Browsing by Author "Hicks, Adam"

Now showing 1 - 2 of 2
  • Thumbnail Image
    Item
    Management of anastomotic leaks following esophagectomy: when to intervene?
    (AME Publishing Company, 2019-01) Manghelli, Joshua L.; Ceppa, DuyKhanh P.; Greenberg, Jason W.; Blitzer, David; Hicks, Adam; Rieger, Karen M.; Birdas, Thomas J.; Department of Surgery, Indiana University School of Medicine
    Background: Esophagectomy is the mainstay treatment for early stage and locoregionally advanced esophageal cancer. Anastomotic leaks following esophagectomy are associated with numerous detrimental sequelae. The management of anastomotic leaks has evolved over time. The present study is a single-institution experience of esophageal leak management over an 11-year period, in order to identify when these can be managed nonoperatively. Methods: All patients undergoing esophagectomy with gastric reconstruction at our institution between 2004 and 2014 were identified. Preoperative patient characteristics and perioperative factors were reviewed. Failure of initial leak treatment was defined as need for escalation of therapy. Length of stay (LOS) and postoperative mortality were the primary outcomes. Follow-up was obtained through institutional medical records and the Social Security Death Index. Results: Sixty-one of 692 (8.8%) patients developed an anastomotic leak. Forty-six patients (75.4%) first underwent observation, which was successful in 35 patients. Predictors of successful observation included higher preoperative albumin (P=0.02), leak diagnosed by esophagram (P=0.004), and contained leaks (P=0.01). Successful observation was associated with shorter LOS (P=0.001). Predictors of mortality included lower preoperative serum albumin (P=0.01) and induction therapy (P=0.03). Thirty and 90-day mortality among patients who developed an anastomotic leak were 9.8% and 16.7%, respectively. Conclusions: Over half of anastomotic leaks were managed successfully with observation alone and did not require additional interventions. We have identified factors that may predict successful therapy with observation in these patients. Further research is warranted to determine more timely interventions for patients likely to fail conservative management.
  • Thumbnail Image
    Item
    Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia and circulatory arrest
    (Elsevier, 2017) Corvera, Joel; Copeland, Hannah; Blitzer, David; Hicks, Adam; Manghelli, Joshua; Hess, Philip; Fehrenbacher, John; Department of Surgery, IU School of Medicine
    Background Chronic dissection of the thoracic and thoracoabdominal aorta as sequela of a prior type A or B dissection is a challenging problem that requires close radiographic surveillance and prompt operative intervention in the presence of symptoms or aneurysm formation. Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia has been our preferred method to treat this complex pathology. The advantages of this technique include organ and spinal cord protection, the flexibility to extend the repair proximally into the arch, and the ability to limit ischemia to all vascular beds. Methods Open repair of arch by left thoracotomy and descending thoracic and thoracoabdominal aortic pathology using deep hypothermia was performed in 664 patients from 1995 to 2015. A subset of this cohort had chronic thoracoabdominal aortic dissection (n = 196). All nonemergency cases received coronary angiography and echocardiography preoperatively. Significant coronary artery disease or severe aortic insufficiency was addressed before repair of the chronic dissection. In recent years, lumbar drains were placed preoperatively in the most extensive repairs (extents II and III). Important intercostal arteries from T8 to L1 were revascularized with smaller-diameter looped grafts. Multibranched grafts for the visceral segment have been preferred in recent years. Results Mean age of patients was 58 ± 14 years. Men comprised 74% of the cohort. Aortopathy was confirmed in 18% of the cohort. Prior thoracic aortic repair occurred in 57% of patients, and prior abdominal aortic repair occurred in 14% of patients. Prior type A aortic dissection occurred in 44% of patients, and prior type B occurred in 56% of patients. Operative mortality was 3.6%, permanent spinal cord ischemia occurred in 2.6% of patients, permanent hemodialysis occurred in 0% of patients, and permanent stroke occurred in 1% of patients. Reexploration for bleeding was 5.1%, and respiratory failure requiring tracheostomy occurred in 2.6%. Postoperative length of stay was 11.9 ± 9.7 days. Reintervention for pseudoaneurysm or growth of a distal aneurysm was 6.9%. The 1-, 5-, and 10-year survivals were 93%, 79%, and 57%, respectively. Conclusions Open repair of chronic thoracic and thoracoabdominal aortic dissection using deep hypothermia and circulatory arrest has low morbidity and mortality. The need for reintervention is low, and long-term survival is excellent. We believe that open repair continues to be the gold standard in patients who are suitable candidates for surgery.