The effect of preoperative body mass index on short-term outcome after esophagectomy for cancer: A nationwide propensity score-matched analysis.

BACKGROUND: The true influence of body mass index on the outcome of esophageal cancer surgery is unclear. The aim of this study was to determine the relation between preoperative body mass index and clinical and oncological outcomes of esophagectomy for cancer in a patient cohort from the Dutch nationwide audit. METHODS: All patients who underwent esophagectomy for cancer between January 2011 and 2016 were identified in the Dutch Upper Gastrointestinal Cancer Audit. Patients were divided into 4 body mass index categories (<18.5 kg/m2 underweight, 18.5 to 25 kg/m2 normal weight, 25 to 30 kg/m2 overweight, and >30 kg/m2 obese) and were compared for clinical and oncological outcomes with the use of propensity score-matched analysis. RESULTS: Of the patients, 2,598 were included (underweight = 70, normal weight = 1,097, overweight = 1,007, and obese = 424). Before propensity score-matched analysis, underweight patients had a significantly longer hospital stay, more chyle leakage, underwent more re-operations, and had a higher in-hospital/30-day mortality compared to the other weight groups. After propensity score-matched analysis, 560 patients were included: 62 were underweight, 180 were normal weight, 165 were overweight, and 153 were obese. Length of hospital stay, chyle leakage, necrosis of the reconstruction, re-interventions, re-operations, re-admittance to the intensive care unit/medium care unit, and in-hospital/30-day mortality were seen most in the underweight group. No differences were seen in intraoperative complications and oncological outcomes. CONCLUSION: Underweight patients are more prone for the development of postoperative complications after esophagectomy. Physicians and dieticians should be aware of the impact of underweight on postoperative outcome. Future studies should focus on nutritional status and the effect of preoperative correction of body weight.

Treating Early Delayed Gastric Tube Emptying after Esophagectomy with Pneumatic Pyloric Dilation.

INTRODUCTION: Endoscopic pneumatic pyloric balloon dilation is a treatment option for early postoperative delayed gastric tube emptying following esophageal resection. This study aimed to determine the safety and effectiveness of endoscopic balloon dilation. METHODS: Between 2015 and 2018, patients with delayed gastric emptying 8-10 days after esophageal resection with gastric tube reconstruction due to esophageal carcinoma were considered for inclusion. Inclusion criteria were ≥1 of the following: nasogastric tube production ≥500 mL/24 h, ≥300 mL gastric retention, ≥50% gastric tube dilatation on X-ray, or nasogastric tube replacement. Patients were excluded on evidence of anastomotic leakage or reintervention. Success was defined as the ability to expand intake without needing to replace the nasogastric tube. Dilation was performed using a 30-mm Rigiflex balloon. RESULTS: Fifteen patients underwent pyloric dilation, 12 according to the study protocol. Treatment was performed at a median of 12 days (IQR 9-15) postoperatively. Success was achieved in 58%. At 3 months, 8 patients progressed to exclusively oral intake. The remaining 4 patients had supplementary nightly enteral tube feeding. There were no adverse events. CONCLUSION: Endoscopic balloon dilation of the pylorus is a safe, feasible therapy for early postoperative delayed gastric emptying. With a success rate of 58%, a clinical trial is a necessary next step.

Gastrointestinal histoplasmosis mimicking peritonitis carcinomatosis: a rare case of an emergent surgical presentation of HIV de novo.

Gastrointestinal perforation due to infection, including disseminated histoplasmosis, is a rare cause of the surgical acute abdomen, especially in an apparently healthy patient. We describe a rare case of gastrointestinal histoplasmosis-induced small intestine perforation as the first manifestation of acquired immune deficiency syndrome in a healthy patient. Remarkably, the disease mimicked peritonitis carcinomatosis during explorative laparoscopy.

Incidence and Treatment of Symptomatic Diaphragmatic Hernia After Esophagectomy for Cancer.

BACKGROUND: Diaphragmatic hernias after esophagectomy are mostly asymptomatic. However, they can also manifest with severe complications and be associated with high morbidity and mortality rates. The aims of this study were to assess the incidence, predictive factors, and preferred treatment of symptomatic diaphragmatic hernias and to evaluate the role of prophylactic cruroplasty in patients after esophagectomy for carcinomas of the esophagus or gastroesophageal junction. METHODS: A prospective database was used to retrospectively analyze consecutive patients who underwent esophagectomy between January 2005 and December 2015. RESULTS: A symptomatic diaphragmatic hernia was diagnosed in 21 (2.5%) of 851 included patients; 15 (4.3%) after 345 minimally invasive esophagectomies and 6 (1.2%) after 506 open esophagectomies (p = 0.004). Minimally invasive Ivor Lewis procedures had the highest incidence (9.4%; p = 0.002) as compared with all other procedures. Prophylactic cruroplasty did not decrease the incidence of symptomatic diaphragmatic hernias (2.1% vs 2.7%; p = 0.608). Surgical treatment consisted of cruroplasty, with reinforcement of Prolene pledgets (Ethicon, Somerville, NJ) in 11 patients. Major complications (Clavien-Dindo grade >IIIb) occurred in 3 patients, all after open repair (n = 9). Recurrences were found in 4 patients (19.0%), three after laparoscopic repair and one after open repair. CONCLUSIONS: The incidence of symptomatic diaphragmatic hernia after esophagectomy was 2.5%, with the highest incidence after minimally invasive Ivor Lewis esophagectomy (9.4%) as compared with other procedures. Although prophylactic cruroplasty is now the standard of care in patients undergoing minimally invasive esophagectomy, a significant lower hernia rate was not found in this study.

Sexual and urinary functioning after rectal surgery: a prospective comparative study with a median follow-up of 8.5 years.

PURPOSE: The purpose of this study was to prospectively compare rectal resection (RR) with colonic resection on sexual, urinary and bowel function and quality of life in both short-term and long-term. METHODS: Eighty-three patients who underwent RR were compared to 53 patients who underwent a colonic resection leaving the rectum in situ (RIS). A questionnaire assessing sexual, urinary and bowel functioning with a quality of life questionnaire (SF-36) was sent to all participants preoperatively, 3 and 12 months postoperatively and approximately 8 years after the onset of the study. RESULTS: Short-term dysfunction included diminished sexual activity in female RR patients at 3 months and significantly more erectile dysfunction in RR patients 1 year postoperatively. Long-term dysfunction included more frequent and more severe erectile dysfunction in RR patients compared to RIS patients. These short-term and long-term outcomes did not influence overall quality of life. The incidence of urinary dysfunction was comparable between both groups. Bowel functioning was significantly better in the RIS group compared to the RR group 3 months and 1 year postoperatively. CONCLUSIONS: Patients who underwent RR experienced up to 1 year postoperatively more sexual and bowel function problems than RIS patients. However, short-term and long-term dysfunction did not influence overall quality of life. Erectile dysfunction in male RR patients persisted in time, whereas other aspects of sexual, urinary and bowel function after RR and colonic resection are similar after a median follow-up of 8.5 years.

Risk factors for development of benign cervical strictures after esophagectomy.

OBJECTIVE: To identify independent risk factors for development of benign cervical anastomotic strictures in general and specifically for refractory strictures after esophagectomy in a large series of patients. SUMMARY BACKGROUND DATA: Benign strictures develop frequently when a cervical anastomosis is performed after esophagectomy, causing burdensome symptoms and poor quality of life. METHODS: From 1996 to 2006, all patients in the Academic Medical Center prospective database undergoing esophagectomy with a cervical anastomosis were included. Stricture was defined as dysphagia requiring endoscopic dilation of the anastomosis. Prediction of stricture was assessed using uni- and multivariate logistic regression analysis. Evaluation of risk factors was also performed for refractory strictures (>2 times the median number of dilations in all patients with stricture) in a similar fashion. RESULTS: A total of 607 patients underwent potentially curative esophagectomy, with an in-hospital mortality of 2.5%. During follow-up, 253 (41.7%) patients developed a stricture after a median time of 74 days, requiring a median number of 5 dilations. Cardiovascular disease (P = 0.002), gastric tube compared with colonic interposition (P = 0.03), and anastomotic leakage (P = 0.002) were predictive for development of stricture in multivariate analysis. Development of stricture within 90 days after surgery (P = 0.001), chemoradiotherapy (P = 0.02), and anastomotic leakage (P = 0.03) were independent predictors for refractory strictures requiring over 10 dilations. CONCLUSIONS: The benign cervical stricture rate after esophagectomy was relatively high. Cardiovascular disease, gastric tube compared with colonic interposition and postoperative anastomotic leakage were independent predictors for development of benign anastomotic stricture. Anastomotic leakage, chemoradiotherapy and early development of stricture were independently associated with the development of refractory strictures, requiring a higher number of dilations. Prevention of anastomotic stricture formation should be focused on prevention of anastomotic leakage.