Transgastric drainage of the perforated esophagus: our experiences over 10 years.

We first described the technique of transgastric drainage of esophageal injuries in 2008. The method establishes vacuum drainage of the lumen of the esophagus, while maintaining patency, effectively exteriorizing the perforation to allow healing. We summarize this technique and present our experiences from the largest published series of patients. Our unit has treated selected esophageal injuries with transgastric drainage for 10 years. Indications include perforations not amenable to primary repair and treatment failure following prior surgical intervention. A 36 French silastic chest drain is pulled through the abdominal and stomach wall and introduced into the esophagus so that it crosses the perforation. Gastropexy is performed. Mediastinal decontamination and drainage are performed as needed. Continuous suction of -10 cm water is applied. Leak resolution is assessed with weekly water-soluble swallows. For this retrospective observational study, we analyzed data for patients with esophageal perforation, between 2012 and 2022. Inpatient mortality and time to leak resolution were set as primary and secondary outcomes. Esophageal perforations were treated with transgastric drain in 35 patients, of whom 68% (n = 24) were men. Median age was 67 (26-84). Spontaneous perforations accounted for 60% (n = 21), 31% (n = 11) were iatrogenic and 6% (n = 2) were ischemic. Inpatient and 30-day mortality was 14% (n = 5). Among successful treatments, the median length to resolution of leak on imaging was 34.5 days (6-80). Transgastric drainage can successfully treat esophageal perforations, where primary repair is not feasible. The mortality rate of 14% and reduced morbidity compares favorably with other traditional methods of management for esophageal perforation.

Gut hormones profile after an Ivor Lewis gastro-esophagectomy and its relationship to delayed gastric emptying.

Delayed gastric emptying (DGE) is common after an Ivor Lewis gastro-esophagectomy (ILGO). The risk of a dilated conduit is the much-feared anastomotic leak. Therefore, prompt management of DGE is required. However, the pathophysiology of DGE is unclear. We proposed that post-ILGO patients with/without DGE have different gut hormone profiles (GHP). Consecutive patients undergoing an ILGO from 1 December 2017 to 31 November 2019 were recruited. Blood sampling was conducted on either day 4, 5, or 6 with baseline sample taken prior to a 193-kcal meal and after every 30 minutes for 2 hours. If patients received pyloric dilatation, a repeat profile was performed post-dilatation and were designated as had DGE. Analyses were conducted on the following groups: patient without dilatation (non-dilated) versus dilatation (dilated); and pre-dilatation versus post-dilatation. Gut hormone profiles analyzed were glucagon-like peptide-1 (GLP-1) and peptide tyrosine tyrosine (PYY) using radioimmunoassay. Of 65 patients, 24 (36.9%) had dilatation and 41 (63.1%) did not. For the non-dilated and dilated groups, there were no differences in day 4, 5, or 6 GLP-1 (P = 0.499) (95% confidence interval for non-dilated [2822.64, 4416.40] and dilated [2519.91, 3162.32]). However, PYY levels were raised in the non-dilated group (P = 0.021) (95% confidence interval for non-dilated [1620.38, 3005.75] and dilated [821.53, 1606.18]). Additionally, after pyloric dilatation, paired analysis showed no differences in GLP-1, but PYY levels were different at all time points and had an exaggerated post-prandial response. We conclude that DGE is associated with an obtunded PYY response. However, the exact nature of the association is not yet established.

Positron emission tomography-computed tomography in oesophageal cancer staging: a tailored approach.

BACKGROUND: Positron emission tomography-computed tomography (PET-CT) scanning is used routinely in the staging of oesophageal cancer to identify occult metastases not apparent on CT and changes the management in typically 3-18% patients. The authors aim to re-evaluate its role in the management of oesophageal cancer, investigating whether it is possible to identify a group of patients that will not benefit and can safely be spared from this investigation. METHODS: Consecutive patients with oesophageal cancer undergoing PET-CT staging between 2010 and 2013 were identified from a specialist modern multidisciplinary team database. Without knowledge of the PET-CT result, patients were stratified into low-risk or high-risk groups according to the likelihood of identifying metastatic disease on PET-CT based on specified criteria routinely available from endoscopy and CT reports. Clinical outcomes in the two groups were investigated. RESULTS: In 383 undergoing PET-CT, metastatic disease was identified in 52 (13.6%) patients. Eighty-three patients were stratified as low risk and 300 as high risk. None of the low-risk patients went on to have metastatic disease identified on PET-CT. Of the high-risk patients, 17% had metastatic disease identified on PET-CT. CONCLUSIONS: In one of the largest studies to date investigating the influence of staging PET-CT on management of patients with oesophageal cancer, the authors report a classification based on endoscopy/CT criteria is able to accurately stratify patients according to the risk of having metastatic disease. This could be used to avoid unnecessary PET-CT 22% of patients, saving cost, inconvenience and reducing potential delay to definitive treatment in this group.

Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy.

BACKGROUND: Minimally invasive esophagectomy (MIO) is now established as a valid alternative to open surgery for the management of esophagogastric cancers. However, a high incidence of ischemia-related gastric conduit failure (ICF) is observed, which is detrimental to any potential benefits of this approach. METHODS: Since April 2004, MIO has been the procedure of choice for esophagogastric resection in the authors' unit. Data relating to the surgical technique were collected, with a focus on ischemic conditioning by laparoscopic ligation of the left gastric artery (LIC) 2 weeks or 5 days before resection. RESULTS: A total of 97 patients underwent a planned MIO. Four in-patient deaths (4.1%) occurred, none of which were conduit related, and overall, 20 patients experienced ICF (20.6%). In four patients, ICF was recognized and dealt with at the initial surgery. The remaining 16 patients experienced this complication postoperatively, with 9 (9.3%) of them requiring further surgery. Of the 97 patients, 55 did not undergo ischemic conditioning, and conduit failure was observed in 11 (20%). Thirty-five patients had LIC at 2 weeks, and 2 (5.7%) experienced ICF. All seven patients (100%) who had LIC at 5 days experienced ICF. Timing of ischemic conditioning (p < 0.0001) had a definite impact on the conduit failure rate, and the benefit of ischemic conditioning at 2 weeks compared with no conditioning neared significance (p = 0.07). CONCLUSIONS: Ischemic failure of the gastric conduit significantly impairs recovery after MIO. Ischemic conditioning 2 weeks before surgery may reduce this complication and allow the benefits of this approach to be realized.

Classification and early recognition of gastric conduit failure after minimally invasive esophagectomy.

BACKGROUND: Esophagectomy is a high-risk procedure, with significant morbidity resulting from gastric conduit failure. Early recognition and management of these complications is essential. This study aimed to investigate the clinical value of routine investigations after minimally invasive esophagectomy (MIO) and to propose a classification system for gastric conduit failure. METHODS: For esophagogastric resection, MIO is the procedure of choice in the authors' unit. Standard postoperative care similar to that for open esophagectomy is undertaken on a specialist ward. Routine investigations include daily assessment of C-reactive protein (CRP), white cell count (WCC), and a contrast swallow on postoperative day (POD) 5. The authors performed a retrospective analysis to assess the utility of these tests. RESULTS: Of a prospective cohort of 50 patients from April 2004 to July 2006, 26 (52%) had an uneventful recovery (U), 24 (48%) experienced complications (C) of varying nature and severity, and 1 died (2%). All the patients demonstrated a transient abnormal rise in CRP until POD 3. In group U, the levels then fell, but in group C, they remained elevated (POD 5: U = 96, C = 180; p < 0.01). This discrepancy trend was further exaggerated in the nine patients with gastric conduit failure (POD 5: GC = 254; p < 0.01), whereas contrast swallow failed to identify this complication in six patients. Simple anastomotic leaks (type 1, n = 4) were managed conservatively. Patients with conduit tip necrosis (type 2, n = 3) and complete conduit ischemia (type 2, n = 2) were managed by repeat thoracotomy and either refashioning of the conduit or take-down and cervical esophagostomy. None of the patients with conduit failure died. CONCLUSION: Postoperative CRP monitoring is a highly effective, simple method for the early recognition of gastric conduit failure. This new system of classification provides a successful guide to conservative management or revisional surgery.

Laparoscopically assisted versus open oesophagectomy for patients with oesophageal cancer-the Randomised Oesophagectomy: Minimally Invasive or Open (ROMIO) study: protocol for a randomised controlled trial (RCT).

INTRODUCTION: Surgery (oesophagectomy), with neoadjuvant chemo(radio)therapy, is the main curative treatment for patients with oesophageal cancer. Several surgical approaches can be used to remove an oesophageal tumour. The Ivor Lewis (two-phase procedure) is usually used in the UK. This can be performed as an open oesophagectomy (OO), a laparoscopically assisted oesophagectomy (LAO) or a totally minimally invasive oesophagectomy (TMIO). All three are performed in the National Health Service, with LAO and OO the most common. However, there is limited evidence about which surgical approach is best for patients in terms of survival and postoperative health-related quality of life. METHODS AND ANALYSIS: We will undertake a UK multicentre randomised controlled trial to compare LAO with OO in adult patients with oesophageal cancer. The primary outcome is patient-reported physical function at 3 and 6 weeks postoperatively and 3 months after randomisation. Secondary outcomes include: postoperative complications, survival, disease recurrence, other measures of quality of life, spirometry, success of patient blinding and quality assurance measures. A cost-effectiveness analysis will be performed comparing LAO with OO. We will embed a randomised substudy to evaluate the safety and evolution of the TMIO procedure and a qualitative recruitment intervention to optimise patient recruitment. We will analyse the primary outcome using a multi-level regression model. Patients will be monitored for up to 3 years after their surgery. ETHICS AND DISSEMINATION: This study received ethical approval from the South-West Franchay Research Ethics Committee. We will submit the results for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN10386621.

Transgastric drainage of the oesophagus: managing difficult oesophageal injuries.

We describe a technique for maintaining patency of the injured or repaired oesophagus while providing vacuum drainage of the oesophageal lumen. A small midline laparotomy is performed. A lubricated 36F soft chest drain (pull-through end) is introduced into the oesophagus using a percutaneous endoscopic gastrostomy (PEG) set, and pulled out through the stomach wall. The drain is brought out through the abdominal wall and the stomach is anchored to the peritoneum. The transgastric drain is positioned across the oesophageal defect. A feeding jejunostomy is placed. Decontamination and drainage of the chest is performed if the patient's condition allows. The patient takes sterile water by mouth to maintain drain patency, with -10 cm H(2)O suction applied. We have used this drainage procedure in seven patients (Boerhaave's syndrome (n=4), operative injury (n=3)). In five patients with injuries close to the oesophagogastric junction, this method was used as an adjunct to primary repair. There were no deaths; the oesophageal defect healed in all patients without stricture. All patients are swallowing normally at follow-up. This procedure is presented as an option for patients who are unfit for primary repair, or whose primary repair would benefit from efficient drainage and protection.

The decision to operate: role of integrated computed tomography positron emission tomography in staging oesophageal and oesophagogastric junction cancer by the multidisciplinary team.

OBJECTIVE: Our objective was to assess the role of fusion positron emission tomography-computed tomography (PET-CT) in staging patients for minimally invasive oesophagectomy (MIO) with potentially resectable disease from the perspective of a multidisciplinary team (MDT) deciding on operability with conventional staging investigations. METHODS: Fifty consecutive patients presenting with potentially operable oesophageal or oesophagogastric junctional tumours were staged with computed tomography (CT) and endoluminal ultrasound (EUS). The MDT categorised patients as group A (n=33; CT N0M0) or group B (n=17; CT N1/possible M1). All patients underwent FDG PET-CT. Patients with localised disease (at T3), including single level N1 disease on PET-CT, were deemed suitable for induction chemotherapy followed by surgery. RESULTS: PET-CT re-categorised 12% of patients as inoperable on grounds of distant metastases (four in group A, two in group B). Five patients did not proceed to resection for other reasons. Two had metastatic disease at thoracoscopy. Resection specimens (n=37) contained 24 nodes (median). Compared with pN status, positive predictive value of PET-CT was 40% and negative predictive value was 43%. The expected PET-CT N1 group had the highest mean number of involved nodes. Median survival for all patients (n=50) was 31.9 months for group A compared with 17.3 months for group B (not statistically significant). There was no significant difference between patients who were PET-CT N0 or N1 in survival or disease-free survival in patients undergoing surgery (n=37). CONCLUSIONS: PET-CT informs the MDT decision to operate in avoiding futile surgery in stage IV disease or widespread nodal disease. In this study, overall PET-CT N1 status has low positive and negative predictive value for overall pN status.

The European societies subjective and objective scores.

This article explores the issue of risk modeling for patients undergoing lung resection. The development of risk stratification in thoracic surgery is discussed together with its application in patient populations and in individual patients. The European Societies Risk Scores (Objective and Subjective) Version 1 are discussed in detail. The development of Version 2 of the risk score is described, and the future role of risk scoring on thoracic surgical practice is considered.

Long term results of diaphragmatic plication for unilateral diaphragm paralysis.

OBJECTIVES: To examine whether diaphragmatic plication is an effective and lasting treatment option for non-malignant diaphragmatic paralysis. METHODS: Nineteen patients who had undergone diaphragm plication (1983-1990) were recalled for interview, pulmonary function testing and chest X-ray. RESULTS: There were 13 men and six women aged 24-73 (mean 55). Diaphragm paralysis was idiopathic (n=9), postsurgical (n=3), related to cervical spondylosis (n=4) and neck injury (n=2). Patients presented with breathlessness (18/19) or orthopnoea (1/19). Symptoms had lasted 3-60 months (mean 24 months). All patients had a raised hemidiaphragm on chest X-ray with paradoxical movement on ultrasound. Mean preoperative FVC was 71% predicted (range 38-93, SD 12.9) and mean FEV(1) was 67% predicted (range 33-90, SD 10.8). Supine lung volumes were 81% (mean) of sitting values. There were six right plications and 13 left. There were no postoperative deaths. One patient required re-plication. Follow-up (18/19 of original operated patients) ranged from 7-14 years (mean 10 years). Three patients had died of unrelated causes and one patient failed to attend long term follow-up, leaving 15 patients of the original 19 operated on. Positional change in lung volumes was not affected by surgery at early (6 week) or late (>5 year) follow-up. FVC, FEV(1), FRC and TLC improved by 10.1*, 11.8*, 16.9* and 9.2*%, respectively, at early follow-up and 11.8*, 15.4*, 26 and 13.3*% at late follow-up (*P<0.005 signed rank). Dyspnoea scores at long term follow-up improved 1 point (n=5), 2 points (n=5) and 3 points (n=2), remained unchanged (n=1) or dropped 1 point (n=2). Of the 15 patients followed up all but one who had been employed returned to work. 14/15 patients expressed satisfaction with their surgery. CONCLUSION: Diaphragm plication is an effective procedure with lasting results.

Surgical time out checklist with debriefing and multidisciplinary feedback improves venous thromboembolism prophylaxis in thoracic surgery: a prospective audit.

OBJECTIVES: There is a significant global burden of preventable morbidity and mortality after surgery caused by avoidable adverse events. Venous thromboembolism (VTE) prophylaxis, despite evidence for its efficacy, is not reliably and consistently prescribed, and is currently a serious concern for patient safety. The aim of this study was to prospectively audit errors captured by an extended surgical time out checklist and relate them to the introduction of a safety culture. METHODS: The use of an extended surgical time out checklist was prospectively audited, in consecutive patients in one operating theatre over a period of two years. Errors captured were analysed and related to other improvements to safety culture; human factors training, debriefing and regular departmental meetings. RESULTS: Time out was performed in 959 patients of 990 (96.8%) undergoing thoracic surgery. Performance was consistent over time. Errors were categorized as VTE prophylaxis (n = 53, 6%), blood products (n = 11), clerical (n = 5), imaging (n = 2) and miscellaneous (n = 2). After a lag period of 15 months, during which the team underwent human factors training, introduced debriefing and escalated VTE prophylaxis to regular departmental meetings, VTE prophylaxis errors were substantially reduced. The temporal relationship between error capture and error elimination is explored. CONCLUSIONS: Use of checklists alongside appropriate human factors training, debriefing and regular multidisciplinary communication can substantially improve VTE prophylaxis in patients undergoing surgery.

Minimally-invasive subtotal oesophagectomy: three-stage thoracoscopic, laparoscopic subtotal oesophagectomy with cervical anastomosis.

This contribution describes a minimally-invasive approach to subtotal oesophagectomy. Indications, pre-emptive ischaemic conditioning and feeding jejunostomy are discussed. In the lateral position, the oesophagus is mobilized thoracoscopically in a specific order, formally identifying 'at risk' structures. A radical en bloc dissection is performed with formal lymphadenectomy. Slings are placed around proximal and distal oesophagus and a paravertebral catheter is inserted for postoperative analgesia. In the supine position, the stomach is mobilized laparoscopically, preserving the gastroepiploic arcade and the right gastric artery. Kocher's manoeuvre is undertaken. Lymphadenectomy is performed around the coeliac axis, common hepatic, left gastric and splenic arteries. The proximal oesophagus is delivered through a cervical approach and transected, suturing the distal end to a delivery system to facilitate passage of the conduit through the mediastinum. The mobilized stomach is delivered through a 6-cm right paramedian minilaparotomy and a wide gastric conduit formed, preserving collateral supply and venous drainage from the distal lesser curve. The conduit is passed to the neck using a vacuum/camera sleeve technique and anastomosed to the transected cervical oesophagus with a semi-mechanical technique. The paramedian minilaparotomy is closed with a local anaesthetic catheter in the posterior sheath and the conduit brought back into an anatomical position laparoscopically. Postoperative care is described.

Calcifying fibrous pseudotumours: an unusual case with multiple pleural and mediastinal lesions.

Calcifying fibrous pseudotumour (CFPT) is a rare soft tissue lesion that has been reported in the pleura and mediastinum. The literature contains reports of multiple pleural lesions. We describe a case of a 22-year-old woman with multiple bilateral pleural and mediastinal CFPTs. The diagnosis was established following the resection of multiple lesions. However, many lesions remain. We discuss the clinical behaviour of CFPTs and the dilemma of leaving remaining lesions in situ.

The European Thoracic Database project: composite performance score to measure quality of care after major lung resection.

BACKGROUND: Performance measurement is an essential element of quality improvement initiatives. The objective of this study was to develop a composite performance score (CPS) incorporating processes and outcomes measures available in the European Society of Thoracic Surgeons (ESTS) Database and apply it to stratify performance of participating units. METHODS: A total of 1656 major lung resections for malignant primary neoplastic disease were collected in the ESTS database from 2001 through 2003 and were analyzed. For the purpose of this study only data collected from units contributing more than 50 consecutive cases were included. Three quality domains were selected: preoperative care, operative care, and postoperative outcome. According to best available evidence the following measures were selected for each domain: preoperative care (% of predicted postoperative carbon monoxide lung diffusion capacity (ppoDLCO) measurement in patients with predicted postoperative forced expiratory volume in one second (ppoFEV1) <40%), operative care (% of systematic lymph node dissection), and outcomes (risk-adjusted cardiopulmonary morbidity and mortality rates). Morbidity and mortality risk models were developed by hierarchical logistic regression and validated by bootstrap analyses. Individual processes and outcomes scores were rescaled according to their standard deviations and summed to generate the CPS, which was used to rate units. RESULTS: CPS ranged from -4.4 to 3.7. Individual scores were poorly correlated with each other. Two units were negative outliers and two positive outliers (outside 95% confidence limits). Compared to the rating obtained by using the risk-adjusted mortality rates, all units changed their positions when ranked by CPS. CONCLUSIONS: The composite performance score methodology may support future peer-based organizational quality benchmarking initiatives and may be used for regulatory and credentialing purposes.

Laparoscopic ischaemic conditioning of the stomach may reduce gastric-conduit morbidity following total minimally invasive oesophagectomy.

OBJECTIVE: Oesophagectomy, whether open or minimal access, is associated with a significant incidence of gastric-conduit-related complications. Previous animal and human studies suggest that ischaemic conditioning of the stomach prior to oesophagectomy improves perfusion of the gastric conduit. We have adopted laparoscopic ligation of the left gastric artery 2 weeks prior to minimally invasive oesophagectomy, having identified a relative high incidence of gastric-tube complications through a cumulative summation (CUSUM) analysis. METHODS: This study included 77 consecutive patients who underwent a Total MIO (thoracoscopic oesophageal mobilisation, laparoscopic gastric tube formation, cervical anastomosis). The ligation group comprised 22 consecutive patients, excluding those with middle-third squamous tumours or early-stage adenocarcinoma, who underwent ligation 2 weeks prior to MIO at staging laparoscopy. The control group comprised 55 patients who did not undergo ischaemic conditioning in this way. We have defined conduit-related complications as: leak managed conservatively (L); tip necrosis requiring resection and re-anastomosis (TN) and conduit necrosis needing resection and oesophagostomy (CN). The values are reported as medians. The effect of ligation of the left gastric artery was followed with a CUSUM analysis. RESULTS: Ligation was performed 15.5 days pre-operatively (median). There were no complications and the length of hospital stay was 1 day. Although gastric mobilisation at MIO was technically more difficult after ligation, there was no significant difference in operating time (ligation, 407 min; control, 425 min) or blood loss (ligation and control, 500 ml). There was less gastric-conduit morbidity in the ligation group (two of 22, 10%; one L, one CN) compared with the control group (11 of 55, 20%; four L, five TN, two CN), but these differences did not reach statistical significance (p=0.211 and p=0.176 Fisher's exact test). The CUSUM analysis showed that during ligation of the left gastric artery, conservatively treated gastric-conduit-related morbidity (leak, resection and re-anastomosis or conduit necrosis) remained within safe limits (10%). Conduit-related-morbidity increased after stopping ligation. CONCLUSION: In this non-randomised clinical setting, our results suggest that ischaemic conditioning of the stomach prior to MIO is safe. There is a trend to reduced morbidity related to gastric-conduit ischaemia, which was demonstrated by a CUSUM analysis. A randomised trial is needed before ligation of the left gastric artery can be routinely recommended.

Survey on chest drainage systems adopted in Europe.

The aim of this survey, promoted by the European Society of Thoracic Surgeons, was to acquire information and advice from 'the field' in order to promote development of technology for thoracic surgery and to provide information for future guidelines on chest drainage. Society members were offered a questionnaire on the European Society of Thoracic Surgeons website (November 2006) composed of seven sections comprehending 21 detailed items. The questionnaire was completed by 120 centres, 100% performed lung surgery, 91.6% mediastinal surgery, 54.1% oesophageal surgery, 10% cardiothoracic surgery. The PVC straight drain (mean 55.9%) and silicon drain (mean 38.4%), water-valve/water suction disposable chest drainage collection system (mean 43.4%), one bottle (mean 24.8%), and two bottles with suction control (mean 18.2%), were the most frequently used. After pneumonectomy 51.2% used a balanced drainage system, 9% periodical thoracocentesis, 39.8% others. In 57.5-92% drainage suction was stopped 4 postoperative days. In 17.6-60.7% drains were removed 4 postoperative days. The survey demonstrates a trend toward the use of updated technical devices, high consideration of the costs, and clinical practice based on personal preferences.

Management of malignant pleural effusion associated with trapped lung syndrome.

Management of recurrent malignant pleural effusion associated with trapped lung syndrome remains problematic. An alternative treatment using a pleural catheter has been advocated. Between August 1999 and August 2002, 127 patients underwent thoracoscopy for malignant pleural effusion. Of these, 52 (41%) with trapped lung were managed by insertion of a pleural catheter. Mean age was 66 years (range, 42-89 years). The most frequent diagnosis was breast cancer. Spontaneous pleurodesis (drainage < 10 mL) occurred in 25 (48%) patients whose catheter was removed after 30 to 255 days (mean, 93.8 days). Symptomatic relief was achieved in 49 (94%) patients. Mean dyspnea score improved significantly from 3.0 to 1.9. Complications comprised catheter blockage, surgical emphysema, cellulitis, and loculated effusion in 2 patients each. Mean length of hospital stay was 3 days (range, 1-16 days). Median survival was 126 days (range, 10-175 days). We conclude that long-term placement of a pleural catheter provides effective palliation for malignant pleural effusion associated with trapped lung syndrome.