Acute bleeding obstruction pancreatitis after Roux-en-Y anastomosis in total gastrectomy: a single center experience

Anastomotic intraluminal bleeding is a well-known complication after total gastrectomy. Nevertheless, few data are published on acute bleeding obstruction pancreatitis (BOP) due to a bleeding from the jejunojejunostomy (JJ). In this paper we describe our experience. A total of 140 gastrectomies for EGJ cancer were performed in our Institute from January 2012 to January 2017. All reconstructions were performed with a Roux-en-Y anastomosis: a mechanical end-to-side esophago-jejunostomy and a mechanical end-to-side JJ. Three patients suffered from a bleeding at the JJ with a consequent BOP. We analyzed the time of diagnosis, the treatment and the outcomes. The three patients presented anemia at the laboratory findings on postoperative day (POD) 1. In patient I laboratory findings of acute pancreatitis were found in POD 2. CT scan was performed and showed signs of BOP. Endoscopic treatment was tried without success. Therefore, patient underwent surgery: JJ take down, bleeding control and anastomosis rebuild were performed. In spite of this the patient died of MOF in POD 4. Patient II had a persistent anemia treated with blood transfusions until POD 3, when laboratory tests showed increased lipase and bilirubin levels. Patient was successfully treated with endoscopy but several blood transfusions and a prolonged recovery were necessary. Patient III had laboratory findings of acute pancreatitis on POD 1. Immediate surgery was performed and patient was discharged on POD 9 without sequelae. BOP is a rare but deadly complication after Roux-en-Y anastomosis. An early diagnosis and an aggressive treatment seem to improve the outcome

Neoadjuvant Concurrent Chemoradiotherapy for Locally Advanced Esophageal Cancer in a Single High-Volume Center.

Background. Neoadjuvant chemoradiotherapy (CRT) is now considered the standard of care bymany centers in the treatment of both squamous cell carcinoma (SCC) and adenocarcinoma of the esophagus. This study evaluates the effectiveness of a neoadjuvant CRT protocol, as regards pathological complete response (pCR) rate and long-term survival.Methods. From 2003 to 2011, at Upper G.I. Surgery Division of Verona University, 155 consecutive patients with locally advanced esophageal cancers (90 SCC, 65 adenocarcinoma) were treated with a single protocol of neoadjuvant CRT (docetaxel, cisplatin, and 5-fluorouracil with 50.4 Gy of concurrent radiotherapy). Response to CRT was evaluated through percentage of pathological complete response (pCR or ypT0N0), overall (OS) and disease-related survival (DRS), and pattern of relapse.Results. One hundred thirty-one patients (84.5 %) underwent surgery. Radical resection (R0) was achieved in 123 patients (79.3 %), and pCR in 65 (41.9 %). Postoperative mortality was 0.7 % (one case). Five-year OS and DRS were respectively 43 and 49 % in the entire cohort, 52 and 59 % in R0 cases, and 72 and 81 % in pCR cases. Survival did not significantly differ between SCC and adenocarcinoma, except for pCR cases. Forty-nine patients suffered from relapse, which was mainly systemic in adenocarcinoma. Only three out of 26 pCR patients with previous adenocarcinoma developed relapse, always systemic.Conclusions. This study suggests that patients treated with the present protocol achieve good survival and high pCR rate. Further research is necessary to evaluate whether surgery on demand is feasible in selected patients, such as pCR patients with adenocarcinoma

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery

Rates of Anastomotic Complications and Their Management Following Esophagectomy: Results of the Oesophago-Gastric Anastomosis Audit (OGAA)

Objective: This study aimed to characterize rates and management of anastomotic leak (AL) and conduit necrosis (CN) after esophagectomy in an international cohort. Background: Outcomes in patients with anastomotic complications of esophagectomy are currently uncertain. Optimum strategies to manage AL/CN are unknown, and have not been assessed in an international cohort. Methods: This prospective multicenter cohort study included patients undergoing esophagectomy for esophageal cancer between April 2018 and December 2018 (with 90 days of follow-up). The primary outcomes were AL and CN, as defined by the Esophageal Complications Consensus Group. The secondary outcomes included 90-day mortality and successful AL/CN management, defined as patients being alive at 90 day postoperatively, and requiring no further AL/CN treatment. Results: This study included 2247 esophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% (n = 319) and CN rate was 2.7% (n = 60). The overall 90-day mortality rate for patients with AL was 11.3%, and increased significantly with severity of AL (Type 1: 3.2% vs. Type 2: 13.2% vs. Type 3: 24.7%, P < 0.001); a similar trend was observed for CN. Of the 329 patients with AL/CN, primary management was successful in 69.6% of cases. Subsequent rounds of management lead to an increase in the rate of successful treatment, with cumulative success rates of 85.4% and 88.1% after secondary and tertiary management, respectively. Conclusion: Patient outcomes worsen significantly with increasing AL and CN severity. Reintervention after failed primary anastomotic complication management can be successful, hence surgeons should not be deterred from trying alternative management strategies

ERAS Protocols for Gastrectomy

The interest in the Enhanced Recovery After Surgery (ERAS) protocols on gastrectomy for cancer is fairly new and mainly comes from Eastern series. Gastrectomy is a major abdominal operation and is still burdened by a 30% overall morbidity and a 4.5% mortality. The ERAS protocol aims to optimize the patient’s condition and reduce surgical and anesthesiologic stress in order to reduce complications and secondarily reduce hospitalization. Two recent meta-analyses evidenced a reduction in length of hospital stay, bowel recovery and cost reduction, while also reporting, however, a higher risk for readmission in patients treated with an ERAS protocol. In this chapter we discuss the importance of implementing a multidisciplinary team focusing on gastrectomy-specific items starting from preoptimization up to discharge. Preoptimization should focus on inspiratory muscle training and optimization of the nutritional status, especially for patients undergoing neoadjuvant treatment. A minimally invasive approach can reduce surgical stress and should be considered in accordance with the current oncological guidelines. Anesthesia should focus on a goal-directed fluid approach and on a defined multimodal analgesia plan. The goal of the postoperative management is an early mobilization and resumption of oral intake through the avoidance of unnecessary tubes. Discharge should be based on defined criteria and the patient’s network

Postoperative and Pathological Outcomes of CROSS and FLOT as Neoadjuvant Therapy for Esophageal and Junctional Adenocarcinoma: An International Cohort Study from the Oesophagogastric Anastomosis Audit (OGAA)

Objective: This study aimed to compare the postoperative and pathological outcomes between CROSS and FLOT in esophageal adenocarcinoma (EAC) patients from an international, multicenter cohort. Summary of background data: Ongoing debate exists around optimum approach to locally advanced esophageal adenocarcinoma (EAC), with proponents for perioperative chemotherapy, such as FLOT, or multimodal therapy, in particular the CROSS regimen. Methods: Patients undergoing CROSS (n = 350) and FLOT (n = 368), followed by curative esophagectomy for EAC were identified from the Oesophagogastric Anastomosis Audit (OGAA). Results: The 90-day mortality was higher after CROSS than FLOT (5% vs 1%, p = 0.005), even on adjusted analyses (odds ratio (OR): 3.97, CI95%: 1.34 - 13.67). Postoperative mortality in CROSS were related to higher pulmonary (74% vs 60%) and cardiac complications (42% vs 20%) compared to FLOT. CROSS was associated with higher pCR rates (18% vs 10%, p = 0.004) and margin-negative resections (93% vs 76%, p < 0.001) compared with FLOT. On adjusted analyses, CROSS was associated with higher pCR rates (OR: 2.05, CI95%: 1.26 - 3.34) and margin-negative resections (OR: 4.55, CI95%: 2.70 - 7.69) compared to FLOT. Conclusion: This study provides real-world data CROSS was associated with higher 90-day mortality than FLOT, related to cardio-pulmonary complications with CROSS. These warrant a further review into causes and mechanisms in selected patients, and at minimum suggest the need for strict radiation therapy quality assurance. Research into impact of higher pCR rates and R0 resections with CROSS compared to FLOT on long-term survival is needed

Utility of Abdominal Drain in Gastrectomy (ADiGe) Trial: study protocol for a multicenter non-inferiority randomized trial

Background: Prophylactic use of abdominal drain in gastrectomy has been questioned in the last 15 years, and a 2015 Cochrane meta-analysis on four RCTs concluded that there was no convincing evidence to the routine drain placement in gastrectomy. Nevertheless, the authors evidenced the moderate/low quality of the included studies and highlighted how 3 out of 4 came from Eastern countries. After 2015, only retrospective studies have been published, all with inconsistent results. Methods: ADiGe (Abdominal Drain in Gastrectomy) Trial is a multicenter prospective randomized non-inferiority trial with a parallel design. It aimed to verify whether avoiding routine use of abdominal drain is burdened with complications, particularly an increase in postoperative invasive procedures. Patients with gastric cancer, scheduled for subtotal or total gastrectomy with curative intent, are eligible for inclusion, irrespective of previous oncological treatment. The primary composite endpoint is reoperation or percutaneous drainage procedures within 30 postoperative days. The primary analysis will verify whether the incidence of the primary composite endpoint is higher in the experimental arm, avoiding routine drain placement, than control arm, undergoing prophylactic drain placement, in order to falsify or support the null hypothesis of inferiority. Secondary endpoints assessed for superiority are overall morbidity and mortality, Comprehensive Complications Index, incidence and time for diagnosis of anastomotic and duodenal leaks, length of hospital stay, and readmission rate. Assuming one-sided alpha of 5%, and cumulative incidence of the primary composite endpoint of 6.4% in the control arm and 4.2% in the experimental one, 364 patients allow to achieve 80% power to detect a non-inferiority margin difference between the arm proportions of 3.6%. Considering a 10% drop-out rate, 404 patients are needed. In order to have a balanced percentage between total and subtotal gastrectomy, recruitment will end at 202 patients for each type of gastrectomy. The surgeon and the patient are blinded until the end of the operation, while postoperative course is not blinded to the patient and caregivers. Discussion: ADiGe Trial could contribute to critically re-evaluate the role of prophylactic drain in gastrectomy, a still widely used procedure. Trial registration: Prospectively registered (last updated on 29 October 2020) at ClinicalTrials.gov with the identifier NCT04227951

Enhanced recovery protocol in esophagectomy, is it really worth it? A cost analysis related to team experience and protocol compliance

Application of enhanced recovery protocols (ERP) in esophageal surgery seems to lead an advantage in terms of length of hospital staying and outcomes, but only few data exist on its cost effectiveness. Previous literature analyzed pre- and post-ERP groups, finding a cost reduction with the introduction of the pathway. We aimed to study the influence on costs of accumulating experience and compliance in an ERP group. Seventy-one patients have been treated at our institution from January 2014 to June 2017 with our ERP for Ivor-Lewis esophagectomy. Direct costs were divided into subcategories and were analyzed as a function of calendar year and compliance. Factor affecting costs were searched. Univariable analysis highlighted a significant reduction in costs over time. Increase in compliance led to a progressive cost reduction for each ERP item completed (\u20ac14 852-\u20ac11 045). While age was not found to significantly influence the cost (p = 0.341), complications seemed to nullify the effect of experience: the median was \u20ac11 507 in uncomplicated patients, and increased to \u20ac13 791 in Clavien-Dindo 3-4 (CD3-4) patients. Compliance and CD3-4 remained significant also in multivariable analysis, accomplished by quantile regression, while year of surgery lost its significance.Our results evidence how accumulating experience in ERP led to a cost reduction over time, which was mainly mediated by an increase in compliance. Indeed, compliance was the main factor in reducing ERP cost while CD3-4 complications were the most important factor in cost increasing, nullifying the benefit of compliance

Laparoscopic transhiatal suture and gastric valve as a safe and feasible treatment for Boerhaave's syndrome: an Italian single center case series study

Boerhaave's syndrome (BS) is a rare life-threating condition with poor prognosis. Unfortunately, due to its very low incidence, no clear evidences or definitive guidelines are currently available: in detail, surgical strategy is still a matter of debate. Most of the case series reports thoracic approach as the most widely used; conversely, transhiatal abdominal management is just described in sporadic case reports. In our center, the laparoscopic approach has been adopted for years: in the present study, we aim to show his feasibility by reporting the outcomes of the largest clinical series available to date

Management, short and long-term outcomes in septegenerians and octegenerians undergoing gastrectomy for cancer

Aims: At present, the recommended treatment strategy in these pa- tients who present with gastric cancer is still controversial. We con- ducted a multicentre cohort study to assess the impact of age in gastric cancer management and outcomes. Methods: A retrospectively collected database demonstrated that 507 patients underwent gastrectomy for gastric adenocarcinoma from January 2004 to December 2014 at two high volume centres (London Royal Marsden Hospital and Verona University hospital). Patients were classified into three groups: Group A included all pa- tients aged 69 years old or less (n Z 266), Group B included 166 patients between 70e79 years (n Z 166), and Group C included pa- tients over 80 years and over (n Z 75). We analysed the data to eval- uate any differences between the groups in terms of patient characteristics, disease characteristics, treatment strategy, surgical outcome, overall survival and oncological outcome after gastrectomy. Results: Groups B and C were associated with a higher ASA and comorbidities (p < 0.001). They were less likely to receive peri-opera- tive chemotherapy (p Z 0.000). Group A presented with more advanced disease in terms of histological subtype (p Z 0.000) and increased metastatic burden (16.3%). In Groups B and C less aggres- sive surgery was performed. Group A had a higher rate of surgical complications (p Z 0.011). Group C demonstrated more medical com- plications (p Z 0.021). Group C had a higher postoperative mortality rate (8.1%, p Z 0.010). Using a Cox multivariable analysis, Group C (p Z 0.001) had a significantly less OS compared to A and B. Of note, DRS did not show significant differences in the three groups. Conclusions: Our data suggests that patients between the age of 70e79 years have a comparable OS risk as that of younger patients un- dergoing gastrectomy for gastric cancer. Patients over 80 years were found to have undergone less aggressive surgery and have more medical comorbidities. Their OS risk was higher. Elderly patients with gastric cancer should be rigorously assessed and medically optimised prior to undergoing surgical management in order to improve overall outcomes