Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2).

BACKGROUND: Management of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. METHODS: Patients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. RESULTS: A total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. CONCLUSION: The incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Roux-en-Y with or without jejunal J-pouch reconstruction after total gastrectomy for gastric cancer: systematic review and meta-analysis of long-term functional outcomes.

BACKGROUND: Increased survival of patients undergoing total gastrectomy for gastric cancer has prompted several efforts to improve long-term postgastrectomy syndrome (PGS) outcomes. Whether a J-pouch (JP) reconstruction may be more beneficial than a standard Roux-en-Y (RY) is controversial. METHODS: A systematic review with meta-analysis was conducted, including studies reporting long-term outcomes of patients treated with total gastrectomy and JP vs RY esophagojejunostomy for gastric adenocarcinoma. A literature search was performed on PubMed, Scopus, and Google Scholar. Primary endpoints were symptom control, weight loss, eating capacity (EC), and quality of life (QoL) with at least 6 months of follow-up. Safety endpoints were explored. RESULTS: Overall, 892 patients were included from 15 studies (6 randomized controlled trials [RCTs] and 9 non-RCTs): 452 (50.7%) in the JP group and 440 (49.3%) in the RY group. Compared with RY, JP showed a significantly lower rate of dumping syndrome (13.8% vs 26.9%, odds ratio [OR], 0.29; 95% confidence interval [CI], 0.14-0.58; P < .001; I2 = 22%) and heartburn symptoms (20.4% vs 39.0%; OR, 0.29; 95% CI, 0.14-0.64; P = .002; I2 = 0%). Reflux (OR, 0.61; 95% CI, 0.28-1.32; P = .21; I2 = 42%) and epigastric fullness (OR, 0.60; 95% CI, 0.18-2.05; P = .41; I2 = 69%) were similar in both groups. Weight loss and EC were similar between the groups. QoL outcome seemed to be burdened by bias. There was no difference in morbidity, mortality, and anastomotic leak rate between groups. Operative time was significantly longer for JP than for RY (271.9 vs 251.6 minutes, respectively; mean difference, 21.55; 95% CI, 4.64-38.47; P = .01; I2 = 96%). CONCLUSION: JP reconstruction after total gastrectomy for gastric cancer is as safe as RY and may provide an advantage in postgastrectomy dumping syndrome and heartburn symptoms.

Textbook outcome as indicator of surgical quality in a single Western center: results from 300 consecutive gastrectomies.

Textbook outcome (TO) has been proposed as a tool to evaluate surgical quality. Textbook oncological outcome (TOO) adds chemotherapeutic compliance to TO. This study was conducted to analyze the TO and TOO of patients with gastric adenocarcinoma who underwent surgery at our center. Data from a prospective database of patients operated on for gastric adenocarcinoma between September 2018 and September 2022 were analyzed. Postoperative management followed Enhanced Recovery After Surgery guidelines. The Dutch Upper Gastrointestinal Cancer Audit group defined TO as a multidimensional measure (10 items). TOO also considers guideline-accordant chemotherapeutic compliance. Three hundred patients underwent surgery during the study period (167 men, 133 women). One hundred seventy-six (58.7%) reached TO. Achieving TO was influenced by patients' comorbidities, calculated via the Charlson Comorbidity Score (3 vs. 4; p = 0.002) and surgery type (subtotal gastrectomy; p < 0.001), but not by the American Society of Anesthesiologists (ASA) score (p = 0.057) or surgical approach (laparoscopic vs. open; p = 0.208). The analysis of TOO included 213 patients. Of these, 71 (33%) underwent complete adequate systemic treatment. Compared with the non-TOO group, patients who achieved TOO had a lower median age (64 vs. 73 years; p < 0.001) and lower ASA score (p < 0.001) and more frequently underwent preoperative chemotherapy (p < 0.001). Our results represent the experience of a single team at a high-volume Western institute. Patients' comorbidities and surgery type influenced whether TO was achieved. Conversely, younger age, lower ASA score and preoperative chemotherapy were associated with TOO.

Implementation of the ERAS program in gastric surgery: a nationwide survey in Italy.

Enhanced recovery after surgery (ERAS) programs have been developed by combining several evidence-based techniques for perioperative care, with the intention of reducing the stress response and organ dysfunction, thus allowing improved clinical results. ERAS programs have been widely adopted for colorectal surgery; however, their adoption for upper gastrointestinal surgery has been challenging even though good results have been reported in the literature. Our intent was to investigate the adoption of ERAS programs for resective gastric surgery in Italy. A survey was conducted among 20 departments of surgery belonging to the Italian Group for Research on Gastric Cancer (GC). Analysis of our survey showed that several evidence-based practices and many items of the ERAS guidelines for gastric surgery are not implemented in real practice in Italian centers dedicated to GC. This situation may be related to the hesitation of surgeons to introduce radical changes to the traditional postoperative management after gastrectomy. A multidisciplinary approach to the perioperative care of these patients is not routinely applied in many Italian centers. A strict collaboration of all clinicians involved in the perioperative care of patients undergoing gastrectomy for GC is key for the future implementation of ERAS in gastric surgery in our departments.

Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes.

Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50-1000 ml). The median overall length of stay was 13 (7-64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.