PS02.165: THE INCIDENCE OF CHYLOTHORAX AFTER ESOPHAGECTOMY CAN BE REDUCED BY LOW FAT TUBE FEEDING

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 168-168
Author(s):  
Bernadette Schurink ◽  
Elena Mazza ◽  
Jelle Ruurda ◽  
Tom Roeling ◽  
Elles Steenhagen ◽  
...  
Keyword(s):  
Gastric Tube ◽  
Lymphatic System ◽  
Conflicts Of Interest ◽  
Multivariable Analysis ◽  
Tube Feeding ◽  
Standard Of Care ◽  
Early Enteral Nutrition ◽  
Lower Body ◽  
Low Fat ◽  
Formula Group

Abstract Background Chylothorax is a treacherous complication after esophagectomy associated with significant morbidity. Early enteral nutrition after surgery is important for recovery, but increases the pressure in the lymphatic system due to the absorption of triglycerids. To lower the incidence of chylothorax after esophagectomy, the use of low fat-containing tube feeding was evaluated as a standard of care following esophagectomy. Methods All consecutive patients who underwent an esophagectomy with gastric tube reconstruction and placement of jejunostomy at the UMC Utrecht between the 1st of January 2012 and the 31st of December 2017 were included. Tube feeding was started as standard of care on postoperative day 1 with a normal fat-containing formula in the period between 2012 and 2014 and with a low fat-containing formula between 2014 and 2017. The clinical diagnosis of chylothorax was confirmed by triglyceride levels > 1.24mmol/L in 27 patients (61.4%). Results Between 2012–2017 200 patients were included; 88(44.0%) received normal fat-containing tube feeding, 112(56.0%) low fat-containing tube feeding. Chylothorax was significantly less observed in the low fat formula group (n = 15, 13.4% versus n = 29, 33%, P = 0.001) No difference was seen in drain output, triglyceride levels in the pleura fluid, treatment strategy and hospital mortality. At multivariable analysis normal fat formula was associated with a 5.1 [2.1–12.1] odds for postoperative chylothorax. Other factors independently associated with chylothorax were transthoracic resection, anastomotic leakage, number of resected lymph nodes, and lower body mass index. Conclusion Administration of low fat-containing tube feed after esophagectomy lowers the incidence of chylothorax. Disclosure All authors have declared no conflicts of interest.

PS01.168: IS IT POSSIBLE TO PREVENT GASTRIC TUBE NECROSIS FOLLOWING ESOPHAGECTOMY?

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 97-97
Author(s):  
Katsunori Nishikawa ◽  
Yujiro Tanaka ◽  
Yuichiro Tanishima ◽  
Shunsuke Akimoto ◽  
Fumiaki Yano ◽  
...  
Keyword(s):  
Gastric Tube ◽  
Assessment Tool ◽  
Imaging System ◽  
Conflicts Of Interest ◽  
Tissue Perfusion ◽  
Early Postoperative Period ◽  
Partial Replacement ◽  
Full Thickness ◽  
Intraoperative Assessment ◽  
Vascular Insufficiency

Abstract Background Gastric tube necrosis (GN) following esophagectomy is a rare, but critical and life threatening complication. Unlike anastomotic leakage due to local ischemia, GN involves extensive full thickness ischemia resulting from vascular insufficiency. Most cases of GN need total or partial replacement of gastric tube. Although quantitative assessment of tissue perfusion during esophageal surgery contributed to reduce the incidence of postoperative anastomotic complications, GN remains a serious complication to be solved. Methods Data were collected retrospectively from 271 patients who underwent esophagectomy and gastric tube reconstruction at a single center between 2008 and 2018, in which cases of GN were identified. Gastric mobilization was mainly performed laparoscopically using a hand-assisted maneuver. The short gastric and left gastric arteries were divided, and the right gastric and gastroepiploic arteries were both preserved. The gastric tube 3.5 cm in width was created along the greater curvature. Intraoperative assessment of perfusion of the gastric tube was performed using our novel Thermal Imaging System (TIS) in all patients. Quantitative tissue perfusion scores defined as anastomotic viability index (AVI) were calculated at various points from the anastomosis. Results The inpatient mortality rate was 1.8% (n = 5). Anastomotic leak (AL) developed in 8.8% (n = 24) of the study group. The mean AVI score of cases with AL was 0.58, which was significantly lower than that without AL (0.71, P < 0.001). GN occurred in two patients (0.7%). The AVI score of the both GN cases were relatively high at 0.74 and 0.82. In one of the cases, circumferential full thickness ischemia 10 cm in length from the esophagogastric anastomosis was revealed by contrast CT scans and endoscopy, which was later identified to be due to severe vascular impairment. Conclusion TIS can be used as a reliable intraoperative assessment tool for perfusion of the gastric tube. We assume that most AL would be caused by delayed anastomotic healing due to poor vascularization of the gastric tube. On the other hand, obvious difference in AVI scores between AL and GN may indicate the involvement of different etiology. Given that development of GN seemed to be caused by acute failure in vascularization during the early postoperative period. Disclosure All authors have declared no conflicts of interest.

Patterns of Care for Stage IA Cervical Cancer: Use of Definitive Radiation Therapy Versus Hysterectomy

2018 ◽  
Vol 28 (4) ◽  
pp. 773-781 ◽  
Author(s):  
Jeffrey M. Ryckman ◽  
Chi Lin ◽  
Charles B. Simone ◽  
Vivek Verma
Keyword(s):  
Cervical Cancer ◽  
Radiation Therapy ◽  
Multivariable Analysis ◽  
Standard Of Care ◽  
National Cancer Data Base ◽  
Positive Margins ◽  
Cancer Data ◽  
Quality Cancer Care ◽  
Surgery Patient ◽  
Fertility Sparing

ObjectiveThe standard of care for clinical IA cervical cancer is surgery, but nonoperative cases may receive definitive radiation therapy (RT). Herein, we investigated national practice patterns associated with the administration of definitive RT as compared with hysterectomy-based surgery (HYS) as well as delivery of adjuvant RT after HYS.Methods/MaterialsThe National Cancer Data Base (NCDB) was queried for clinical IA primary cervical cancer cases (2004–2013) receiving definitive RT or HYS with or without adjuvant RT. Patients with unknown RT or surgery status were excluded, as were benign histologies and receipt of non-HYS such as fertility-sparing surgery. Patient, tumor, and treatment parameters were extracted. Univariable and multivariable logistic regression determined variables associated with receipt of RT and HYS.ResultsIn total, 3816 patients were analyzed (n = 3514 [92.1%] HYS alone, n = 100 [2.6%] RT alone, n = 202 [5.3%] combination). On multivariable analysis of HYS versus definitive RT, RT was more likely to be given to patients who were older (P < 0.001) and with Medicare (P = 0.011), Medicaid/other government insurance (P = 0.011), or uninsured/unknown status (P = 0.003). In addition, treatment with surgery alone was associated with patients in the 2 highest income quartiles (P = 0.013, P = 0.054). On multivariable analysis of patients receiving RT in addition to HYS, adjuvant RT was added most commonly for positive margins (P < 0.001) and increasing age (P < 0.001).ConclusionsThis is the largest analysis to date evaluating definitive RT for IA cervical cancer. Younger age and higher socioeconomic status are associated with receipt of HYS instead of definitive RT, and positive margins are most associated with the addition of adjuvant RT. Although these data must be further validated with better defined patient selection and do not imply causation, several socioeconomic findings discovered herein need to be addressed to ensure the highest quality cancer care to all patients.

Psychiatric ethics

2020 ◽  
pp. 329-346
Author(s):  
Rachel E. Zettl ◽  
John Z. Sadler
Keyword(s):  
Decision Making ◽  
Mentally Ill ◽  
Conflicts Of Interest ◽  
Standard Of Care ◽  
Critical Discussion ◽  
Background Information ◽  
Professional Relationships ◽  
Treatment Refusal ◽  
Physician Impairment ◽  
Decision Making Capacity

As psychiatric practice becomes more embedded in social, cultural, and financial networks, it is hardly surprising that the scrutiny of psychiatrists by organizations and institutions grows almost daily. This chapter focuses on the scrutiny of psychiatric ethics. Seven papers are reviewed, ranging from the mid-1950s up to 2009. Topics considered include: professional relationships between psychiatrists, physician impairment, confidentiality in the context of dangerousness, standard-of-care disputes, assessments of competency and decision-making capacity, the history and ethics of psychosurgery and neuromodulation, treatment refusal in chronically mentally ill patients, and conflicts of interest in clinical practice guideline authorship. Each paper is summarized with background information, methods, results, and a critical discussion of its significance.

PS01.174: AN EXAMINATION OF OUTCOMES AFTER ANTE-THORACIC ROUTE WITH RIGHT HEMICOLON RECONSTRUCTION AFTER ESOPHAGECTOMY.

2018 ◽  
Vol 31 (Supplement_1) ◽  
pp. 99-99
Author(s):  
Yuki Hirata ◽  
Hirofumi Kawakubo ◽  
Shuhei Mayanagi ◽  
Kazumasa Fukuda ◽  
Rieko Nakamura ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Gastric Tube ◽  
Conflicts Of Interest ◽  
Average Duration ◽  
Oral Intake ◽  
Recurrent Nerve ◽  
Nerve Paralysis ◽  
Recurrent Nerve Paralysis ◽  
Reconstruction Group ◽  
Group 1

Abstract Background In our institute, we usually use gastric tube for reconstruction organ after esophagectomy. When we can’t use gastric tube, we use right hemi-colon with ante-thoracic route. Previously, we reconstructed by 1-step after esophagectomy, but from 2012, we have done by 2-step for reduce postoperative complications. Methods We enrolled 15 esophageal cancer patients who underwent esophagectomy and right hemicolon reconstruction between April 2004 and December 2016. Results The average age of 15 patients is 67.3. The reasons of using right hemicolon are as follows; post gastrectomy 13, stomach double cancer 2. The reasons of gastrectomy are as follows; gastric cancer 8, duodenum cancer 1, gastric ulcer 4. The average duration from gastrectomy to esophagectomy is 12.5 year. We reconstructed by 1-step for 5 patients, and after 2012, we reconstructed by 2-step for 10 patients. Anastomotic leakages were found in 2 cases (40.0%) in 1-step reconstruction group, and 3 cases (20.0%) in 2-step reconstruction group. In 1-step reconstruction group, 1 case occurred multiple anastomotic leakages and DIC, and another 1 case was found necrosis of reconstructive colon. In 2-step reconstruction group, we found 1 case of major leakage and 1 case of recurrent nerve paralysis and 2 cases of postoperative pneumonia. However, there were no case of tracheotomy. The incidence of pneumonia did not differ between the two groups. And the term of postoperative oral intake tend to shorter in 2-step reconstruction group (P = 0.06). 2 severe postoperative complications (Clavian-Dindo V or IVa) cases were found in 1-step reconstruction group, on the other hand, 2 cases severe complications (CD IIIa) in 2-step reconstruction group. Conclusion In the case of using right hemicolon as a reconstructive organ, 2-step reconstruction approach is useful and superior from the viewpoints of postoperative complications. Disclosure All authors have declared no conflicts of interest.

Sign in / Sign up

Export Citation Format

Share Document