Real-life introduction of powered circular stapler for esophagogastric anastomosis: cohort and propensity matched score study.

Anastomotic leakage after esophagectomy is one of the most feared complications, which results in increased morbidity and mortality. Our aim was to evaluate the impact of a powered circular stapler on complications after esophagectomy with intrathoracic anastomosis for esophageal cancer. Between May 2019 and July 2021, all consecutive oesophagectomies for cancer with intrathoracic anastomosis in a high-volume center were included in this retrospective study. Surgeons were free to choose either a manual or a powered circular stapler. Preoperative characteristics and postoperative complications were recorded in a prospective database, according to EsoData. Propensity score matching (age, body mass index, Eastern cooperative oncology group (ECOG) performance and neoadjuvant therapy) was conducted to reduce potential confounding. We included 128 patients. Powered and manual circular staplers were used in 62 and 66 patients, respectively. Fewer anastomotic leakages were observed with the powered stapler group (OR = 7.3 (95%CI: 1.58-33.7); [3.2% (n = 2) vs 19.7% (n = 13), respectively; p = 0.004]). After propensity score matching, this remained statistically significant (OR = 8.5 (95%CI: 1.80-40.1); [4.1% (n = 2) vs 20.4% (n = 10), respectively; p = 0.013]). Additionally, anastomotic diameter was significantly higher with the powered stapler (median: 29 mm (63.3%) vs 25 mm (57.1%), respectively; p < 0.0001). There was no significant difference in comprehensive complication index (p = 0.146). A decreased mean length of stay was observed in the powered stapler group (11.1 vs 18.7 days respectively; p = 0.022). Postoperative anastomotic leakage after esophageal resection was significantly reduced after the introduction of the powered circular stapler, consequently resulting in a reduced length of stay. Further evaluation on long-term strictures and quality of life are warranted to support these results.

Centralisation of oesophageal cancer services: experiences and outcomes of the first year of implementation at a Belgian non-academic teachinghospital.

INTRODUCTION: Oesophageal surgery recently became centralised in Belgium. This study aims to evaluate surgical outcomes and service delivered one year after implementation of centralisation. PATIENTS AND METHODS: All patients undergoing an oesophagectomy between the start of the centralisation; 1st of June 2019 and 31st of May 2020, were included from a prospectively maintained database. RESULTS: 53 patients (41 male, 12 female) underwent an oesophagectomy during the study period. Most oesophagectomies were performed through an open left thoracoabdominal approach (64.2%), 30.2% via a minimally invasive approach and hybrid approaches were carried out in 5.7% of patients. In this study population, the 30 day mortality rate was 0% and the 90 day mortality rate was 3.8%, equating to 2 deaths. The overall 30 day readmission rate was 7.5%. Clinically significant anastomotic leaks occurred in 4 patients, (7.5%). Pneumonia and atrial fibrillation were the most frequent complications, both having a prevalence of 32.1%. The median length of stay was 11 days (IQR 9.5-14.5). CONCLUSION: The results from our centre are comparable to those from international registers which demonstrate that centralisation of complex cancer services can be safely implemented.

Carotid Bifurcation Resection and Interposition of a Polytetrafluorethylene Graft (BRIG) for Carotid Disease: A Retrospective Study of 153 Consecutive Procedures.

BACKGROUND: Carotid endarterectomy (CEA) is the gold standard for treatment of carotid artery stenosis. CEA can be challenging, even technically impossible. Prosthetic carotid bypass grafting is a proven and safe alternative when CEA is hazardous. An alternative technique that is prosthetic carotid bifurcation resection and interposition of a polytetrafluorethylene graft (BRIG) is described in this article. METHODS: In our Department of Vascular Surgery, between January 2007 and October 2014, 103 BRIG procedures were performed. The outcome of conventional CEA and patients treated by the BRIG procedure were compared. Within the same period of time 50 CEA procedures (32.7%) were performed. Morbidity, mortality, and postoperative restenosis were compared. RESULTS: The 30-day mortality was 1% for the BRIG group and 0% in the CEA group (P value, 0.4839). The 30-day stroke rate was 1.9% for the BRIG group and 0% in the CEA group (P value, 0.3222). One patient died in the early postoperative period from acute myocardial infarction. A total of 13 (8.5%) patients died during follow-up, none of which were surgery related. Median follow-up was 29.1 months. There was a statistically higher restenosis rate in the CEA group compared with the BRIG group (16.0% vs. 1.9%, P value, 0.0053). Other complications were comparable. Mean operating and clamping time were significantly shorter in the BRIG group. CONCLUSIONS: BRIG appears to be a safe and feasible surgical alternative to CEA. The technique allows for shorter operating time, shorter clamping time, and appears to result in lower restenosis rates. Complication rates seem to be comparable to CEA. Prospective, randomized controlled trials on this topic are needed. To perform bilateral procedures, a bifurcation graft should be created to revascularize both the internal and external carotid artery.

How to handle brain tumors after esophagectomy with curative intent: A single center 20-year experience.

BACKGROUND: Brain metastases after esophagectomy are rare. Moreover, a diagnostic uncertainty remains as pathology is rarely obtained and radiological features can show similarities to primary brain tumors. Our aim was to demonstrate the diagnostic uncertainty and identify risk factors associated with brain tumors (BT) after esophagectomy with curative intent. METHODS: All patients who underwent an esophagectomy with curative intent from 2000 to 2019 were reviewed. Diagnostics and characteristics of BT were analyzed. Multivariable logistic and cox regression were performed to determine factors associated with development of BT and survival, respectively. RESULTS: In total, 2131 patients underwent esophagectomy with curative intent, of which 72 patients (3.4%) developed BT. Pathological diagnosis was obtained in 26 patients (1.2%), of which 2 patients were diagnosed with glioblastoma. On multivariate analysis, radiotherapy (OR, 7.71; 95%CI: 2.66-22.34, p < 0.001) was associated with an increased risk of BT and early-stage tumors (OR, 0.29; 95%CI: 0.10-0.90, p = 0.004) with a decreased risk of BT. Median overall survival was 7.4 months (95%CI: 4.80-9.96). BT treated with curative intent (surgery or stereotactic radiation) had a significantly better median overall survival (16 months; 95%CI: 11.3-20.7) compared to those without (3.7 months; 95%CI: 0.9-6.6, p < 0.001) CONCLUSIONS: Advanced stage tumors and radiotherapy seem related to the development of brain tumors after esophagectomy with curative intent. However, an important diagnostic uncertainty remains in these patients as pathological diagnosis is only obtained in a minority of cases. Tissue confirmation can be useful to inform a patient-tailored multimodality treatment strategy in select patient.

The Effect of Dumping on Weight Loss in Conversion of Failed Restrictive Surgery: a Cross-Sectional Pilot Study.

PURPOSE: Dumping is currently seen as a negative side effect of Roux-en-Y gastric bypass (RYGB). However, it may help patients to comply with their prescribed diet. In this study, we assess the role of dumping on weight loss in patients who have undergone conversion of failed restrictive surgery into RYGB. METHODS: An analysis was performed of 100 consecutive patients who underwent revisional RYGB (rRYGB) between 2006 and 2011 due to inadequate weight loss or band intolerance after laparoscopic adjustable gastric banding (LAGB). The percentage of excess weight loss (%EWL) was used to evaluate weight reduction. The Sigstad clinical diagnostic index was used to detect dumping symptoms. RESULTS: Fifty-five patients (59.1%) suffered from dumping. Overall, dumpers showed a greater %EWL than non-dumpers (83.8 ± 48.0 vs 66.9 ± 44.1%, respectively, p = 0.0725). When rRYGB was performed because of inadequate weight loss following LAGB, dumping played a crucial role in weight loss (88.0 ± 21.2 vs 68.9 ± 34.5%, p = 0.0137). This effect positively correlates to post-LAGB body mass index (BMI) with a statistically significant result at BMI > 35 kg/m2 (82.4 ± 15.7 vs 58.4 ± 32.4%, p = 0.00341). A regression analysis of the Sigstad dumping score and %EWL shows that dumping tends to increase the %EWL. CONCLUSIONS: This study provides new insights into the effect of dumping on weight loss in patients who underwent conversion of failed restrictive surgery into RYGB. Based on the findings in our patient group, we suggest that dumping helps patients achieve sustainable weight loss. Therefore, dumping can be regarded as a positive side effect rather than a complication.

Moderating the Enthusiasm of Sleeve Gastrectomy: Up to Fifty Percent of Reflux Symptoms After Ten Years in a Consecutive Series of One Hundred Laparoscopic Sleeve Gastrectomies.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a popular one-stage bariatric procedure with a proven efficacy on weight loss. However, the relationship between LSG and gastroesophageal reflux disease (GERD) remains a subject of debate. The objective is to determine the long-term effect of LSG on weight loss and reflux disease. METHODS: A retrospective analysis of 100 consecutive patients who underwent an LSG between January 2005 and March 2009 was performed. The effect of LSG on weight evolution and the relationship between preoperative and postoperative GERD symptoms and PPI dependency was analyzed. RESULTS: A mean follow-up of 8.48 years (range 6.1-10.3) was achieved. We observed a long-term % excess weight loss (%EWL) of 60%. A significant increase in reflux symptoms and use of PPIs was seen. Seventeen percent suffered from reflux disease preoperatively versus 50% at the end of the postoperative follow-up (RR = 2.5882, 95% CI [1.6161-4.1452], p value = 0.0001). The chance of developing de novo reflux after LSG was 47.8% (32/67). Reflux disease was present in 7 of the 26 patients who underwent a secondary Roux-en-Y gastric bypass (RYGB). In four of these seven patients, reflux disease disappeared completely after the secondary RYGB (57.1%). CONCLUSIONS: A satisfactory long-term effect on weight loss was achieved. However, a significant increase in GERD and PPI dependency after LSG was noted. New onset GERD was seen in more than 40% of the study population. Conversion to RYGB is a good option in patients with refractory reflux disease after LSG.