A reduced gastric corpus microvascular blood flow during Ivor-Lewis esophagectomy detected by laser speckle contrast imaging technique.

BACKGROUND: Reduced microvascular blood flow is related to anastomotic insufficiency following esophagectomy, emphasizing a need for intraoperative monitoring of the microcirculation. This study evaluated if laser speckle contrast imaging (LSCI) was able to detect intraoperative changes in gastric microcirculation. METHODS: Gastric microcirculation was assessed prior to and after reconstruction of gastric continuity in 25 consecutive patients operated for adenocarcinoma with open Ivor-Lewis esophagectomy while hemodynamic variables were recorded. RESULTS: During upper laparotomy, microcirculation at the corpus decreased by 25% from baseline to mobilization of the stomach (p = .008) and decreased further (to a total decrease of 40%) following gastric pull to the thorax (p = .013). On the other hand, microcirculation at the antrum did not change significantly after gastric mobilization (p = .091). The decrease in corpus microcirculation took place unrelated to central cardiovascular variables. CONCLUSION: Using LSCI technique, we identified a reduced microcirculation at the corpus area during open Ivor-Lewis esophagectomy. LSCI provides an option for real-time assessment of gastric microcirculation and could form basis for intraoperative stabilization of the microcirculation.

Single-operator cholangioscopy is useful for visual assessment of bile duct pathology.

INTRODUCTION: Single-operator cholangioscopy (SOC) is increasingly used for evaluation of the biliary tree following endoscopic retrograde cholangiopancreaticography (ERCP). This study aimed to determine the visual and histological success rates of SOC at a single Danish tertiary referral centre. METHODS: All patients undergoing SOC between 2008 and 2015 were retrospectively included from a prospectively maintained database. Patient characteristics and proced-ure-related variables were obtained from medical records. A visual and a histological success rate were determined according to predefined criteria. RESULTS: In total, 54 patients underwent SOC, most often due to suspicion of malignancy (n = 53; 98%). In one case, access to the common bile duct failed, and in six cases malignant disease was missed. Thus, the cholangioscopies were successful in 47 of 54 procedures corresponding to a visual success rate of 87%. Nine patients (17%) had a mean of 1.3 ± 1.0 SOC-guided biopsies taken. The extracted tissue was inadequate for histological evaluation in seven of nine cases, corres-pond-ing to a histological success rate of 22% (two out of nine tissue samples were eligible for histological diagnosis). CONCLUSIONS: Considering the reasonable visual success rate, SOC seems to be a useful extension of ERCP during diagnostic work-up for detection of malignant disease in the biliary tree. However, one biopsy per patient is insufficient for histological verification of common bile duct malignancy. TRIAL REGISTRATION: The Danish Health Authority (3-3013-1299/1) and The Danish Data Protection Agency (RH-2015-229). FUNDING: none.

Robot-Assisted Hybrid Esophagectomy Is Associated with a Shorter Length of Stay Compared to Conventional Transthoracic Esophagectomy: A Retrospective Study.

AIM: To compare the peri- and postoperative data between a hybrid minimally invasive esophagectomy (HMIE) and the conventional Ivor Lewis esophagectomy. METHODS: Retrospective comparison of perioperative characteristics, postoperative complications, and survival between HMIE and Ivor Lewis esophagectomy. RESULTS: 216 patients were included, with 160 procedures performed with the conventional and 56 with the HMIE approach. Lower perioperative blood loss was found in the HMIE group (600 ml versus 200 ml, p < 0.001). Also, a higher median number of lymph nodes were harvested in the HMIE group (median 28) than in the conventional group (median 23) (p = 0.002). The median length of stay was longer in the conventional group compared to the HMIE group (11.5 days versus 10.0 days, p = 0.03). Patients in the HMIE group experienced fewer grade 2 or higher complications than the conventional group (39% versus 57%, p = 0.03). The rate of all pulmonary (51% versus 43%, p = 0.32) and severe pulmonary complications (38% versus 18%, p = 0.23) was not statistically different between the groups. CONCLUSIONS: The HMIE was associated with lower intraoperative blood loss, a higher lymph node harvest, and a shorter hospital stay. However, the inborn limitations with the retrospective design stress a need for prospective randomized studies. Registration number is DRKS00013023.

Intrathoracic anastomotic leakage after gastroesophageal cancer resection is associated with increased risk of recurrence.

OBJECTIVE: Intrathoracic anastomotic leakage after intended curative resection for cancer in the esophagus or gastroesophageal junction has a negative impact on long-term survival. The aim of this study was to investigate whether an anastomotic leakage was associated with an increased recurrence rate. METHODS: This nationwide study included consecutively collected data on patients undergoing curative surgical resection with intrathoracic anastomosis, alive 8 weeks postoperatively, between 2003 and 2011. Patients with incomplete resection, or metastatic disease intraoperatively, were excluded. Only biopsy-proven recurrences were accepted. RESULTS: In total, 1085 patients were included. The frequency of anastomotic leakage was 8.6%. The median follow-up time was 29 months (interquartile range [IQR]: 13-58 months). Overall, 369 (34%) patients had disease recurrence, of which 346 patients died of recurrent gastroesophageal carcinoma. Twenty-three patients were alive with recurrence at the censoring date. In the study period, 333 patients died without signs of recurrent disease. The overall median time to recurrence was 66 weeks (IQR: 38-109 weeks). Distant metastases were found in 267 (25%), and local disease recurrence in 102 (9%) patients. Overall, 5-year disease-free survival in patients with leakage was 27%, versus 39% in those without leakage (P = .017). Anastomotic leakage was independently associated with higher risk of recurrence (hazard ratio [HR] = 1.63; 95% confidence interval [CI]: 1.17-2.29, P = .004) and all-cause mortality (HR = 1.57; 95% CI: 1.23-2.05, P < .0001). CONCLUSIONS: Intrathoracic anastomotic leakage increased the risk of recurrence in patients who underwent curative gastroesophageal cancer resection.