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2.
Ann Surg Oncol ; 28(1): 203, 2021 Jan.
Article in English | MEDLINE | ID: covidwho-1456031

ABSTRACT

The increasing prevalence of morbid obesity in the United States has been accompanied by a concomitant rise in bariatric surgery to help combat the epidemic. The relationship between obesity and certain cancers, such as esophageal adenocarcinoma, is well established. The need for minimally invasive techniques to treat esophageal cancer in patients with previous bariatric surgery is growing and can present a unique surgical challenge. This report presents the case of a 55-year-old woman with a previous Roux-en-Y gastric bypass who was shown by endoscopy to have an invasive adenocarcinoma located in the distal thoracic esophagus. This necessitated an excision of the thoracic esophagus and the gastric pouch. A laparoscopic and thoracoscopic Ivor-Lewis esophagogastrectomy was performed for this complex patient with esophageal adenocarcinoma. The remnant stomach was fashioned into a gastric conduit using a 60-mm linear stapler with a staple height of 4.1 mm (Echelon, Ethicon Endosurgery, Blue Ash, OH). The reconstruction was performed using a 25-mm Orvil (Covidien, Minneapolis, MN, USA) and EEA 25-mm DST XL (Covidien) to create a circular stapled thoracic esophagogastric anastomosis. A feeding jejunostomy was placed in the residual 130-cm Roux limb. The study demonstrated that minimally invasive esophagectomy is safe and technically feasible with appropriate oncologic outcomes for patients with previous gastric bypass. This cohort of patients will undoubtedly continue to grow in the coming years.


Subject(s)
Adenocarcinoma , Esophageal Neoplasms , Gastric Bypass , Laparoscopy , Adenocarcinoma/surgery , Anastomosis, Surgical , Esophageal Neoplasms/surgery , Esophagectomy , Female , Gastrectomy , Humans , Middle Aged
3.
Surg Endosc ; 36(2): 1675-1682, 2022 02.
Article in English | MEDLINE | ID: covidwho-1401033

ABSTRACT

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.


Subject(s)
COVID-19 , Esophageal Neoplasms , Robotics , Anastomosis, Surgical , Anastomotic Leak/etiology , Esophageal Neoplasms/surgery , Esophagectomy , Humans , Retrospective Studies , SARS-CoV-2
4.
Chirurg ; 92(10): 929-935, 2021 Oct.
Article in German | MEDLINE | ID: covidwho-1375626

ABSTRACT

BACKGROUND: The outbreak of the coronavirus disease 2019 (COVID-19) pandemic imposed limitations for elective surgery, impacting the associated hospital standards worldwide. As certain treatment windows must be adhered to in oncological surgery, the limited intensive care unit (ICU) capacity had to be critically distributed in order to do justice to both acutely ill and oncology patients. This manuscript summarizes the impact of COVID-19 on the management of oncological surgery of the upper gastrointestinal tract and particularly esophageal surgery in German medical centers. MATERIAL AND METHODS: A survey of German centers for esophageal surgery was performed on the impact of COVID-19 on operative management for esophageal surgery during the first lockdown. After inspection, assessment, critical analysis and interpretation, the results were compared to the international literature. RESULTS AND DISCUSSION: Initial recommendations of international societies warned for caution and restraint regarding interventions of the upper gastrointestinal tract that were not absolutely necessary. Oncological surgery should be performed under strict restrictions, especially only after negative testing for COVID-19 and only with sufficiently available personal protective equipment for the personnel. Furthermore, minimally invasive procedures were preferably not recommended. In diseases with alternative treatment options, such as definitive chemoradiotherapy of esophageal squamous cell carcinoma, these should be given priority when possible. In the further development of the pandemic, it was shown that due to a high standardization of preoperative management, postoperative results comparable to pre-pandemic times could be achieved particularly with respect to the diagnostics of infections.


Subject(s)
COVID-19 , Esophageal Neoplasms , Esophageal Squamous Cell Carcinoma , Upper Gastrointestinal Tract , COVID-19 Testing , Communicable Disease Control , Esophageal Neoplasms/surgery , Humans , SARS-CoV-2
5.
Ann Surg Oncol ; 28(9): 4805-4813, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1172853

ABSTRACT

BACKGROUND: Many hospitals postponed elective surgical care during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. Some centers continued elective surgery, including esophageal cancer surgery, with the use of preoperative screening methods; however, there is no evidence supporting the safety of this strategy as postoperative outcomes after esophageal cancer surgery during the COVID-19 pandemic have not yet been investigated. METHODS: This multicenter study in four European tertiary esophageal cancer referral centers included consecutive adult patients undergoing elective esophageal cancer surgery from a prospectively maintained database in a COVID-19 pandemic cohort (1 March 2020-31 May 2020) and a control cohort (1 October 2019-29 February 2020). The primary outcome was the rate of respiratory failure requiring mechanical ventilation. RESULTS: The COVID-19 cohort consisted of 139 patients, versus 168 patients in the control cohort. There was no difference in the rate of respiratory failure requiring mechanical ventilation (13.7% vs. 8.3%, p = 0.127) and number of pulmonary complications (32.4% vs. 29.9%, p = 0.646) between the COVID-19 cohort and the control cohort. Overall, postoperative morbidity and mortality rates were comparable between both cohorts. History taking and reverse transcription polymerase chain reaction (RT-PCR) were used as preoperative screening methods to detect a possible severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in all centers. No patients were diagnosed with COVID-19 pre- or postoperatively. CONCLUSION: Esophageal cancer surgery during the first wave of the COVID-19 pandemic was not associated with an increase in pulmonary complications as no patients were diagnosed with COVID-19. Esophageal cancer surgery can be performed safely with the use of adequate preoperative SARS-CoV-2 screening methods.


Subject(s)
COVID-19 , Esophageal Neoplasms , Adult , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/surgery , Humans , Pandemics , Postoperative Complications/epidemiology , SARS-CoV-2
6.
Curr Oncol ; 28(2): 1348-1353, 2021 Mar 27.
Article in English | MEDLINE | ID: covidwho-1154295

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has had a substantial impact on the provision of medical healthcare. Due to an increased risk of severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) transmission, elective surgical treatment has been suspended in many centers. The effects of COVID-19 in the early post-operative period after esophagectomy remains unknown. In this report, we present three cases of patients diagnosed with esophago-gastric junction cancer who were scheduled for elective esophagectomy with a curative intention during second wave of COVID-19 pandemic in a single high-volume tertiary center. Despite all available safety measures, one of the patients developed COVID-19 pneumonia on post-operative day two, leading to an impaired respiratory function and increased pleural fluid collection from the chest tube, resulting in a prolonged time of hospital stay. Finding a good balance between the COVID-19-related perioperative risks and consequences of delaying surgical treatment in patients diagnosed with esophago-gastric cancer is a challenge. In order to achieve the best possible outcome, care must be taken to ensure availability of necessary treatment options and to reduce the risk of SARS-Cov-2 transmission perioperatively.


Subject(s)
COVID-19/etiology , Esophageal Neoplasms/surgery , Esophagectomy/adverse effects , Postoperative Complications/virology , Adult , Aged , COVID-19/diagnostic imaging , Esophageal Neoplasms/pathology , Esophagogastric Junction/pathology , Humans , Male , Postoperative Complications/diagnostic imaging
8.
Ir J Med Sci ; 191(2): 831-837, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1137175

ABSTRACT

INTRODUCTION: The emergence of the novel coronavirus Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and the coronavirus disease COVID-19 has impacted enormously on non-COVID-19-related hospital care. Curtailment of intensive care unit (ICU) access threatens complex surgery, particularly impacting on outcomes for time-sensitive cancer surgery. Oesophageal cancer surgery is a good example. This study explored the impact of the pandemic on process and short-term surgical outcomes, comparing the first wave of the pandemic from April to June in 2020 with the same period in 2019. METHODS: Data from all four Irish oesophageal cancer centres were reviewed. All patients undergoing resection for oesophageal malignancy from 1 April to 30 June inclusive in 2020 and 2019 were included. Patient, disease, and peri-operative outcomes (including COVID-19 infection) were compared. RESULTS: In 2020, 45 patients underwent oesophagectomy, and 53 in the equivalent period in 2019. There were no differences in patient demographics, co-morbidities, or use of neoadjuvant therapy. The median time to surgery from neoadjuvant therapy was 8 weeks in both 2020 and 2019. There were no significant differences in operative interventions between the two time periods. There was no difference in operative morbidity in 2020 and 2019 (28% vs 40%, p = 0.28). There was no in-hospital mortality in either period. No patient contracted COVID-19 in the perioperative period. CONCLUSIONS: Continuing surgical resection for oesophageal cancer was feasible and safe during the COVID-19 pandemic in Ireland. The national response to this threat was therefore successful by these criteria in the curative management of oesophageal cancer.


Subject(s)
COVID-19 , Esophageal Neoplasms , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/surgery , Humans , Ireland/epidemiology , Pandemics , SARS-CoV-2
9.
Dis Esophagus ; 34(6)2021 Jun 14.
Article in English | MEDLINE | ID: covidwho-947651

ABSTRACT

Coronavirus Disease-19 (COVID-19) outbreak has significantly burdened healthcare systems worldwide, leading to reorganization of healthcare services and reallocation of resources. The Italian Society for Study of Esophageal Diseases (SISME) conducted a national survey to evaluate changes in esophageal cancer management in a region severely struck by COVID-19 pandemic. A web-based questionnaire (26 items) was sent to 12 SISME units. Short-term outcomes of esophageal resections performed during the lockdown were compared with those achieved in the same period of 2019. Six (50%) centers had significant restrictions in their activity. However, overall number of resections did not decrease compared to 2019, while a higher rate of open esophageal resections was observed (40 vs. 21.7%; P = 0.034). Surgery was delayed in 24 (36.9%) patients in 6 (50%) centers, mostly due to shortage of anesthesiologists, and occupation of intensive care unit beds from intubated COVID-19 patients. Indications for neoadjuvant chemo (radio) therapy were extended in 14% of patients. Separate COVID-19 hospital pathways were active in 11 (91.7%) units. COVID-19 screening protocols included nasopharyngeal swab in 91.7%, chest computed tomography scan in 8.3% and selective use of lung ultrasound in 75% of units. Postoperative interstitial pneumonia occurred in 1 (1.5%) patient. Recovery from COVID-19 pandemic was characterized by screening of patients in all units, and follow-up outpatient visits in only 33% of units. This survey shows that clinical strategies differed considerably among the 12 SISME centers. Evidence-based guidelines are needed to support the surgical esophageal community and to standardize clinical practice in case of further pandemics.


Subject(s)
COVID-19 , Communicable Disease Control , Digestive System Surgical Procedures/statistics & numerical data , Esophageal Neoplasms , Pandemics , Surgeons/psychology , COVID-19/prevention & control , Disease Outbreaks , Esophageal Neoplasms/epidemiology , Esophageal Neoplasms/surgery , Humans , Italy/epidemiology , SARS-CoV-2
10.
Ann R Coll Surg Engl ; 103(2): 134-137, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-921027

ABSTRACT

INTRODUCTION: Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. METHODS: We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24-48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. RESULTS: Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. CONCLUSIONS: ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.


Subject(s)
Adenocarcinoma/surgery , COVID-19/epidemiology , Esophageal Neoplasms/surgery , Esophageal Squamous Cell Carcinoma/surgery , Esophagectomy , Hospital Mortality , Length of Stay/statistics & numerical data , Postoperative Complications/epidemiology , Adult , Aged , Aged, 80 and over , COVID-19 Nucleic Acid Testing , Female , Humans , Male , Middle Aged , Neoadjuvant Therapy , Preoperative Care , Prospective Studies , SARS-CoV-2
11.
Surg Endosc ; 35(11): 6081-6088, 2021 11.
Article in English | MEDLINE | ID: covidwho-898015

ABSTRACT

BACKGROUND: Surgical society guidelines have recommended changing the treatment strategy for early esophageal cancer during the novel coronavirus (COVID-19) pandemic. Delaying resection can allow for interim disease progression, but the impact of this delay on mortality is unknown. The COVID-19 infection rate at which immediate operative risk exceeds benefit is unknown. We sought to model immediate versus delayed surgical resection in a T1b esophageal adenocarcinoma. METHODS: A decision analysis model was developed, and sensitivity analyses performed. The base case was a 65-year-old male smoker presenting with cT1b esophageal adenocarcinoma scheduled for esophagectomy during the COVID-19 pandemic. We compared immediate surgical resection to delayed resection after 3 months. The likelihood of key outcomes was derived from the literature where available. The outcome was 5-year overall survival. RESULTS: Proceeding with immediate esophagectomy for the base case scenario resulted in slightly improved 5-year overall survival when compared to delaying surgery by 3 months (5-year overall survival 0.74 for immediate and 0.73 for delayed resection). In sensitivity analyses, a delayed approach became preferred when the probability of perioperative COVID-19 infection increased above 7%. CONCLUSIONS: Immediate resection of early esophageal cancer during the COVID-19 pandemic did not decrease 5-year survival when compared to resection after 3 months for the base case scenario. However, as the risk of perioperative COVID-19 infection increases above 7%, a delayed approach has improved 5-year survival. This balance should be frequently re-examined by surgeons as infection risk changes in each hospital and community throughout the COVID-19 pandemic.


Subject(s)
COVID-19 , Esophageal Neoplasms , Aged , Esophageal Neoplasms/pathology , Esophageal Neoplasms/surgery , Esophagectomy , Humans , Male , Neoplasm Staging , Pandemics , SARS-CoV-2 , Treatment Outcome
12.
Surg Today ; 50(10): 1240-1248, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-888203

ABSTRACT

PURPOSE: Patients who receive trastuzumab (T-mab) plus chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer sometimes respond remarkably well and can undergo radical surgery. However, the clinical outcomes of preoperative T-mab combined chemotherapy with radical gastrectomy remain unclear. We conducted this study to investigate the clinical outcomes of this multimodal treatment. METHODS: From among a total of 199 patients who received T-mab-based chemotherapy for stage IV HER2-positive gastric or gastroesophageal junction cancer between 2011 and 2018, the subjects of this retrospective analysis were 20 patients who subsequently underwent radical gastrectomy. RESULTS: Seven patients had gastroesophageal junction cancer and 13 had gastric cancer. Eleven patients had unresectable stage IV cancer and 9 had resectable metastatic disease. Chemotherapy regimens included capecitabine, cisplatin + T-mab (11 patients), and S-1, oxaliplatin + T-mab (nine patients). The median number of chemotherapy cycles before surgery was three (range, 2-62). During preoperative chemotherapy, grade 3/4 adverse events developed in six patients. None suffered grade ≥ 3b postoperative complications. The 3-year relapse-free survival (RFS) and overall survival (OS) rates were 58.9% and 89.5%, respectively. CONCLUSION: Combined preoperative T-mab-based chemotherapy and surgery appears to be safe and effective for stage IV HER2-positive gastric or gastroesophageal junction cancer, with a clinically meaningful impact on RFS and OS.


Subject(s)
Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Esophageal Neoplasms/drug therapy , Esophageal Neoplasms/surgery , Esophagogastric Junction , Gastrectomy , Receptor, ErbB-2 , Stomach Neoplasms/drug therapy , Stomach Neoplasms/surgery , Trastuzumab/administration & dosage , Adult , Aged , COVID-19/drug therapy , Combined Modality Therapy , Coronavirus Infections/drug therapy , Disease-Free Survival , Esophageal Neoplasms/genetics , Esophageal Neoplasms/pathology , Female , Humans , Male , Middle Aged , Neoplasm Staging , Preoperative Care , Retrospective Studies , Stomach Neoplasms/genetics , Stomach Neoplasms/pathology , Young Adult
13.
Dis Esophagus ; 33(9)2020 Sep 04.
Article in English | MEDLINE | ID: covidwho-723451

ABSTRACT

BACKGROUND: The COVID-19 pandemic continues to have a significant impact on the provision of medical care. Planning to ensure there is capability to treat those that become ill with the virus has led to an almost complete moratorium on elective work. This study evaluates the impact of COVID-19 on cancer, in particular surgical intervention, in patients with esophago-gastric cancer at a high-volume tertiary center. METHODS: All patients undergoing potential management for esophago-gastric cancer from 12 March to 22 May 2020 had their outcomes reviewed. Multi-disciplinary team (MDT) decisions, volume of cases, and outcomes following resection were evaluated. RESULTS: Overall 191 patients were discussed by the MDT, with a 12% fall from the same period in 2019, including a fall in new referrals from 120 to 83 (P = 0.0322). The majority of patients (80%) had no deviation from the pre-COVID-19 pathway. Sixteen patients had reduced staging investigations, 4 had potential changes to their treatment only, and 10 had a deviation from both investigation and potential treatment. Only one patient had palliation rather than potentially curative treatment. Overall 19 patients underwent surgical resection. Eight patients (41%) developed complications with two (11%) graded Clavien-Dindo 3 or greater. Two patients developed COVID-19 within a month of surgery, one spending 4 weeks in critical care due to respiratory complications; both recovered. Twelve patients underwent endoscopic resections with no complications. CONCLUSION: Care must be taken not to compromise cancer treatment and outcomes during the COVID-19 pandemic. Excellent results can be achieved through meticulous logistical planning, good communication, and maintaining high-level clinical care.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Esophageal Neoplasms/surgery , Pneumonia, Viral/epidemiology , Stomach Neoplasms/surgery , Adult , Aged , Aged, 80 and over , COVID-19 , Coronavirus Infections/prevention & control , Critical Pathways , Endoscopy , Female , Humans , Infection Control , Male , Middle Aged , Pandemics/prevention & control , Patient Selection , Pneumonia, Viral/prevention & control , SARS-CoV-2 , United Kingdom/epidemiology
16.
J Thorac Cardiovasc Surg ; 160(2): 585-592.e2, 2020 08.
Article in English | MEDLINE | ID: covidwho-46386

ABSTRACT

OBJECTIVES: To illustrate the clinical course and difficulties in early diagnosis of coronavirus disease 2019 (COVID-19) in patients after thoracic surgery. METHODS: We retrospectively analyzed the clinical course of the first 11 patients diagnosed with COVID-19 after thoracic surgery in early January 2020. Postoperative clinical, laboratory, and radiologic records and the time line of clinical course were summarized. Potential prognostic factors were evaluated. RESULTS: In the 11 confirmed cases (3 female, 8 male), median days from symptom onset to case detection was 8. Insidious symptom onset and misinterpreted postoperative changes on chest computed tomography (CT) resulted in delay in diagnosis. There were 3 fatalities due to respiratory failure, whereas 4 severe and 4 mild cases recovered and were discharged. All patients had once experienced leukocytosis and eosinopenia. Remittent fever and resected lung segments ≥5 were associated with fatality. CONCLUSIONS: The case fatality rate of postsurgical patients subsequently diagnosed with COVID-19 was 27.3%. Insidious symptom onset, postoperative leukocytosis with lymphopenia, and postsurgical CT changes overshadowed the early signs of viral pneumonia. Dynamic symptom monitoring, serial chest CTs, and tests for viral RNA and serum antibody improve the chance for prompt detection of COVID-19. Consideration should be given to preadmission and preoperative screening and strict contact isolation during the postoperative period.


Subject(s)
Betacoronavirus/pathogenicity , Clinical Laboratory Techniques , Coronavirus Infections/diagnosis , Esophageal Neoplasms/surgery , Lung Neoplasms/surgery , Pneumonia, Viral/diagnosis , Thoracic Surgical Procedures/adverse effects , Aged , COVID-19 , COVID-19 Testing , Coronavirus Infections/mortality , Coronavirus Infections/therapy , Coronavirus Infections/virology , Delayed Diagnosis , Diagnostic Errors , Esophageal Neoplasms/diagnostic imaging , Esophageal Neoplasms/mortality , Female , Host Microbial Interactions , Humans , Lung Neoplasms/diagnostic imaging , Lung Neoplasms/mortality , Male , Middle Aged , Pandemics , Pneumonia, Viral/mortality , Pneumonia, Viral/therapy , Pneumonia, Viral/virology , Predictive Value of Tests , Retrospective Studies , Risk Assessment , Risk Factors , SARS-CoV-2 , Thoracic Surgical Procedures/mortality , Time Factors , Treatment Outcome
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