Endoscopic Management of Esophageal Anastomotic Leaks After Surgery for Malignant Disease.

BACKGROUND: Esophageal anastomotic leaks after cancer surgery remain a major cause of morbidity and mortality. Endoscopic interventions, including covered metal stents (cSEMS), clips, and direct percutaneous endoscopic jejunostomy (dPEJ) tubes are increasingly used despite limited published data regarding their utility in this setting. This study aimed to determine the efficacy and safety of a multimodality endoscopic approach to anastomotic leak management after operation for esophageal or gastric cancer. METHODS: We performed a retrospective review of prospectively maintained databases of gastric and esophageal operations at our hospital between January 2003 and December 2012. Included patients had an operation for esophageal or gastric cancer, demonstrated evidence of an anastomotic leak at the esophageal anastomosis, and underwent attempted endoscopic therapy. Healing was defined as clinical and radiographic leak resolution. RESULTS: Forty-nine patients with leaks underwent endoscopic management. Of the 49 patients, 31 (63%) received cSEMS, 40 (82%) had dPEJ tubes inserted, and 3 (6%) received clips. Twenty-three (47%) patients underwent a combined approach. Overall, 88% of patients achieved healing in a median of 83 days. Twenty-two of 23 patients (96%) who underwent a multimodality endoscopic approach healed. Only 1 patient had a major complication associated with stent erosion into the pulmonary artery, which was successfully treated with operative repair. CONCLUSIONS: Esophageal anastomotic leaks after esophageal and gastric cancer operations can be managed successfully and safely with endoscopic therapy. Combining cSEMS for leak control and dPEJ tube placement for nutritional support was highly effective in achieving healing, without the need for surgical repair.

Can the cognitively impaired safely use patient-controlled analgesia?

Although patient-controlled analgesia (PCA) is considered the standard in postoperative pain control, research examining PCA use among cognitively impaired older adults is lacking. The authors reviewed a case series of 10 adults aged 65 years and older admitted to the geriatrics or orthopedic services of an urban tertiary care center in New York City with acute pain and cognitive impairment or dementia who were administered PCA. Four patients from this cohort are presented in detail, demonstrating the challenges of PCA use in this population. A series of clinical pearls follows each case, outlining strategies for improving pain management. The authors' findings suggest that cognitive evaluations limited to alertness and orientation and failure to perform functional assessments may binder the identification of patients who are poor candidates for PCA. Once PCA has been initiated, clinicians must regularly review device use and document cognitive function and pain score patterns to identify PCA underuse or misuse. Finally, rapid fluctuations in cognitive or functional status may require adoption of a more flexible pain management strategy. Despite these challenges, a subset of cognitively impaired older adults can successfully understand and operate PCA devices. Additional research is needed to (1) develop screening tools for identifying and monitoring older adults who may benefit from PCA and (2) create innovative approaches for improving pain management in the cognitively impaired.