Time to endoscopic vacuum therapy-lessons learned after > 150 robotic-assisted minimally invasive esophagectomies (RAMIE) at a German high-volume center.

OBJECTIVE OF THE STUDY: In esophageal surgery, anastomotic leak (AL) remains one of the most severe and critical adverse events after oncological esophagectomy. Endoscopic vacuum therapy (EVT) can be used to treat AL; however, in the current literature, treatment outcomes and reports on how to use this novel technique are scarce. The aim of this study was to evaluate the outcomes of patients with an AL after IL RAMIE and to determine whether using EVT as an treatment option is safe and feasible. MATERIAL AND METHODS: This study includes all patients who developed an Esophagectomy Complications Consensus Group (ECCG) type II AL after IL RAMIE at our center between April 2017 and December 2021. The analysis focuses on time to EVT, duration of EVT, and follow up treatments for these patients. RESULTS: A total of 157 patients underwent an IL RAMIE at our hospital. 21 patients of these (13.4%) developed an ECCG type II AL. One patient died of unrelated Covid-19 pneumonia and was excluded from the study cohort. The mean duration of EVT was 12 days (range 4-28 days), with a mean of two sponge changes (range 0-5 changes). AL was diagnosed at a mean of 8 days post-surgery (range 2-16 days). Closure of the AL with EVT was successful in 15 out of 20 patients (75%). Placement of a SEMS (Self-expandlable metallic stent) after EVT was performed in four patients due to persisting AL. Overall success rate of anastomotic sealing independently of the treatment modality was achieved in 19 out of 20 Patients (95%). No severe EVT-related adverse events occurred. CONCLUSION: This study shows that EVT can be a safe and effective endoscopic treatment option for ECCG type II AL.

[ICG lymph node mapping in cancer surgery of the upper gastrointestinal tract]. / ICG-Lymphknoten-Mapping in der Tumorchirurgie des oberen Gastrointestinaltrakts.

The importance of the assessment of the N­status in gastric carcinoma, tumors of the gastroesophageal junction and esophageal cancer is undisputed; however, there is currently no internationally validated method for lymph node mapping in esophageal and gastric cancer. Near-infrared fluorescence imaging (NIR) is an innovative technique from the field of vibrational spectroscopy, which in combination with the fluorescent dye indocyanine green (ICG) enables intraoperative real-time visualization of anatomical structures. The ICG currently has four fields of application in oncological surgery: intraoperative real-time angiography for visualization of perfusion, lymphography for visualization of lymphatic vessels, visualization of solid tumors, and (sentinel) lymph node mapping. For imaging of the lymph drainage area and therefore the consecutive lymph nodes, peritumoral injection of ICG must be performed. Several studies have demonstrated the feasibility of peritumoral injection of ICG administered 15 min to 3 days preoperatively with subsequent intraoperative visualization of the lymph nodes. So far prospective randomized studies on the validation of the method are still lacking. In contrast, the use of ICG for lymph node mapping and visualization of sentinel lymph nodes in gastric cancer has been performed in large cohorts as well as in prospective randomized settings. Up to now, multicenter studies for ICG-guided lymph node mapping during oncological surgery of the upper gastrointestinal tract are lacking. Artificial intelligence methods can help to evaluate these techniques in an automated manner in the future as well as to support intraoperative decision making and therefore to improve the quality of oncological surgery.

Fast-track rescue weight reduction therapy to achieve rapid technical operability for emergency bariatric surgery in patients with life-threatening inoperable severe obesity - A proof of concept study.

BACKGROUND AND AIMS: Severe obesity (BMI ≥60 kg/m2) in multimorbid patients can be acutely life-threatening. While emergency weight-loss surgery is urgently needed to preserve life, most patients are in an inoperable state. Pre-surgical bridging therapy is required to achieve technical operability through weight reduction. Standard bridging using an intragastric balloon (IB) can achieve operability in 6 months but is unsuitable for some patients in a critical condition. A non-invasive fast-track rescue therapy to achieve very rapid operability is urgently needed. We investigated whether a rescue weight reduction therapy (RWR) consisting of liraglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, a leucine-rich amino acid infusion and a hypocaloric diet, can accelerate readiness for emergency surgery in patients with acutely life-threatening severe obesity. METHODS: In this proof-of-concept study, prospective data from patients treated with RWR (intervention group 1, n = 26) were mathematically matched with retrospective biometric data of 26 patients with severe obesity (historic control group 2) who underwent standard 6-month bridging with IB. A rating scale was developed to identify patients needing urgent fast-track bridging. RESULTS: Rapid weight loss was observed in all patients on the RWR therapy. All achieved operability after a mean RWR bridging duration of 20.7 ± 6.9 days. Baseline weight was 236.3 ± 35.8 kg in group 1 compared with 230.1 ± 32.7 kg in group 2. Mean body weight loss during RWR was 27.5 ± 14.1 kg, compared with 20.9 ± 10.5 kg in group 2 (P = 0.0629). CONCLUSIONS: Pre-operative bridging using liraglutide in combination with a leucine-rich amino acid infusion and hypocaloric diet was effective in all cases of acutely life-threatening severe obesity, achieving technical operability within only ca. 2-4 weeks. This therapy has potential as a life-saving rescue therapy for multimorbid patients with severe obesity who were previously untreatable. This study is registered at ClinicalTrials.gov (identifier: NCT02616003).

Endoscopic Management of Clinically Severe Obesity: Primary and Secondary Therapeutic Procedures.

PURPOSE OF REVIEW: In the treatment of epidemic obesity and metabolic disorders, conservative approaches often fail to achieve the treatment goal in patients with very high BMI. To date, bariatric surgery accomplishes the most sustainable results in patients with morbid obesity. This leads to a treatment gap for lower and middle classes of obesity defined by BMI. Primary endoscopic procedures, which are less invasive than surgery, may be able to sufficiently fill this gap. Furthermore, secondary endoscopic procedures have developed into an essential addition regarding complication management of bariatric surgeries. The purpose of this review was to point out the latest developments in the field of bariatric endoscopy, including both primary and secondary procedures. RECENT FINDINGS: Innovative devices and their possible applications will be discussed. These include various endoscopic suturing techniques as well as newly developed implants for the upper gastrointestinal tract to counteract the obesity epidemic. The growing understanding of the pathophysiology of obesity and the role of the gastrointestinal tract allows for the development of more effective endoscopic procedures regarding obesity treatment.

Are We Missing Treatment Standards for Thromboprophylaxis of the Obese and Super-Obese Patient Population? A Prospective Systematic Cohort Study.

BACKGROUND: Venous thromboembolism (VTE) is the most frequent 30-day complication in patients with morbid obesity undergoing bariatric surgery. Therefore, there is a need for optimized low molecular weight heparin (LMWH) thromboprophylaxis dosing strategies in order to avoid VTE-associated morbidity and mortality in this patient population. OBJECTIVE: The primary goal was to evaluate if a pre-specified enoxaparin dosing regimen in patients undergoing bariatric surgery reaches anti-factor Xa (aFXa) levels in the defined target range (0.2-0.4 U/ml). Second, we aimed to identify biometric and laboratory parameters that might influence the aFXa value. METHODS: A prospective database of 236 patients with obesity who received thromboprophylaxis with enoxaparin was established. These patients were divided into two weight-adjusted groups (group 1 < 150 kg, group 2 ≥ 150 kg). Enoxaparin was administered twice daily; dosing was determined by weight (group 1, 2 × 40 mg/day; group 2, 2 × 60 mg/day). In both groups, the peak aFXa serum level was evaluated 3 days after initiating the thromboprophylaxis. RESULTS: In group 1 (body mass index (BMI) 42.94 ± 6.84 kg/m2, weight of 121.7 ± 17.49 kg), seventy-one of the included 124 patients (57.25%) reached the aFXa target range of 0.2 to 0.4 U/m. In group 2 (BMI 63.21 ± 10.05 kg/m2, weight of 191.66 ± 33.37 kg), 68 of 112 (60.71%) patients scored prophylactic aFXa range. Multiple regression of the biometric and laboratory parameters showed significance for weight, waist-to-hip ratio, glomerular filtration rate (GFR), creatinine, and HbA1c exclusively in group 1. There was no case of VTE within 3 months after surgery and no case of severe perioperative bleeding in those patients who underwent surgery. CONCLUSIONS: Measurement of the aFXa level helps to define the real prophylactic thromboprophylaxis status in patients with obesity, especially in those with a weight above 150 kg. In patients at risk, the measurement of aFXa should be considered in routine clinical practice.