Efficiency and Complications of Esophageal Stenting in the Management of Postoperative Fistulas.

Esophageal anastomotic fistula (AF) is a frequent and severe complication of an esophagectomy due to esophageal or eso-gastric junction cancer, regardless of the selected surgical technique. AF is usually treated by endoscopic stent placement. Objectives: This study aims to examine the efficacy of stents in the treatment of AF, analyzing the healing period and the factors that contribute to its delay. Methods: We collected data from 55 patients who underwent stent implantation for AF, and analyzed multiple variables related to patient healing time and surgical technique with two primary endpoints: post-stenting hospital stay and the time of stent usage until fistula closure. The patients were divided into three groups based on the anastomosis type (eso-gastric anastomosis, eso-gastric cervical anastomosis and eso-jejunal anastomosis) and they were compared using the primary endpoints. Results: Our findings show the differences between the three groups, with a longer hospital stay for eso-gastric anastomosis, and an extended time of fistula closure in the case of eso-gastric cervical anastomosis. We also found a significant correlation between the size of the fistula and the hospital stay (R = 0.4, p < 0.01). Regarding patients' risk factors, our results show an extended post-stenting hospital stay for those patients that underwent preoperative radiotherapy. Conclusions: Our results offer an extended view of the efficiency, hospitalization duration and healing time for esophageal anastomotic fistula, and reveal some of the factors that interfere with its resolution.

The Clinical Efficacy, and Long-Term Outcomes Between Pneumatic Dilation and Laparoscopic Heller Myotomy in Achalasia.

Introduction: Achalasia is the most well-known motility disorder, characterized by the lack of optimal relaxation of the lower esophageal sphincter during swallowing and the absence of peristalsis of the esophageal body. Laparoscopic Heller esocardiomyotomy (LHM) and pneumatic dilation (PD) were the main treatment options for achalasia. Currently, the therapeutic methods are complemented by per-oral endoscopic myotomy (POEM). Materials and Methods: we performed a retrospective study, analyzing the data and evolution of 98 patients with achalasia, admited and treated in the General and Esophageal Surgery Clinic of the St. Mary Clinical Hospital-Bucharest between January 2016 and June 2023. The treatment was performed by PD in 25 cases and the majority LHM. The average duration of symptoms in the case of PD was 48 months, and 24 months in LHM. The patients were evaluated before and after the treatment procedures by the Eckardt clinical score and investigations such as timed barium esophagogram (TBO) and esophageal manometry. Results: Although patients had the same Eckardt score before treatment, a statistically significant decrease of the Eckardt score was obtained at the post-therapeutic evaluation after undergoing LHM compared to PD. Recurrence of symptoms was more frequent in the case of PD, requiring another therapeutic intervention. The cost of treatment, as well as the number of hospitalization days were reduced in the case of PD. Conclusions: The treatment of achalasia with LHM is more effective regarding recurrence of symptoms, even if it involves higher costs and a longer hospital stay compared to DP.

Minimally invasive surgery for gastro-oesophageal junction adenocarcinoma: Current evidence and future perspectives.

Minimally invasive surgery is increasingly indicated in the management of malignant disease. Although oesophagectomy is a difficult operation, with a long learning curve, there is actually a shift towards the laparoscopic/thoracoscopic/ robotic approach, due to the advantages of visualization, surgeon comfort (robotic surgery) and the possibility of the whole team to see the operation as well as and the operating surgeon. Although currently there are still many controversial topics, about the surgical treatment of patients with gastro-oesophageal junction (GOJ) adenocarcinoma, such as the type of open or minimally invasive surgical approach, the type of oesophago-gastric resection, the type of lymph node dissection and others, the minimally invasive approach has proven to be a way to reduce postoperative complications of resection, especially by decreasing pulmonary complications. The implementation of new technologies allowed the widening of the range of indications for this type of surgical approach. The short-term and long-term results, as well as the benefits for the patient - reduced surgical trauma, quick and easy recovery - offer this type of surgical treatment the premises for future development. This article reviews the updates and perspectives on the minimally invasive approach for GOJ adenocarcinoma.

The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review.

Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS: We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS: The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS: Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.

Laparoscopic Esocardiomyotomy-Risk Factors and Implications of Intraoperative Mucosal Perforation.

BACKGROUND: Mucosal perforation during laparoscopic esocardiomyotomy is quite frequent, and its consequences cannot always be neglected. The purpose of the study is to investigate the risk factors for intraoperative mucosal perforation and its implications on the postoperative outcomes and the functional results three months postoperatively. MATERIAL AND METHODS: We retrospectively identified the patients with laparoscopic esocardiomyotomy performed at Sf. Maria Hospital Bucharest, in the period between January 2017-January 2022 and collected the data (preoperative-clinic, manometric and imaging, intra-and postoperative). To identify the risk factors for mucosal perforations, we used logistic regression analysis. RESULTS: We included 60 patients; intraoperative mucosal perforation occurred in 8.33% of patients. The risk factors were: the presence of tertiary contractions (OR = 14.00, 95%CI = [1.23, 158.84], p = 0.033206), the number of propagated waves ≤6 (OR = 14.50), 95%CI = [1.18, 153.33], p < 0.05), the length of esophageal myotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), the length of esocardiomyotomy (OR = 1.74, 95%CI = [1.04, 2.89] p < 0.05), and a protective factor-the intraoperative upper endoscopy (OR = 0.037, 95%CI = [0.003, 0.382] p < 0.05). CONCLUSIONS: Identifying risk factors for this adverse intraoperative event may decrease the incidence and make this surgery safer. Although mucosal perforation resulted in prolonged hospital stays, it did not lead to significant differences in functional outcomes.

Mortality Risk Stratification in Emergency Surgery for Obstructive Colon Cancer-External Validation of International Scores, American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (SRC), and the Dedicated Score of French Surgical Association (AFC/OCC Score).

BACKGROUND: The increased rates of postoperative mortality after emergency surgery for obstructive colon cancer (OCC) require the use of risk-stratification scores. The study purpose is to external validate the surgical risk calculator (SRC) and the AFC/OCC score and to create a score for risk stratification. PATIENTS AND METHODS: Overall, 435 patients with emergency surgery for OCC were included in this retrospective study. We used statistical methods suitable for the aimed purpose. RESULTS: Postoperative mortality was 11.72%. SRC performance: strong discrimination (AUC = 0.864) and excellent calibration (11.80% predicted versus 11.72% observed); AFC/OCC score performance: adequate discrimination (AUC = 0.787) and underestimated mortality (6.93% predicted versus 11.72% observed). We identified nine predictors of postoperative mortality: age > 70 years, CHF, ECOG > 2, sepsis, obesity or cachexia, creatinine (aN) or platelets (aN), and proximal tumors (AUC = 0.947). Based on the score, we obtained four risk groups of mortality rate: low risk (0.7%)-0-2 factors, medium risk (12.5%)-3 factors, high risk (40.0%)-4 factors, very high risk (84.4%)-5-6 factors. CONCLUSIONS: The two scores were externally validated. The easy identification of predictors and its performance recommend the mortality score of the Clinic County Emergency Hospital of Galați/OCC for clinical use.

Ivor Lewis Minimally Invasive Esophagectomy - What Do We Choose? Literature Review.

PURPOSE: The transition from open esophagectomy to Ivor Lewis to minimally invasive surgery has been gradual through hybrid approaches. The aim of this study was to present a comparison of the current variants of minimally invasive Ivor Lewis esophagectomy. Methods: A systematic literature search was performed to analyze the technical features of minimally invasive Ivor Lewis esophagectomy and their postoperative results. The research was performed in the PubMed and Medscape databases with the keywords Ivor Lewis minimally invasive esophagectomy, gastric tube, esogastric anastomosis, and the selection of articles was performed taking into account the technical variance used and the results obtained. Results: The research of the data in the literature shows that there is currently a consensus of the essential steps in the Ivor Lewis technique, but their performance allows the use of different options, each surgeon taking into account primarily their own experience and existing facilities in each hospital. Although, over time, there have been multiple transformations of some steps in the basic technique, currently there are still conflicting opinions on certain aspects of the surgical technique, all of which are motivated by research undertaken to improve postoperative results. Conclusions: Ivor Lewis Minimally invasive esophagectomy further raises debatable issues on the practical way to perform the essential steps of the technique; their clarification could lead to finding the optimal option.

The Role of Esophageal Stenting in the Management of Anastomotic Leaks after Esophageal and Esophago-Gastric Cancer Resections. Literature Review.

Introduction: Anastomotic fistulas after surgery for esophageal cancer, remain a challenge for both the surgeon and the gastroenterologist. The aim of the study is to highlight the role of esophageal stenting in the management of leaks after esophagectomy for malignancies. Materials and Methods: We reviewed the available literature on the endoscopic treatment of esophageal anastomotic leaks, especially articles on endoscopic stenting in the management of this complication. Pubmed and ClinicalKey databases were searched using keywords such as esophageal anastomotic leaks, fully covered self-expanding metal stents, esophageal neoplasm. The relevant literature has been reviewed and included in the article. Results and Conclusions: The insertion of self-expanding stents in the fistulas of the esophageal anastomosis, represents an efficient method of treatment both for the closure of the fistula and in the control of sepsis. The morbidity and mortality associated with this method of treatment may be significant.

Management of Esophageal Perforations During Achalasia Treatment Experience of the General and Esophageal Surgery Clinic, Sf Maria Hospital.

Introduction: Achalasia is a motility disorder characterized by the absence of optimal relaxation of the lower esophageal sphincter (LES) with swallowing and lack of peristalsis of the esophageal body. Excepting temporary medical options, the treatment aims to lower the LES pressure by endoscopic or surgical means. Either method involves a risk of perforation. We analyzed the management of esophageal perforations in patients who received treatment for achalasia. Material and Method: we conducted a retrospective study of patients with achalasia hospitalized and treated in the Clinic of General and Esophageal Surgery within the Sf. Maria Clinical Hospital in Bucharest between January 2016 and December 2021. Results: There were 57 patients, 35 men, with a mean age of 50 years and a mean duration of symptoms of 35 months. Almost all (91.89%) patients presented with dysphagia. Preoperative manometry was performed in 52 patients, of whom 17 were type I, 35 were type II. The treatment was laparoscopic Heller eso-cardiomyotomy (LHM) in most cases (55), with Dor anterior fundoplication. There were 10 recurrent cases after dilation or surgery in another medical unit. There were 3 mucosal perforations after LHM. The treatment varied from simple suture to a combined endoscopic and surgical approach, involving the use of esophageal stent, abscess drainage, and feeding jejunostomy. We also present the management of two cases of esophageal perforation after endoscopic dilation, in which the support of the surgical team was necessary. Conclusion: Esophageal perforation in the treatment of achalasia, either endoscopic or surgical, requires immediate identification and treatment to provide the best chance of favorable evolution. The treatment of achalasia is indicated to be performed in dedicated centers, prepared even in case of complications.

Management of Chylothorax in Esophageal Surgery by Minimally Invasive Thoracoscopic Approach: Case Series.

Chylothorax is a rare complication, especially after esophageal cancer surgery. It may occur mainly in the thoracic stage of esophagectomy. The management of chylothorax is usually conservative, surgical reoperation with thoracic duct ligation being reserved for those cases refractory to that treatment. We discuss issues of diagnosis and therapeutic attitude, as evidenced by the literature, although a general consensus has not been established, most likely due to the low frequency of this complication. We emphasize the minimally invasive thoracoscopic approach, as it has been applied for two cases with this type of complication. A high rate of suspicion for thoracic duct injury should be maintained in all patients after esophageal surgery, with any pleural effusion entering the differential diagnosis of chylothorax.

Invasive Treatment Options for Gastro-Esophageal Reflux Disease.

Reflux disease continues to be one of the most common pathologies in the world. There is much discussion regarding the mechanism of developing and the variety of possible symptoms. In recent years, the use of new technologies, like high-resolution manometry and pH impedance, brought new insights into this disease. Also, there are emerging therapies that are covering the gap between the patients treated with proton-pump inhibitor (PPI) therapy and those who benefit the most from laparoscopic treatment (hiatal hernia, complications of gastroesophageal reflux disease (GERD). Also, most of them are less invasive than a laparoscopic fundoplication. We present a short review of the treatment options in patients who need more than lifestyle changes and PPI therapy.

Postoperative Esophageal Leaks in Malignant Pathology - Optimal Management: A Systematic Review.

BACKGROUND AND AIMS: Postoperative esophageal leaks are one of the major causes of postoperative mortality and morbidity. The purpose of this study was to review current knowledge of current methods of diagnosis and management of postoperative esophageal leaks. Methods: A systematic literature search was performed in the PubMed/Medline database using the terms "postoperative esophageal leaks" and "postesophagectomy complications" to identify articles relevant to the current diagnostic and prophylactic and curative treatment of post-oesophagectomy anastomotic fistulas. Results: Several papers have shown that the incidence of fistulas varies and is dependent on several factors: the location of the anastomosis, the type of suture used, the biological condition of the patient. Due to the severity of the mediastinal anastomotic fistula, great importance is being given to the methods of preventing its occurrence by intraoperative testing or improving the gastric tube vascularity. The most recent articles present endoscopic methods of treating this complication by using coated esophageal stents and endoluminal vacuum therapy. CONCLUSION: In patients with mediastinal postoperative esophageal fistulas, diagnosis and management represent a real challenge for the surgeon-endoscopist-therapist team. The early diagnosis and the establishment of an optimal therapy to address the parietal defect and the biological status of the patient are mandatory conditions for resolving this postoperative complication.

The Value of Intraoperative Endoscopy and Manometry in the Surgical Treatment of Achalasia.

Introduction: Achalasia is the most common esophageal motility disorder. So far, the treatment, which can be medical, endoscopic or surgical, provides only symptomatic relief. However, this can grant a normal life to the patients. We focused our study on the value of pre- and intraoperative endoscopy and manometry for improving outcome of surgical treatment. MATERIAL AND METHOD: This is a retrospective chart review of a cohort of patients diagnosed with achalasia at St Mary Clinical Hospital, Bucharest between 2013 and 2017. The objective of this study was the assessment of the immediate and long term efficacy of laparoscopic Heller myotomy associated with Dor anterior fundoplication, intraoperative endoscopy and intraoperative manometry, as well as the assessment of late post-operative complications. The diagnosis of achalasia was based on symptoms, barium esophagogram, upper endoscopy and esophageal manometry. The immediate efficacy was assessed by comparing Eckhart score, LES pressure and LES vector volume before and after surgery. Results: In total, 47 patients, had surgical treatment for achalasia between 2013 and 2017. For 7 patients who failed prior endoscopic or surgical, this was the second therapeutic intervention. 39 patients underwent laparoscopic surgery, 30 patients had associated intraoperative endoscopy and, 22 patients had associated intraoperative manometry. There was a significant improvement in mean Eckardt score (from 6,5 to 1,26, p 0,001), mean LES pressure (from 18,5 mmHg to 7 mmHg, p 0,001). Morbidity was 2,12 % and we have had 1 recurrence and 2 postoperative esophagitis. Conclusions: At present, laparoscopic Heller myotomy with an anterior Dor fundoplication, is a standard indication in achalasia, proving its efficiency and safety. Intraoperative use of endoscopy is recommended and intraoperative manometry may provide additional information on the effectiveness of myotomy. Surgical treatment of achalasia should be performed in specialized, experienced centers.

Current Management of Locally Advanced Junction Esophagogastric Adenocarcinoma.

Adenocarcinoma of the gastroesophageal junction is more common in the West. Preoperative chemotherapy or chemoradiotherapy is performed for locally advanced disease. Recent studies are suggesting higher rates of curative resection and reduced rates of local recurrence in patients with neoadjuvant combination of chemotherapy and radiation therapy. The role of targeted agents in neoadjuvant therapy is under investigation.

Early Postoperative Complications of Thoracic Esophageal Diverticula: A Review of 10 Cases from "Saint Mary" Hospital, Bucharest, Romania.

Introduction: Thoracic esophageal diverticulum is a rare pathology frequently associated with esophageal motility disorders. Surgery is the only option in patients with severe symptoms. METHOD: This is a retrospective case series study of 10 patients who underwent diverticulectomy for thoracic (epiphrenic or mid-esophageal) diverticula. It was recorded: main preoperative symptoms, usual blood tests, barium swallow, upper endoscopy and esophageal manometry. We analyzed the postoperative complications, length of stay in hospital and intensive care unit. Results: Most patients presented with regurgitation and/or dysphagia. The surgical approach was through left thoracotomy or abdominal for epiphrenic diverticula and through right thoracotomy or thoracoscopy for mid-esophageal diverticula. 4 patients had severe complications: 3 had major leaks (one death) and one had chylothorax. DISCUSSIONS: Surgery for thoracic diverticula is associated with high mortality and morbidity rates. Leak from the suture line is the most common complication, unlike chylothorax which is a rare complication. Conclusions: Thoracic diverticula represent a benign pathology which can have "žmalignant" postoperative complications. A thorough preoperative work-up is mandatory for choosing the appropriate surgical technique. Use of multiple cartridges for stapling suture increase the risk of leakage, but oversewing the suture may diminish it.

Clinical and Therapeutic Implications of the 8th Edition TNM Classification of Adenocarcinomas of the Esophagogastric Junction.

The 8th edition of TNM cancer staging is based on data from large patient cohorts, data collected from the Worldwide Collaboration Cancer Esophageal (WECC) group, or the International Association for Gastric Cancer (IGCA), including treated patients surgically per primate or after neoadjuvant treatment. This edition redefines the esophago-gastric junction tumors and recommends different TNMs staging: Siewert type I and II should be classified according to TNM recommendations for esophageal adenocarcinoma, while for Siewert type III the TNM classification for gastric cancer should be considered. Anatomical characteristics feature type T (tumor invasion), type N (regional lymph node invasion) and type M (distant metastasis). Non-anatomic characteristics include tumor differentiation (G) and tumor localization (L). Category descriptors are currently evaluated by endoscopy with biopsy, fine needle aspiration (EUS-FNA), thoraco-abdomino-pelvic computer tomography (CT) and positron emission tomography (CT-PET). The new TNM staging edition presents separate classifications applicable for therapeutic strategy: clinical staging cTNM (prior to any treatment), pathological staging pTNM (after surgery first) and neoadjuvant pathologic staging ypTNM (after neoadjuvant treatment followed by surgery). The refinement of each category and subcategory of T, N, M makes the 8th edition more accurate and adaptable to current practice, including for therapeutic strategy. The purpose of this study is to evaluate the clinical and therapeutical implications of the 8th edition of the TNM staging for esophago gastric junction adenocarcinoma.

Somatostatinoma of the first jejunal loop in a patient with neurofibromatosis von Recklinghausen and bilateral pheochromocytoma.

Somatostatinoma is a rare neuroendocrine tumor which especially develops in the pancreas. There are few communicated cases about extra-pancreatic localization, having as a particularity the absence of somatostatin hypersecretion syndrome and frequent association with von Recklinghausen neurofibromatosis. We present the case of a 42-year old patient with Von Recklinghausen neurofibromatosis admitted in our clinic with a chronic upper digestive obstruction syndrome. The presence of a first jejunal loop somatostatinoma was an intraoperative surprising diagnosis that imposed jejunal resection and association of complementary specific treatment. Despite the therapeutic correct management, the status of the patient deteriorated very fast, confirming the aggressiveness of this neoplasia.

The treatment of Barrett's esophagus.

The reflux of the gastric juice in the esophagus can determine the injury of the esophageal epithelium. When the healing of the lesion is done by replacing the normal squamous epithelium with columnar epithelium, the entity is called Barrett's esophagus (BE). Although controversial, some studies showed 0,5% per year the incidence of the esophageal adenocarcinoma in patients with BE, 30 times more often than general population. Taking into consideration the possible development of an adenocarcinoma, the patients with Barrett's esophagus require endoscopic surveillance after a standardized protocol. There is still much controversy about the treatment of patients with Barrett's esophagus, especially in the presence of dysplasia. The aims of the treatment are gastro-esophageal reflux symptoms control, healing of associated esophagitis and prevention of development of adenocarcinoma.