TOMOGRAPHIC SARCOPENIA PREDICTS ANASTOMOTIC LEAKS AND LONG-TERM SURVIVAL IN GASTRIC CANCER PATIENTS OPERATED WITH CURATIVE INTENT.

BACKGROUND: The preoperative nutritional state has prognostic postoperative value. Tomographic density and area of psoas muscle are validated tools for assessing nutritional status. There are few reports assessing the utility of staging tomography in gastric cancer patients in this field. AIMS: This study aimed to determine the influence of sarcopenia, measured by a preoperative staging computed tomography scan, on postoperative morbimortality and long-term survival in patients operated on for gastric cancer with curative intent. METHODS: This retrospective study was conducted from 2007 to 2013. The definition of radiological sarcopenia was by measurement of cross-sectional area and density of psoas muscle at the L3 (third lumbar vertebra) level in an axial cut of an abdominopelvic computed tomography scan (in the selection without intravascular contrast media). The software used was OsirixX version 10.0.2, with the tool "propagate segmentation", and all muscle seen in the image was manually adjusted. RESULTS: We included 70 patients, 77% men, with a mean cross-sectional in L3 of 16.6 cm2 (standard deviation+6.1) and mean density of psoas muscle in L3 of 36.1 mean muscle density (standard deviation+7.1). Advanced cancers were 86, 28.6% had signet-ring cells, 78.6% required a total gastrectomy, postoperative surgical morbidity and mortality were 22.8 and 2.8%, respectively, and overall 5-year long-term survival was 57.1%. In the multivariate analysis, cross-sectional area failed to predict surgical morbidity (p=0.4) and 5-year long-term survival (p=0.34), while density of psoas muscle was able to predict anastomotic fistulas (p=0.009; OR 0.86; 95%CI 0.76-0.96) and 5-year long-term survival (p=0.04; OR 2.9; 95%CI 1.04-8.15). CONCLUSIONS: Tomographic diagnosis of sarcopenia from density of psoas muscle can predict anastomotic fistulas and long-term survival in gastric cancer patients treated with curative intent.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis.

BACKGROUND: Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis. METHODS: A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes. RESULTS: A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29). CONCLUSION: The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Contrast-enhanced swallow study sensitivity for detecting esophagojejunostomy leakage. / Sensibilidad del trago de contraste hidrosoluble para la detección de fugas de anastomosis esofagoyeyunal.

INTRODUCTION AND AIM: Sixty percent of the patients with gastric carcinomas are candidates for surgical resection through total gastrectomy and esophagojejunostomy, the latter of which is associated with leaks in up to 12.3% of cases. There is no standardized procedure for diagnosing anastomotic leaks. The aim of the present study was to establish the diagnostic sensitivity of the contrast-enhanced swallow study for detecting esophagojejunostomy leakage after total gastrectomy. MATERIALS AND METHODS: A retrospective analysis was conducted on patients that underwent total gastrectomy due to gastric adenocarcinoma, within the time frame of 2002 and 2017. Demographic, clinical, and laboratory factors were identified, emphasizing the clinical and radiologic detection of anastomotic leaks. Descriptive statistics were carried out and the sensitivity of the contrast-enhanced swallow study for diagnosing leakage was calculated. RESULTS: Fifty-eight patients were included in the study. Their mean age was 61.5 years. A total of 55.2% of the patients were men and 44.8% were women. Gastric adenocarcinoma was the indication for gastrectomy in 100% of the cases. Anastomotic leak presented in 31.01% of the patients. Diagnostic sensitivity of the contrast-enhanced swallow study for detecting leaks was 66%. CONCLUSIONS: According to our analysis, the contrast-enhanced swallow study had limited diagnostic efficiency for detecting anastomotic leaks, with a sensitivity of 66%. We suggest maintaining high diagnostic suspicion in patients with studies that are initially negative and basing decisions on a more extensive approach.

Rat models of high risk colorectal anastomoses 1.

PURPOSE: To evaluate the most frequent surgical techniques of high-risk colorectal anastomoses in rats. METHODS: Wistar rats were enrolled in three different models comprising inflammatory (TNBS enema), vascular (portal vein occlusion) or obstructive (a non-ischemic constricting ring) mechanisms associated with colonic anastomosis that had accomplished after these former lesions. Histological analyses (Hematoxylin and eosin and Picrosirius red) were performed. RESULTS: All anastomoses techniques were associated with risk factors and had complications, mainly anastomotic leakage. In Study 1, the use of a pharmacological agent, trinitrobenzene sulfonic acid (TNBS) mimicked an inflammatory bowel disease such as Crohn's disease with 50% of anastomosis leakage, the higher percentage among all models tested. In Study 2, after portal ischemia followed by reperfusion it was observed a dense neutrophil infiltrate in the midst of necrotic tissue and fibrin at the anastomotic site and 5 days after the anastomosis, no collagen was produced. In Study 3, 5 days after the mechanical obstruction some denuded areas of epithelium with marked oedema of mucosa and submucosa were seen, at the anastomotic site and anastomosis group showed some reduction of collagen density when compared with Control/Sham group. CONCLUSION: All the experimental surgical techniques tested in rats were associated with high-risk colorectal anastomoses and were useful to study colonic anastomotic healing and intestinal leakage.

Rat models of high risk colorectal anastomoses

Abstract Purpose: To evaluate the most frequent surgical techniques of high-risk colorectal anastomoses in rats. Methods: Wistar rats were enrolled in three different models comprising inflammatory (TNBS enema), vascular (portal vein occlusion) or obstructive (a non-ischemic constricting ring) mechanisms associated with colonic anastomosis that had accomplished after these former lesions. Histological analyses (Hematoxylin and eosin and Picrosirius red) were performed. Results: All anastomoses techniques were associated with risk factors and had complications, mainly anastomotic leakage. In Study 1, the use of a pharmacological agent, trinitrobenzene sulfonic acid (TNBS) mimicked an inflammatory bowel disease such as Crohn's disease with 50% of anastomosis leakage, the higher percentage among all models tested. In Study 2, after portal ischemia followed by reperfusion it was observed a dense neutrophil infiltrate in the midst of necrotic tissue and fibrin at the anastomotic site and 5 days after the anastomosis, no collagen was produced. In Study 3, 5 days after the mechanical obstruction some denuded areas of epithelium with marked oedema of mucosa and submucosa were seen, at the anastomotic site and anastomosis group showed some reduction of collagen density when compared with Control/Sham group. Conclusion: All the experimental surgical techniques tested in rats were associated with high-risk colorectal anastomoses and were useful to study colonic anastomotic healing and intestinal leakage.

Imaging after Bariatric Surgery: When Interpretation Is a Challenge, from Normal to Abnormal.

Bariatric surgery has proven to be the most effective weight loss strategy in severe obesity. Imaging in the immediate postoperative period of bariatric surgery is not done routinely. However, it is helpful in the assessment of early and late complications, which are estimated to be present in < 1% of patients. In some cases, the imaging interpretation of anatomical outcomes and complications related to these procedures represents a challenge for surgeons and radiologists. The aim of this review is to describe the imagenologic findings after bariatric surgery and focuses on the findings of the most frequent procedures performed in Colombia such as laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and laparoscopic adjustable gastric banding. Contrasted CT scan and fluoroscopic studies have shown a high sensitivity in the early and late diagnosis of bariatric surgery complications, but in order to be able to appropriately identify these complications, it is important to be familiar with the normal or expected radiological findings.

Contrast-enhanced swallow study sensitivity for anastomotic leak detection in post-esophagectomy patients. / Sensibilidad del estudio contrastado para la detección de fuga de la anastomosis en pacientes post-esofagectomía.

INTRODUCTION AND AIMS: Esophagectomy is a highly invasive surgery and one of its postoperative complications is anastomotic leakage, occurring in 53% of cases. The aim of the present study was to determine the sensitivity of the contrast-enhanced swallow study as a method for diagnosing anastomotic leak in patients that underwent esophagectomy. MATERIAL AND METHODS: The present retrospective study included the case records of patients that underwent esophagectomy with reconstruction and cervical anastomosis at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán within the time frame of January 1, 2000 and May 31, 2016. Demographic, clinical, and laboratory data emphasizing clinical and radiographic anastomotic leak detection were identified. Descriptive statistics were carried out and contrast-enhanced swallow study sensitivity for diagnosing leakage was calculated. RESULTS: Seventy patients were included in the analysis. The mean age of the patients was 50.6 years, 51 of the patients were men (72.86%), and 19 were women (27.14%). Indications for surgery were benign lesion in 29 patients (41.4%) and malignant lesion in 41 (58.6%). A total of 44.3% of the patients presented with a comorbidity, with diabetes mellitus and high blood pressure standing out. Thirty patients (42.85%) presented with anastomotic leak. Contrast-enhanced swallow study sensitivity for leak detection was 43.33%. CONCLUSIONS: The diagnostic sensitivity of the contrast-enhanced swallow study was very low. Therefore, we recommend the discontinuation of its routine use as a method for diagnosing anastomotic leaks.

[Usefulness of upper gastrointestinal series to detect leaks in the early postoperative period of bariatric surgery]. / Utilidad del estudio contrastado precoz del tracto digestivo superior después de cirugía bariátrica: ¿se justifica su uso rutinario?

BACKGROUND: Postoperative leaks are the most undesirable complication of bariatric surgery and upper gastrointestinal (GI) series are routinely ordered to rule them out. Despite the published literature recommending against its routine use, it is still being customarily used in Chile. AIM: To examine the usefulness of routine upper GI series using water-soluble iodinated contrast media for the detection of early postoperative leaks in patients undergoing bariatric surgery. MATERIAL AND METHODS: A cohort of 328 patients subjected to bariatric surgery was followed from October 2012 to October 2013. Most of them underwent sleeve gastrectomy. RESULTS: Upper GI series on the first postoperative day were ordered to 308 (94%) patients. Postoperative leaks were observed in two patients, with an incidence of 0.6%. The sensitivity for upper GI series detection of leak was 0% and the negative predictive value was 99%. CONCLUSIONS: Routine upper GI series after bariatric surgery is not useful for the diagnosis of postoperative leak, given the low incidence of this complication and the low sensitivity of the technique.

Utilidad del estudio contrastado precoz del tracto digestivo superior después de cirugía bariátrica: ¿se justifica su uso rutinario? / Usefulness of upper gastrointestinal series to detect leaks in the early postoperative period of bariatric surgery

Background: Postoperative leaks are the most undesirable complication of bariatric surgery and upper gastrointestinal (GI) series are routinely ordered to rule them out. Despite the published literature recommending against its routine use, it is still being customarily used in Chile. Aim: To examine the usefulness of routine upper GI series using water-soluble iodinated contrast media for the detection of early postoperative leaks in patients undergoing bariatric surgery. Material and Methods: A cohort of 328 patients subjected to bariatric surgery was followed from October 2012 to October 2013. Most of them underwent sleeve gastrectomy. Results: Upper GI series on the first postoperative day were ordered to 308 (94%) patients. Postoperative leaks were observed in two patients, with an incidence of 0.6%. The sensitivity for upper GI series detection of leak was 0% and the negative predictive value was 99%. Conclusions: Routine upper GI series after bariatric surgery is not useful for the diagnosis of postoperative leak, given the low incidence of this complication and the low sensitivity of the technique.

Classification and management of leaks after gastric bypass for patients with morbid obesity: a prospective study of 60 patients.

The most important and frequent major complication after gastric bypass is the appearance of a leak, which can result in death of a patient. The purpose of this prospective study was to determine the incidence of a postoperative leak, to propose a classification and to evaluate the results of conservative or surgical treatment. All patients submitted to gastric bypass either laparotomic or laparoscopic were included in a prospective protocol. In all radiological evaluation at 4(th) day after surgery was performed. The presence of a leak was evaluated according to the day of appearance, its location and its severity. Results of medical or surgical treatment were analyzed. From 1764 patients submitted to Roux-en-Y gastric bypass, 60 had a postoperative leak (3.4%). This leak appeared early after surgery (before 4 days) in 20%. It was a localized subclinical leak in 20% and clinical - septic in 80%. There were 7 possible anatomic location of a leak, being the gastrojejunal anastomosis the most frequent location (53%) followed by gastric pouch. The highest mortality was associated to the jejuno-jejunal anastomosis. Conservative treatment was employed in near 65% of the patients: The mean time of closure of a leak was 34 days. The appearance of a postoperative leak is a major and serious complication. It can be classified according to the day of appearance, its severity and its location. Conservative or surgical treatment can be employed properly if these 3 parameters are carefully evaluated.

Gastric leak after sleeve gastrectomy: analysis of its management.

BACKGROUND: Bariatric surgery is increasingly being performed and sleeve gastrectomy (SG) has proved to be effective and safe. Among its complications, leaks are the most serious and life threatening. METHODS: The focus of the study is nine patients who underwent a SG and developed a gastric leak after surgery. Our data were obtained from the clinical charts of the patients and through interviews with the surgeon who performed the index surgery. RESULTS: Eight patients underwent SG at outside institutions while one was operated at Clinica Alemana. Three patients developed symptoms within 5 days after surgery, while the rest were diagnosed after 10 days from the surgery. A CT scan was the method used to confirm the diagnosis in all patients. The three patients who had a leak detected during the immediate postoperative period underwent laparoscopic reoperation. Among the rest of the patients, percutaneous drainage was employed in one patient as the primary procedure while the other underwent surgical drainage. An esophageal endoluminal stent was employed in four patients. The leak closed in all patients with the healing time ranging from 21 to 240 days. CONCLUSIONS: Diagnosis of a leak after a SG required a greater index of suspicion in order to perform an early diagnosis. Sepsis control and nutritional support are the cornerstones of this treatment. Evolution is characterized by longer periods of time that are necessary in order to wait until the leak closes. Management must be tailored to each patient.