASTRIC CONDUIT BLOOD SUPPLY EVALUATION

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 107-107
Author(s):  
Paolo Parise ◽  
Andrea Cossu ◽  
Leonardo Garutti ◽  
Francesco Puccetti ◽  
Ugo Elmore ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Blood Supply ◽  
Near Infrared ◽  
Conflicts Of Interest ◽  
Gastric Conduit ◽  
Smoking History ◽  
Ivor Lewis ◽  
Ivor Lewis Esophagectomy ◽  
Group A ◽  
Group B

Abstract Background Indocyanine Green—Angiography (ICG-A) has been recently introduced for visceral perfusion evaluation. Aim of this study is to assess whether the intraoperative use of ICG-A can improve the evaluation of blood supply of the gastric conduit in Ivor-Lewis esophagectomy for cancer. Methods This is an interim analysis of a prospective interventional study ongoing at our Institution, on 160 Ivor-Lewis esophagectomy patients. After an intravenous bolus of ICG during the abdominal and thoracic stage, the gastric conduit perfusion was evaluated by means of a near infrared ICG-A and graded as ‘well’, ‘hypo-perfused’ or ‘ischemic’. If present, the ischemic or hypo-perfused area was resected. Demographic and clinical parameters and others, such as conduit perfusion speed, intra or post-operative hypotensive episodes have been analyzed. Results Currently 26 patients have been enrolled. An anastomotic leak of any grade was identified in 7 patients. Patients were divided in Group A (7 patients) who developed a leak and Group B (19 patients) who do not. No statistically significant differences were evidenced on demographic and preoperative clinical features, except for higher cigarette smoking history incidence in Group A. Those who developed a leak had an ‘hypo-perfused’ conduit at ICG-A in 71.4% and those who do not in only 15.8% (p 0.014). Median time from ICG injection to appearance of fluorescence at the basis of the gastric conduit was significantly longer in Group A than in Group B, 36 sec. (32–43.5) vs 28 sec. (20–39.8) (p 0.04) but median gastric conduit perfusion speed was similar. Patients in Group B had a higher median width of the conduit than Group A, 5cm (5.0–6.0) vs 4 (4.0–5.0) (p 0.032). Post-operative prolonged hypotensive episodes were seen more frequently in Group A than Group B (p 0.028). No differences were evidenced in terms of fluids infusions, blood loss, conduit length or intraoperative hypotensive episodes. Conclusion Preliminary results seem to show the usefulness of ICG-A in identifying patients at risk of leakage. Nevertheless no reduction of leakage incidence was induced by surgical strategy modification, probably because post-operative events may affect clinical course too. Definitive data have to be awaited. Disclosure All authors have declared no conflicts of interest.

VS03.05: VASCULAR ASSESSMENT OF THE GASTRIC TUBE IN MINIMALLY INVASIVE IVOR-LEWIS ESOPHAGECTOMY USING INDOCYANINE GREEN

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 48-48
Author(s):  
Dulce Nombre De Maria Momblan ◽  
Victor Turrado-Rodriguez ◽  
Alba Torroella ◽  
Ainitze Ibarzabal ◽  
Arlena Sofia Espinoza ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Indocyanine Green ◽  
Conflicts Of Interest ◽  
Vascular Supply ◽  
Gastric Conduit ◽  
Leak Rate ◽  
Esophagogastric Anastomosis ◽  
Ivor Lewis ◽  
Invasive Esophagectomy ◽  
Ivor Lewis Esophagectomy

Abstract Description One of the major concerns in esophagic surgery is the safety of the esophagogastric anastomosis. Anastomotic leak is associated with important morbidity and mortality. Leak rates have been reported in 4.7% of patients in the Ivor-Lewis procedure and 5.2% for cervical anastomosis. Leak rate has been associated with insufficient vascular supply to the gastric conduit. Indocyanine green (ICG) assessment of the vascularization may be a useful tool to avoid this dreadful complication. Methods A 50-year-old man with medical history of high blood pressure and right pneumothorax was diagnosed of adenocarcinoma of the lower esophagus cT3N3. Neoadjuvant chemo-radiotherapy following CROSS principles was administered. Six weeks after the end of neoadjuvant chemo-radiotherapy a minimally invasive Ivor-Lewis esophagectomy was performed. ICG helped the identification of the right gastroepiploic arcade and of the adequate vascular supply to the gastric conduit. During thoracoscopy, ICG was helpful to assess the vascular supply to the gastric conduit after pull-up into the chest and to check the vascularization of the esophagogastric anastomosis. Results Postoperative evolution was uneventful. Oral intake was resumed on the third postoperative day. Patient was discharged on the 8th postoperative day. Conclusions ICG assessment of the vascularization of the gastric conduit is feasible, safe and helpful in Ivor-Lewis minimally invasive esophagectomy and may decrease the leak rate. Disclosure All authors have declared no conflicts of interest.

P207 COMPARISON OF OPIOID vs OPIOID PLUS LOCAL ANESTHETIC EPIDURAL ADMINISTRATION IN IVOR LEWIS ESOPHAGECTOMY

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
E Papaioannou ◽  
P Doka ◽  
E Koziakas ◽  
A Analyti ◽  
D Danassi ◽  
...  
Keyword(s):  
Side Effects ◽  
Vital Signs ◽  
Opioid Analgesics ◽  
Epidural Administration ◽  
Ivor Lewis ◽  
Thoracic Epidural ◽  
Ivor Lewis Esophagectomy ◽  
Arterial Blood ◽  
Group A ◽  
Group B

Abstract Aim of the study was the comparison of single morphine vs morphine plus ropivacaine epidural administration for intraoperative pain management in Ivor Lewis esophagectomy. Background & Methods In a randomized prospective clinical trial, after informed consent, 20 patients were assigned to groups A (n=10): Morphine, and B (n=10=): Morphine and ropivacaine combination, according to the medication they were administered epidurally (ed), when submitted to Ivor Lewis esophagectomy. In both groups’ patients a thoracic epidural (T5-7) was inserted preoperative, and anesthetic protocol was the same, apart from opioid analgesics, that were titrated according to patients’ requirements. In group A morphine 1.5-3mg in 10-12ml normal saline volume, while in group B morphine 1.5-3mg plus ropivacaine 0.25% in a total volume of 10-12 ml were ed administered at least 20min before surgical incision. Opioids requirement, heart rate, arterial blood pressure, increments of muscle relaxant (rocuronium bromide) repetitive doses intraoperatively, and rescue analgesics need and side effects such as nausea, vomiting, drowsiness, respiratory depression and patients’distress in case of leg movement inability were recorded postoperatively. Results Patients’ demographics were similar in both groups. Intraoperatively, group A received significantly higher (p<0.001) fentanyl doses (4-6mcg/kg initially and 2hrs repetitive increments of 1-2mcg) vs group B (2-2.5mcg/kg initially, 4 (40%) patients didn’t require any supplementary dose and the rest 2-3mcg/kg in 1-2 increment doses until the end of operation). Vital signs were stable in both groups. Rocuronium requirement was significantly lower (p<0.001) in group B (apart from initial dose 1mg/kg, which was the same in both groups, group B demanded repetitive dose only before single to two-lumen endotracheal tube replacement, while group A required 0.2-0.3mg increment doses hourly). All patients were transferred awake postoperatively in ICU. None of any group patients demonstrated any side effects, but 3 (30%) group A patients required rescue analgesic (pain score > 4). Conclusion Morphine plus ropivacaine combination administered epidurally seems to provide lower pain scores and reduces the need for extra opioids intra- and postoperatively, and reduces muscle relaxants requirement during operation. Further studies are required to support these findings.

P206 EVALUATION OF PREEMPTIVE MULTIMODAL ANALGESIA IN IVOR LEWIS ESOPHAGECTOMY

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
E Papaioannou ◽  
P Doka ◽  
E Mavrommatis ◽  
D Danassi ◽  
E Kalogiannis ◽  
...  
Keyword(s):  
Side Effects ◽  
Prospective Trial ◽  
Vital Signs ◽  
Multimodal Analgesia ◽  
Anesthesia Induction ◽  
Surgical Incision ◽  
Ivor Lewis ◽  
Ivor Lewis Esophagectomy ◽  
Group A ◽  
Group B

Abstract Aim of the study is the evaluation of preemptive multimodal analgesia vs established technique of single epidural, in Ivor Lewis esophagectomy, perioperatively. Background & Methods In a randomized prospective trial, 25 patients were randomly assigned to two groups (A=12: preemptive multimodal analgesia, and B=13: epidural analgesia) after informed consent. Patients with coagulative disorders, and renal or hepatic impairment were excluded from study. In all patients a thoracic epidural (T5 – T7) was placed before anesthesia induction. Anesthetic protocol was the same, according body weight, in both groups, apart from analgesic drugs. Group A patients received morphine 1.5-3mg and ropivacaine 0.25% 10-12 ml epidurally (ed), and paracetamol 1gr, parecoxib 40mg, clonidine 150mcg, dexamethasone 8mg, lidocaine 1mg/kg, and magnesium sulfate 25% 10 ml iv, at least 20 min before surgical incision, while in group B same doses of ed morphine and ropivacaine were administered post-incision and iv paracetamol and parecoxib were administered 1hr before end of surgery. Surgical incision infiltration in both wounds with ropivacaine 0.375% 20ml was performed jn both groups’ patients. Intraoperative opioid doses were titrated accordingly. Analgesic needs intra- and postoperatively, as well as vital signs stability and side effects such as postoperative nausea or vomiting (PONV), dizziness, sleepiness, and respiratory suppression were recorded. Results Group A patients received significantly lower opioid doses intraoperatively (p<0.001), 2 (17%) of them did not need extra opioids at all, and in 8 (67%), operation was completed with only one low dose of fentanyl (2-3mcg/kg) before abdominal surgical incision. Group A patients had stable heart rate (HR) and blood pressure (BP) during whole operation, while 11 (84.6%) from group B (p<0.001) demonstrated HR and BP raising in certain surgical times. All both groups’ patients were transferred to ICU awake. 5 (38.46%) group B patients (p>0.005) required rescue amalgesic post-awakening. None of both groups’patients demonstrated any drugs’ side effects. Conclusion Preemptive multimodal analgesia seems to be more efficient, reducing needs for opioids intraoperatively, rescue analgesics postoperatively and providing better hemodynamic stability, than single epidural. Further studies are needed to support this conclusion.

RA01.08: LAPAROSCOPIC ROUX-EN-Y GASTROJEJUNOSTOMY FOR GASTRIC CONDUIT OUTLET OBSTRUCTION FOLLOWING ESOPHAGECTOMY FOR CANCER

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 19-19
Author(s):  
Daniele Bernardi ◽  
Matteo Porta ◽  
Emanuele Asti ◽  
Veronica Lazzari ◽  
Chiara Ceriani ◽  
...  
Keyword(s):  
Gastric Outlet Obstruction ◽  
Conflicts Of Interest ◽  
Outlet Obstruction ◽  
Gastric Conduit ◽  
Long Term Results ◽  
Ivor Lewis ◽  
Gastric Emptying Scintigraphy ◽  
Ivor Lewis Esophagectomy ◽  
Swallow Study

Abstract Description After Ivor Lewis esophagectomy, gastric outlet obstruction refractory to prokinetic therapy and/or endoscopic pyloric dilatation is a challenging clinical problem. Thoracoscopic implant of a gastric neurostimulator has been reported to be effective, but long-term results are lacking. The patient, a 57-year-old woman, underwent a Ivor Lewis esophagectomy for T1N0 adenocarcinoma in 2007. Postoperatively, the patient complained of persistent dysphagia, regurgitation, and 29-kg weight loss. A mechanical obstruction was ruled out by barium swallow study and upper gastrointestinal endoscopy. Several conservative attempts with prokinetic agents and endoscopic dilatations failed, and the patient was exclusively fed through jejunostomy until the thoracoscopic implant of a gastric neurostimulator in October 2015. The postoperative course was uneventful. At six-months follow-up, the patient was able to assume a soft diet and reported a weight gain of 3 kg, with a significant improvement of the total symptom score and gastric emptying scintigraphy. Nevertheless, this encouraging clinical benefit gradually disappeared after the first year of follow-up. At the beginning of 2017, the patient experienced persistent episodes of vomiting and returned to jejunostomy feeding. The video shows the technique of laparoscopic Roux-en-Y gastrojejunostomy. After adhesiolysis and transhiatal mobilization of the distal gastric conduit, a 50 cm long Roux-en-Y alimentary limb was fashioned and anastomosed to the antrum. Post-operative course was uneventful and a gastrographin swallow study showed a satisfactory emptying of the conduit. At the 3-month follow-up the patient was able to resume a soft oral diet. Laparoscopic Roux-en-Y gastrojejunostomy appears to be safe and effective in treating refractory gastric outlet obstruction following Ivor-Lewis esophagectomy. Disclosure All authors have declared no conflicts of interest.

PS01.227: THE IMPACT OF ELDERLY ON SURGICAL OUTCOMES AFTER IVOR-LEWIS ESOPHAGECTOMY: REVIEW OF A SINGLE INSTITUTION EXPERIENCE

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 114-114
Author(s):  
Andrea Cossu ◽  
Paolo Parise ◽  
Francesco Puccetti ◽  
Leonardo Garutti ◽  
Carlo Ferrari ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Elderly Patients ◽  
Conflicts Of Interest ◽  
High Morbidity ◽  
Consecutive Series ◽  
Ivor Lewis ◽  
High Morbidity Rate ◽  
Group A ◽  
Group B ◽  
The Impact

Abstract Background Esophagectomy is a surgical procedure burdened by a high morbidity rate. The effect of minimally invasive (MI) approach on elderly patients is still not clear. Aim of this study was to analyze the impact of MI approach on post-operative course according to the patient age. Methods A consecutive series of 692 patients underwent to elective oncological esophagectomy between 1997 and 2017. All data were entered into a prospective database. Patients submitted to 3-flield or trans-hiatal esophagectomy were excluded and only Ivor-Lewis open, hybrid or totally minimally invasive esophagectomy were evaluated. Patients were stratified according to age in 3 groups: Group A (≤ 50 years) 53 patients, Group B (> 51 and < 70 years) 269 and Group C (were ≥ 71 years) 126. Clinical and pathological factors influencing surgical outcome were evaluated. Complications were classified according to Clavien-Dindo (CD). Results As expected outcomes worsened with patients age (CD ≥ 3b: 7.5% group A, 13% group B and 21% group C. P = 0.001), mortality (0% group A, 3% group B and 5.5% group C. P = 0.035) and length of stay (10 days group A, 11 days group B and 13 days group C. P = 0.001). A statistically significant higher incidence of anastomotic leaks was observed among patients submitted to totally MI esophagectomy in group C vs A and B that were respectively 12,5%, 0% and 7%. Major respiratory complications were not statistically different among these 3 three sub-groups. Conclusion Old age has a significant impact on outcomes after esophagectomy. In this subset of patients a MI approach could also increase postoperative morbidity. Elderly patients should be carefully selected before to be submitted to MI esophagectomy. Disclosure All authors have declared no conflicts of interest.

469 ASSESSMENT OF PERFUSION OF GASTRIC CONDUIT AND PROXIMAL ESOPHAGEAL STUMP BY INDOCYANINE GREEN FLUORESCENCE IMAGING IN PATIENTS UNDERGOING ESOPHAGECTOMY

2021 ◽  
Vol 34 (Supplement_1) ◽  
Author(s):  
Subramanyeshwar Rao Thammineedi
Keyword(s):  
Indocyanine Green ◽  
Fluorescence Imaging ◽  
Visual Inspection ◽  
Near Infrared ◽  
Infrared Camera ◽  
Visual Assessment ◽  
Transhiatal Esophagectomy ◽  
Gastric Conduit ◽  
Indocyanine Green Fluorescence ◽  
Laparoscopic Assisted

Abstract   Post esophagectomy anastomotic leakage and stricture are crucial factors in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complications. This prospective study assesses the utility of intraoperative indocyanine green (ICG) fluorescence imaging to determine gastric conduit vascularity in patients undergoing esophagectomy. Methods Thirteen consecutive patients who were undergoing esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019, were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic assisted esophagectomy. Reconstruction was done by gastric pull up via posterior mediastinal route. Vascularity of gastric conduit was assessed by the near-infrared camera using ICG. Results On visual assessment of perfusion at the tip of gastric conduit, it was dusky in 11 patients, pink in two. Fuorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, needing revision. In one patient visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit’s tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 seconds (10 to 23 seconds). Conclusion Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is more objective and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. It could complement the visual inspection to decide the site of anastomosis.

PS02.069: CERVICAL GASTROPLASTY ANASTOMOSIS AFTER ESOPHAGECTOMY: INDOCYANINE GREEN FLUORESCENCE IMAGING EVALUATION AND TECHNICAL SURGICAL ASPECTS

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 140-140
Author(s):  
Flavio Takeda ◽  
Ulysses Ribeiro Jr ◽  
Rubens Sallum ◽  
Julio Mariano Rocha ◽  
Andre Duarte ◽  
...  
Keyword(s):  
Indocyanine Green ◽  
Fluorescence Imaging ◽  
Conflicts Of Interest ◽  
Visual Assessment ◽  
Gastric Conduit ◽  
Linear Stapler ◽  
Recurrent Nerve ◽  
Imaging Evaluation ◽  
Indocyanine Green Fluorescence ◽  
Surgical Aspects

Abstract Description One of the most frequent complication after esophagectomy is the anastomotic leakage, which is a determiming factor of morbidity and mortality after surgical treatment. The best location for the esophagogastric anastomosis (cervical or intra-thoracic) has been topic of discussion for many years, and surgical aspects as resected margins, recurrent nerve trauma and mainly the vascularization of the anastomosis. In this video we performed a cervical gastroplasty anastomosis (McKeown), side-to-side, stapled (linear stapler) with a thin gastric tube conduit, and after that we aimed to determine the feasibility and usefulness of indocyanine green (ICG) fluorescence imaging to evaluate the gastric conduit perfusion during an esophagectomy. After pulling up the gastric conduit trhought the mediastinum and after performing the cervical anastomosis, 5 mg of ICG was in jected as a bolus and visual assessment of the blood supply of the gastric conduit was seen. This patient was a 63 years old, male, with adenocarcinoma of esophago-gastric junction (Siewert II) underwent to neoadjuvant quimiotherapy (FOLFOX regimen) and submitted after 3 cycles to esophagectomy (thoracoscopy and laparoscopy). No fistula was found in post operative follow-up, and either complications. Disclosure All authors have declared no conflicts of interest.

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