Ashish Rohatgi

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence, risk factors and management

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3-year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty-three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor-related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor-related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor-related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.

Multivariate analysis of clinicopathological factors influencing survival following esophagectomy for cancer

BACKGROUND A number of clinicopathological characteristics can influence survival following esophagectomy for cancer. The aim of this study was to determine the factors affecting survival in a consecutive series of patients undergoing esophagectomy for cancer at a single tertiary centre over a 7 year period. MATERIALS & METHODS We analyzed a prospective database of 314 consecutive patients (247 males and 67 females), with a mean age of 62.8 +/- 9.1 years, who underwent esophagectomy for cancer at a single, high-volume centre between January 2000 and June 2007. The impact of 11 variables on survival following esophagectomy was determined by univariate and multivariate analysis. RESULTS On univariate analysis, gender, ASA grade, blood transfusion, type of cancer, tumor stage, lymph node status, lymphovascular invasion (LVI), longitudinal resection margin (LRM) involvement and circumferential resection margin (CRM) involvement were significant (p<0.05) negative factors for survival. Multivariate analysis using Cox proportional hazard regression demonstrated that the only independent factors negatively impacting on survival were ASA grade (p=0.012), tumor stage (p=0.009), LVI (p=0.009) and LRM involvement (p=0.031). CONCLUSIONS In the current study we demonstrated that independent variables effecting survival after esophagectomy for cancer were ASA grade, tumor stage, lymphovascular invasion and longitudinal resection margin involvement. Contrary to other studies we did not find CRM involvement to be an independent predictor for survival.

The role of oesophageal diversion and exclusion in the management of oesophageal perforations

AIM Persistent sepsis from an oesophageal perforation has a near 100% mortality. We describe our experience with early oesophageal diversion and exclusion for patients in-extremis. METHODS A retrospective review of oesophageal perforations was performed between 2000 and 2007. There were five cases Boerhaaves and one case of iatrogenic perforation that required oesophageal diversion and exclusion. 4 males, 2 females with a mean age of 67.6 (58-72) years. RESULTS The primary procedure was performed within 24h in four patients; the other two were after 3 and 10 days. The intensive care unit (ITU) stay was a median of 25 days. Mortality rate was 50%. Median length of stay for the survivors was 60 days. Three patients underwent a successful colonic interposition in our unit after 6 months. CONCLUSION Exclusion and diversion procedures are required in very rare circumstances. In conditions of persistent leak and continuing sepsis or those patients not fit to undergo a major procedure they could be lifesaving if performed early. As it is a relatively easy and quick procedure it should be considered early as a 2nd line management option.

Surgical management of Boerhaave's syndrome in a tertiary oesophagogastric centre

INTRODUCTION The aim of this study was to review the management and outcome of patients with Boerhaaves syndrome in a specialist centre between 2000-2007. PATIENTS AND METHODS Patients were grouped according to time from symptoms to referral (early, < 24 h; late, > 24 h). The effects of referral time and management on outcomes (oesophageal leak, reoperation and mortality) were evaluated. RESULTS Of 21 patients (early 10; late 11), three were unfit for surgery. Of the remaining 18, immediate surgery was performed in 8/8 referred early and 6/10 referred late. Four patients referred late were treated conservatively. Oesophageal leak (78% versus 12.5%; P < 0.05) and mortality (40% versus 0%; P < 0.05) rates were higher in patients referred late. For patients referred late, mortality was higher in patients managed conservatively (75% versus 17%; not significant). CONCLUSIONS The best outcomes in Boerhaaves syndrome are associated with early referral and surgical management in a specialist centre. Surgery appears to be superior to conservative treatment for patients referred late.

Transhiatal oesophagectomy: treatment of choice for high-grade dysplasia

OBJECTIVE To demonstrate that transhiatal oesophagectomy should remain the gold standard treatment for patients with high-grade dysplasia. BACKGROUND The conventional management of high-grade dysplasia of the oesophagus is surgery. Perceived high incidence of operative morbidity and mortality associated with oesophagectomy has led some to advocate alternative less invasive treatments such as endoscopic mucosal resection (EMR) and photodynamic therapy (PDT). We present our data on the use of transhiatal oesophagectomy for the management of high-grade dysplasia. METHODS Twenty-three patients underwent transhiatal oesophagectomy for biopsy-proven high-grade dysplasia in a high volume centre, between March 2000 and December 2006. Twenty-two were male and 1 female with a mean age of 63.5 years (+/- 6.5). Staging was ascertained by gastroscopy, EUS and CT. Two patients had PET CT. ASA grade was I (2), II (14), III (6) and IV (1). RESULTS Clinical anastomotic leak occurred in two patients (9%); this was managed conservatively. Four patients required intensive care admission. Occult adenocarcinoma was found in 35% (8/23) of surgical specimens; there were no involved nodes present. No re-operations were required. Median length of stay was 15 days (10-69). Thirty-day and in-hospital mortality was zero. There was one case of locally recurrent disease, and one death meaning that disease-free survival was 96%, and overall survival was 96% (22/23) at a mean follow-up of 35.4 months. CONCLUSIONS Transhiatal oesophagectomy for high-grade dysplasia can be performed with acceptable mortality and morbidity when performed at a specialist centre.

Bilateral retrovascular femoral hernia

A 34-year-old woman with cystic fibrosis presented with bilateral femoral hernias, which were found to be retrovascular at operation. The hernias were not amenable to conventional open or laparoscopic repair, and were repaired using pre-peritoneal mesh inserted deep to transversalis fascia. The anatomical basis and management of uncommon variants of femoral hernia are discussed.

Surgical Management of Late Complications After Colonic Interposition for Esophageal Atresia

Late complications after colonic interposition for neonatal esophageal atresia may lead to debilitating symptoms, poor quality of life, and malnutrition in young adults with otherwise normal life expectancies. We report our experience with 3 patients who underwent revision surgery more than 20 years after colonic interposition. Revision surgery may relieve symptoms and improve quality of life in selected patients. However, for patients with recurrent symptoms, further reconstructive options may be limited due to the lack of an available conduit, and long-term enteral feeding may be the only option for these patients.

Training in oesophageal surgery – The gold standard: A prospective study

INTRODUCTION Competency in complex oesophagogastric surgery, within the current climate of changes to medical training and reduced hours, requires repeated, focused, hands-on training. We describe the training methods for oesophagectomy in our institution. METHODS All oesophageal resections under the care of one consultant surgeon are regarded as training cases. When trainees start they are shown the first resection; subsequently, the trainees then perform every case with the consultant scrubbed. Consultant input consists of retraction and tips in difficult situations. All data were collected on a prospective database. RESULTS Two hundred and seventy patients (215 males, median age=64 years) underwent primary oesophagectomy under the consultant, between January 2000 and May 2007. Fifteen resections (6%) were performed solely by the consultant. ASA grading was: I=15, II=154, III=95, IV=5, and unrecorded=1. In-hospital mortality and clinically apparent leak rate was 1.9% (5 deaths) and 6.2% (n=17), respectively. Reoperation was required in 15 patients (5.5%). The median length of hospital stay was 14 days (range=8-95 days). Median lymph node yield was 13 (range=0-64). CONCLUSIONS Trainees under supervision can competently perform an oesophagectomy without compromising patient care. An early hands-on approach leads to a rapid ascent of the learning curve and is essential in todays climate of limited training opportunity.

Transhiatal oesophagectomy: Techniques, tips and outcomes

AIM To demonstrate our technique and valuable tips for transhiatal oesophagectomies. METHOD 215 patients underwent transhiatal oesophagectomies in our unit between 2000 and 2006. RESULTS In-hospital mortality was 0.9%. Anastomotic leak in 12 patients (5.6%). Chyle leak was seen in five patients and recurrent nerve neuropraxia in six patients. Iatrogenic splenectomy rate was 6%. The median operative time was 151 minutes (range 93-276 minutes). Overall median length of hospital stay was 15 days (range 8-95 days). The median survival for all patients undergoing transhiatal oesophagectomy for invasive malignancy was 42.9 months and the one-year and five-year survival were 81% and 48% respectively. CONCLUSION This is a safe and oncologically sound procedure. We feel that the tips can be helpful for anyone performing this procedure.

Boerhaave’s syndrome secondary to colonic interposition graft perforation

Dear Editor: Spontaneous esophageal perforation (Boerhaaves syndrome) remains a difficult diagnostic and management problem. Boerhaave first reported a syndrome in 1724 on Baron Wassenaar, Grand Admiral of the Dutch fleet, a glutton who practiced the Roman habit of autoemesis. Mackler described the triad classical presentation of vomiting, lower thoracic pain and subcutaneous emphysema following a large meal. However, atypical presentations can occur. The diagnosis carries a significant morbidity and mortality of up to 30%. Late or misdiagnosis is common in 50% of cases due to the rarity of the condition and its nonspecific presentation. Management is controversial since the treatment can be surgical or non-surgical. The indications vary according to the site, size of lesion and associated conditions: time elapsed between injury and presentation, functional state of oesophagus, degree of mediastinal contamination and preference of the team. To our knowledge, this is the first case in the literature of perforation in a patient with colonic interposition repair of the oesophagus as a child. A 50-year-old patient presented to a local hospital with chest pain, epigastric pain and dysponea. The pain had developed after vomiting following a meal. Past medical history included an operation on the oesophagus carried out through a left thoracotomy at age 2 and 7, respectively—the nature of which was not known to the patient or her family. Co-morbidities included long-standing gastro-esophageal reflux disease and epilepsy. Remaining history was unremarkable. On examination the patient was systemically well with no initial evidence of sepsis. There was tenderness over the right upper quadrant and epigastium. The initial diagnosis was acute cholecystitis, with a differential of right-sided pneumonia. Chest X-ray showed a small left-sided pleural effusion. Due to a worsening type I respiratory failure, a chest and abdominal CAT scan was organized. This demonstrated mediastinal air, fluid around the distal oesophagus, air under the diaphragm and bilateral pleural effusions. The oesophagus was dilated and there was intrathoracic gastric herniation. The findings were suggestive of a ruptured oesophagus. Gastrograffin contrast study confirmed an obvious leak on the right and a chest drain was inserted. The patient was commenced on IV antibiotics and transferred to a tertiary upper GI surgical centre where she was promptly taken to theatre. The patient underwent an upper midline laparotomy; there were dense adhesions in the upper abdomen and the stomach had herniated into the thoracic cavity. On repositioning the stomach into the abdominal cavity, it was evident that there was a colonic segment interposed between the stomach and the oesophagus. The perforation was visualized at gastroscopy to be in the colonic segment at 30 cm ab oral. This was not amiable for primary repair R. Attia :M. Scarci Department of Cardiothoracic Surgery, Guy’s and St Thomas’ Hospital NHS Foundation Trust, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH, UK