Intraoperative Right Colic Graft Ischemia, Followed by Delayed Oesophagoplasty Including an Ileo-Transverse Anastomosis and the Cervical Revascularisation of the Ileum: Case Report.

The ischemic complications during the isolation of the substituting oesophageal graft placement and after its placement may lead to graft necrosis and to the need to find a different reconstructive procedure. The most frequent reports of graft necroses occur in the days following the reconstruction. We are presenting the case of a 27-y.o. with full dysphagia as a result of caustic stenosis, in whose case the oesophageal reconstruction was abandoned following the irreversible ischemia of the right colic graft during the vascular isolation, followed by right-side hemicolectomy and ileo-transverse anastomosis. 4 years post the ingestion of a caustic substance and 2 years post the right colic graft ischemic necrosis, we performed an oesophageal reconstruction using a pediculated, cervically revascularized, ileo-colic graft on the left colic vessels. The graft's particularity is that is formed from left and transverse colon and ileum portions, including the ileo-transverse anastomosis performed 2 years prior to the oesophageal reconstruction.

Repair, Reconstruct, or Divert: Fate of the Perforated Esophagus.

OBJECTIVES: The aim of this study was to determine differences in esophageal perforation populations undergoing different advanced interventions for perforated esophagus and identify predictors of treatment outcomes. SUMMARY BACKGROUND DATA: Contained esophageal perforation can often be managed expectantly, but uncontained perforation is uniformly fatal without invasive intervention. Treatment options for the latter range from simple endoscopic control through advanced intervention. Clinical presentation varies greatly and directs which intervention is most appropriate. METHODS: From 1996 to 2017, 335 patients were treated for esophageal perforation, and 166 for advanced interventions: 74 primary repair with tissue flap (repair), 26 esophagectomy and gastric pull-up (resection), and 66 esophagectomy and immediate diversion with planned delayed reconstruction (resection-diversion). Patient characteristics, clinical presentation, operative outcomes, and survival were abstracted. Pittsburgh Severity Scores (PSS) were retrospectively calculated. Random survival forest analysis was performed for 90-day mortality and competing risks for reconstruction after resection-diversion. RESULTS: Repair and resection patients had lower PSS than resection-diversion patients (3 vs 3 vs 6, respectively). Ninety-day mortality for repair, resection, and resection-diversion was 11% vs 7.7% vs 23%, and 5-year survival was 71% vs 63% vs 47%. Risk of death after resection-diversion was highest within 1 year, but 52% of patients had reconstruction of the upper alimentary tract within 2 years. CONCLUSIONS: Several advanced interventions exist for critically ill patients with uncontained esophageal perforation. Repair and organ preservation are always preferred; however, patients at extremes of illness might best be treated with resection-diversion, with the understanding that the competing risk of death may preclude eventual reconstruction.

Overlap method versus functional method for esophagojejunal reconstruction using totally laparoscopic total gastrectomy.

BACKGROUND: Laparoscopic intracorporeal esophagojejunostomy (EJ) is a useful method in totally laparoscopic total gastrectomy (TLTG) for treating upper-third gastric cancer. The two methods of laparoscopic intracorporeal EJ-functional and overlap-have not been compared side-by-side in terms of safety and feasibility. METHODS: Retrospective review and analysis of the data of 490 consecutive patients who underwent TLTG by either functional method (n = 365) or overlap (n = 125) method for upper- or middle-third gastric cancer was conducted between January, 2011 and May, 2018 at Asan Medical Center (Seoul, Korea). One-to-one propensity score matching (PSM) was performed to compare age, sex, body mass index, American Society of Anesthesiologist score, the presence of comorbidity, number of comorbidities, clinical T stage, clinical nodal stage, clinical TNM stage, history of previous abdominal surgery, and combined surgery. After PSM, 244 patients were divided into functional method group and overlap method group (n = 122, each). The surgical outcomes and EJ-related complications were compared between the two groups. RESULTS: No significant difference was found between the two groups in terms of early surgical outcomes such as operative time, time to first flatus, postoperative hospital stay, transfusion during surgery, transfusion after surgery, and administration of analgesics. However, the pain score was significantly lower in overlap method group (6.21 ± 1.83) than functional method group (6.97 ± 2.09, p < 0.05). The overlap method was also associated with significantly fewer late complications (3.28% vs. 12.30%; p < 0.05), lower Clavien-Dindo classification grade (p < 0.05), and fewer EJ-related complications (0.82% vs. 6.56%; p < 0.05), as compared with the functional method. CONCLUSION: The overlap method was safer and more feasible than the functional method for TLTG in gastric cancer patients, based on the finding of significantly lower incidence of EJ-related complications.

Radiation burden in patients with esophageal atresia: a systematic review.

Esophageal atresia (EA) is the most common congenital esophageal disorder. Radiological imaging facilitates diagnosis, surgical interventions, and follow-up. Despite this, standardized monitoring guidelines are lacking. We aimed to: (1) review the literature regarding radiation burden in children with EA; (2) establish the presence of guidelines for diagnosis and follow-up in children with EA. The systematic review was performed according to PRISMA protocol. Two investigators conducted independent searches (PubMed, Ovid, Cochrane Review) and data extraction. Analysis focused on pre- and post-operative imaging type and frequency to determine the radiation burden. Seven studies met the inclusion criteria (337 patients). All authors agreed upon the need to minimize radiation burden, recommending symptoms-guided management, use of dosimeters, and non-radiating imaging. One study identified a median 130-fold increase in cumulative lifetime cancer risk in children with EA compared with other babies in the special care unit. The most common investigations were X-ray and CT (pre-operatively), and X-ray and contrast swallow (post-operatively). Standardized guidelines focused upon the frequency and type of radiological imaging for children with EA are lacking. Children with EA are subjected to more radiation exposure than the general population. Implementation of non-radiating imaging (ultrasonography, manometry) is recommended.

Long-term outcome and efficiency of symptom-selective approach to assess gastroesophageal reflux prior to gastrostomy in neurologically impaired children.

PURPOSE: To evaluate the necessity of preoperative screening for gastroesophageal reflux (GER) prior to gastrostomy in neurologically impaired children. METHODS: Medical records of neurologically impaired children, who have undergone laparoscopic gastrostomy between January, 2004 and June, 2018, were retrospectively reviewed. Before the year of 2014, all patients who required gastrostomy had been routinely screened for GER pre-operatively, but after the year of 2014, only the ones with GER-related symptoms were tested. The characteristics and outcomes of Routine Screening (RS) and Selective Screening (SS) periods were compared. RESULTS: There were 55 and 54 patients in the RS and SS periods, respectively. Demographics, primary pathologies, and mean follow-up durations (> 2 years) were similar. The rate of GER screening was significantly lower in the SS period (29.6% vs. 63.6%). The rate of Laparoscopic Nissen Fundoplication (LNF) combined with gastrostomy was significantly lower in the SS period (14.8% vs. 38.2%). During follow-up, the rates of new-onset GER symptoms (13% vs. 11.7%) and LNF requirement later on (6.5% vs. 8.8%) were statistically similar between the two periods. CONCLUSION: Routine screening for GER is not necessary prior to gastrostomy in neurologically impaired children. Symptom-selective screening algorithm is safe and efficient in the long term.

Quantifying Factors Essential to the Integrity of the Esophagogastric Junction During Antireflux Procedures.

OBJECTIVE: To quantify the contribution of key steps in antireflux surgery on compliance of the EGJ. BACKGROUND: The lower esophageal sphincter and crural diaphragm constitute the intrinsic and extrinsic sphincters of the EGJ, respectively. Interventions to treat reflux attempt to restore the integrity of the EGJ. However, there are limited data on the relative contribution of critical steps during antireflux procedures to the functional integrity of the EGJ. METHODS: Primary antireflux surgery was performed on 100 consecutive patients with pathologic reflux. Intraoperative EGJ measurements including distensibility index (DI), cross-sectional area (CSA), and HPZ length were collected using EndoFLIP. Data was acquired pre-repair, post-diaphragmatic re-approximation with sub-diaphragmatic EGJ relocation, and post-sphincter augmentation. RESULTS: Patients underwent Nissen (45%), Toupet (44%), or LINX (11%). After diaphragmatic re-approximation, DI decreased by a median 0.77 mm2/mm Hg [95%-confidence interval (CI): -0.99, -0.58; P < 0.0001], CSA decreased 16.0 mm2 (95%-CI: -20.0, -8.0; P < 0.0001), whereas HPZ length increased 0.5 cm (95%-CI: 0.5, 1.0; P < 0.0001). After sphincter augmentation, DI decreased 0.14 mm2/mm Hg (95%-CI: -0.30, -0.04; P = 0.0005) and CSA decreased 5.0 mm2 (95%-CI: -10.0, 1.0; P = 0.0.0015), whereas HPZ length increased 0.5 cm (95%-CI: 0.50, 0.54; P < 0.0001). Diaphragmatic re-approximation had a higher percent contribution to distensibility (79% vs 21%), CSA (82% vs 18%), and HPZ (60% vs 40%) than sphincter augmentation. CONCLUSION: Dynamic intraoperative monitoring demonstrates that diaphragmatic re-approximation and sub-diaphragmatic relocation has a greater effect on EGJ compliance than sphincter augmentation. As such, antireflux procedures should address both for optimal improvement of EGJ physiology.

Quantitative Assessment of Blood Flow in the Gastric Conduit With Thermal Imaging for Esophageal Reconstruction.

OBJECTIVE: The study's primary aim was to evaluate the effectiveness of thermal imaging (TI) and its secondary aim was to compare TI and indocyanine green (ICG) fluorescence angiography, with respect to the evaluation of the viability of the gastric conduit. SUMMARY BACKGROUND DATA: The optimal method for evaluating perfusion in the gastric conduit for esophageal reconstruction has not been established. METHODS: We reviewed the prospectively collected data of 263 patients who had undergone esophagectomy with gastric conduit reconstruction. TI was used in all patients. ICG fluorescence was concomitantly used in 24 patients to aid comparison with TI. A cut-off value of the anastomotic viability index (AVI) was calculated using the receiver operating characteristic curve in TI. RESULTS: Anastomotic leak was significantly less common in patients with AVI > 0.61 compared with those with AVI ≤ 0.61 (2% vs 28%, P< 0.001). Microvascular augmentation was performed in 20 patients with a low AVI score and/or preoperative chemoradiotherapy. Overall ability was comparable between TI and ICG fluorescence regarding the qualitative evaluation of the gastric conduit. However, TI was superior in the quantitative assessment of viability. CONCLUSIONS: TI could delineate the area of good perfusion in the gastric conduit for esophageal reconstruction, which can help identify patients at high risk of anastomotic leak.

Outcomes for Correction of Long-Gap Esophageal Atresia: A 22-Year Experience.

BACKGROUND: Long-gap esophageal atresia (LGEA) precludes immediate primary repair. When delayed primary esophagoesophagostomy (DPE) is not feasible, a reverse gastric tube (RGT) is a potential salvage option. The purpose of this study was to determine if DPE and RGT had both similar short-term and long-term outcomes. METHODS: A retrospective review of all EA patients from 1994 to 2016 was undertaken. Data were stratified by surgical management (DPE versus RGT). Baseline demographics, operative information, postoperative management, and complications were analyzed. Descriptive statistics were used and P-values <0.05 were considered statistically significant. RESULTS: Two hundred and eighteen patients with EA were treated during this period; 37/218 (17%) had LGEA. Mean gap length was 3.3 ± 1.2 cm. Thirty-three patients underwent some form of repair, all of which were managed initially with a gastrostomy tube feeds. Twenty-five patients underwent DPE with 89% of these never requiring revision, and 86% having excellent function with long-term follow-up. In eight patients, esophageal length was never adequate for DPE; therefore, six were reconstructed with RGT, and two underwent gastric transposition. There were no significant differences in complications, revisions, ventilator days, overall length of stay, weight percentiles, or conduit function between children undergoing RGT compared with DPE at a mean follow-up of 5.5 years. CONCLUSIONS: Surgical treatment of LGEA is complex, and controversy exists regarding the optimal repair method when DPE is not feasible. In this series, DPE after gastrostomy tube feeds often allowed for sufficient esophageal lengthening with satisfactory long-term esophageal function. However, when adequate length for DPE was not attainable, these data suggest that RGT is a viable conduit with favorable postoperative outcomes.

30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis.

INTRODUCTION: The optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018. METHODS: Demographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes. RESULTS: Of the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009). CONCLUSIONS: Among children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Linear or circular stapler? A propensity score-matched, multicenter analysis of intracorporeal esophagojejunostomy following totally laparoscopic total gastrectomy.

BACKGROUND: Presently, there is no consensus as to what procedure of intracorporeal esophagojejunostomy (EJS) in totally laparoscopic total gastrectomy (TLTG) is best to reduce postoperative complications. The aim of this study was to demonstrate the superiority of linear stapled reconstruction in terms of anastomotic-related complications for EJS in TLTG. METHODS: We collected data on 829 consecutive gastric cancer patients who underwent TLTG reconstructed by the Roux-en-Y method with radical lymphadenectomy between January 2010 and December 2016 in 13 hospitals. The patients were divided into two groups according to reconstruction method and matched by propensity score. Postoperative EJS-related complications were compared between the linear stapler (LS) and the circular stapler (CS) groups. RESULTS: After matching, data from 196 patients in each group were analyzed. The overall incidence of EJS-related complications was significantly lower in the LS group than in the CS group (4.1% vs. 11.7%, p = 0.008). The incidence of EJS anastomotic stenosis during the first year after surgery was significantly lower in the LS group than in the CS group (1.5% vs. 7.1%, p = 0.011). The incidence of EJS bleeding did not differ significantly between the groups, although no bleeding was observed in the LS group (0% vs. 2.0%, p = 0.123). The incidence of EJS leakage did not differ significantly between the groups (2.6% vs. 3.6%, p = 0.771). CONCLUSION: The use of linear stapled reconstruction is safer than the use of circular stapled reconstruction for intracorporeal EJS in TLTG because of its lower risks of stenosis.

Laparoscopic Nissen fundoplication improves disease-specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction.

INTRODUCTION: The optimal management of functional esophagogastric junction outflow obstruction (EJOO) remains controversial particularly in the setting of concomitant gastroesophageal reflux disease (GERD). There remains a paucity of data regarding the outcomes of laparoscopic Nissen fundoplication (LNF) in this patient population. We hypothesized that GERD patients with manometric findings of EJOO on preoperative manometry do not have increased rates of postoperative dysphagia compared to those with normal or hypotensive LES pressures. MATERIALS AND METHODS: This retrospective cohort study of patients undergoing LNF for GERD compared outcomes in patients with and without functional EJOO (fEJOO). The outcomes of interest included disease-specific quality of life improvement, dysphagia scores, and the need for endoscopic dilation following fundoplication. RESULTS: Two hundred and eleven patients underwent LNF for GERD and 15 (7.1%) were classified as having fEJOO. Baseline GERD-HRQL [30.0 (21.5-37) vs. 31 (21-37), p = 0.57] were similar between fEJOO and control patients, respectively. There was no difference in baseline dysphagia scores [3.5 (2-5) vs. 2.0 (1-4), p = 0.64] between the two groups. Postoperative GERD-HRQL [5.0 (2-13) vs. 4.0 (1-8), p = 0.59] scores did not differ between fEJOO and control patients at 6-week follow-up. One year after surgery, GERD-HRQL [8.0 (3-9) vs. 4.5 (2-13), p = 0.97] did not differ between groups. Dysphagia rates were similar at 6-week (p = 0.78) and 1-year follow-ups (p = 0.96). The need for dilation at 1 year following fundoplication was similar in both cohorts (13%, p = 0.96). CONCLUSION: GERD patients with functional EJOO achieved similar improvements in disease-specific quality of life without increased incidence of dysphagia postoperatively.

A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective.

BACKGROUND: Medication-refractory gastroesophageal reflux disease (GERD) is sometimes treated with laparoscopic Nissen fundoplication (LNF); however, this is a non-reversible procedure associated with important side effects and the need for repeat surgery. Removable magnetic sphincter augmentation (MSA) devices are an alternative, effective, and safe treatment option for such patients who have some lower esophageal sphincter function. The objective of this study was to assess the economic impact of introducing MSA technology (i.e., LINX Reflux Management System) into current practice from a US-payer perspective. METHODS: An economic budget impact model was developed over a 1-year time horizon that compared current treatment of GERD patients who are medically managed (but refractory) or receiving LNF to future treatment of GERD patients that included a mix of patients treated with medical management only, LNF, or MSA. Resources included within the analyses were index procedures (inpatient and outpatient use), reoperations (revisions and removals), readmissions, healthcare visits, diagnostic tests, procedures, and medications. Medicare payment rates were typically used to inform unit costs. RESULTS: Assuming a hypothetical commercial insurance population of 1 million members, the base-case analysis estimated a net cost savings of $111,367 with introduction of the MSA. This translates to a savings of $0.01 per member per month. Results were largely driven by avoided inpatient procedures with use of the MSA device. Alternative analyses exploring the potential impact of increasing surgical volumes predicted that results would remain cost saving if the proportion of MSA market share taken from LNF was ≥ 90%. CONCLUSIONS: This study predicts that the introduction of the MSA device would lead to favorable budget impact results for the treatment of medication-refractory mechanical GERD for commercial payers. Future analyses will benefit from inclusion of middle-ground treatments as well as longer time horizons.

Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system.

INTRODUCTION: Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective. METHODS AND PROCEDURES: This prospective observational study was performed in conjunction with the region's largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members' claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups. RESULTS: There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195-14,439) for those who underwent MSA and $13,388 (9951-16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10). CONCLUSION: When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.

Evaluation of the Associations between Gastric Tube Preparation Methods and the Incidence of Cervical Anastomotic Leakage after Esophagectomy for Thoracic Esophageal Cancer.

BACKGROUND: A gastric tube (GT) is most often selected as a reconstruction conduit in esophageal reconstruction. Although some leakage from esophagogastric anastomoses is induced by blood flow failure in reconstruction conduits, the association between the GT and the anastomotic leakage (AL) is unclear. OBJECTIVES: We retrospectively evaluated the incidence of AL according to the GT shape. METHODS: Between February 2013 and September 2017, 188 consecutive patients who underwent esophagectomy with GT reconstruction were enrolled in this cohort study. We performed GT reconstruction using a narrow GT (Gr.N) until May 2016. Subsequently, we began preparing and using a stretched GT (Gr.S). RESULTS: AL occurred in 29 of 188 (15.4%) patients. The frequency of AL was lower with Gr.S than with Gr.N (p = 0.034). Sex, body mass index, Brinkman index, hypertension, and anemia were significantly associated with AL (p = 0.033, 0.041, 0.003, 0.030, and 0.042, respectively). In a multivariate logistic regression analysis, the GT shape and the Brinkman index were shown to be independent risk factors for AL (p = 0.016 and 0.020, respectively). CONCLUSIONS: The GT preparation method is an independent risk factor for AL after cervical esophagogastrostomy. Thus, improved GT preparation methods could contribute to the reduction of AL after esophagectomy.

The value of prophylactic chest tubes in tracheoesophageal fistula repair.

PURPOSE: Intraoperative chest tubes (IOCTs) can be placed during esophageal atresia/tracheoesophageal fistula (EA/TEF) repair to control pneumothoraces and detect esophageal leaks, potentially preventing the need for postoperative chest tubes (POCTs). However, data are lacking regarding IOCTs' effect. We hypothesized that IOCT placement would not reduce the risk of POCT placement and would increase hospital length of stay (LOS). METHODS: This was a single-center case-control study of type C EA/TEF patients repaired at a tertiary referral center between 2006 and 2017. Postoperative complications of patients who received IOCTs (n = 83) were compared to that of patients who did not receive IOCTs (n = 26). Patients were compared via propensity score matching. Additionally, sensitivity analyses excluding low birth weight (LBW) patients and patients undergoing delayed esophageal anastomosis were also performed. RESULTS: There was no significant difference in rates of pneumothoraces or esophageal leaks between the IOCT and no-IOCT groups, nor were either of these complications detected earlier in the IOCT group. Rates of POCT placement and mortality also did not differ between groups. IOCT patients were associated with increased hospital LOS (28 vs 15.5 days, p < 0.001) and esophageal strictures (30% vs 8%, p = 0.04) requiring a return to the operating room (RTOR). CONCLUSION: IOCTs did not improve outcomes in EA/TEF repair. IOCTs seem associated with increased LOS and ROTR for esophageal stricture, suggesting that IOCTs may not be beneficial after EA/TEF repair.

[Quality of life after reconstructive procedures for esophageal strictures]. / Otsenka kachestva zhizni bol'nykh posle rekonstruktivnykh operatsii pri rubtsovykh suzheniyakh pishchevoda.

OBJECTIVE: To study the long-term results of reconstructive procedures for esophageal strictures and evaluate quality life after each type of esophageal repair using own criteria. MATERIAL AND METHODS: The study was conducted among patients who underwent esophageal repair with gastric transplant (172), colonic transplant (25), intestinal transplant (14) and repair of short cervical strictures (7). The age of patients ranged from 5 to 60 years. All patients underwent X-ray and endoscopic examination. Survey also included external respiration function and cardiac function, digestive function, measurement of height and weight, analysis of social aspects (work, study), female genital function. Five-score scale for quality of life assessment was developed. RESULTS: Long-term results were studied in 218 patients for the period from 3 months to 31 years (2002-2017). Excellent and good results were obtained in 180 patients. The best results were obtained after repair of short cervical strictures (4.42 scores), good results - after esophageal repair with gastric (4.14 scores) and intestinal (4.07 scores) transplants. Colonic repair was followed by satisfactory outcome (3.16 scores). CONCLUSION: Gastric and small bowel grafts are preferred for total esophageal repair due to better quality of life in long-term postoperative period.

Risk factors associated with increased drainage volumes of chest tubes after transthoracic esophagectomy for esophageal cancer.

PURPOSE: Prolonged chest drain placement can extend the postoperative hospital stay after esophagectomy in esophageal cancer (EC) patients. This study aimed to identify whether or not the risk factors associated with this prolonged chest tube placement are clinically important. METHODS: A total of 138 patients who underwent subtotal esophagectomy for thoracic EC were retrospectively analyzed. Using the 75th percentile of the total drainage volume of chest tubes as a cutoff value, the high-output (HO; n = 35) and low-output (LO; n = 103) groups were compared in terms of the clinicopathological parameters. RESULTS: The median durations of right and left chest tube placement were 6 and 9 days, respectively, with a median total drainage volume of 2692 ml. When compared with the LO group, the HO group was significantly associated with male gender, a subcutaneous route for reconstruction, blood transfusion, higher morbidity, and prolonged chest drainage and postoperative hospital stays. A multivariable analysis further identified blood loss (p = 0.03) and the subcutaneous route for reconstruction (p = 0.04) as independent risk factors for increased chest tube drainage after esophagectomy. CONCLUSION: Blood loss and the subcutaneous route of reconstruction are risk factors for increased drainage of chest tube after esophagectomy for EC.

Esophageal reconstruction after oncological total laryngopharyngoesophagectomy: Algorithmic approach.

BACKGROUND: Reconstruction for total laryngopharyngoesophagectomy is accomplished mainly by gastrointestinal transposition but can be complicated by anastomotic tension or associated neck-skin defect. Here, we present the results of total esophageal reconstruction by gastrointestinal transposition alone or with additional free tissue transfer and propose an algorithm accordingly. METHODS: We reviewed patients who had oncologic total laryngopharyngoesophagectomy between January 2012 and January 2016. Twenty-four men and one woman were included with a mean age of 54 (range, 41-72) years. Patients were grouped by reconstruction into the gastric pull-up (GP, n = 15), colon interposition (CI, n = 2), GP combined with free jejunal flap (GPFJ, n = 6), or GP combined with anterolateral thigh flap (GPALT, n = 2) group to compare clinical outcomes. RESULTS: The mean operation time was 1037.3 minutes and was significantly longer in the GPALT group than in the GP group (1235.0 ± 50.0 minutes vs. 929.7 ± 137.7 minutes, p =.009). All flaps survived. After a mean follow-up of 18 months, the overall leakage, stricture, and successful swallowing rates were 44%, 4%, and 76%, respectively. There was no significant difference in the leakage (53.3%, 50.0%, 16.7%, and 50.0%, p =.581), stricture (6.7%, 0%, 0%, and 0%, p = 1.000), or successful swallowing (73.3%, 50.0%, 83.3%, and 100%, p =.783) rates between GP, CI, GPFJ, and GPALT groups, respectively. CONCLUSIONS: The proposed algorithm that ranks gastric pull-up as a priority and uses additional free tissue transfer to overcome the anastomotic tension or associated neck-skin defect is feasible.

The multi-disciplinary management of complex congenital and acquired tracheo-oesophageal fistulae.

AIM OF THE STUDY: Complex tracheo-oesophageal fistulae (TOF) are rare congenital or acquired conditions in children. We discuss here a multidisciplinary (MDT) approach adopted over the past 5 years. METHODS: We retrospectively collected data on all patients with recurrent or acquired TOF managed at a single institution. All cases were investigated with neck and thorax CT scan. Other investigations included flexible bronchoscopy and bronchogram (B&B), microlaryngobronchoscopy (MLB) and oesophagoscopy. All cases were subsequently discussed in an MDT meeting on an emergent basis if necessary. MAIN RESULTS: 14 patients were referred during this study period of which half had a congenital aetiology and the other half were acquired. The latter included button battery ingestions (5/7) and iatrogenic injuries during oesophageal atresia (OA) repair. Surgical repair was performed on cardiac bypass in 3/7 cases of recurrent congenital fistulae and all cases of acquired fistulae. Post-operatively, 9/14 (64%) patients suffered complications including anastomotic leak (1), bilateral vocal cord paresis (1), further recurrence (1), and mortality (1). Ten patients continue to receive surgical input encompassing tracheal/oesophageal stents and dilatations. CONCLUSIONS: MDT approach to complex cases is becoming increasingly common across all specialties and is important in making decisions in these difficult cases. The benefits include shared experience of rare cases and full access to multidisciplinary expertise.

Comparison of Outcomes of Total Esophageal Reconstruction With Supercharged Jejunal Flap, Colonic Interposition, and Gastric Pull-up.

BACKGROUND: Esophageal reconstruction following esophagectomy is a complex operation with significant morbidity. Gastric pull-up (GPU) has historically been the first-line operation followed by the colonic interposition (CI) graft, but recently, the use of a pedicled, supercharged jejunal flap (SJF) has reemerged as an alternative. However, comprehensive reports on outcomes of SJFs remain limited, with exceedingly few direct comparisons of outcomes. METHODS: A retrospective chart review was completed for patients who underwent thoracic or total esophageal reconstruction between 2004 and 2014 at a single institution. A comparison of patient characteristics and outcomes was performed for 15 patients reconstructed with an SJF, 4 with CI, and 85 with GPU. RESULTS: Ten patients in the SJF group and 3 in the CI group underwent prior GPU with complications resulting in esophageal discontinuity. The CI group had significantly longer intensive care and overall hospital stays than either other group. Forty percent (SJF), 100% (CI), and 56% (GPU) experienced at least 1 complication during their postoperative hospitalization, most frequently bowel obstruction after SJF, anastomotic leak (CI), and pulmonary complications and arrhythmias (GPU). Rates of anastomotic leakage were 13% (GPU), 75% (CI), and 13% (SJF). Reoperation was required in 27% following SJF compared with 75% following CI and 19% following GPU. There was 1 CI graft failure and no SJF failures. CONCLUSIONS: The SJF is a reasonable first-line option for esophageal reconstruction, with comparable recovery, complication rate, and functional outcomes compared with the traditional GPU. When the stomach is unavailable, the SJF is superior to CI.