Robotic-assisted minimally invasive esophagectomy - our first experience.

INTRODUCTION: Minimally invasive esophagectomy is associated with lower postoperative morbidity and better quality of life compared to open esophagectomy in patients with comparable oncological outcomes. Robotic-assisted surgery represents the next step in the development of mini- mally invasive surgery. We aim to present the results of a pilot cohort of patients undergoing robotic-assisted minimally invasive esophagectomy (RAMIE). METHODS: An initial cohort of patients with RAMIE was retrospectively analyzed. Operative characteristics, histopathological results, postoperative course, incidence of complications, and postoperative mortality were evaluated. RESULTS: From 3/2022 to 6/2023, a total of 31 patients underwent RAMIE at our institution, including hybrid RAMIE (robotic abdomen, open chest) in 11 and total RAMIE in 20 patients. Most patients were male, had locally advanced tumors, predominantly adenocarcinoma and neoadjuvant treat- ment. Thirty patients had Ivor-Lewis and one patient had McKeown esophagectomy. The median total operative time was 495 minutes and median blood loss was 200 mL. R0 resection was achieved in 87% of patients. A median of 26 lymph nodes were removed. Postoperative Clavien-Dindo ≥3 complications occurred in 9 (29%) patients. Four (13%) patients required reoperation. Anastomotic leak was found in 5 (16%) and pneumonia in 9 (29%) patients. The median hospital stay was 9 days. One patient died in the postoperative period. Thirty-day and 90-day mortality rates were 0% and 3.2%, respectively. CONCLUSION: Our initial experience shows that RAMIE is a safe surgical procedure and we consider its implementation at our institution to be success- ful. After overcoming the learning curve, we hope to reduce the operative time and increase the medical benefit for the patient.

Treatment of anastomotic leak after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic leak (AL) is one of the most serious surgical complications after esophagectomy. Endoscopic, radiological and surgical methods are used in the treatment of AL. The aim of this study was to retrospectively evaluate our therapeutic procedures and results of AL treatment after Ivor Lewis esophagectomy (ILE). METHODS: Retrospective audit of all ILEs performed in the years 20052019. Evaluation of AL treatment results according to Esophagectomy Complication Consensus Group (ECCG) classification and according to the primary therapeutic procedure with a focus on the treatment with esophageal stent. RESULTS: Out of 817 patients with ILE, AL was detected in 80 patients (9.8%): ECCG type I 33 (41%), type II 23 (29%) and type III 24 (30%) patients. Some 33 patients (41%) were treated conservatively. Esophageal stents were used in 39 patients (49%), of which 18 (23%) had concomitant percutaneous drainage and 17 (21%) were reoperated. Reoperation without a stent insertion was performed in 7 patients (9%). Esophageal diversion with cervical esophagostomy was performed in a total of 16 patients (20%). Esophageal stent treatment was successful in 24/39 patients (62%). Airway fistula occurred in 4 patients treated with stent (10%). Endoscopic vacuum therapy was successfully used in three patients after stent failure. Eight patients (10%) died as a result of AL. Mortality of AL type I, II and III was 0%, 4% and 29%. CONCLUSION: Successful treatment of AL requires an individual and multidisciplinary approach. The primary effort should aim to preserve anastomosis using endoscopic and radiological methods. In case of insufficient clinical effect, we recommend not to hesitate with reoperation. If primary therapy fails, the life-saving procedure is a cervical esophagostomy.

[18 F]Fluorodeoxyglucose PET/CT and prediction of histopathological response to neoadjuvant chemotherapy for adenocarcinoma of the oesophagus and oesophagogastric junction.

BACKGROUND: The aim of this prospective study was to assess whether [18 F]fluorodeoxyglucose PET can be used to predict histopathological response early in the course of neoadjuvant chemotherapy in patients with adenocarcinoma of the oesophagus and oesophagogastric junction. METHODS: Following the PET response criteria in solid tumours (PERCIST 1.0) as a standardized method for semiquantitative assessment of metabolic response, FDG-PET/CT was performed before (PET1) and after (PET2) initiation of the first cycle of chemotherapy. The relative changes in the peak standardized uptake value (ΔSUL) and total lesion glycolysis (ΔTLG) between PET1 and PET2 were correlated with histopathological response, defined as less than 50 per cent viable tumour cells in the resection specimen. A receiver operating characteristic (ROC) curve analysis was used to identify the optimal cut-off value with the highest accuracy of histopathological response prediction. RESULTS: PET2 was performed a median of 16 (range 12-22) days after the start of chemotherapy. Some 27 of 90 patients who underwent surgery had a histopathological response. There was no association between the median ΔSUL or median ΔTLG and the histopathological response. A post hoc analysis in 47 patients with PET2 performed 16 days or less after the start of chemotherapy showed that ΔTLG, but not ΔSUL, was associated with the histopathological response (P = 0·009). The optimal cut-off value of ΔTLG was 66 per cent or more. CONCLUSION: FDG-PET/CT after the first cycle of chemotherapy does not predict histopathological response in patients with adenocarcinoma of the oesophagus and oesophagogastric junction.

[Intramural haematoma of the oesophagus - a case report and literature review]. / Intramurální hematom jícnu - kazuistika a prehled literatury.

Intramural hematoma of the oesophagus is a rare diagnosis presenting with retrosternal pain, dysphagia and haematemesis. It is caused by barotrauma or direct injury to the esophagus, or it may occur spontaneously without apparent cause, which is more common in patients taking antiplatelet or anticoagulant medications. In most cases, treatment is conservative. Rarely, endoscopic, endovascular or surgical treatment is effective. This article presents a case report of a female patient with spontaneous haematoma of the oesophagus solved conservatively and discusses further possibilities of the course and treatment of the disease.Key words: intramural haematoma of the oesophagus IHE.

[Are antibiotics necessary in the treatment of uncomplicated diverticulitis?]. / Jsou nutná antibiotika v lécbe nekomplikované divertikulitidy?

INTRODUCTION: This paper deals with the results of recently published studies on the importance of the use of antibiotics in the treatment of uncomplicated diverticulitis. It is based on the articles available in the Medline database. CONCLUSION: The prevalence of diverticulosis in the developed countries of the Western world is increasing and, along with it, the costs of treatment of diverticulitis. The use of antibiotics in the treatment of uncomplicated diverticulitis does not reduce the incidence of complications or shorten the treatment, nor does it reduce the risk of recurrence.

The effect of postoperative pain treatment on the incidence of anastomotic insufficiency after rectal and rectosigmoideal surgery.

The aim of prospective study was to evaluate the pain relief in the postoperative period and consumption of opioid and non-opioid analgesics as a risk factor of the anastomotic insufficiency after rectal and rectosigmoideal resection for carcinoma. Anastomotic insufficiency is one of the most feared and life threatening early complications. No articles about the effect of the response to opioid therapy in the postoperative period on the risk of this major clinical problem have been published. We compared the effect of opioid and non-opioid analgesics in 109 patients who underwent rectal and rectosigmoideal resection in a prospective study. We evaluated the appearance of anastomotic insufficiency and clinical conditions in the relationship with the pain relief in the postoperative period and consumption of opioid and non-opioid analgesics. The pain intensity and the consumption of analgesics were significantly increased in the group of nonresponders. The rate of PONV (postoperative nausea and vomiting) in the responders and nonresponders groups was 69% and 78%, respectively. However, the differences did not reach significant level. Other clinical conditions were not significantly different between the both groups, too. The difference in the incidence of anastomotic insufficiency between both groups was highly significant, 6% cases of anastomotic insufficiency in the responders group and 19% in nonresponders group (χ2 = 7.73; p=0.0054). Nonrespoders to opioid therapy and their high consumption of second-line analgesics is a high risk factor for anastomotic insufficiency.

[Esophageal perforation]. / Perforace jícnu.

OBJECTIVE: Evaluation of patients with acute esophageal perforations with single institution experience. MATERIAL AND METHODS: The authors evaluate the set of 64 consecutive patients with esophageal perforation treated in our department between January 2000 and December 2010. In all patients were before decision making performed CT scans and X-ray examination with contrast agent administration. For selected patients was also accompanied upper endoscopy. Excluded were patients with malignant tracheoesophageal fistula and patients with perforation of malignant stenosis treated with palliative intent. RESULTS: The mean age was 62 years (range 24-90), of which one third (34.4%) were aged 70 years or more. We received the iatrogenic perforation in 45 (70%) patients, less than one quarter (n = 15; 23%) consisted of spontaneous perforation, in three patients we have failed to determine the cause of perforation (5%) and one patient experienced perforation during removal of foreign body. Perforation of the thoracic esophagus in 41 patients, in 20 (31%) cases in the upper and middle third and 21 (33%) in the distal third of the thoracic esophagus. Cervical perforation was noted in 14 patients (22%) and abdominal of the 9 patients (14%). 92% of patients were treated surgically (n = 59). 43% (n = 27) were treated by primary suture of the perforation, esophageal resection with primary reconstruction was performed in 4 patients, esophagectomy with terminal esophagostomy and nutritional jejunostomy in 7 patients, 4 patients were treated by surgical drainage and only 7 patients, we introduced endless lavage. In 9 cases we have resected affected portion of esophagus with stapler closure in the chest. Conservative management of esophageal perforation we proceeded in 5 patients in whom a stent was introduced and the perforation successfully healed. Overall mortality in our set of patients is 23.4%. CONCLUSION: Conservative procedure in carefully selected patients could be an alternative to radical and inherently surgical procedures. Published results and our little experience are encouraging, but this topic is still under study.