Browsing by Subject "Esophagectomy"
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Item Commentary: Minimally invasive esophagectomy-practice what you preach(Elsevier, 2020-11-16) Wilkerson, Jordan A.; Ceppa, DuyKhanh P.; Surgery, School of MedicineMinimally invasive esophagectomy (MIE) is associated with improved patient outcomes. The teaching community must advocate for increased utilization of MIE or hybrid approaches for the benefit of patients and trainees.Item Esophagectomy: Minimally Invasive versus Open(2022-12-13) Dijak, FrankItem An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function(Journal of Visualized Experiments, 2020-04-17) Ramchandani, Neal K.; Kesler, Kenneth A.; Rogers, Jonathon D.; Valsangkar, Nakul; Stokes, Samatha M.; Surgery, School of MedicineWe describe a novel esophagogastric anastomotic technique ("side-to-side: staple line-on-staple line", STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution. The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures. There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p<0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients. The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.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 MedicineBackground: 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.Item Management of clinical T2N0 esophageal cancer: a review(AME Publishing Company, 2019-08-11) Vining, Patrick; Birdas, Thomas J.; Surgery, School of MedicineWhile management of locally advanced esophageal cancer has mostly involved multimodality therapy, management of clinical T2N0 patients has been more controversial, primarily as a result of inaccurate clinical staging with existing modalities. This review article examines current literature on this topic and provides recommendations for management of individual patients.Item Outcomes of submucosal (T1b) esophageal adenocarcinomas removed by endoscopic mucosal resection(Baishideng Publishing Group, 2016-12-16) Ballard, Darren D.; Choksi, Neel; Lin, Jingmei; Choi, Eun-Young; Elmunzer, B. Joseph; Appelman, Henry; Rex, Douglas K.; Fatima, Hala; Kessler, William; DeWitt, John M.; Department of Pathology and Laboratory Medicine, IU School of MedicineAIM: To investigate the outcomes and recurrences of pT1b esophageal adenocarcinoma (EAC) following endoscopic mucosal resection (EMR) and associated treatments. METHODS: Patients undergoing EMR with pathologically confirmed T1b EAC at two academic referral centers were retrospectively identified. Patients were divided into 4 groups based on treatment following EMR: Endoscopic therapy alone (group A), endoscopic therapy with either chemotherapy, radiation or both (group B), surgical resection (group C) or no further treatment/lost to follow-up (< 12 mo) (group D). Pathology specimens were reviewed by a central pathologist. Follow-up data was obtained from the academic centers, primary care physicians and/or referring physicians. Univariate analysis was performed to identify factors predicting recurrence of EAC. RESULTS: Fifty-three patients with T1b EAC underwent EMR, of which 32 (60%) had adequate follow-up ≥ 12 mo (median 34 mo, range 12-103). There were 16 patients in group A, 9 in group B, 7 in group C and 21 in group D. Median follow-up in groups A to C was 34 mo (range 12-103). Recurrent EAC developed overall in 9 patients (28%) including 6 (38%) in group A (median: 21 mo, range: 6-73), 1 (11%) in group B (median: 30 mo, range: 30-30) and 2 (29%) in group C (median 21 mo, range: 7-35. Six of 9 recurrences were local; of the 6 recurrences, 5 were treated with endoscopy alone. No predictors of recurrence of EAC were identified. CONCLUSION: Endoscopic therapy of T1b EAC may be a reasonable strategy for a subset of patients including those either refusing or medically unfit for esophagectomy.Item Preventing Postoperative Delirium After Major Noncardiac Thoracic Surgery—A Randomized Clinical Trial(Wiley, 2018) Khan, Babar A.; Perkins, Anthony J.; Campbell, Noll L.; Gao, Sujuan; Khan, Sikandar H.; Wang, Sophia; Fuchita, Mikita; Weber, Daniel J.; Zarzaur, Ben L.; Boustani, Malaz A.; Kesler, Kenneth; Medicine, School of MedicineObjectives: To assess the efficacy of haloperidol in reducing postoperative delirium in individuals undergoing thoracic surgery. Design: Randomized double-blind placebo-controlled trial. Setting: Surgical intensive care unit (ICU) of tertiary care center. Participants: Individuals undergoing thoracic surgery (N=135). Intervention: Low-dose intravenous haloperidol (0.5 mg three times daily for a total of 11 doses) administered postoperatively. Measurements: The primary outcome was delirium incidence during hospitalization. Secondary outcomes were time to delirium, delirium duration, delirium severity, and ICU and hospital length of stay. Delirium was assessed using the Confusion Assessment Method for the ICU and delirium severity using the Delirium Rating Scale-Revised. Results: Sixty-eight participants were randomized to receive haloperidol and 67 placebo. No significant differences were observed between those receiving haloperidol and those receiving placebo in incident delirium (n=15 (22.1%) vs n=19 (28.4%); p = .43), time to delirium (p = .43), delirium duration (median 1 day, interquartile range (IQR) 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, ICU length of stay (median 2.2 days, IQR 1-3.3 days vs median 2.3 days, IQR 1-4 days; p = .29), or hospital length of stay (median 10 days, IQR 8-11.5 days vs median 10 days, IQR 8-12 days; p = .41). In the esophagectomy subgroup (n = 84), the haloperidol group was less likely to experience incident delirium (n=10 (23.8%) vs n=17 (40.5%); p = .16). There were no differences in time to delirium (p = .14), delirium duration (median 1 day, IQR 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, or hospital length of stay (median 11 days, IQR 10-12 days vs median days 11, IQR 10-15 days; p = .26). ICU length of stay was significantly shorter in the haloperidol group (median 2.8 days, IQR 1.1-3.8 days vs median 3.1 days, IQR 2.1-5.1 days; p = .03). Safety events were comparable between the groups. Conclusion: Low-dose postoperative haloperidol did not reduce delirium in individuals undergoing thoracic surgery but may be efficacious in those undergoing esophagectomy.Item Role of surgery following neoadjuvant chemoradiation in patients with lymph node positive locally advanced esophageal adenocarcinoma: a national cancer database analysis(AME, 2021) Mamdani, Hirva; Birdas, Thomas; Jalal, Shadia I.; Surgery, School of MedicineBackground: Concurrent chemoradiation (CRT) followed by surgery is a standard of care for locally advanced esophageal adenocarcinoma. It remains unclear if surgery following CRT offers any meaningful survival benefit compared to CRT alone in patients with clinical N3 disease who are at the highest risk of developing distant disease relapse. Methods: We conducted analysis of the National Cancer Database (NCDB) to compare overall survival (OS) of patients with locally advanced esophageal adenocarcinoma (cTanyN1-3M0 based on AJCC 7th staging system) who underwent CRT with or without surgery and analyzed outcomes based on the cN stage. Results: 7,520 patients were included in the analysis-74.7% had cN1 disease, 21.1% had cN2 disease, and 4.3% had cN3 disease. The median OS advantage offered by CRT followed by surgery was 22, 15.8, and 9.6 months compared to CRT alone in cN1, cN2, and cN3 patients, respectively. The 5-year OS estimates in the surgical group were 36.9%, 31.6% and 15.9% in cN1, cN2 and cN3 groups, respectively. Conclusions: Surgery following CRT in patients with locally advanced esophageal adenocarcinoma leads to improvement in OS, with the largest benefit noted in patients with cN1 and cN2 disease. Surgery following CRT also confers meaningful long-term survival advantage for a subset of cN3 patients.Item Serum Biomarkers in Postoperative Delirium after Esophagectomy(Elsevier, 2022) Khan, Sikandar H.; Lindroth, Heidi; Jawed, Yameena; Wang, Sophia; Nasser, Jason; Seyffert, Sarah; Naqvi, Kiran; Perkins, Anthony J.; Gao, Sujuan; Kesler, Kenneth; Khan, Babar; Medicine, School of MedicineBackground: Esophagectomy is associated with postoperative delirium, but its pathophysiology is not well defined. We conducted this study to measure the relationship among serum biomarkers of inflammation and neuronal injury and delirium incidence and severity in a cohort of esophagectomy patients. Methods: Blood samples were obtained from patients preoperatively and on postoperative days 1 and 3 and were analyzed for S100 calcium-binding protein B, C-reactive protein (CRP), interleukin (IL) 8 and IL-10, tumor necrosis factor-α, and insulin-like growth factor 1. Delirium was assessed twice daily using the Richmond Agitation Sedation Scale and Confusion Assessment Method for Intensive Care Unit. Delirium severity was assessed once daily with the Delirium Rating Scale-Revised-98. Results: Samples from 71 patients were included. Preoperative biomarker concentrations were not associated with postoperative delirium. Significant differences in change in concentrations from preoperatively to postoperative day 1 were seen in IL-8 (delirium, 38.6; interquartile range [IQR], 29.3-69.8; no delirium, 24.8; IQR, 16.0-41.7, P = .022), and IL-10 (delirium, 26.1; IQR, 13.9-36.7; no delirium, 12.4; IQR, 7.7-25.7; P = .025). Greater postoperative increase in S100 calcium-binding protein B (Spearman r = 0.289, P = .020) and lower levels of insulin-like growth factor 1 were correlated with greater delirium severity (Spearman r = -0.27, P = .040). Greater CRP change quartiles were associated with higher delirium incidence adjusting for severity of illness (odds ratio, 1.68; 95% confidence interval, 1.03-2.75; P = .037) or comorbidities (odds ratio, 1.70; 95% confidence interval, 1.05-2.76, P = .030). Conclusions: Differences in change in serum CRP, IL-8, and IL-10 concentrations were associated with postoperative delirium, suggesting biomarker measurement early in the postoperative course is associated with delirium.Item Substernal reconstruction following esophagectomy: operation of last resort?(AME Publishing Company, 2017-12) Moremen, Jacob R.; Ceppa, DuyKhanh P.; Rieger, Karen M.; Birdas, Thomas J.; Surgery, School of MedicineBackground: The posterior mediastinum is the preferred location for reconstruction following esophagectomy. Occasionally alternative routes are required. We examined patient outcomes of esophageal reconstruction in order to determine whether substernal reconstruction (SR) is an equivalent alternative to orthotopic placement. Methods: Following IRB approval, we performed a retrospective review of all patients who underwent an esophagectomy from 1988-2014. Only patients reconstructed with a gastric conduit and cervical anastomosis by either substernal or posterior mediastinal (PM) routes were included in the study. Endpoints assessed included anastomotic leak rate, post-operative complications, reoperation, hospital length of stay, and 30- and 90-day mortality. Results: Thirty-three patients underwent SR and 182 had a PM gastric conduit with cervical anastomosis. The SR pathology was predominantly benign while PM was mostly malignant. Sixteen SR patients had a delayed reconstruction after prior diversion. Mean hospital LOS was longer in the SR group (P<0.001). There was no significant difference in 30- and 90-day mortality. PM patients had significantly fewer respiratory complications (P<0.04), reoperations (P<0.04), and transfusions (P<0.0001) and a trend towards fewer anastomotic leaks (17.1% vs. 30.3%; P<0.09). Conclusions: This single institution experience demonstrated no significant difference in mortality between substernal and PM reconstruction following esophagectomy. However, SR was associated with significantly increased LOS and morbidity, including a trend toward increased anastomotic leaks. SR reconstruction should probably be considered an option of last resort.