Karen J. Dickinson

Individualizing Management of Complex Esophageal Pathology Using Three-Dimensional Printed Models

PURPOSE In complex esophageal cases, conventional two-dimensional imaging is limited in demonstrating anatomic relationships. We describe the utility of three-dimensional (3D) printed models for complex patients to individualize care. DESCRIPTION Oral effervescent agents, with positive enteric contrast, distended the esophagus during computed tomography (CT) scanning to facilitate segmentation during post-processing. The CT data were segmented, converted into a stereolithography file, and printed using photopolymer materials. EVALUATION In 1 patient with a left pneumonectomy, aortic bypass, and esophageal diversion, 3D printing enabled visualization of the native esophagus and facilitated endoscopic mucosal resection, followed by hiatal dissection and division of the gastroesophageal junction as treatment. In a second patient, 3D printing allowed enhanced visualization of multiple esophageal diverticula, allowing for optimization of the surgical approach. CONCLUSIONS Printing of 3D anatomic models in patients with complex esophageal pathology facilitates planning the optimal surgical approach and anticipating potential difficulties for the multidisciplinary team. These models are invaluable for patient education.

Management of Conduit Necrosis Following Esophagectomy

The management of conduit necrosis during or after esophagectomy requires the assembly of a multidisciplinary team to manage nutrition, sepsis, intravenous access, reconstruction, and recovery. Reconstruction is most often performed as a staged procedure. The initial surgery is likely to involve esophageal diversion onto the chest where possible, making an effort to preserve esophageal length. Optimization of patients before reconstruction enhances outcomes following reconstruction with either jejunum or colon after gastric conduit failure. Maintaining enteral access for feeding at all times is imperative. Management of patients should be performed at high-volume esophageal centers performing regular reconstructions.

Prehabilitation: Prevention is better than cure

The benefit of pulmonary rehabilitation for patients undergoing lung resections for non–small cell lung cancer (NSCLC) or, indeed, any thoracic surgery is well established. Gaining momentum in many surgical specialties, often as part of enhanced recovery pathways, is the concept of prehabilitation. This describes presurgical exercise interventions used in an attempt to reduce morbidity and mortality. With so much emphasis being placed on smoking cessation to prevent lung cancer, one may wonder why prehabilitation before thoracic surgery is not routine practice. Patients with surgically resectable lung cancer often smoke and may have an abnormal forced expiratory volume in 1 second and diffusing capacity for carbon monoxide due to background parenchymal disease. Diffusing capacity for carbon monoxide may be further reduced by alveolar damage during administration of preoperative induction chemoradiotherapy. Chemoradiotherapy regimens also may have a global negative impact on a patient’s mobility and impede surgical recovery. In patients undergoing neoadjuvant chemotherapy for rectal cancer, fitness levels were restored to baseline with the institution of a prehabilitation regimen. In this issue of the Journal, the effects of pulmonary prehabilitation during induction chemotherapy for stage IIb-IV lung cancer before surgical resection are reported by Tarumi and colleagues. Their prehabilitation regimen included smoking cessation, relaxation, respiratory and cough training, lowerextremity exercise, and training in activities of daily living. Patients received this throughout their induction chemoradiotherapy, and pulmonary function was measured before and 2 weeks after its completion. Patients underwent lobectomies and pneumonectomies (including bilobectomy, sleeve resections, and chest wall resections), with an incidence of respiratory complications of 6.1% overall. In smokers and those patients with respiratory impairment (forced expiratory volume in 1 second/forced vital capacity <70% or forced vital capacity <80% predicted), lung function improved significantly after prehabilitation.

Results of Pulmonary Resection: Colorectal Carcinoma

Whether pulmonary metastasectomy improves survival in patients with metastatic colorectal cancer is controversial. Wedge resection is the most common form of surgical intervention. When anatomic resection is required, segmentectomy may be preferable to lobectomy for preservation of lung parenchyma. Each intervention to remove metastatic pulmonary parenchymal disease should consider future disease recurrence. Nonoperative modalities, such as radiofrequency ablation, cryoablation, and microwave ablation, are becoming more popular regarding parenchymal preservation. The future may embrace complex risk-profile analysis including molecular markers, nomograms to predict survival, and hybrid treatment approaches. Minimally invasive surgical techniques are used with increased frequency, making reoperative metastasectomy less tedious.

Minimally Invasive Approaches to Chest Wall and Superior Sulcus Tumors

The resection of chest wall tumors, including superior sulcus tumors, has traditionally been performed via an open approach given the extent of structures to be removed. Recently, more advanced experience with minimally invasive techniques (both VATS and robotic) have allowed thoracic surgeons to perform these operations through smaller incisions and avoid the trauma to the overlying major muscles of the chest wall. One of the earliest reports of VATS-assisted chest wall resection by Widmann et al. described performance of wedge resection of lung with VATS followed by en bloc removal of ribs 3 and 4 along with the wedge of lung, which was accomplished without the use of rib spreading [1]. More recently, Hennon et al. reported a series of 17 patients who underwent VATS chest wall resection, which comprised 36 % of overall chest wall resections done at their institution from 2007 to 2013 [2]. The utilization of minimally invasive techniques for chest wall resection has become a more common phenomenon, as surgeons explore the ways in which it may benefit patients in terms of postoperative pain and morbidity. The phrase “minimally invasive chest wall resection” (MICWR) is a bit misleading, as any chest wall resection by definition requires the resection of the same amount of bone and intercostal muscle as in an “open” operation; however the method by which this is accomplished can take advantage of some of the same tools and techniques by which VATS surgery is performed, and hence we will use the term since it reduces the morbidity of cutting muscle.

Factors influencing length of stay after surgery for benign foregut disease.

OBJECTIVES Length of stay (LOS) is an important measure of quality and healthcare costs. Variation occurs due to individual and institutional practices, case complexity and patient/social factors. Identification of variables affecting LOS may help develop enhanced recovery protocols. This study aims to identify factors influencing LOS following surgery for hiatal hernia, gastro-oesophageal reflux and achalasia. METHODS We identified all patients who underwent benign foregut surgery between August 2013 and July 2014 inclusive. Data from a prospectively maintained database were collected and univariate/multivariable analyses were performed. All patients were contacted to determine their 30-day readmission rate to any hospital. RESULTS One hundred and sixty-five patients were identified in the 12-month period; 68% underwent laparoscopic surgery and 32% open surgery. The rates of laparoscopic conversion to open surgery and operative mortality were zero. Statistically, the most significant predictor of LOS was the surgical approach. The median LOS was 2 days for laparoscopic surgery and 4 days for open surgery. Beyond the surgical approach, the following factors were significant in predicting LOS: for laparoscopic surgery patients, younger age, shorter operative time, nasogastric (NG) tube removal in the operation theatre (OT), OT exit before noon, low postoperative nausea counts and discharge to home rather than a skilled facility were associated with reduced LOS. For open surgery patients, younger age, American Society of Anesthesiologists grade I-II, urinary catheter removal before discharge, discharge to home and discharge on the weekend were associated with reduced LOS. Whether surgery was primary or reoperation did not affect LOS. The overall 30-day readmission rate was 5% (laparoscopic 3% and open 12%; P = 0.003). CONCLUSIONS The laparoscopic surgery approach, where feasible, in the treatment of benign foregut diseases is the strongest predictor of a decreased LOS. Modifiable factors influencing LOS include OT exit time, NG tube removal in the OT, urinary catheter removal in hospital and postoperative nausea control. Any implementation of enhanced recovery pathways to optimize these factors must monitor readmission rates and complications to confirm efficacy.

Esophageal Anatomy as Seen During Endoscopy and Basic Endoscopic Orientation

The art of surgical endoscopy has revolutionized the diagnosis and treatment of gastrointestinal disorders. Gastroenterologists and esophageal surgeons must familiarize themselves with the proper technique of examining a patient for upper endoscopy.

Management of Esophageal Leaks and Fistulas

Esophageal leaks and fistulas traditionally have been treated with surgical management. The development of endoscopic therapy has provided new therapeutic options in treating patients with esophageal perforation and fistulas. This chapter discusses the endoscopic and surgical management of esophageal leaks and fistulas. Some techniques involving the use of esophageal stents are off-label uses that have not been approved by the US Food and Drug Administration (FDA).