Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial.

Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5 days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.

Surface microdialysis measures local tissue metabolism after Ivor Lewis esophagectomy; an attempt to predict anastomotic defect.

Anastomotic defect (AD) after esophagectomy can lead to severe complications with need for surgical or endoscopic intervention. Early detection enables early treatment and can limit the consequences of the AD. As of today, there are limited methods to predict AD. In this study, we have used microdialysis (MD) to measure local metabolism at the intrathoracic anastomosis. Feasibility and possible diagnostic use were investigated. Sixty patients planned for Ivor Lewis esophagectomy were enrolled. After construction of the anastomosis, surface MD (S-MD) probes were attached to the outer surface of the esophageal remnant and the gastric conduit in close vicinity of the anastomosis and left in place for 7 postoperative days (PODs). Continuous sampling of local tissue concentrations of metabolic substances (glucose, lactate, and pyruvate) was performed postoperatively. Outcome, defined as AD or not according to Esophagectomy Complications Consensus Group definitions, was recorded at discharge or at first postoperative follow up. Difference in concentrations of metabolic substances was analyzed retrospectively between the two groups by means of artificial neural network technique. S-MD probes can be attached and removed from the gastric tube reconstruction without any adverse events. Deviating metabolite concentrations on POD 1 were associated with later development of AD. In subjects who developed AD, no difference in metabolic concentrations between the esophageal and the gastric probe was recorded. The technical failure rate of the MD probes/procedure was high. S-MD can be used in a clinical setting after Ivor Lewis esophagectomy. Deviation in local tissue metabolism on POD 1 seems to be associated with development of AD. Further development of MD probes and procedure is required to reduce technical failure.

Early endoscopic assessment after esophagectomy can predict anastomotic complications: a novel scoring system.

BACKGROUND: Anastomotic leakage after esophagectomy is a serious and demanding complication. Early detection and treatment can probably prevent clinical deterioration of the patient. We have used early endoscopic assessment and a novel endoscopy score to predict anastomotic complications. METHODS: 57 patients planned for Ivor Lewis esophagectomy were included. Endoscopy videos were recorded and biopsies were taken from the gastric conduit on day 7 or 8 after esophagectomy. A scoring system based on the endoscopic appearance, the combined endoscopy score (0-6), was developed. Scoring of the videos was done blinded. Patient outcome with regards to anastomotic complications was registered on postoperative day 30 in accordance with the ECCG definitions and compared to histopathology assessment and the combined endoscopy score retrospectively. RESULTS: The rate of anastomotic defect (necrosis and leakage, ECCG definitions) was 19%. 7 out of 8 patients with a combined endoscopy score of ≥ 4 developed anastomotic defects. The combined endoscopy score was the only predictor for anastomotic complications. CONCLUSION: Prediction of anastomotic complications enables early detection and treatment which often limits the clinical extent of the complication. Early postoperative endoscopy is safe and a relatively simple procedure. The combined endoscopy score is an accurate tool to predict anastomotic complications.

Third time recurrent Boerhaave's syndrome: a case report.

BACKGROUND: Effort rupture of the esophagus or Boerhaave's syndrome is a rare entity, and prognosis is largely dependent on early diagnosis and treatment. Recurrent effort ruptures are very rare, only reported in a few case reports in English literature. We present a case with a third time effort rupture, and to the best of our knowledge there are no such previous publications. Furthermore, the presented case is also distinct because each episode was treated by different methods, reflecting the pathophysiology of recurrent disease as well as the last decade's advancements in the management of esophageal perforations in our clinic and globally. CASE PRESENTATION: The patient is a 60-year-old White male, suffering from alcohol abuse, mild reflux esophagitis, and a history of effort esophageal ruptures on two previous occasions. He was now admitted to our ward once again because of a third bout of Boerhaave's syndrome. The first time, 10 years ago, he was managed by thoracotomy and laparotomy with primary repair, and the second time, 5 years ago, by transhiatal mediastinal drainage through a laparotomy and endoscopic stent placement. Now he was successfully managed by endovascular vacuum-assisted closure therapy alone. CONCLUSIONS: Recurrent cases of Boerhaave's syndrome are very rare, and treatment must be tailored individually. The basic rationale is, however, no different from primary disease: (1) early diagnosis, (2) adequate drainage of extraesophageal contamination, and (3) restoration of esophageal integrity. Recurrent disease is usually contained and exceptionally suitable for primary endoscopic treatment. To cover the full panorama and difficult nature of complex esophageal disease, endoscopic modalities such as stent placement and endovascular vacuum-assisted closure, as well as the capacity for prompt extensive surgical interventions such as esophagectomy, should be readily accessible within every modern esophageal center.

Hospital costs and health-related quality of life from complications after esophagectomy.

BACKGROUND: Approximately 50% of all patients undergoing esophagectomy experience complications. This paper estimates the costs due to complications after esophagectomy in a Swedish context. MATERIAL AND METHODS: The Swedish National Register for Esophageal and Gastric Cancer (NREV) and the Healthcare Consumption Register in Region Skåne (RSVD) were crossmatched for patients undergoing esophagectomy between 2010 and 2015 in Region Skåne, Sweden (n = 132). Multivariable linear regression analysis was performed on the logarithm of total healthcare cost. HRQoL was presented descriptively. RESULTS: The mean total healthcare costs were 335,016 SEK (€33,502) for the group with no complications and 438,320 SEK (€43,832) and 808,461 SEK (€80,846) for minor and major complications (p < 0.001), respectively. Pneumonia (p < 0.001), laryngeal nerve paresis (p = 0.002) and other complications (p < 0.001) showed significant associations with increased healthcare cost. No significant difference was found in QALY-weights between the complication grades. Patients that underwent esophagectomy reported poorer HRQoL than the scores valued by the general background population. CONCLUSION: Complications following esophagectomy incrementally increase the healthcare costs, where more severe complications led to higher healthcare costs. The severity of complications did not affect the mean QALY-weights.

Surface Microdialysis Detects Ischemia After Esophageal Resection-An Experimental Animal Study.

BACKGROUND: After an esophageal resection, continuity is commonly restored by a gastric tube reconstruction and an intrathoracic anastomosis to the remaining proximal esophagus. Ischemia of the anastomotic region is considered to play a pivotal role in anastomotic leakage. Microdialysis (µD) is an excellent method to measure local biochemical substances and parameters in a specific organ or compartment aiming at early detection of ischemia. This animal study evaluates ischemia of the gastric tube reconstruction using a novel method-µD on organ surfaces. This promising method may have the potential to detect an anastomotic leakage before clinical symptoms develop. METHODS: Anesthetized normoventilated pigs were used. Surface microdialysis (S-µD) catheters and an intraparenchymal oxygen tension catheter were placed on the stomach. A gastric tube was made and the gastroepiploic artery was divided halfway along the greater curvature to produce severe ischemia at the top of the gastric tube. µD data from four locations (gastric tube, ileum and peritoneal cavity) were recorded every 20 min during the experiment. Tissue samples from all catheter sites underwent histopathological analysis. Intraparenchymal oxygen partial pressure, systemic blood tests, and hemodynamic parameters were recorded. RESULTS: S-µD data showed values indicating severe ischemia at the top of the gastric tube and intermediate ischemia at the level of transection of the gastroepiploic artery. Ischemia was verified by histopathological analysis of tissue samples and intraparenchymal oxygen tension data. CONCLUSIONS: S-µD can detect and grade severity of local ischemia in real time, in an animal model.

Surface microdialysis on small bowel serosa in monitoring of ischemia.

BACKGROUND: Ischemic injury of an organ causes metabolic change from aerobic to anaerobic metabolism. It has been shown in experimental studies on the heart and liver that such conversion may be detected by conventional microdialysis probes placed intra-parenchymatously, as well as on organ surfaces, by assaying lactate, pyruvate, glucose, and glycerol in dialysate. We developed a microdialysis probe (S-µD) intended for use solely on organ surfaces. The aim of this study was to assess whether the newly developed S-µD probe could be used for detection and monitoring of small bowel ischemia. METHODS: In anesthetized normoventilated pigs, a control S-µD probe was applied on the jejunal serosa 50 cm downstream from the duodenojejunal junction (DJJ). Starting 100 cm from DJJ, a 100-cm long ischemic segment was created by division of all mesenteric vessels. S-µDs were applied at 2.5, 5, 20, and 50 cm from the starting point of ischemia by serosal sutures. A standard µD probe was placed in the abdominal cavity as a further control. Dialysate was harvested before inducing ischemia and subsequently every 20 min for 4 h. Central venous blood was drawn every hour to monitor systemic lactate, C-reactive protein, and white blood cell count. RESULTS: Microdialysis lactate levels were significantly higher than baseline from 20 min on into protocol time in the ischemic segment and in the control S-µD probe. The peritoneal cavity probe showed no significant elevation. Lactate levels from the ischemic segment reached a plateau at 60 min. Courses of pyruvate, glucose, and glycerol levels were in accordance with transition from an aerobic to anaerobic metabolism in the bowel wall. No statistically significant changes in hemoglobin, white blood cell count, or lactate values in central venous blood were recorded. CONCLUSIONS: Assaying the aforementioned compounds in dialysate, harvested by the newly developed S-µD probe, allowed detection and monitoring of small bowel ischemia from 20 min on following its onset.

Morbidity related to defunctioning loop ileostomy in low anterior resection.

AIM: A defunctioning loop ileostomy in low anterior resection reduces the incidence and morbidity of an anastomotic leakage, but complications related to the stoma may occur. We explored stoma-associated complications during the stoma period and after stoma reversal. METHODS: A retrospective analysis of rectal cancer patients operated with low anterior resection and a defunctioning loop ileostomy at Helsingborg Hospital and Malmö University Hospital from January 2007 to June 2009 was undertaken. RESULTS: Ninety-two patients were included, of whom 82 (89 %) underwent stoma reversal. The median stoma period was 6.2 ± 3.2 months. Sixty-six percent of the patients suffered from minor or major stoma-associated morbidity. The complication rate was significantly related to the stoma time (p < 0.01). Twenty-nine percent (27/92) had at least one episode of dehydration, leading to readmittance in half of the cases. Elderly patients were more prone to develop dehydration. Dehydration most commonly occurred early in the postoperative period (mean, 5.8 weeks). The mean hospital stay for stoma reversal was 6.5 ± 4.0 days. Forty percent (33/82) had some complication associated with the reversal. CONCLUSION: This study indicates high morbidity associated with defunctioning loop ileostomy. Our data suggest that the stoma time should be limited to reduce complications. Monitoring and early stoma reversal should be considered in elderly patients. Furthermore, stoma reversal is not uneventful, and more studies are needed to address how to minimize complications.