Comparable Esophagectomy Outcomes by Surgeon Specialty: A NSQIP Analysis

Background A few observational studies have found that outcomes after esophagectomies by thoracic surgeons are better than those by general surgeons. Methods Non-emergent esophagectomy cases were identified in the 2016-2017 American College of Surgeons NSQIP database. Associations between patient characteristics and outcomes by thoracic versus general surgeons were evaluated with univariate and multivariate logistic regression. Results Of 1,606 cases, 886 (55.2%) were performed by thoracic surgeons. Those patients differed from patients treated by general surgeons in race (other/unknown 19.3% vs 7.8%; P<.001) but not in other baseline characteristics (age, sex, BMI, and comorbidities). Thoracic surgeons performed an open approach more frequently (48.9% vs 30.8%, P<.001) and had operative times that were 30 minutes shorter (P<.001). General surgeons had lower rates of reoperation (11.8% vs 17.2%; P=.003) and were more likely to treat postoperative leak with interventional means (6.3% vs 3.4%, P=.01). Thoracic surgeons were more likely to treat postoperative leak with reoperation (5.9% vs 3.6%, P=.01). There were no other differences in univariate comparison of outcomes between the two groups, including leak, readmission, and death. General surgery specialty was associated with lower risk of reoperation. Our multivariable model also found no relationship between general surgeon and risk of any complication (odds ratio 1.10; 95% CI .86 to 1.42). Discussion In our large, national database study, we found that outcomes of esophagectomies by general surgeons were comparable with those by thoracic surgeons. General surgeons managed postoperative leaks differently than thoracic surgeons.

Is Staple LRE to Prevent Post-Operative Staple Line Leak and Haemorrhage after Laparoscopic Sleeve Gastrectomy

Background: Staple line haemorrhage and leak are considered to be common complications of laparoscopic sleeve gastrectomy. Some strongly recommend staple line reinforcement to deal with these complications while some consider it non beneficial. Aim: To analyze if staple line reinforcement is essential to prevent staple line haemorrhage and leaks. Methods: This retrospective study was conducted in Surgical unit 1 Fatima Memorial Hospital. A total of 100 patients were selected and divided into two groups of 50 each. Group 1 had staple line reinforced while group 2 had no reinforcement at all. All patients were observed for 24-48 hours for post-operative bleeding and leak. Results: Staple line leakage was found to be 4% in patients with staple line reinforcement whereas it was 6% in patients without staple line reinforcement with a p value of 0.284 which was not significant. Likewise, staple line bleeding in both groups were 2% and 6% with p value of 0.129 which was also insignificant. Conclusion: There is no added benefit to reinforce the staple line to prevent postoperative leak or bleeding but reinforcement only prolongs the operation time. Keywords: Laparoscopic sleeve gastrectomy, leak, post-operative bleeding, staple line reinforcement

Endoscopic management of anastomotic leak after esophageal or gastric resection for malignancy: a multicenter experience

Background: Most anastomotic leaks after surgical resection for esophageal or esophagogastric junction malignancies are treated endoscopically with esophageal stents. Internal drainage by double pigtail stents has been used for the endoscopic management of leaks following bariatric surgery, and recently introduced for anastomotic leaks after resections for malignancies. Our aim was to assess the overall efficacy of the endoscopic treatment for anastomotic leaks after esophageal or gastric resection for malignancies. Methods: We conducted a multicenter retrospective study in four digestive endoscopy tertiary referral centers in France. We included consecutive patients managed endoscopically for anastomotic leak following esophagectomy or gastrectomy for malignancies between January 2016 and December 2018. The primary outcome was the efficacy of the endoscopic management on leak closure. Results: Sixty-eight patients were included, among which 46 men and 22 women, with a mean ± SD age of 61 ± 11 years. Forty-four percent had an Ivor Lewis procedure, 16% a tri-incisional esophagectomy, and 40% a total gastrectomy. The median time between surgery and the diagnosis of leak was 9 (6–13) days. Endoscopic treatment was successful in 90% of the patients. The efficacy of internal drainage and esophageal stents was 95% and 77%, respectively ( p = 0.06). The mortality rate was 3%. The only predictive factor of successful endoscopic treatment was the initial use of internal drainage ( p = 0.002). Conclusion: Endoscopic management of early postoperative leak is successful in 90% of patients, preventing highly morbid surgical revisions. Internal endoscopic drainage should be considered as the first-line endoscopic treatment of anastomotic fistulas whenever technically feasible.

Duodenal Perforation: Outcomes after Surgical Management at a Tertiary Care Centre—A Retrospective Cross-Sectional Study

Introduction. Duodenal perforation is a common surgical emergency and carries mortality ranging from 4% to 30% reported in Western countries, but there is a paucity of reports from India. We aimed to determine the factors which influence the surgical outcomes in patients with duodenal perforation. Methods. We retrospectively analyzed prospectively collected data from January 2010 to December 2018. Results. A total of 55 patients were included in the study of which 69% (38) were males and 31% (17) were females (M : F = 4.5 : 2). The mean age was 52.3 years. The cause for duodenal perforation was duodenal ulcer (n = 25, 45.5%), followed by post-ERCP complications (n = 15, 27.3%), surgery (n = 11, 20%), and blunt trauma (n = 4, 7.2%) with perforations localized at D2 (n = 28, 51%) and at D1 (n = 27, 49%). Patients underwent primary repair with an additional diversion procedure (n = 28, 51%) and repair only in 18 (32.8%). There were 21 (38%) deaths. Patients with ERCP-associated duodenal perforation had longer hospital stay ( P ≤ 0.001 ), ICU stay ( P = 0.049 ), duration of drainage ( P ≤ 0.001 ), and higher leak rate ( P = 0.001 ) and re-exploration rate ( P = 0.037 ). A high mortality rate was seen in patients with preoperative organ failure (n = 18, 78% versus 9.4%, P = 0.001 ), postoperative leak (n = 7, 64% versus 32%, P = 0.05 ), and longer duration from onset of symptoms to surgery (≥4 days) ( P = 0.045 ). Conclusion. Perforation of the duodenum is associated with high morbidity and mortality regardless of its cause and is higher in those who have a longer interval to surgery, preoperative organ failure, and a postoperative leak.

A large anastomotic leakage after esophageal surgery treated with endoluminal vacuum-assisted closure: a case report

The treatment of anastomotic post-esophagectomy leaks and fistula is challenging. Endoluminal vacuum-assisted closure (EVAC) is an emerging technique that employs negative pressure wound therapy to treat anastomotic leaks endoscopically. Esosponge is specifically designed for esophageal EVAC therapy. We report on a 49-year-old woman who underwent a totally mini-invasive Ivor–Lewis esophagectomy and developed a giant postoperative leak with a complex pleural collection, but she was not fit for surgical re-intervention. The patient healed almost completely after 14 exchange sessions of Esosponge over 35 days.

Early detection of anastomotic leakage after hand-sewn colorectal anastomoses

Background: Colorectal anastomotic leakage is a serious complication leading to major postoperative morbidity and mortality. In the present study, author investigated the early detection of anastomotic leakage before its clinical presentation.Methods: This prospective study was including 80 consecutive patients with colorectal anastomoses using hand sewn technique. Patients follow-up was done to detect postoperative leak, study variables included hospital stay, wound infection, postoperative daily C-reactive protein, parameters of DULK-score and microbiological study of peritoneal fluid.Results: Clinically evident AL occurred in twelve patients (15%) and diagnosed postoperatively on median day 6. The median interval between appearance of the initial signs of clinical deterioration and the confirmation of AL was three days using DULK-score. C-reactive protein was significantly higher in patients with leakage with a cut-off value of 120 mg/l on 3rd postoperative day. Intraperitoneal bacterial colonization was significantly higher in patients with clinical evidence of AL (p value 0.012). Wound infection was significantly higher in anastomotic leakage group (p value 0.001). The hospital stay for the patients with anastomotic leakage was significantly longer than those without AL (p value 0.001).Conclusions: Routine application of DULK-score leads to diagnosis of AL three days earlier. C-reactive protein is a simple way to ensure a safe discharge from hospital after colorectal surgery.

Impact of Multilayer Vascularized Reconstruction after Skull Base Endoscopic Endonasal Approaches

Background The use of vascularized flap to reconstruct the skull base defects has dramatically changed the postoperative cerebrospinal fluid (CSF) leak rates allowing the expansion of endoscopic skull base procedures. At present, there is insufficient scientific evidence to permit identification of the optimal reconstruction technique after the endoscopic endonasal approach (EEA). Objective The main purpose of this article is to establish the risk factors for failure in the reconstruction after EEA and whether the use of a surgical reconstruction protocol can improve the surgical results. Material and Methods A retrospective cohort study was conducted in our institution, selecting patients that underwent EEA with intraoperative CSF leak. Two reconstructive protocols were defined based on different reconstructive techniques; both were vascularized but one monolayer and the other multilayer. A multivariate analysis was performed with outcome variable presentation of postoperative leak. Results One hundred one patients were included in the study. Patients reconstructed with protocol 1, with the diagnosis different to the pituitary adenoma and older than 45 years old had higher risk of presenting postoperative leak, and with statistically significant differences when we adjusted for the remaining variables. Conclusion The vascularized reconstructions after endoscopic endonasal skull base approaches have demonstrated to be able to obtain a low rate of postoperative CSF leak. The multilayer vascularized technique may provide a more evolved technique, even reducing the postoperative leak rates comparing with the monolayer vascularized one. The reconstructive protocol employed in each case, as well as age and histological diagnosis, is independent risk factor for presenting postoperative leak.

Successful treatment of large cavity esophageal disruptions with transluminal washout and endoscopic vacuum therapy: a report of two cases

Acute, high-grade esophageal perforation and postoperative leak after esophagogastrostomy are associated with high morbidity and mortality due to the development of mediastinitis and thoracic contamination. Endoscopic vacuum therapy has proven to be a feasible, safe therapy for management of esophageal wall defects, but with limited success. We describe a retrospective single-center analysis of two patients who underwent endoscopic vacuum therapy for significant esophageal disruptions with a median cross-sectional diameter of 10.7 cm. The technique involved the use of a standard upper video endoscope, nasogastric tube, and vacuum-assisted closure dressing kit, with endoscopic placement of a polyurethane sponge and nasogastric tube assembly into the mediastinal or thoracic cavity. Serial washout and debridement were performed prior to each sponge insertion. Data were collected on indication, size of the cavities, time to intervention, number of procedures, time to resolution, outcomes, and adverse events. Two patients underwent therapy with a mean age of 69.5. The median size of the collections via longest cross-sectional diameter was 10.7 cm. The average number of endoscopic vacuum therapy performed was six and average duration of therapy was 49 days. Complete resolution was achieved in both patients. One patient died 6 weeks later due to severe sepsis from aspiration pneumonia. Endoscopic washout and debridement followed by endoscopic vacuum therapy can be effective for large, even multiple, thoracic and mediastinal contaminations following esophageal perforation and gastroesopagheal anastomotic dehiscence and leaks in appropriately selected patients.