Gastric peroral endoscopic myotomy (GPOEM) for severe gastroparesis after lung transplantation: A promising minimally invasive option.

BACKGROUND: After lung transplantation (LT), gastroparesis is frequent, occurring in 25-63% of cases and leading to pulmonary infections. In refractory disease, classical management has demonstrated limited efficacy. Gastric peroral endoscopic myotomy (G-POEM) is a recently developed safe and effective procedure that has been performed here on five patients with severe post-LT gastroparesis. METHODS: In all patients, the diagnosis was confirmed by disturbed gastric emptying scintigraphy and GCSI calculation showing severe disease. Upper gastrointestinal endoscopies confirmed the absence of organic lesions. All patients were informed about the procedure and signed informed consent forms. The procedure consisted of performing an endoscopic pyloromyotomy under general anesthesia. RESULTS: The patients were between 35 and 64 years of age. Four had chronic disease, starting approximately 1 year following LT, and one had acute, severe gastroparesis requiring intubation in the intensive care unit. All patients underwent G-POEM after failure of medical treatment, without any complications. Three of the patients with chronic disease improved; they resumed a normal diet and gained weight. The patient with acute disease was discharged within a few days following the procedure and resumed oral intake. CONCLUSION: G-POEM is promising for managing post-LT refractory gastroparesis and should be further evaluated.

Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers: An International Consensus Statement.

This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice. Background: Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally. Methods: This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume. Results: In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks. Conclusions: Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.

Pleural packing, revisional surgeries, and delayed chest closure: A salvage strategy in lung transplant.

Coagulopathy during lung transplantation leads to 2 major problems: first, control of diffuse bleeding becomes challenging and second, massive lung edema can cause significant volume expansion. To control these potentially lethal complications, we used a combined technique of pleural packing and delayed chest wall closure with negative pressure wound therapy. We retrospectively reviewed 100 bilateral lung transplants performed in our institute over the past 30 months and identified 7 cases of coagulopathy. Five of the 7 were weaned from pleural packing and ECMO, and had a secondary chest wall closure. The combination of pleural packing and delayed wall closure is a effective management option in cases of coagulopathy and lung edema.