Management of intrathoracic anastomotic leakage after esophagectomy by means of endoscopic stent insertion has gained wide acceptance as an alternative to surgical reintervention. Between January 2004 and March 2013 all patients who underwent esophagectomy at a German high-volume center for esophageal surgery were included in this retrospective study. The study comprises 356 patients. Anastomotic leakage occurred in 49 cases. There were no significant differences in age, American Society of Anesthesiologists (ASA) score, or frequency of neoadjuvant therapy between cases with and without leak. However, leak patients sustained significantly more often postoperative pneumonia, pleural empyema, sepsis, and acute renal failure. Moreover, leak victims had higher odds for fatal outcome (16 of 49 vs 33 of 307; odds ratio, 5.94; 95% confidence interval, 2.65 to 13.15; P < 0.0001). The leakage was amendable by endoscopic stenting in 29 cases, whereas rethoracotomy was mandatory in 20 patients. Between stent and rethoracotomy cases, we observed no significant differences in age, ASA score, neoadjuvant therapy, occurrence of pneumonia, pleural empyema, or tracheostomy rate. Rethoracotomy patients sustained more often sepsis (16 of 20 vs 14 of 29; P = 0.04) and acute renal failure (nine of 20 vs four of 29; P = 0.02) as expression of more severe septic disease. Nevertheless, there was no significant difference in mortality (seven of 29 vs nine of 20; P = 0.21). Furthermore, we observed three cases of stent-related aortic erosion with peracute death from exsanguination. Despite being the preferred treatment option, endoscopic stenting was only feasible in approximately 60 per cent of all intrathoracic leaks. The results are marred by the occurrence of deadly vascular erosion. Therefore, individualized strategies should be preferred to a general recommendation for endoscopic stenting.
INTRODUCTION Oesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation. METHODS This retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013. RESULTS A total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70-121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06-14.96, p=0.027) were more common among the emergency cases.Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13).Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23-16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57-24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52-1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14-16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients.Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77-13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5-46 months). The two-year-survival-rate was 38.5% (5/13). CONCLUSIONS Despite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.
Background Up to 22% of the patients, after laparoscopic Roux-en-Y gastric bypass (LRYGB) can complain about gastroesophageal reflux disease (GERD) symptoms, there is little evidence about the most effective treatment of this situation.Materials and Method This video shows a laparoscopic reintervention after a LRYGB in a 42-year-old woman presenting with untreatable GERD. GERD was treated with maximum doses of PPIs with no effect on the symptoms; the patient had a 24-h pH and impedance manometry that showed an acid and non-acid reflux, and for that reason, we decided to perform a laparoscopic fundoplication. First, very dense adhesions of the greater omentum and the stomach to the parietal peritoneum and the left lobe of the liver are dissected. The gastric remnant is dissected from the pouch, and as the adhesions are very hard, we use a linear stapler device to definitely separate remnant from the pouch, then, short gastric vessels are taken down, to allow mobilization to the medial side of the patient, being careful to preserve the dorsal gastric artery branch of the splenic artery. AToupet fundoplication is performed with the gastric remnant, and a crural repair is performed with Ethibond stitches reinforced with a polypropylene mesh. Results After 1 year from the surgery, the patient is asymptomatic, with a normal pH metry and barium swallow. Conclusions The laparoscopic fundoplication [1] after a LRYGB is one feasible surgical option intervention, but it must be performed with experienced hands and in a hospital with bariatric/esophagogastric surgery unit, in those patients with severe GERD after LRYGB and with no response to medical treatment.
Highlights Weight regain is a common problem within Bariatric Surgery and about 20% of patients who undergo Roux-en-Y gastric bypass patients may experience weight regain. Among the arsenal of alternatives to treat weight regain we have endoscopic therapies and surgical modifications of the primary technique, among others. This case represents the first report in which endoscopic therapy via transjejunal is used in conjunction with distalization of the biliopancreatic limb.
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