A comprehensive review of anastomotic technique in 432 esophagectomies.

BACKGROUND: Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) (longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques. METHODS: From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed. RESULTS: There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p=0.01) and LS anastomoses had the lowest risk of stricture (p=0.006). CONCLUSIONS: When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation.

Hiatal hernia after esophagectomy: analysis of 2,182 esophagectomies from a single institution.

BACKGROUND: Esophageal resection is a complex operation often associated with morbidity. Hiatal hernia after esophagectomy is an unusual complication. We reviewed our experience with this complication. METHODS: From February 1988 through February 2009 we performed 2,182 esophagectomies. Fifteen (0.69%) patients experienced a hiatal hernia. We reviewed our prospective database for demographics, presentation, operative approaches, and outcomes. RESULTS: There were 14 men and 1 woman with a mean age of 59 years. Hernia developed after Ivor Lewis approach in 9, transhiatal in 5, and substernal colon interposition in 1. Presenting symptoms included pain in 7 patients, obstructive symptoms in 5, high chest tube output in 2, shortness of breath in 2, diarrhea in 1, and cough with dysphagia in 1. Two patients were asymptomatic. Radiographic studies revealed bowel in the left chest in 11 patients, right chest in 2, bilaterally in 1, and posterior mediastinum in 1. Hernia repair was through the abdomen in 14 patients and left chest in 1. All had reduction of the herniated contents and closure of the defect; 2 required mesh. There was no early mortality. Complications included wound infection, deep venous thrombosis, chylothorax, urinary retention, sacral decubiti, atrial arrhythmias, respiratory failure, and empyema. Mean follow-up was 34 months. Ten patients are still alive. There have been two hernia recurrences. CONCLUSIONS: Hiatal hernia after esophagectomy is rare. Repair can be accomplished with low mortality; however, there is substantial morbidity. Because of the increased risk of incarceration or strangulation, these herniae should be repaired. Long-term outcome is usually excellent.

Atypical tamponade hemodynamic in a patient with temporary left ventricular assist device.

Postoperative bleeding and tamponade are considered major complications after implantation of left ventricular assist devices. Firstly, 40% of patients supported by ventricular assist devices experience early postoperative bleeding, and 20% developed tamponade requiring re-exploration. Secondly, we present a case of a patient with tamponade, on temporary left ventricular assist device (LVAD) support with atypical hemodynamic and echocardiographic manifestations demonstrated with computed tomography (CT)-M mode, conventional Doppler, color Doppler and echo imaging.

Zollinger-Ellison syndrome due to primary gastrinoma of the extrahepatic biliary tree: three case reports and review of literature.

OBJECTIVE: To report 3 cases of primary neuroendocrine tumors (PNT) of the extrahepatic biliary tree (EHBT) in patients with Zollinger-Ellison syndrome (ZES), 2 of whom had multiple endocrine neoplasia type 1 (MEN 1). METHODS: Three new cases of gastrin-producing tumors of the EHBT are presented, and the pertinent literature relating to PNT of the EHBT is reviewed. RESULTS: Eighty-one previous cases of PNT of the EHBT have been reported in the world literature, 7 of which were hormonally active and associated with peptic ulcer disease, diarrhea, or ZES. Three additional patients presented to us with ZES due to PNT of the EHBT. One patient with MEN 1 was treated with a Whipple procedure for a common bile duct gastrinoma. A second patient underwent left hepatectomy with resection of the confluence of the right and left hepatic ducts for a primary left hepatic duct gastrinoma. The second patient with MEN 1 under-went resection of a gastrinoma at the junction of the cystic duct and the common bile duct. CONCLUSION: Although PNT of the EHBT are uncommon, the association with ZES is even more so. Often, nonfunctioning tumors are diagnosed late in the course of the disease from symptoms related to biliary obstruction. Patients with ZES may be diagnosed earlier because of symptoms resulting from gastrin excess. Surgical resection is the only chance for cure and is often helpful in the palliation of symptoms.