Background. Postoperative pneumonia is a common complication after esophagectomy and is associated with a high mortality rate. Although many randomized, controlled trials have been conducted on the prevention of postoperative pneumonia, little attention has been paid to the efficacy of antimicrobial prophylaxis. The purpose of this study was to investigate the impact of antimicrobial prophylaxis on the prevention of postoperative pneumonia. Methods. Data of patients with esophageal cancer who underwent thoracoscopic esophagectomy between 2016 and 2020 were collected. Early-period patients received cefazolin (CEZ) per protocol as antimicrobial prophylaxis (n = 250), and later-period patients received ampicillin/sulbactam (ABPC/SBT) (n = 106) because of the unavailability of CEZ in Japan. The incidence of pneumonia was compared between treatments in this quasiexperimental setting. Pneumonia detected by routine computed tomography (CT) on postoperative Days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later was defined as late-onset pneumonia.Results. The incidence of early-onset pneumonia was significantly lower (3.8% vs. 13.6%, P = 0.006), and the median length of postoperative hospital stay was significantly shorter (17 vs. 20 days, P \ 0.001) in the ABPC/ SBT group than in the CEZ group. The incidence of lateonset pneumonia was similar between groups (9.4% vs. 10.0%, P = 0.870). The incidence of Clostridioides difficile infections and the incidence of multidrug-resistant organisms were similar between groups. Multivariate analyses consistently showed the superiority of ABPC/SBT to CEZ in preventing early-onset pneumonia (odds ratio: 0.20, P = 0.006). Conclusions. ABPC/SBT after esophagectomy was better at preventing early-onset pneumonia compared with CEZ and was feasible regarding the development of antimicrobial resistance.
Background/Aims: This study investigated the impact of Braun anastomosis on the incidence of delayed gastric emptying (DGE) and on the intragastric bile reflux after pancreatoduodenectomy with Child reconstruction. Methods: Sixty-eight patients who underwent subtotal stomach-preserving pancreatoduodenectomy were included. Patients were randomly assigned to a group with or without Braun anastomosis intraoperatively. Twenty-four-hour intragastric bilirubin monitoring was performed to investigate the extent of intragastric bile reflux after surgery. The incidence of DGE and other complications was also monitored. Results: There were no differences between the non-Braun and Braun groups in terms of patient characteristics. The incidence rate of DGE was 29.4% (n = 10/34) in the non-Braun group and 20.6% (n = 7/34) in the Braun group (p = 0.401). Forty-six of the 68 patients consented to intragastric bilirubin monitoring. The fraction time of intragastric bilirubin reflux was comparable between the 2 groups. Although the fraction time of intragastric bilirubin reflux had no impact on the incidence of DGE, the incidence of pancreatic fistula was significantly higher in patients with DGE than those without DGE (47.1 vs. 21.6%, p = 0.043). Conclusion: The addition of Braun anastomosis after pancreatoduodenectomy did not effectively reduce the intragastric bile reflux and had minor impact in reducing the incidence of DGE.
Highlights Significance of resection in patients with pancreatic metastasis from lung cancer. A long-term survivor of pancreatic metastasis from lung cancer after pancreatectomy. Consider resection if the disease is localized and the patient’s condition is good.
Effects of changes in body composition during neoadjuvant chemotherapy (NAC) on perioperative complications and prognosis are unknown in patients with esophageal squamous cell carcinoma (ESCC). A total of 175 patients who underwent surgery for ESCC in our hospital between 2016 and 2019 were examined. The psoas muscle index (PMI) was calculated from the total psoas muscle area, and the visceral fat mass (VFM) at the umbilical level was measured. We defined body composition change (BCC) group as those with increased VFM of ≥ 3% and decreased PMI of ≥ 3% during NAC. Sarcopenia (S) was defined as PMI < 5.89 (male) and <4.06 (female). Nutritional assessment using the Subjective Global Assessment tool was performed upon admission. The percentages of BCC group, pre-NAC S, and post-NAC S was 32.5%, 79.4%, and 80.0%, respectively. BCC group had significantly more postoperative complications (p < 0.01) and longer hospital stays (p = 0.03) than groups pre-NAC S and post-NAC S. Overall survival (OS) analysis using the Cox hazard model showed that stage III (p < 0.01) and post-NAC S (p = 0.03) were poor prognostic factors. Changes in body composition during NAC affected perioperative complications and prognosis of patients with ESCC.
BackgroundTracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.Case presentationA 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.ConclusionA TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.
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