Egyud and colleagues evaluated plasma levels of circulating tumor (ct)DNA in patients with esophageal adenocarcinoma, ranging from stage I to stage IV. The quantity of ctDNA and likelihood of ctDNA detection was greater at later stages, suggesting that it may be challenging to use for early-stage diagnosis. However, changes in ctDNA levels were indicative of response to therapy and recurrence, and the authors conclude that they may serve as a dynamic biomarker to monitor a patient’s response to treatment.
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In this multiinstitutional retrospective study, administration of adjuvant chemotherapy for patients with persistent nodal disease after induction therapy and esophagectomy was associated with improved survival.
Regionalization of care for complex problems remains an open question in most countries. This review demonstrated that, for high risk cancer operations in the US, the Leapfrog group's volume standards did not differentiate between surgical mortality outcomes for lung and esophageal cancer surgery. However, differences were evident comparing lowest and highest volume quintiles for operative mortality associated with these procedures.
Gwan-Nulla D. Zenker's Diverticulectomy With Cricopharyngeal Myotomy. August 2019. doi:10.25373/ctsnet.9273494.
Zenker's or pharyngoesophageal diverticulum is the most common diverticulum of the esophagus. It is herniation of the esophageal mucosa and submucosa through a weak point in the muscle layers of the hypopharynx. The most common herniation site, known as Killian’s triangle, is bordered by the inferior constrictor muscle or thyropharyngeus superiorly, and by the cricopharyngeus muscle inferiorly. A Zenker’s diverticulum is a false or pseudodiverticulum, as its wall is not full thickness. Characteristic symptoms include dysphagia, spontaneous regurgitation of food, coughing, and episodic choking. Surgical intervention is indicated for symptoms and/or a large size (greater than 3 cm). Surgical treatment options include open cricopharyngeal myotomy with diverticulectomy or diverticulopexy and transoral endoscopic diverticulotomy.
- Lerut T, Coosemans W, Decaluwé H, et al. Zenker’s Diverticulum. Multimed Man Cardiothorac Surg. 2009 Jan 1;2009(224):mmcts.2007.002881.
- Samson P, Puri V. Esophageal Diverticula. In: LoCicero J, Feins RH, Colson YL, Rocco G, eds. Shields’ General Thoracic Surgery. 8th ed. Philadelphia, PA: Wolters Kluwer; 2018:1826-1833.
Trevis J, Dunning J. Postesophagectomy Drainage of Subcarinal Collection via Mediastinoscopy. August 2019. doi:10.25373/ctsnet.9172292.
This video demonstrates the drainage of a subcarinal collection via mediastinoscopy in a patient who had recently undergone esophagectomy. The chyle leak was localized over the gastric conduit and unsuccessfully drained percutaneously. However, computed tomography imaging showed a 4.9 mm margin inferior to the carina whereby drainage could be accomplished via mediastinoscopy.
Postoperative chylous leakage is a rare but well-documented complication of esophagectomy, with an incidence varying from 1.3-3.4% following procedures involving the thorax or the neck. Chyle leakage is a serious complication, with mortality ranging from 0 to 50%, due to significant loss of fluid, plasma protein, and immunoregulatory lymphocytes. Symptomatic patients exhibit signs of severe malnutrition, hyponatremia, acidosis, hypocalcemia, and increased susceptibility to infection.
- Lagarde SM, Omloo JMT, de Jong K, Busch OR, Obertop H, van Lanschot JJ. Incidence and management of chyle leakage after esophagectomy. Ann Thorac Surg. 2005;80(2):449-454.
- Tamura T, Kubo N, Yamamoto A, et al. Cervical chylous leakage following esophagectomy that was successfully treated by intranodal lipiodol lymphangiography: a case report. BMC Surg. 2017;17(1):20.
The Throacic Surgery Residents Association (TSRA) Decision Algorithms in Cardiothoracic Surgery is a 100-chapter compendium with an individual algorithm for clinical decisions spanning the entire scope of cardiothoracic surgery. The resource was developed for cardiothoracic surgery residents by residents and cardiothoraicc surgery faculty.
Gupta V, Darling G. Giants of Cardiothoracic Surgery: An Interview With Gail Darling. July 2019. doi:10.25373/ctsnet.8940074.
In this Giants of Cardiothoracic Surgery interview, Vaibhav Gupta of the University of Toronto in Ontario, Canada, speaks with Gail Darling, Professor of Surgery and the Crest Family Chair in Esophageal Cancer Research at the University of Toronto. Dr Darling shares her path to thoracic surgery, and to esophageal surgery in particular. They discuss her work in esophageal cancer research, her leadership in health policy for thoracic oncology care, and her service as director of thoracic surgery training at her institution. Dr Darling notes that work in both health policy and surgical training are especially rewarding for the opportunity they present to affect the care of many patients.
van Wagenberg F, Kernstine K, Maaraoui K, Kalsbeek A. Quick Tips and Tricks for Robot-Assisted Esophagectomy: Ivor Lewis and McKeown. July 2019. doi:10.25373/ctsnet.8428886.
This video demonstrates the common pitfalls of robot-assisted esophagectomy and presents tips and techniques to performing the Ivor Lewis and McKeown procedures.
To begin making the conduit, it is advisable to begin at the lesser curvature and to use a 4.0 cm silk tie in order to gauge the width of the conduit—this helps to avoid creating a conduit that is either too narrow, too wide, or uneven. Using a 45 mm staple load, rather than a 60 mm load, affords better control over the length of the conduit, and it assists with maintaining consistent width. This size staple load also allows the surgeon to stretch the conduit and maximize the number of stapler firings, which helps to achieve full conduit length in the neck.
When pulling the conduit and specimen into the chest, two figure-of-eight sutures can be used to prevent any twisting along a singular suture line; this style of suture also helps prevents tears in the tissue and provides added stability as the conduit and specimen are pulled through the diaphragm.
Rather than performing a pyloroplasty, injection of the pylorus with Botox provides similar results. Using a 20 gauge mediastinoscopy aspirating needle affixed to a 5 ml syringe, injection of 100 units of Botox mixed with 4 ml of saline is performed, using 1 ml in each quadrant. It is important to create a wheal in the muscular part of the pylorus at each point and avoid injecting any vessels.
The Kocher maneuver is avoided in this procedure, as it may cause pyloric dysfunction and may facilitate bile reflux.
Placing two marking sutures on the conduit before pulling it up into the chest can help gauge how much of the conduit has been pulled into the chest, as oftentimes it can be misleading how much has been pulled through and how much remains below the diaphragm.
After moving into the chest and dissecting the esophagus, ligation of the azygos vein is performed for two reasons:
- Often the anastomosis is in this area, and ligating the azygos gives the surgeon a better view.
- Additionally, if the azygous becomes engorged, it could cause pressure on the conduit or the anastomosis.
As the specimen is pulled up, avoid twisting of the conduit by ensuring that the staple line on the conduit is facing toward the screen. Note that this will only prevent 180 degree twisting, and not 360 degree twisting.
Once the conduit is in the chest, avoid grasping it with the Cadiere graspers or ProGrasp™ forceps as these can cause traumatic injury.
There are several ways to pull up the conduit:
- Using the lead point of the conduit to pull;
- Using a Forrester Ring Clamp or Landreneau Ring Clamp;
- Using 2 ProGrasps as seen in the video; or
- Rolling up surgicel as a buffer to prevent any traumatic tearing of the conduit.
After incising the esophagus, a Foley catheter with about 30 ml of water can be inserted to dilate the lumen of the esophagus so that it can more easily take the 29 mm anvil. The Foley can also be used to gauge what size of anvil the esophagus will take.
A 3-0 Prolene® on an SH needle is used to baseball stitch the mucosa and submucosa and provide a purse string around the anvil. A second concentric purse string of the same suture about 5 mm away from the initial one is placed to help secure the anvil in the proximal esophagus. The authors avoid taking too much tissue with wide bites, as this can result in misfiring of the EEA.
After creating the anastomosis, wrapping it with a pedicle of omentum can promote healing and help control any kind of leakage if a leak were to occur. The authors then secure the anastomosis to the pleura to prevent any excessive movement. Finally, they use a suture to tighten the crura where the conduit emerges from the diaphragm in order to prevent any hiatal hernia from occurring. The thoracic duct is often ligated with a large stitch at this time with as well.
Nawaz MA, Shah R. Operative Management of a Rare Gastrobronchial Fistula. May 2019. doi:10.25373/ctsnet.8160170.
The development of a gastrobronchial fistula is a relatively rare occurrence. The patient in this video underwent esophagectomy for esophageal cancer and a stomach pull-up operation was performed. A few weeks later, the patient experienced chest infection and pneumonia due to repeated aspiration. Further investigations including computed tomography, a contrast swallow study, and esophagogastroscopy confirmed the presence of a fistulous communication between the stomach—the neo-esophagus—and the intermediate bronchus. This required operative intervention as it was sizeable, about 1.5 cm.
The authors performed a right redo thoracotomy, mobilized the lung, identified the fistulous communication, and verified this by intraoperative bronchoscopy. The gastric fistula was closed over a T-tube that was exteriorized through the right chest wall. The authors harvested a longitudinal vascularized strip of diaphragm. The diaphragm was primarily closed using Prolene® and mesh. The vascularized diaphragm pedicle was then used to close the bronchial fistula using interrupted Prolene sutures, and a very good repair was confirmed on intraoperative bronchoscopy and with an air-leak test.
Patient Care and General Interest
Uruguay’s fight against tobacco and Phillip Morris was highlighted at the recent Annual Meeting of the American College of Cardiology, and one physician shares her thoughts.
The University of California Los Angeles has opened a new center, the Robert G. Kardashian Center for Esophageal Health, to focus on treatment, research, and education for esophageal disorders.