Risk factors of esophagojejunal anastomosis leakage after total gastrectomy

Background/AimEsophagojejunal anastomotic leakage (EJAL) after total gastrectomy is one of the most frequent life-threatening complications. The rate of EJAL after total gastrectomy is about 2–11% worlwide. The aim of this study was to identify the independent prognostic risk factors that may predict EJAL progression for patients after total gastrectomy.Materials and methodsThis retrospective study analyzed medical records of 175 patients. All these patients had underwent radical gastrectomy due to gastric cancer. The analyzed factors were: age, gender, American Society of Anaesthesiologists (ASA) funtional class, splenectomy, anastomosis technique, operative time, cancer stage, the number of dissected lymph nodes, the number of metastatic lymph nodes, resection margins. White blood cells count, C reactive protein (CRP) value, body temperature, drain output were calculated in the early postoperative period.ResultsThe average age of the patients was 63.2 ± 11.5 years. The EJAL rate was found to be 6.3%. The mortality rate among patients who developed EJAL was 9%. Postoperative laboratory and clinical findings significantly related to EJAL were the average temperature of 4 postoperative days >37.2 oC (p = 0.018), postoperative white blood cell count >16.7 x 109/l (p = 0.031), postoperative CRP level >160 mg/l (p = 0.001) and operative time >248 min (p = 0.009), although the binary logistic regression analysis revealed that none of these variables can be used as statisticaly significant predictors for EJAL.ConclusionsThe esofagojejunal anastomotic leakage rate of 6.3% was found among patients undergoing radical gastrectomy due to gastric carcinoma. Mortality rate in case of EJAL increases up to 9%. In our study, we didn’t find any independent predictors for EJAL.Key words: gastrectomy, esophagojejunal anastomosis leakage, risk factorsEzofagojejuninės jungties nesandarumo išsivystymo rizikos veiksniai po gastrektomijosĮvadasEzofagojejuninės jungties nesandarumas (EJJN) po gastrektomijos yra viena iš didžiausią grėsmę gyvybei keliančių komplikacijų. Mokslinių tyrimų duomenimis, EJJN dažnis svyruoja nuo 2 iki 11 %. Darbo tikslas – nustatyti rizikos veiksnius,darančius įtaką ezofagojejuninės jungties nesandarumo vystymuisi po gastrektomijos dėl skrandžio vėžio, ir prognozuoti jų įtaką EJJN išsivystymui.Ligoniai ir metodaiRetrospektyviai ištirta 175 pacientų medicininė dokumentacija. Tirtiems pacientams 2006–2010 metais atlikta gastrektomija dėl skrandžio vėžio. Analizuoti veiksniai: amžius, lytis, Amerikos anesteziologų asociacijos (ASA) funkcinė klasė, splenektomija, jungties susiuvimo būdas, operacijos trukmė, naviko stadija, operacijos metu pašalintų limfmazgių skaičius, limfmazgių su mestazėmis skaičius, rezekciniai kraštai. Ankstyvuoju pooperaciniu laikotarpiu vertinta leukocitų kiekis, C reaktyviojo baltymo (CRB) koncentracija kraujyje, pooperacinė temperatūra, sekrecija pro drenus.RezultataiTirtų pacientų amžiaus vidurkis 63,2±11,5 metų. Vyrų 50,6 %, moterų 49,4 %. EJJN dažnis 6,3 %. Turėjusių EJJN pacientų mirtingumas siekė 9 %. Nustatyti rizikos veiksniai, statistiškai patikimai susiję su EJJN išsivystymu. Jų reikšmės patikslintosrandant ROC kreivės lūžio taškus: 4 parų vidutinė temperatūra 37,15oC (p=0,018), maksimalios leukocitų (11,7x109/l, p=0,031) ir C reaktyviojo baltymo reikšmės (159,95 mg/l, p=0,001), operacijos trukmė 247,5 min (p=0,009). Tačiau binarinė logistinė regresija parodė, kad šie kriterijai negali būti statistiškai patikimi prognoziniai EJJN vystymosi veiksniai.IšvadosEzofagojejuninės jungties nesandarumo dažnis po gastrektomijos dėl skrandžio vėžio yra 6,3%, šią komplikaciją turėjusių pacientų mirštamumas – 9%. Savo tyrime neradome prognostiškai reikšmingų rizikos veiksnių.Reikšminiai žodžiai: gastrektomija, ezofagojejuninės jungties nesandarumas, rizikos veiksnia

Risk factors of esophagojejunal anastomosis leakage after total gastrectomy

Background/AimEsophagojejunal anastomotic leakage (EJAL) after total gastrectomy is one of the most frequent life-threatening complications. The rate of EJAL after total gastrectomy is about 2–11% worlwide. The aim of this study was to identify the independent prognostic risk factors that may predict EJAL progression for patients after total gastrectomy.Materials and methodsThis retrospective study analyzed medical records of 175 patients. All these patients had underwent radical gastrectomy due to gastric cancer. The analyzed factors were: age, gender, American Society of Anaesthesiologists (ASA) funtional class, splenectomy, anastomosis technique, operative time, cancer stage, the number of dissected lymph nodes, the number of metastatic lymph nodes, resection margins. White blood cells count, C reactive protein (CRP) value, body temperature, drain output were calculated in the early postoperative period.ResultsThe average age of the patients was 63.2 ± 11.5 years. The EJAL rate was found to be 6.3%. The mortality rate among patients who developed EJAL was 9%. Postoperative laboratory and clinical findings significantly related to EJAL were the average temperature of 4 postoperative days >37.2 oC (p = 0.018), postoperative white blood cell count >16.7 x 109/l (p = 0.031), postoperative CRP level >160 mg/l (p = 0.001) and operative time >248 min (p = 0.009), although the binary logistic regression analysis revealed that none of these variables can be used as statisticaly significant predictors for EJAL.ConclusionsThe esofagojejunal anastomotic leakage rate of 6.3% was found among patients undergoing radical gastrectomy due to gastric carcinoma. Mortality rate in case of EJAL increases up to 9%. In our study, we didn’t find any independent predictors for EJAL.Key words: gastrectomy, esophagojejunal anastomosis leakage, risk factorsEzofagojejuninės jungties nesandarumo išsivystymo rizikos veiksniai po gastrektomijosĮvadasEzofagojejuninės jungties nesandarumas (EJJN) po gastrektomijos yra viena iš didžiausią grėsmę gyvybei keliančių komplikacijų. Mokslinių tyrimų duomenimis, EJJN dažnis svyruoja nuo 2 iki 11 %. Darbo tikslas – nustatyti rizikos veiksnius,darančius įtaką ezofagojejuninės jungties nesandarumo vystymuisi po gastrektomijos dėl skrandžio vėžio, ir prognozuoti jų įtaką EJJN išsivystymui.Ligoniai ir metodaiRetrospektyviai ištirta 175 pacientų medicininė dokumentacija. Tirtiems pacientams 2006–2010 metais atlikta gastrektomija dėl skrandžio vėžio. Analizuoti veiksniai: amžius, lytis, Amerikos anesteziologų asociacijos (ASA) funkcinė klasė, splenektomija, jungties susiuvimo būdas, operacijos trukmė, naviko stadija, operacijos metu pašalintų limfmazgių skaičius, limfmazgių su mestazėmis skaičius, rezekciniai kraštai. Ankstyvuoju pooperaciniu laikotarpiu vertinta leukocitų kiekis, C reaktyviojo baltymo (CRB) koncentracija kraujyje, pooperacinė temperatūra, sekrecija pro drenus.RezultataiTirtų pacientų amžiaus vidurkis 63,2±11,5 metų. Vyrų 50,6 %, moterų 49,4 %. EJJN dažnis 6,3 %. Turėjusių EJJN pacientų mirtingumas siekė 9 %. Nustatyti rizikos veiksniai, statistiškai patikimai susiję su EJJN išsivystymu. Jų reikšmės patikslintosrandant ROC kreivės lūžio taškus: 4 parų vidutinė temperatūra 37,15oC (p=0,018), maksimalios leukocitų (11,7x109/l, p=0,031) ir C reaktyviojo baltymo reikšmės (159,95 mg/l, p=0,001), operacijos trukmė 247,5 min (p=0,009). Tačiau binarinė logistinė regresija parodė, kad šie kriterijai negali būti statistiškai patikimi prognoziniai EJJN vystymosi veiksniai.IšvadosEzofagojejuninės jungties nesandarumo dažnis po gastrektomijos dėl skrandžio vėžio yra 6,3%, šią komplikaciją turėjusių pacientų mirštamumas – 9%. Savo tyrime neradome prognostiškai reikšmingų rizikos veiksnių.Reikšminiai žodžiai: gastrektomija, ezofagojejuninės jungties nesandarumas, rizikos veiksnia

How useful is antireflux surgery in lung transplant patients with gastroesophageal reflux?

Background and objective: Respiratory function deteriorates over time after lung transplant. Reflux disease with pulmonary complications is a possible cause of this decline. This case series we aim to assess whether respiratory function improves after Nissen fundoplication in lung transplant patients and if surgery reduces gastroesophageal reflux disease (GERD) symptoms and use of proton pump inhibitors (PPIs). Materials and methods: A retrospective case series of lung transplant patients with reflux disease and Nissen fundoplication. Clinical symptoms, pH-metry data, use of PPIs were recorded before the procedure and up to 18 months postoperatively. The FEV1 values before and after Nissen fundoplication were recorded at 3 monthly intervals. Patients' satisfaction scores were recorded before operation and postoperatively. Results: A total of64lungtransplant patientswereselected.AfterNissenfundoplication,thepH studies were done on 26 patients. The mean overall acid exposure fraction was 1.03% (P < 0.05). FEV1 declined for 6 months postoperatively and then gradually improved. The comparison of FEV1 at 3 months preoperatively to 3 months postoperatively showed no significant difference (P = 0.067) as well as at 6 months. A significant improvement in clinical GERD symptoms was achieved after antireflux surgery; however, the patients remained receiving PPIs. Conclusions: NF has been established as a safe operation for lung transplant patients. Late Nissen fundoplication did not improve lung function significantly amongst lung transplanted patients, however patients with symptomatic GERD may have benefited from Nissen fundo- plication in terms of symptom relief. A multicenter randomized control trial is needed to assess the effect of early unselected reflux control on respiratory function and graft survival

Hernia hiatus esophagi and gastroesophageal reflux: possibilities and results of surgical treatment

In this article we analyze our experience of surgical treatment of hiatal hernia, complicated with gastroesophageal reflux. We operated 134 patients with hernia hiatus esophagi, complicated with gastroesophageal reflux, from 03.1998 till 10.2001. One hundred twenty-six Nissen and 8 Toupet laparoscopic gastrofundoplications were performed. We evaluated clinical signs of gastroesophageal reflux, performed endoscopy and esophageal biopsy with histological examination and stomach X-ray examination with barium meal before the operation. Esophagus and stomach X-ray examination with water contrast on the first day after operation were performed in order to evaluate the position and function of created wrap. We also analyzed intraoperative and postoperative complications. Long-term follow-up (12 months) was obtained by using a structured questionnaire. We evaluated heartburn, dysphagia, regurgitation and patient\u92s satisfaction of surgery. Results. Postoperative complications rate was 8.96%. Eighty-two percent of our patients completed our questionnaire. Ninety-one percent of patients had no heartburn signs, 95.5% any signs of regurgitation. Eightythree percent of our patients were satisfied with our performed laparoscopic gastrofundoplication. We performed 6 refundoplications, when gastroesophageal reflux clinical signs renewed shortly after operation. Conclusions. Laparoscopic gastrofundoplication is a safe and effective treatment of hernia hiatus esophagi, complicated with gastroesophageal reflux. Operation success was about 90% in our study. Recurrences are more frequent in elderly patients or those with long disease anamnesis. Refundoplications can be successfully done laparoscopicaly as well

Hiatal hernia recurrence after laparoscopic fundoplication

Objectives. To determine the influence of hiatal hernia size and the laparoscopic fundoplication technique on the rate of hernia recurrence. Patients and methods. The preoperative, operative, and postoperative observational data of 381 patients operated on at the Department of Surgery of Kaunas University of Medicine during the period of 1998–2004 for hiatal hernia complicated with gastroesophageal reflux were analyzed. The surgery technique (Nissen or Toupet operation) was chosen independently of the hernia size. The radiological investigation of the esophagus–stomach using barium contrast as well as esophagogastroduodenoscopy and biopsy was performed for all patients before the surgery. The subjective and objective assessment of the patients’ health status was investigated before and no less than 12 months after surgery. If the disease symptoms remained or new ones (i.e. pain behind the sternum, dysphagia, etc.) occurred after surgery, the hernia recurrence was suspected. The radiological investigation of the esophagus–stomach using barium contrast, as well as esophagogastroduodenoscopy and biopsy were performed at the consultative outpatient clinic. The hernia recurrence was confirmed after performing these two investigations. When analyzing the results, the patients were divided into two groups: Group 1 – patients with small hiatal hernia (grade 1 and 2 hernia according to radiological classification), Group 2 – patients with large hiatal hernia (grade 3 and 4 hernia according to radiological classification). Results. A total of 272 (71.4%) patients had small hiatal hernia, and 109 (28.6%) patients had large ones. Hernia recurrence was diagnosed in 7 (2.58%) patients in Group 1, while in Group 2, 11 (10.1%) patients had hernia recurrence (P&lt;0.05). Laparoscopic Nissen fundoplication was performed in 287 (75.4%) patients, after which 14 (4.98%) patients had hernia recurrence, while Toupet fundoplication was performed in 94 (24.6%) patients, after which 4 (4.3%) patients had hernia recurrence (P&gt;0.05). Conclusions. The recurrence rate of hiatal hernia after laparoscopic fundoplications is significantly higher in patients with large hernias (grade 3 and 4 according to radiological classification). The surgery technique (Nissen or Toupet fundoplication) was not a significant factor affecting the recurrence rate of hiatal hernia

The Influence of Operation Technique on Long-Term Results of Achalasia Treatment

Currently, the most effective therapy for achalasia is laparoscopic Heller myotomy with partial fundoplication. The aim of this study was to compare the long-term results between 2 different laparoscopic operation techniques in achalasia treatment. Material and Methods. This was a retrospective study, where 46 achalasia patients were examined: 23 patients underwent laparoscopic Heller myotomy followed by the full gastric fundus mobilization, total hiatal dissection, and posterior Toupet (270°) fundoplication (group 1); other 23 patients underwent laparoscopic Heller myotomy with limited surgical cardia region dissection, not dividing the short gastric vessels and performing anterior partial Dor fundoplication (group 2). Long-term findings included the evaluation of postoperative dysphagia according Vantrappen and Hellemans and intensity of heartburn according the standard grading system. Results. The patients in these 2 groups were similar in terms of age, weight, height, and postoperative hospital stay. The median follow-up was 66 months in the group 1 and 39 months in the group 2 (P&lt;0.05). Laparoscopic operation was effective in 82.6% of patients (excellent and good results) in the group 1; treatment was effective in 78.3% of patients in the group 2 (P&gt;0.05). Clinically significant heartburn was documented in 39% of patients in the group 1 and only in 13% of patients in the group 2 (P&lt;0.05). Conclusions. According our study results, both laparoscopic techniques were similarly effective (82.6% vs. 78.3%) in achalasia treatment. Postoperative heartburn was significantly more common (39% vs. 13%) after laparoscopic myotomy, followed by the full gastric fundus mobilization, total hiatal dissection, and posterior Toupet (270°) fundoplication

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