Prone position thoracoscopic management of neck chyle leak following major head and neck surgery. A case series.

Chyle leak is a major compication following head and neck surgery, with reported incidence of 0.5% up to 8.3% in published literature. Cervical chyle leak may be challenging to manage with significant morbidity, resulting from extensive fluid and nutritional losses. This manuscript presents four cases of cervical chyle leak after head and neck surgery. Cervical thoracic duct injury had been identified intra-operatively. Conservative treatment failed to reduce chylous output post-operatively. All patients were offered thoracocscopic thoracic duct ligation in prone position; thoracic duct was dissected above the right diaphragm and ligated. Immediate resolution of their symptoms followed, with no recurrence at the follow-up period. Intra-operative repair of cervical thoracic duct remains controversial, while when identified early reduces the following comorbidities. Conservative management addresses reduction of chylous output, while amplifying hydration and alimentation. Thoracoscopic thoracic duct ligation offers a safe and feasible treatment for cervival chyle leak following head and neck surgery with all the advances of minimally-invasive surgery. KEY WORDS: Chyle leak, Head and Neck Surgery, Thoracoscopic, Thorasic Duct, Ligation, Minimally-Invasive.

Minimally invasive esophagectomy for esophageal cancer in octogenarians. Clinical and oncological outcomes.

PURPOSE: Studies on patients undergoing esophagectomy for esophageal cancer have shown that thoracic and abdominal surgery may be performed safely in patients without an uppermost age cut-off. The aim of this study was to evaluate the morbidity and mortality of radical minimally invasive esophagectomy for cancer in patients over 80 years old. METHODS: A retrospective analysis of prospectively collected data over a period of 4 years was conducted. During the study period 184 esophagectomies were performed. A total of 12 octogenarians that underwent Minimally Invasive Esophagectomy (MIE) for cancer were included in the study. Our results were compared to the UK national outcomes as presented in the National Esophago-Gastric Cancer Audit (NOGCA) 2017 report. RESULTS: Median overall survival (OS) was 16.5 months (range: 6-38) and progression-free survival (PFS) 14.5 months (tange:3-38). 30-and 90-day postoperative mortality was zero. Postoperative complications included chest infection (CI) in 4 (33.3%) patients, anastomotic leakage (AL) in 3 (25%) and atrial fibrillation in 2 (16.7%). CONCLUSIONS: MIE should therefore be considered as an effective treatment strategy even in elderly patients over 80 years of age.

Hybrid Minimally-invasive Esophagectomy for Esophageal Cancer: Clinical and Oncological Outcomes.

BACKGROUND/AIM: Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality that has traditionally been performed by an open approach. Although minimally invasive procedures for benign esophageal disease have been widely accepted worldwide, they have not yet been established for the treatment of malignancy. PATIENTS AND METHODS: A total of 137 consecutive hybrid esophagectomies for cancer were performed by the same surgical team. Surgical approach included either 2-stage or 3-stage hybrid minimally-invasive esophagectomy. RESULTS: Median age of patients was 64 years. Respiratory complication and anastomotic leak rates were 16.78% and 9.48%, respectively. Median follow-up was 48 months with median overall survival and disease free survival were 58 and 48 months, respectively. CONCLUSION: Advances in minimally invasive surgery can benefit patients with esophageal cancer, mainly by reducing post-operative respiratory complications. Hybrid esophagectomy is safe and feasible in tertiary esophago-gastric centers with vast expertise that can lead to improved clinical and oncological outcomes.

Reinforcement of intrathoracic oesophago-gastric anastomosis with fibrin sealant (Tisseel®) in oesophagectomy for cancer: A prospective comparative study.

PURPOSE: Fibrin sealant (Tisseel) is a human protein and thrombin soluble fibrinogen that has been indicated for reinforcement of gastro-intestinal anastomoses to prevent leakage. The objective of this study is to examine the impact of fibrin sealant regarding anastomotic leak, following Ivor-Lewis procedure. METHODS: This is a prospective comparative study on 2-stage oesophagectomy for cancer of the distal oesophagus or oesophagogastric junction. N = 57 individuals were randomly subjected; n = 22 patients to Tisseel in combination to surgical anastomosis versus n = 35 patients to surgical anastomosis alone. The test of probability was assessed through Chi-Square, independent samples paired T-Test and Log-Rank analysis. RESULTS: Of the 57 cases included, 56 underwent hybrid and 1 open oesophagectomy. In the Tisseel group, n = 5(22.7%) developed anastomotic leak comparing to n = 3(8.6%) of the control group. No statistically significant difference in leak rate was shown between the two groups; the test of probability was rejected. CONCLUSIONS: Our results are not supportive of Tisseel tissue sealing property on the intrathoracic oesophago-gastric anastomosis and fibrin sealant's use cannot be justified.

Preservation of replaced left hepatic artery during 3D laparoscopic totally minimally invasive esophagectomy for cancer.

Preserving a replaced left hepatic artery may be feasible and safe during 3D laparoscopic totally minimally invasive esophagectomy. Avoidance of conversion to an open procedure may be achieved after careful dissection of the celiac trunk lymph nodes, expertise and the visual advantage that 3D vision offers.

Prognostic Value of Subcarinal Lymph Nodes in Minimally Invasive Esophagectomy for Cancer.

BACKGROUND/AIM: Surgical resection for esophageal cancer has remained the gold-standard therapy provided worldwide. Subcarinal lymph-nodes are classified as peri-esophageal nodes and their dissection may be performed during a 2- or 3-stage esophagectomy. The necessity and prognostic value of subcarinal lymphadenectomy is still debatable. The purpose of this study was to investigate the rate of invaded subcarinal lymph-nodes out of the total lymph-nodes resected. Detection of invaded nodes was correlated with clinical staging and tumor differentiation. PATIENTS AND METHODS: This is a retrospective analysis of consecutive esophagectomies for cancer, performed in a UK tertiary center. The study was conducted over a 3-year period. RESULTS: The rate of subcarinal lymph-node invasion was extremely low according to the results of our analysis. CONCLUSION: Lymphadenectomy is not devoid of clinical impact on patients and therefore, the decision should actually be the outcome of a dynamic balance between complications and survival benefit.

Thoracoscopic total esophagogastrectomy with supercharged colon interposition for the treatment of esophageal adenocarcinoma in situs inversus.

Background: Esophagectomy in situs inversus is challenging. With long-segment supercharged reconstruction, it becomes more perplexing and multidisciplinary surgical skills are needed. Challenges met and the surgical technique used is presented in this case report. Methods: The case of a 49-year old patient with situs inversus abdominus and a locally advanced distal esophageal adenocarcinoma extending to the stomach is presented. Results: Following neoadjuvant chemotherapy and due to inability to use the stomach as a conduit, a thoracoscopic total esophagogastrectomy with long-segment reconstruction was performed. The conduit used was the left colon and was supercharged with venous and arterial anastomoses in the neck. Conduit perfusion, as assessed by the Spy system revealed marked improvement post supercharging. No anastomotic leak was noted and oral diet was started on day 4. On day 26 the patient developed pneumonia necessitating intubation that was declined. Organ support was withheld with patient death at day 29. Conclusion: In long-segment esophageal reconstruction with supercharged colon, although thoracoscopy is feasible, laparoscopy is found unsafe. Careful preoperative planning and colon assessment via computed tomography(CT) colonography/angiography and a multidisciplinary team approach is recommended. Adjuncts to assess conduit perfusion like the Spy system are helpful. Supercharging the long colonic conduit is a way of minimizing ischemia-related complications.

Vesicouterine Fistula (VUF) as a Rare Urogenital Complication Managed with Delayed Surgical Repair: A Case Report and Review of the Literature.

Vesicouterine fistula (VUF) represents a rare urogenital complication. It is considered to be the least common type of urogenital fistulas. Iatrogenic reasons have been shown to be the most prominent cause, with lower segment caesarean section accounting for approximately two-thirds of the cases. The highest incidence concerns young females of reproductive age. VUF can present with clinical symptoms varying from cyclic hematuria, amenorrhea, and vaginal leakage of urine to secondary infertility and first-trimester abortion. Quality of life (QoL) for patients having this pathology is strongly affected due to the psychological burden. Surgical excision of the fistula remains the mainstay of treatment, as less than 5% of patients respond to conservative therapy. Recently laparoscopic and robotic-assisted VUF repair started gaining ground with comparable results to open surgery. Herein, we presented the successful delayed surgical repair of VUF in a 32-year-old female patient. A review of the published literature was also performed, summarizing all the available evidence regarding this rare clinical entity.

Chronic ileitis with transmural migration of ingested foreign body treated by laparoscopy.

BACKGROUND: Ingestion of foreign bodies such as fish bone or chicken bone is relatively common in adults; however, resultant transmural migration is extremely rare. METHODS: We present a case of a 79-year-old woman with chronic low-grade abdominal pain, worsening over the last 4 days. Computed tomography revealed segmental small bowel wall thickening with chronic inflammation suggestive of Crohn's ileitis and oral steroids were commenced; only later, ingestion of a foreign body was suspected. RESULTS AND CONCLUSION: At diagnostic laparoscopy, a linear foreign body resembling a wooden splinter was identified. It had partly migrated through the chronically inflamed bowel wall without causing perforation or abdominal contamination. It was removed laparoscopically without an enterotomy or bowel resection. Microscopy revealed non-viable bone, likely fish or chicken bone. The patient made an uneventful recovery and was discharged 3 days later. Herein we emphasise on the differential diagnosis and presentation of chronically ingested foreign bodies, as well as the feature of chronic ileitis with uncomplicated transmural migration of the ingested foreign body that was treated laparoscopically without an enterotomy.

Gastric conduit obstruction due to gastroduodenal compression: a new complication post-Ivor-Lewis oesophagectomy.

INTRODUCTION: Oesophagectomy for oesophageal carcinoma carries a high risk of significant morbidity and mortality. Delayed gastric emptying is a relatively common complication following this procedure. A variety of medical, surgical and endoscopic strategies have been described to manage it. The vast majority of cases are related to post-operative pyloric dysfunction and are amenable to conventional management strategies. PATIENTS AND METHODS: We present a new case of a patient with a duodenal hiatus hernia resulting in extrinsic gastroduodenal compression by the massively distended gastric conduit as a cause of gastric outlet obstruction following laparoscopic-assisted Ivor-Lewis oesophagectomy 2 years previously. RESULTS AND CONCLUSIONS: Surgical repair of the hiatus hernia restored the post-oesophagectomy anatomy and resolved this patient's symptoms where conventional management of post-oesophagectomy gastric outlet obstruction had failed on multiple occasions. Most cases of delayed gastric emptying post-oesophagectomy occur as a result of pyloric dysfunction and can be managed using a combination of prokinetics, surgical intervention or more commonly, endoscopic dilatation. Other potential causes and therefore investigative and management strategies should be considered in patients who repeatedly fail conventional management. We offer an alternative diagnosis that may be considered in these patients and present a novel approach to their investigation and management.

Percutaneous minimally invasive management of iatrogenic ureteral injuries.

PURPOSE: To present experience with the percutaneous management of iatrogenic ureteral injuries. PATIENTS AND METHODS: Eighteen women and six men with a mean age of 59.3 years (range 33-80 years) received a diagnosis of ureteral injury sustained during gynecologic, urologic, and general surgical procedures. In a total of 25 injured ureters, 12 had interruption of continuity of their lumen, 10 were associated with contrast extravasation, and 3 were related to both. A standard percutaneous nephrostomy tract was established on the side of the afflicted kidney. Combined use of hydrophilic guidewires and balloon dilations were performed to achieve antegrade recanalization of the ureteral lesion. Then, a ureteral stent was inserted to assure patency. RESULTS: Average stricture length was 1.21 (range 0.5-1.9 cm). Success of the aforementioned technique was possible in 18 ureters. Successful management in one session took place in 14 ureters. Average hospitalization time was 1.8 days (range 0-5 d). The follow-up period ranged between 12 and 18 months, with mean follow-up time of 12.9 months. Ureteral patency was evident at 1 week follow-up in six patients with obstructed ureters. In the remaining patients, balloon dilation of the stricture was repeated, and another stent was placed. Extravasation of contrast was observed in two patients with extravasating ureters in the same period. Nephrostomy tubes were removed after a mean indwelling period of 5.9 weeks (range 1-12 wks). Two patients treated by the described method died during their hospitalization in the intensive care unit because of sepsis from peritonitis that was related to colon injury and multiple concomitant injuries. Major complications were not observed in the remaining 22 patients during the follow-up period. CONCLUSION: The minimally invasive management of ureteral injuries is a safe and efficient method for both ureteral obstruction and/or laceration in a wide range of iatrogenic ureteral injuries.

Laparoscopy in the emergency setting: a retrospective review of 540 patients with acute abdominal pain.

BACKGROUND: Laparoscopy has been widely accepted among surgeons for the diagnosis and management of acute abdominal conditions. In this study, we aim to evaluate and summarize the experience in laparoscopic procedures, both diagnostic and interventional, for emergency nontraumatic abdominal conditions, in a tertiary academic center. METHODS: From June 2005 to June 2009, a total of 1414 patients were subjected to a variety of emergency procedures at the university hospital of Patras and 540 of these patients were managed laparoscopically (38.2%). Indications for operations in the laparoscopic group were abdominal pain mimicking appendicitis in 229 patients (42.4%), acute cholecystitis in 248 patients (45.9%), gastroduodenal perforated ulcer in 14 patients (2.6%), small bowel obstruction in 24 patients (4.4%), and nonspecific abdominal pain in 25 patients (4.6%). RESULTS: Diagnosis was established in 530 patients (98.2%) and definitive laparoscopic treatment was offered to 514 patients (95.2%). The conversion rate was 2.2%. Total mortality was 1.1% and total morbidity was 7.9%. CONCLUSIONS: Laparoscopic approach to abdominal emergency provides high diagnostic accuracy and therapeutic options. Surgical experience, optimal procedural timing, and appropriate patient selection criteria diminish perioperative mortality and morbidity, and are associated with nominal conversion.