Marc Bludau

Options in the management of esophageal perforation: analysis over a 12‐year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12-year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro- or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.

Ivor-Lewis Esophagectomy With and Without Laparoscopic Conditioning of the Gastric Conduit

BackgroundAnastomotic leakage is still the major surgical complication following transthoracic esophagectomy with intrathoracic esophagogastrostomy (Ivor-Lewis procedure). Modifications of this standard procedure aim to reduce postoperative morbidity and mortality.MethodsIn this retrospective analysis of a 12-year period, 419 patients who had an Ivor-Lewis (IL) procedure for esophageal carcinoma were included. Due to modifications of the standard procedure, two different groups were compared with respect to their mortality and anastomotic leakage rate. In 181 patients (43.1%), esophagectomy and gastric reconstruction was performed as a one-stage procedure (classical IL group). Two hundred thirty-eight patients (56.9%) underwent a modified IL procedure that included minimally invasive gastric mobilization and a two-stage operation following ischemic conditioning of the gastric conduit.ResultsThe hospital mortality rate was lower in the modified IL group without statistical significance (2.9 vs. 6.1%). Thirty-five anastomotic leaks were diagnosed postoperatively, 17 in the classical IL group (9.4%) and 18 in the modified IL group (7.6%). The rate of late leakages (after the 10th postoperative day) was higher in the modified IL group. Septic complications and mortality following anastomotic leakage were less frequent in the modified IL group. Leaks in the classical IL group predominantly required rethoracotomy, whereas leaks of the modified IL group were sufficiently treated with endoscopic stenting.ConclusionsSurgical modifications of the classical IL procedure, including a minimally invasive approach and ischemic conditioning of the gastric conduit, seem to reduce postoperative morbidity and mortality. However, due to the retrospective design of this study, the impact of other factors influencing the outcome cannot be ruled out.

The Resection of the Azygos Vein — Necessary or Redundant Extension of Transthoracic Esophagectomy?

Due to the increasing use of minimally invasive techniques, some authors have questioned the necessity to dissect the azygos vein as part of the en-bloc esophagectomy in patients with esophageal cancer. This study investigates the nodal clearance associated with resection of the azygos vein. Ninety-two patients with esophageal carcinoma were included in this prospective analysis. In all patients, a standard transthoracic en-bloc esophagectomy was performed including the resection of the azygos vein from the superior vena cava to the level of the diaphragm. After resection, the azygos vein with its adjacent connective tissue was separated from the tubular esophagus. The separated azygos vein specimen was histopathologically examined for the presence of lymph nodes (LN) and possible nodal metastasis. A total of 2,778 LN with a mean of 30.2 LN for each patient were resected. In 60 patients, 216 of 1,666 mediastinal LN (13.0%) were located along the azygos vein. Seven of 39 pN1 patients (17.9%) had LN metastases in the separated azygos vein specimen. In these seven patients, a total of 23 metastatic nodes were detected along the azygos vein. LN metastases along the azygos vein are too frequent to neglect their existence. Therefore, standard en-bloc esophagectomy including dissection of the azygos vein should not be abandoned irrespective of the surgical approach.

Effect of aging on esophageal motility in patients with and without GERD.

Background/Aims: The impact of aging on esophageal motility is not completely understood. This study aims at assessing 1) whether degeneration of esophageal body motility occurs with age and 2) whether this development is influenced by gastroesophageal reflux disease (GERD). Methods: 326 consecutive patients with symptoms of GERD underwent a diagnostic work-up including a water-perfused esophageal manometry. Patients were divided by age: 17–39 years (group 1, n=75), 40–49 years (group 2, n=79), 50–59 years (group 3, n=64), 60–69 years (group 4, n=74), and >70 years (group 5, n=34). GERD was diagnosed if patients had erosive esophagitis at endoscopy, a positive pH-metry, or both. The amplitude of esophageal contraction waves 3 cm and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed and correlated to GERD. Results: A normal esophageal manometry was found in 86.7%, 73.4%, 67.2%, 58.1%, and 55.9% (p<0.01) in groups 1–5, respectively. Esophageal contraction wave amplitudes were affected by age in patients positive for GERD only (p<0.01). Esophageal body peristalsis was affected by age (p<0.01) independent of the diagnosis of GERD. Conclusion: Aging is correlated to esophageal motor abnormalities. GERD has a significant impact on esophageal contraction wave amplitude, but not on peristalsis.

Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus.

OBJECTIVE Chylothorax is a major complication after esophagectomy. As recent studies refer to heterogeneous patient cohorts and surgical procedures, this study was conducted to report the incidence and evaluate the optimal management of chylous fistula in patients treated with transthoracic esophagectomy and 2-field lymphadenectomy for esophageal cancer. METHODS From January 2005 to December 2013, a total of 906 patients underwent transthoracic esophageal resection for esophageal carcinoma at our institution. En bloc esophagectomy was performed with routine supradiaphragmatic ligation of the thoracic duct. The incidence of chylothorax, and associated morbidity and mortality, were analyzed, and subsequent therapeutic management was reviewed. RESULTS Chylothorax after Ivor Lewis esophagectomy was observed in 17 (1.9%) patients. Fifteen patients required surgical intervention with rethoracotomy and repeat duct ligation. Thoracic duct ligation was successful in all patients. Two patients died within 90 days after primary esophageal resection. The median time between initial tumor resection and rethoracotomy was 13 days. Average daily chest-tube output at time of reoperation was 1900 mL. In 2 patients, pleural effusion did not exceed 1000 mL per day. In these cases, conservative management with additional thoracic drainage and total parenteral nutrition led to complete resolution of chylous fistula. CONCLUSIONS Occurrence of chylothorax after prophylactic thoracic duct ligation during transthoracic esophagectomy for esophageal cancer is rare. In patients with high-output chylous fistula, an early rethoracotomy with repeat ligation of the thoracic duct is safe and helps to shorten recovery time. In cases of low-volume drainage, a conservative approach is feasible.

Quantitative measurement of gastric mucosal microcirculation using a combined laser Doppler flowmeter and spectrophotometer

Anastomotic leakage after esophagectomy and esophagogastrostomy depends on the vascularization of the gastric conduit. So far, no adequate methods are available to monitor postoperatively mucosal microcirculation of the gastric conduit. The aim of this experimental study was to assess a recently developed microprobe with a microlight-guide spectrophotometer (O2C, Fa. LEA Medizintechnik, Giessen, Germany) to quantitatively measure gastric mucosal blood flow (MBF) and mucosal oxygen saturation (MOS) of different gastric areas. Eighteen patients without gastric pathology were included in this study. During conventional gastroscopy the microprobe was introduced via the working channel of a standard endoscope and positioned in well-defined areas of the antrum and fundus. The tip of the microprobe consisted of a combined laser Doppler and tissue spectrometer measuring continuously the MBF (perfusion units, PU) and MOS (SO(2), in %). The mean MOS of the antrum was significantly higher compared with the fundus (antrum: 82% +/- 7.9 standard deviation [SD], fundus: 72% +/- 10.4; P = 0.0002). The mean MBF was not significantly different between antrum and fundus (antrum: 201 PU +/- 40 SD, fundus: 223 PU +/- 29 SD). This study demonstrates the feasibility of the gastric O2C microprobe to measure parameters of gastric microcirculation from the endoluminal side.

Transthoracic esophagectomy after endoscopic mucosal resection in patients with early esophageal carcinoma.

IntroductionFor patients with esophageal carcinoma limited to the mucosa endoscopic mucosal resection (EMR) is the therapy of choice whereas surgical resection is advocated for submucosal tumors.MethodsThis study analyzes the histopathologic results of patients with early esophageal carcinoma who underwent EMR prior to transthoracic esophagectomy. Sixteen patients with early esophageal carcinoma and EMR as first line treatment were included in this retrospective study. Ten patients underwent transthoracic esophagectomy because of submucosal infiltration combined incomplete tumor resection at the lateral/basal resection margin. In one patient each, surgical therapy was indicated due to submucosal infiltration or incomplete resection only. Three patients underwent surgical resection due to residual neoplasia within an esophageal stenosis following EMR. Surgical specimens were examined for pT and pN stage according to the UICC.ResultsThree patients had a squamous cell carcinoma (SCC) and 13 patients an adenocarcinoma (AC), nine patients with a long segment Barrett’s esophagus. The distribution of the pT stages was as follows: 6× pT0 (no histopathologic evidence of residual tumor), 1× pT1m1, 1× pT1m2, 3× pT1m3, 1× pT1sm1, 1× pT1sm2, 1× pT2, and 2× pT3. Three of 16 patients (18.8%) with a pT1sm1, pT2, and pT3 stage had nodal metastases. In all three patients metastatic nodes were located in the mediastinum. In two patients, a second carcinoma was detected during histopathologic work-up (1× AC in the cardia and 1× SCC in the cervical esophagus).ConclusionThe data of this highly selected patients indicate that the boundary between the therapy of mucosal and submucosal tumors is not as clear as stated. Therefore, treatment of early esophageal carcinoma demands a close interdisciplinary cooperation.

Results of endoscopic vacuum-assisted closure device for treatment of upper GI leaks

BackgroundEsophageal perforations and postoperative leakage of esophagogastrostomies are considered to be life-threatening conditions due to the potential development of mediastinitis and consecutive sepsis. Vacuum-assisted closure (VAC) techniques, a well-established treatment method for superficial infected wounds, are based on a negative pressure applied to the wound via a vacuum-sealed sponge. Endoluminal VAC (E-VAC) therapy as a treatment for GI leakages in the rectum was introduced in 2008. E-VAC therapy is a novel method, and experience regarding esophageal applications is limited. In this retrospective study, the experience of a high-volume center for upper GI surgery with E-VAC therapy in patients with leaks of the upper GI tract is summarized. To our knowledge, this series presents the largest patient cohort worldwide in a single-center study.MethodsBetween October 2010 and January 2017, 77 patients with defects in the upper gastrointestinal tract were treated using the E-VAC application. Six patients had a spontaneous perforation, 12 patients an iatrogenic injury, and 59 patients a postoperative leakage in the upper gastrointestinal tract.ResultsComplete restoration of the esophageal defect was achieved in 60 of 77 patients. The average duration of application was 11.0 days, and a median of 2.75 E-VAC systems were used. For 21 of the 77 patients, E-VAC therapy was combined with the placement of self-expanding metal stents.ConclusionThis study demonstrates that E-VAC therapy provides an additional treatment option for esophageal wall defects. Esophageal defects and mediastinal abscesses can be treated with E-VAC therapy where endoscopic stenting may not be possible. A prospective multi-center study has to be directed to bring evidence to the superiority of E-VAC therapy for patients suffering from upper GI defects.

Effect of Laparoscopic Antireflux Surgery on Esophageal Motility

Background/Aims: The effect of laparoscopic antireflux surgery on esophageal motility is incompletely understood, and any indication for this procedure in patients with motility disorder is disputed in literature. We evaluated the influence of laparoscopic Nissen fundoplication on impaired esophageal motility. Methods: In this pathological manometric study, we divided the patients into two groups preoperatively: the hypomotility group (mean amplitude of esophageal contraction wave <40 mm Hg; HYPO group, n = 11) and the normal group (mean amplitude of esophageal contraction wave >40 mm Hg; NORM group, n = 43). The amplitudes of esophageal contraction waves 3 and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed pre- and postoperatively. Results: In total, 54 patients with GERD underwent esophageal manometry before and 6 months after Nissen fundoplication. The length and pressure of the lower esophageal sphincter were increased in both groups postoperatively (p < 0.01). Patients in the HYPO group (n = 11) showed a statistically significant increase of mean amplitude of esophageal contraction (32.8 vs. 57.3 mm Hg; p < 0.01), while no change was found in the NORM group (n = 43). A total of 72% of patients with preoperative motility disorder showed normal postoperative manometry. Conclusion: Nissen fundoplication normalizes esophageal motility, especially in patients with preoperative hypomotility. Patients with impaired esophageal motility should not per se be excluded from antireflux surgery.

Vascular endothelial growth factor expression following ischemic conditioning of the gastric conduit

The partial devascularization of the stomach, necessary for esophageal reconstruction with a gastric conduit, impairs microcirculation in the anastomotic region of the gastric fundus. Ischemic conditioning of the gastric tube is considered as a possible approach to improve microcirculation in the gastric mucosa. The aim of this study was to investigate whether ischemic conditioning induces neo-angiogenesis in the gastric fundus by expression of vascular endothelial growth factor (VEGF). Twenty patients with an esophageal carcinoma scheduled for esophagectomy and gastric reconstruction were included. To compare VEGF expression before and after ischemic conditioning, preoperative endoscopic biopsies were taken from the gastric fundus. The surgical procedure consisted of two separate steps, the complete gastric mobilization including partial devascularization of the stomach and after a delay of 4-5 days high transthoracic esophagectomy with intrathoracic gastric reconstruction (Ivor-Lewis procedure). The second tissue sample was obtained from the donut of the stapled esophagogastrostomy. For further work-up, preoperative biopsies and the gastric donuts were fixed in liquid nitrogen. Preoperative and intraoperative VEGF expression was measured by quantitative real-time reverse transcription-polymerase chain reaction (VEGF×100/β-actin) and results were compared using Wilcoxon test for paired samples. In all 40 specimens, a distinct expression of VEGF could be detected. Comparing the level of VEGF expression of the preoperative biopsies and postoperative tissue sample, no significant difference could be demonstrated following ischemic conditioning. In this model of ischemic conditioning with delayed reconstruction of 4-5 days, no induction of neo-angiogenesis could be demonstrated by measurement of VEGF expression.