Surgical Techniques and Related Perioperative Outcomes After Robot-assisted Minimally Invasive Gastrectomy (RAMIG): Results From the Prospective Multicenter International Ugira Gastric Registry.

OBJECTIVE: To gain insight in global practice of RAMIG and evaluated perioperative outcomes using an international registry. BACKGROUND: The techniques and perioperative outcomes of robot-assisted minimally invasive gastrectomy (RAMIG) for gastric cancer vary substantially in literature. METHODS: Prospectively registered RAMIG-cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia and South-America. Techniques for the resection, reconstruction, anastomosis and lymphadenectomy were analyzed, and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group. RESULTS: Between 2020-2023, 759 patients underwent total (n=272), distal (n=465) or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%) or D2+ (12%). Median nodal harvest yielded 31 nodes [IQR 21-47] after total and 34 nodes [IQR 24-47] after distal gastrectomy. R0-resection rates were 93% after total and 96% distal gastrectomy. Hospital stay was 9 days after total and distal gastrectomy, and was 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%. CONCLUSIONS: This large multicenter study provided a worldwide overview of current RAMIG-techniques with their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG and can be considered an international reference for surgical standardization.

Outcome of Emergency Pulmonary Lobectomy under ECMO Support in Patients with COVID-19.

BACKGROUND: Not much is known about the results of nonelective anatomical lung resections in coronavirus disease 2019 (COVID-19) patients put on extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyze the outcome of lobectomy under ECMO support in patients with acute respiratory failure due to severe COVID-19. METHODS: All COVID-19 patients undergoing anatomical lung resection with ECMO support at a German university hospital were included into a prospective database. Study period was April 1, 2020, to April 30, 2021 (first, second, and third waves in Germany). RESULTS: A total of nine patients (median age 61 years, interquartile range 10 years) were included. There was virtually no preexisting comorbidity (median Charlson score of comorbidity 0.2). The mean interval between first positive COVID-19 test and surgery was 21.9 days. Clinical symptoms at the time of surgery were sepsis (nine of nine), respiratory failure (nine of nine), acute renal failure (five of nine), pleural empyema (five of nine), lung artery embolism (four of nine), and pneumothorax (two of nine). Mean intensive care unit (ICU) and ECMO days before surgery were 15.4 and 6, respectively. Indications for surgery were bacterial superinfection with lung abscess formation and progressive septic shock (seven of nine) and abscess formation with massive pulmonary hemorrhage into the abscess cavity (two of nine). All patients were under venovenous ECMO with femoral-jugular configuration. Operative procedures were lobectomy (eight) and pneumonectomy (one). Weaning from ECMO was successful in four of nine. In-hospital mortality was five of nine. Mean total ECMO days were 10.3 ± 6.2 and mean total ICU days were 27.7 ± 9.9. Mean length of stay was 28.7 ± 8.8 days. CONCLUSION: Emergency surgery under ECMO support seems to open up a perspective for surgical source control in COVID-19 patients with bacterial superinfection and localized pulmonary abscess.

Predictors of Outcome in Modern Surgery for Lung Abscess.

Background Surgery for lung abscess is a challenging task. Timing and indications for surgery are not well established. Identification of predictors of outcome could help to clarify the role of surgery. Methods Patients who underwent major thoracic surgery for infectious lung abscess were identified at six centers for general thoracic surgery in Germany, Spain, the United Kingdom, and the United States. Study period was 2000 to 2016. Results There were 91 patients. Pulmonary sepsis (48), pleural empyema (43), persistent air leakage (25), acute renal failure (12), and respiratory failure with mechanical ventilation (25) were already preoperatively present. The mean Charlson index of comorbidity was 3.0 (median: 2.0; interquartile range: 3). Procedures were segmentectomy (18), lobectomy (58), and pneumonectomy (15). The 30-day mortality following surgery was 13/91.Preoperative sepsis (odds ratio [OR]: 13.69; 95% confidence interval [CI]: 1.86-610.53; p < 0.01), preoperative persistent air leak (OR: 13.46, 95% CI: 3.00-85.37, p < 0.01), respiratory failure (OR: 5.60; 95% CI: 1.41-24.84; p < 0.01), acute renal failure (OR: 6.15 ; 95% CI: 1.24-29.56 ; p = 0.01), and Charlson index of comorbidity ≥ 3 (OR: 7.19 ; 95% CI: 1.43-71.21 ; p < 0.01) are associated with higher mortality, whereas age > 70 years (p = 0.46) and the extent of pulmonary resection (segmentectomy, lobectomy, pneumonectomy) have no significant influence on mortality. Patients with fatal outcome have significantly higher Charlson index of comorbidity (p < 0.01). Conclusions Delayed referral for surgery is common. Significant predictors for fatal outcome are pulmonary sepsis, septic complications (air leak, pleural empyema), septic organ failure (respiratory, acute renal failure), and preexisting comorbidity (Charlson index of comorbidity ≥ 3). The extent of surgical resection shows no significant influence.

Surgery for parapneumonic pleural empyema--What influence does the rising prevalence of multimorbidity and advanced age has on the current outcome?

OBJECTIVE: Pleural empyema is a critical condition. In the western world the share of sufferers with multiple comorbidities and advanced age is rapidly increasing. METHODS: This retrospective study comprises all patients who underwent surgery for parapneumonic pleural empyema at a major center for thoracic surgery in Germany between January 2006 and April 2013. RESULTS: A total of 335 patients (mean age 60.4 years) were included. The average ASA grade was 2.8. Empyema stage 1, 2 and 3 (classification of the American Thoracic Society) was encountered in 30, 230 and 75 cases, respectively. The most common comorbidities were cardiac disorders (124), diabetes mellitus (76), COPD (66) and alcoholism (54). The mean Charlson index of comorbidity score was 2. Minimally invasive surgery was feasible in 290 cases. A total of 88 patients sustained pulmonary sepsis. The overall mortality was 29/335 (8.7%). The occurrence of pulmonary sepsis (OR: 17.95; 95% CI: 6.38-62.69; p < 0.001), respiratory failure (OR: 23.08; 95% CI: 8.52-73.35; p < 0.001) and acute renal failure (OR: 8.20; 95% CI: 3.18-20.80; p < 0.001) and Charlson score ≥ 3 (OR: 6.65; 95% CI: 2.76-17.33; p < 0.001) were associated with higher mortality. On the other hand, very elderly sufferers (≥80 years) showed neither higher odds for pulmonary sepsis (OR: 0.78) nor for fatal outcome (OR: 0.92; 95% CI: 0.22-2.86; p = 1). CONCLUSIONS: Parapneumonic pleural empyema is still associated with considerable morbidity and mortality. Pre-existing comorbidity, the occurrence of pulmonary sepsis and sepsis related complications have a determining influence on the results whereas advanced age itself shows no higher risk for adverse outcome. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

1913: Annus mirabilis of esophageal surgery.

Although Sir Ronald Belsey once called the year 1904 "annus mirabilis," it is actually the year 1913 that stands out as the true milestone in esophageal surgery. Within a year, Torek performed the first transpleural resection for cancer in the thoracic esophagus, Zaaijer successfully resected the distal esophagus through the transpleural route, Heller performed the first myotomy for achalasia, and it was also the year of Ach's pioneering transmediastinal esophagectomy. Previously, in 1912, after a series of animal experiments by Beck and Jianu, Roepke successfully used the greater curvature of the stomach as a presternal conduit. Other previous approaches included reconstruction with jejunum (Roux-1907), colon (Kelling-1911), and skin tube (Bircher-1907). Several technical advances made these operations possible, most of all were the giant leaps in the perioperative medicine.

Surgical therapy for necrotizing pneumonia and lung gangrene.

OBJECTIVE: Necrotizing pneumonia, pulmonary abscess, and lung gangrene are rare complications of severe pulmonary infection with devitalization and sloughing of lung tissue. Pulmonary necrosis is often associated with alcoholism and other chronic disorders with known immunodeficiency. Mortality is significant and both treatment strategies as well as the role of surgery are controversially debated. METHODS: In a retrospective review at a German tertiary referral hospital, 20 patients with pulmonary resection for necrotizing lung disorders were identified since 2008. At hospital admission, all patients suffered from pulmonary sepsis and despite adequate medical treatment progressing parenchymal destruction and devitalization took place. The majority of the patients sustained pleural empyema (13/20) and five patients a persisting air leak. On account of failing medical therapy, eight patients (40%) developed severe sepsis with septic shock and four patients (20%) were already preoperatively ventilated. Chronic alcoholism was present in 10 patients (50%). RESULTS: Gangrene of a complete lung was seen in four cases. Lobar gangrene or necrotizing pneumonia complicated by fulminate abscess was seen in the right lower lobe (8/20), middle lobe (4/20), right upper lobe (2/20), and left lower lobe (2/20). Procedures included pneumectomy (4/20), lobectomy (13/20), and limited resection (3/20). The bronchial stump was reinforced with a pedicle muscle flap in seven cases. There were three postoperative deaths due to septic shock with multiorgan failure. The remaining 17 patients (85%) recovered well and were transferred to rehabilitation clinics specialized on pulmonary disorders. CONCLUSION: Necrotizing pulmonary infections are infrequent but are life-threatening disease entities. Patients often present with severe comorbidity and chronic disorders causing immunodeficiency. If initial medical therapy fails surgery offers a reasonable therapeutic approach. Aim of surgical therapy is resection of all gangrenous lung parenchyma and effective drainage of pleural empyema. Then recovery is feasible in up to 80%.

Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management.

OBJECTIVE: Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Fistulization occurs either through the esophageal hiatus or straight through the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed diagnosis is frequent. Initial conservative treatment fails in a significant number of cases. Ascending infection via the fistulous tract results in empyema and life-threatening sepsis. METHODS: All patients who underwent surgery for pancreaticopleural fistula-induced empyema thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective case study. RESULTS: Altogether six patients with pancreaticopleural fistula and associated pleural empyema were identified. All patients suffered from pancreatitis and received initial medical and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection led to left-sided pleural empyema in four and bilateral empyema in two cases. The contagious spread took place through the fistulous tract connecting the pancreatic duct with the pleural cavity. The patients were referred for surgery with considerable delay and already advanced pleural empyema. Minimally invasive thoracic surgery with pleural debridement was performed in all cases. Furthermore, left pancreatic resection was mandatory in five cases and cystostomy in one case. All patients recovered well and upon follow-up there were no further complications. CONCLUSION: Surgical management combining minimally invasive thoracic surgery and removal of the fistulous tract is highly effective. If initial medical treatment fails, surgery should be considered early to prevent severe sepsis. Further improvement seems achievable by reducing the time between fruitless conservative efforts and surgical intervention.

Video-assisted thoracoscopic surgery for posttraumatic hemothorax in the very elderly.

OBJECTIVE: Thoracic injury is a life-threatening condition with advanced age being an independent risk factor for both higher morbidity and mortality. Furthermore, elderly patients often have severe comorbidity and in case of chest trauma with rib fractures and hemothorax, their clinical condition is likely to deteriorate fast. Aim of this study is to investigate the feasibility and results of video-assisted thoracoscopy for the treatment of posttraumatic hemothorax in very elderly patients of 80 years or more. METHODS: The outcomes of 60 consecutive patients who received video-assisted thoracoscopic surgery for posttraumatic hemothorax in a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS: There were 39 male and 21 female patients. The median age was 63.2 years. The in-hospital-mortality was 1.7% (1/60). Fifteen of the 60 patients were 80 years or older (80-91). Main reason for hemothorax was blunt chest trauma. Altogether 23 patients had fractures of three or more ribs including six octogenarians. Elderly patients suffered from preexisting cardiopulmonary disease and were often referred to the thoracic surgeon with considerable delay. Video-assisted thoracoscopic surgery was feasible and all octogenarian patients finally recovered well without in-hospital-mortality. CONCLUSIONS: Video-assisted thoracoscopic surgery for treatment of posttraumatic hemothorax shows excellent results in very elderly patients of 80 years or more. Despite severe comorbidity and often delayed surgery all patients recovered. We therefore conclude that advanced age is no contraindication for surgical management of posttraumatic hemothorax by means of video-assisted thoracoscopy.

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation.

BACKGROUND: Management of endoscopic retrograde cholangiopancreatography (ERCP)-associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment. METHODS: A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival. RESULTS: Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days. CONCLUSION: Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.

Intraoperative conversion and complications in robotic assisted primary and redo gastric bypass surgery.

The rise of robotic assisted surgery in the treatment of morbidly obese patients has enlarged the armamentarium for surgeons involved in bariatric surgery. This in particular is of great advantage not only in primary cases, but also in patients undergoing revisional procedures following preceding upper GI surgery. In the following, our experience with intraoperative conversions and complications in revisional robotic surgery using the Da Vinci robotic system will be reported and compared to primary robotic bypass surgery and the literature. In a 36-month period, a total of 157 minimally invasive bariatric procedures (48 robotic assisted, 109 laparoscopic) were performed. Out of 43 patients receiving a gastric bypass 32 (74%) were performed robotically. Out of these 20 (62.5%) had previous operations (RRBP): one hiatal mesh repair, one open Mason operation, eight gastric band, nine gastric sleeve, one sleeve with fundoplication. The Da Vinci Xi was used for all surgeries. 3/20 (15%) RRBP were converted to open laparotomy because of a huge left liver lobe (1), extreme adhesions (1) and short mesentery (1) (p = 0.631 vs 1/12 RBP). One out of these had to be reoperated for an insufficiency of the gastroenterostomy. 3/17 (23%) patients (RRBP) without conversion had complications: hemorrhage (1), insufficiency of biliodigestive anastomosis (1), insufficiency of gastroenterostomy (1). There was no mortality and length of hospital stay was 3.5 days in uncomplicated cases and 12.3 days in complicated cases (p < 0.05). This preliminary experience suggests, that robotic revisional surgery can be performed safely even in complicated cases. Conversion to laparoscopic or open surgery may be required when adverse anatomical conditions are present. However, the incidence of complications was not increased when conversion was performed. In this series, the incidence of complications was not greater in case of revisional surgery.

Use of extracorporeal membrane oxygenation in non-elective major thoracic surgery for infectious lung abscess.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) support for elective cardiothoracic surgery is well established. In contrast, there are not much data regarding the usefulness and outcome of ECMO in non-elective major lung resections for infectious lung abscess. METHODS: All patients undergoing non-elective major lung surgery for infectious lung abscess at 5 centres in Germany, UK and Spain were enrolled in a prospective database. Malignant disorders and intrathoracic complications of other procedures were excluded. RESULTS: There were 127 patients. The median age was 59 years (interquartile range 18.75). The mean Charlson index of comorbidity was 2.83 (standard deviation 2.57). Surgical procedures were lobectomy (89), pneumectomy (20) and segmentectomy (18). ECMO was used for 10 patients (pneumectomy 2, lobectomy 8) and several more received pre-ECMO treatment. Mortality was 17/127. Intraoperatively no ECMO-associated complications were encountered. EMCO [1/10 vs 16/117; odds ratio (OR): 0.70, 95% confidence interval (CI) 0.08-5.91, P = 0.74] and the extent of pulmonary resection were not associated with higher mortality. Preoperative sepsis (OR: 17.84, 95% CI 2.29-139.28, P < 0.01), preoperative air leak (OR: 13.12, 95% CI 4.10-42.07, P < 0.001), acute renal failure (OR: 7.00, 95% CI 2.19-22.43, P < 0.01) and Charlson index of comorbidity ≥3 (OR: 10.83, 95% CI 2.36-49.71, P < 0.01) were associated with significantly higher mortality. CONCLUSIONS: The application of ECMO is widening the possibilities for successful surgical management of infectious, non-malignant lung abscesses. Particularly, patients with marginal functional operability benefit from the availability and readiness to use ECMO. Mortality is determined by the burden of pre-existent comorbidity, severe sepsis and septic shock.

Canine Saliva as a Possible Source of Antimicrobial Resistance Genes.

While the One Health issues of intensive animal farming are commonly discussed, keeping companion animals is less associated with the interspecies headway of antimicrobial resistance. With the constant advance in veterinary standards, antibiotics are regularly applied in companion animal medicine. Due to the close coexistence of dogs and humans, dog bites and other casual encounters with dog saliva (e.g., licking the owner) are common. According to our metagenome study, based on 26 new generation sequencing canine saliva datasets from 2020 and 2021 reposited in NCBI SRA by The 10,000 Dog Genome Consortium and the Broad Institute within Darwin's Ark project, canine saliva is rich in bacteria with predictably transferable antimicrobial resistance genes (ARGs). In the genome of potentially pathogenic Bacteroides, Capnocytophaga, Corynebacterium, Fusobacterium, Pasteurella, Porphyromonas, Staphylococcus and Streptococcus species, which are some of the most relevant bacteria in dog bite infections, ARGs against aminoglycosides, carbapenems, cephalosporins, glycylcyclines, lincosamides, macrolides, oxazolidinone, penams, phenicols, pleuromutilins, streptogramins, sulfonamides and tetracyclines could be identified. Several ARGs, including ones against amoxicillin-clavulanate, the most commonly applied antimicrobial agent for dog bites, were predicted to be potentially transferable based on their association with mobile genetic elements (e.g., plasmids, prophages and integrated mobile genetic elements). According to our findings, canine saliva may be a source of transfer for ARG-rich bacteria that can either colonize the human body or transport ARGs to the host bacteriota, and thus can be considered as a risk in the spread of antimicrobial resistance.

Hybrid robotic versus hybrid laparoscopic Ivor Lewis oesophagectomy: a case-matched analysis.

OBJECTIVES: Robotic-assisted oesophagectomy for cancer has been increasingly employed worldwide; however, the benefits of this technique compared to conventional minimally invasive oesophagectomy are unclear. Since 2016, hybrid robotic minimally invasive oesophagectomy (R-HMIE) has increasingly replaced hybrid laparoscopic minimally invasive oesophagectomy (HMIE) as the standard of care in our institution. The aim of this study was to compare these procedures. METHODS: Over a 10-year period, 686 patients underwent oesophagectomy at our institution. Out of these patients, 128 patients with cancer were treated with a hybrid minimally invasive technique. Each patient who underwent R-HMIE was matched according to gender, age, comorbidity, American Society of Anesthesiologists classification, Union International Contre le Cancer stage, localization, histology and neoadjuvant treatment with a patient who underwent HMIE. Perioperative parameters were extracted from our database and compared between the 2 groups. RESULTS: After the matching procedure, 88 patients were included in the study. Between HMIE and R-HMIE, no significant differences (P > 0.05) were found in operating time (median 281 vs 300 min), R0 resection rate (n = 42 vs 42), harvested lymph nodes (median 28 vs 24), hospital stay (median 19 vs 17 days) and intensive care unit stay (median 7 vs 6.5 days). Regarding surgical complications, no difference could be observed either (n = 42 vs 44). CONCLUSIONS: Minimally invasive oesophagectomy remains a challenging operation with high morbidity even in a high-volume institution. According to our intra- and short-term results, we have found no difference between R-HMIE and HMIE.

Minimally Invasive Conversion of a Gastric Bypass into Sleeve Gastrectomy for Postprandial Hyperinsulinemic Hypoglycemia.

The treatment of postprandial hyperinsulinemic hypoglycemia following gastric bypass surgery for obesity can be challenging despite dietetic and medical treatment and eventually surgical treatment remains the exclusive treatment to resolve the problem for the patient. In the following, the experience with a conversion surgery from a complicated Roux-en-Y gastric bypass to sleeve gastrectomy using the Da Vinci robotic system will be reported.

A glimpse of antimicrobial resistance gene diversity in kefir and yoghurt.

Antimicrobial resistance (AMR) is a global threat gaining more and more practical significance every year. The main determinants of AMR are the antimicrobial resistance genes (ARGs). Since bacteria can share genetic components via horizontal gene transfer, even non-pathogenic bacteria may provide ARG to any pathogens which they become physically close to (e.g. in the human gut). In addition, fermented food naturally contains bacteria in high amounts. In this study, we examined the diversity of ARG content in various kefir and yoghurt samples (products, grains, bacterial strains) using a unified metagenomic approach. We found numerous ARGs of commonly used fermenting bacteria. Even with the strictest filter restrictions, we identified ARGs undermining the efficacy of aminocoumarins, aminoglycosides, carbapenems, cephalosporins, cephamycins, diaminopyrimidines, elfamycins, fluoroquinolones, fosfomycins, glycylcyclines, lincosamides, macrolides, monobactams, nitrofurans, nitroimidazoles, penams, penems, peptides, phenicols, rifamycins, tetracyclines and triclosan. In the case of gene lmrD, we detected genetic environment providing mobility of this ARG. Our findings support the theory that during the fermentation process, the ARG content of foods can grow due to bacterial multiplication. The results presented suggest that the starting culture strains of fermented foods should be monitored and selected in order to decrease the intake of ARGs via foods.

Traumatic oesophageal perforation: a successful management based on the Pittsburgh Perforation Severity Score.

Oesophageal perforation is a severe life-threatening clinical condition with high mortality and morbidity needing rapid interdisciplinary approach to be effectively managed. Recently, on the basis of multicentric retrospective data, we proposed a decision tree for the treatment of oesophageal perforations based on the Pittsburgh Perforation Severity Score (PSS). We now report the first case of a traumatic oesophageal perforation, which was successfully treated according to the application of the PSS decision tree.

Prognostic Value of Chest-Tube Amylase Versus C-Reactive Protein as Screening Tool for Detection of Early Anastomotic Leaks After Ivor Lewis Esophagectomy.

INTRODUCTION: Intrathoracic anastomotic leaks after esophagectomy are a significant cause of morbidity and death. Early detection and timely management are crucial. This study evaluates the effectiveness of daily drain amylase levels in detecting early leaks after esophagectomy compared with C-reactive protein (CRP). MATERIALS AND METHODS: Between June 2015 and September 2017, 126 esophagectomies were performed in our department. Amylase levels were collected in 80 of these patients, as long right-sided chest tubes were in place. Mostly, chest tubes were removed before postoperative day (POD) 5. CRP levels were measured daily. Early leaks were defined as occurring with the chest tubes in place. According to the obtained receiver operating characteristics curves, amylase levels >335 U/L, and CRP >30 mg/dL were considered positive. Sensitivity and specificity for both drain amylase and CRP were calculated. RESULTS: Overall anastomotic leak rate was 7.5% (6/80). An early disruption occurred in 4 of 80 patients (5%). Three patients had a positive amylase level and none a positive CRP on POD 1. These 3 patients had on POD 2 a positive CRP. The fourth patient presented at POD 2 bilious secretion in the chest tubes. He showed normal amylase and CRP levels on POD 1. Sensitivity and specificity for amylase level and CRP within the first 3 PODs were 0.75 and 0.98 versus 0.75 and 0.85, respectively. The patients with leak were reoperated at POD 2. They were all discharged between PODs 15 and 19. CONCLUSIONS: Amylase level after esophagectomy is a more accurate screening tool for detection of early leaks than CRP. It could facilitate their detection up to 24 hours earlier than CRP.