Rudolf J. Stadlhuber

Endoscopic stent insertion for anastomotic leakage following oesophagectomy

Introduction Intrathoracic anastomotic leakage following oesophagectomy is a crushing condition. Until recently, surgical re-exploration was the preferred way of dealing with this life threatening complication. However, mortality remained significant. We therefore adopted endoscopic stent implantation as the primary treatment option. The aim of this study was to investigate the feasibility and results of endoscopic stent implantation as well as potential hazards and pitfalls. Methods Between January 2004 and December 2011, 292 consecutive patients who underwent an oesophagectomy at a single high volume centre dedicated to oesophageal surgery were included in this retrospective study. Overall, 38 cases with anastomotic leakage were identified and analysed. Results A total of 22 patients received endoscopic stent implantation as primary treatment whereas a rethoracotomy was mandatory in 15 cases. There were no significant differences in age, frequency of neoadjuvant therapy or ASA grade between cases with and without a leak. However, patients with a leak were five times more likely to have a fatal outcome (odds ratio: 5.10, 95% confidence interval: 2.06–12.33, p<0.001). Stent migration occurred but endoscopic reintervention was feasible. In 17 patients (77%) definite closure and healing of the leak was achieved, and the stent was removed subsequently. Two patients died owing to severe sepsis despite sufficient stent placement. Moreover, stent related aortic erosion with consecutive fatal haemorrhage occurred in three cases. Conclusions Stent implantation for intrathoracic oesophageal anastomotic leaks is feasible and compares favourably with surgical re-exploration. It is an easily available, minimally invasive procedure that may reduce leak related mortality. However, it puts the already well-known risk of stent-related vascular erosion on the spot. Awareness of this life threatening complication is therefore mandatory.

Risk of Stent-Related Aortic Erosion After Endoscopic Stent Insertion for Intrathoracic Anastomotic Leaks After Esophagectomy

BACKGROUNDnIntrathoracic anastomotic leakage after esophagectomy is associated with high morbidity and mortality. Because of disappointing results after surgical reexploration endoscopic stent implantation was introduced as primary treatment option with improved outcome. Aortoesophageal fistula is a very rare complication and has thus far only anecdotally been reported after esophagectomy. The aim of this retrospective study was to investigate if endoscopic stent implantation increases the incidence of postoperative aortoesophageal fistula by reason of stent-related erosion of the thoracic aorta.nnnMETHODSnBetween January 2004 and October 2010, 213 patients underwent esophageal resection mainly for esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 25 patients. Seventeen patients received endoscopic implantation of a self-expanding stent as primary treatment. In 8 patients a rethoracotomy was mandatory.nnnRESULTSnAfter successfully accomplished endoscopic stent placement, complete closure of the anastomotic leak was radiologically proven in all 17 patients. In 13 cases, definitive closure and healing of the leak was achieved and the stent could subsequently be removed. In 1 patient, because of early recurrence of very malignant small cell cancer, the stent remained in situ. Three patients developed an erosion of the thoracic aorta with subsequent massive hemorrhage. The mean time between stent insertion and occurrence of aortoesophageal fistula was 26 days. All 3 patients died of exsanguination with severe hypovolemic shock. Postmortem examination confirmed an aortoesophageal fistula in each case.nnnCONCLUSIONSnWhile endoscopic stent implantation seems to be effective in the control of intrathoracic anastomotic leakage, nevertheless the incidence of aortoesophageal fistula caused by stent-related aortic erosion exceeds the thus far reported numbers. Awareness of this life-threatening complication after stent insertion is therefore mandatory.

Treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation

Intrathoracic anastomotic leakage in patients with esophagectomy is associated with high morbidity and mortality. Until recently surgical reexploration was the preferred way of dealing with this life-threatening complication. But mortality remained significant. After the first successful reports we adopted endoscopic stent implantation as a primary treatment option. The aim of this study was to investigate the feasibility and the results of endoscopic stent implantation. Between January 2004 and December 2009, 167 patients underwent an esophageal resection. Surgery was mainly the result of esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 17 patients. Twelve patients received an implantation of a self-expanding stent as a primary treatment. An endoscopic stent placement was accomplished in all 12 patients. In nine patients a definitive closure of the leak was achieved and the stent could subsequently be removed. Two patients died due to severe sepsis in spite of sufficient stent placement. Because of early recurrence of very malign small cell cancer the stent remained in situ in one patient. In conclusion, stent implantation for intrathoracic esophageal anastomotic leaks is feasible and compares favorable with the results of surgical reexploration. It is an easily available minimally-invasive procedure which may reduce leak-related mortality and morbidity.

Endovascular stent--graft repair of a symptomatic superior mesenteric artery aneurysm.

BACKGROUNDnAneurysms of the visceral branches of the abdominal aorta are uncommon and potential life-threatening entities. Although hepatic and splenic artery aneurysms have the highest prevalence among splanchnic aneurysms, superior mesenteric artery aneurysms are even more uncommon. For ruptured visceral arteries aneurysms, a mortality rate of between 20% and 100% has been reported. Besides rupture, the aneurysms can also erode into adjacent visceral organs, which results in severe hemorrhage. Emergency surgery of visceral artery aneurysms is related with significant mortality. In recent years, endovascular therapies have been successfully established in the elective setting. Therefore, we adopted the endovascular stent-graft insertion technique for dealing with an acute symptomatic aneurysm of the superior mesenteric artery.nnnMETHODnWe report the case of a 79-year-old male patient with a symptomatic aneurysm of the proximal superior mesenteric artery. Using an endovascular approach, the aneurysm was excluded with an endoluminal stent--graft.nnnRESULTnThe endoluminal stent--graft repair resulted in total exclusion of the aneurysm. Patency of the superior mesenteric artery continued and no ischemic complications occurred. Pain and other symptoms disappeared and the patient recovered entirely.nnnCONCLUSIONSnEndovascular management of symptomatic superior mesenteric artery aneurysm is feasible and may display excellent results in selected cases. Therefore, endoluminal stent--graft repair should be considered as an alternative to traditional surgical treatment. However, in each patient, the individual anatomy of the mesenteric circulation and the location of the aneurysm play a major role in determining whether endovascular management is possible or surgical repair should be preferred.

The origins of an operation: a brief history of transhiatal esophagectomy.

Summary Although Orringer and Sloan deserve credit for convincingthesurgicalworldoftheroleoftransmediastinalesophagectomy,weshould be mindful of the efforts of pioneer surgeons who alsocontributed to the origins of this unique surgical procedure. ACKNOWLEDGMENTS The authors would like to thank Fumiaki Yano, MD, PhD andKazuto Tsuboi, MD from Department of Surgery, Jikei UniversitySchool of Medicine, Tokyo, Japan for their help in providinginformation on the Japanese sources. REFERENCES 1. Orringer MB, Sloan H. Esophagectomy without thoracotomy. J ThoracCardiovasc Surg. 1978;76(5):643–654.2. Denk W. Zur radikaloperation des oesophaguskarzinoms. Zentralbl-Chir .1913;40:1065.3. Dubecz A, Schwartz SI. Franz John A. Torek. Ann Thorac Surg . 2008;85(4):1497–1499.4. Levy W. Versuche u¨ber die resektion der Speisero¨hre. Langenbecks ArchChir . 1898;56:839.5. von Ach A. Beitra¨ge zur o¨sophagus-chirurgie !Dissertation. Munchen; 1913.Courtesy of the Hungarian Museum of Medical Sciences.6. Turner G. The Henry Bigelow lecture - some experiences in the surgery of theoesophagus.

Modern History of Surgical Management of Lung Abscess: From Harold Neuhof to Current Concepts

Harold Neuhof was one of the pioneers of thoracic surgery in the early decades of the last century. Inspired by his preceptor Howard Lilienthal he proposed an entirely new concept for surgery on acute lung abscess. The aim of his one-stage procedure was adequate drainage of the abscess cavity. His approach proved to be the first major breakthrough in the treatment of acute lung abscess. Therapy of pulmonary abscess was again radically changed by the advent of antibiotics in the late 1940s. However, the basic principles of Neuhofs concept still influence modern-day management of putrid lung abscess.

Emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal cancer.

INTRODUCTIONnOesophageal perforation following chemoradiotherapy for oesophageal cancer is a devastating condition but there have been no studies investigating the role of emergency oesophagectomy for this life threatening situation.nnnMETHODSnThis retrospective study comprised all cases of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal carcinoma at a major centre for oesophageal surgery in Germany between 2004 and 2013.nnnRESULTSnA total of 13 patients (mean age: 58.9 years) were identified. During the same time period, 356 elective oesophagectomies were performed. Tumour entities were squamous cell carcinoma (n=12) and adenocarcinoma of the oesophagus (n=1). Alcoholism (odds ratio [OR]: 25.79, 95% confidence interval [CI]: 6.70-121.70, p<0.0001) and chronic pulmonary disease (OR: 3.76, 95% CI: 1.06-14.96, p=0.027) were more common among the emergency cases. Oesophageal rupture was caused by perforation of an oesophageal stent (10 cases) or perforation during implantation of a percutaneous endoscopic gastrostomy tube (3 cases). Emergency oesophagectomy was carried out either as discontinuity resection (10/13) or oesophagectomy with immediate reconstruction (3/13). Compared with the elective cases, patients undergoing emergency oesophagectomy had significantly higher odds for sustaining perioperative sepsis (OR: 4.42, 95% CI: 1.23-16.45, p=0.01), acute renal failure (OR: 6.49, 95% CI: 1.57-24.15, p=0.005) and pneumonia (OR: 24.33, 95% CI: 3.52-1,046.65, p<0.0001). Furthermore, slow respiratory weaning was more common and there was a significantly higher tracheostomy rate (OR: 4.64, 95% CI: 1.14-16.98, p=0.02). Oesophageal discontinuity was eventually reversed in eight patients. Emergency oesophagectomy patients had odds that were three times higher for fatal outcome (OR: 3.59, 95% CI: 0.77-13.64, p=0.05). The overall mortality was 4/13. The remaining nine patients had a mean survival of 25.1 months (range: 5-46 months). The two-year-survival-rate was 38.5% (5/13).nnnCONCLUSIONSnDespite the most unfavourable preconditions, the results of emergency oesophagectomy for oesophageal perforation after chemoradiotherapy are not desperate. The procedure is not only justified but life saving.

290 Time-Trends and Disparities in Lymphadenectomy for Gastrointestinal Cancer in the United States: A Population-Based Analysis of 342,792 Patients

Background nThe value of lymphadenectomy in most localized gastrointestinal (GI) malignancies is well established. Our objectives were to evaluate the time trends of lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample.