Your browser does not fully support modern features. Please upgrade for a smoother experience.
Please note this is an old version of this entry, which may differ significantly from the current revision.
Subjects:
Allergy
Endoscopic treatment plays a major role in both immediate and delayed aftercare. Essential therapeutic measures have been established in the past. A continuous development of these achievements in the field of endoscopy can be expected.
- esophageal cancer
- endoscopic complication management
- postsurgical complication
1. Introduction
Esophageal cancer ranks seventh in terms of incidence and sixth in overall mortality of cancer-related deaths in the world, with relevant differences in regional frequency [1]. The incidence of esophageal cancer (EC), especially adenocarcinomas of the gastroesophageal junction (AEG), has been rising rapidly during the last decades.
Surgical resection remains the “gold standard” of curative treatment for esophageal cancer [2]. According to the size and location of the tumor, the following different surgical methods and treatment strategies can be utilized. Standard esophageal resection procedures are:
-
McKeown technique = right thoracotomy followed by laparotomy, gastric tube formation for conduit and neck incision with cervical anastomosis;
-
Ivor Lewis esophagectomy = right thoracotomy and laparotomy with gastric tube formation for conduit;
-
and Transhiatal approach = oncological gastrectomy with extended distal esophageal resection.
All types of esophageal surgery are increasingly performed as minimally invasive procedures [2,3,4,5]. Esophagectomy remains an example of complex major surgery associated with a significant risk of major morbidity and a substantial impact on health-related quality of life. Mortality after esophageal resection has decreased significantly from over 30% in the 1970s to below 5% in specialized centers today, but morbidity rates remain high with up to 50% reported [6].
Endoscopic procedures can avoid surgery for early stages of EC [7,8,9]. Endoscopic resection techniques, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) or newly endoscopic full-thickness resection (EFTR), can completely remove early lesions.
In addition to its role as a diagnostic and primary endoscopic therapeutic measure, endoscopy plays also a relevant role in the treatment of postoperative complications after EC resection [10]. Postoperative complications that may require endoscopic therapy are as follows: anastomotic hemorrhage, anastomotic insufficiency, delayed gastric emptying, and anastomotic stenosis. Anastomotic hemorrhage is an acute postoperative complication. In order not to harm the anastomosis itself and not to restrict its blood flow, the available hemostasis techniques should be well known. Anastomotic insufficiencies represent the most serious type of complications, since they are associated with increased morbidity and mortality. Delayed gastric emptying and anastomosis stenoses occur in a delayed time when the patient re-starts to eat solid food again. Then, relevant problems may arise due to regurgitations and restricted nutrition. Several innovative techniques have been developed in recent years to treat patients after surgical esophagectomy with a minimally invasive, endoscopic approach to optimize the perioperative care of patients and to treat complications effectively, thus finally minimizing morbidity.
2. Current Insights
The flexible endoscopy plays an important role for the management of acute and delayed complications in patients after EC resections offering numerous effective treatment strategies for anastomotic bleeding, anastomotic insufficiency, PDGE, and anastomotic strictures. Numerous therapeutic strategies have evolved over time, and new methods and devices for endoscopic diagnosis and therapy still enter the clinical stage every year. In several cases, technical developments were initially implemented for other indications and then adapted for successful utilization in the context of complications after EC resections. Here, endoscopic negative pressure therapy represents a prominent example.
In addition to technical developments in endoscopic diagnostics and therapy, there were also substantial developments in surgical resection techniques and perioperative patient care. Improved perioperative management, early postoperative enteral nutrition, pulmonary physiotherapy, prevention of hypoxemia and hypotension, laparoscopic and thoracoscopic resection techniques, and real-time intraoperative quantitative fluorescent-guided perfusion assessment during resections are important measures resulting in reduces incidence of postoperative complications [6,112].
This entry is reporting on endoscopic treatment of four complications after EC resection: anastomotic hemorrhage, anastomotic insufficiency, anastomotic stenosis, and PDGE. Here, the first two conditions represent acute, early-postoperative complications. These complications usually occur immediately after surgery or within approximately 1–5 days postoperatively [33]. In contrast, the latter two complications occur with a latency of up to 3 or 6 months after surgical resection. An early flexible endoscopy for fresh anastomoses is frequently performed for follow-up nowadays. Here, it is a critical and important fact that only low pressure is applied to the endoscope in the anastomosis area, and that the examination is performed with carbon dioxide [113].
Hemostasis techniques currently use TTSCs that have been available since the 1980s. These devices have been undergoing further development and refinement, so current TTSC models can also rotate and re-open. Other devices have been newly designed and developed, such as hemostasis powders and the OTSC [13]. The overall success rates of the new hemostasis techniques are good. However, high quality data on therapeutic options for the anastomotic bleeding situation after EC resection is currently still lacking.
For the treatment of anastomotic insufficiencies, impressive clinical success rates could be achieved by utilizing the therapy methods presented in this review. Overall mortality rate of patients with anastomotic insufficiencies steadily decreased from 35.7% [114] at the beginning of 2000 to 11.8% [115] nowadays. This reduction in mortality has been realized through many different achievements in the complex interdisciplinary care of these critically ill patients [116], with flexible endoscopy playing a central role. If anastomotic insufficiency is detected, an immediate intervention with adequate drainage and minimization of further contamination is essential. The use of fully covered metal stents in addition to CT-guided or laparoscopic placed drains or the use of ENPT can significantly reduce patients´ mortality and morbidity. The prevention of anastomotic insufficiencies after EC resection in high-risk patients using pENPT is a new, promising approach [88,89]. Future publications will help to define the role of preventive negative pressure therapy in the anastomosis area.
The long-term complications of anastomotic stenosis and PDGE are primarily treated mechanically. The incidence of anastomotic stenoses could also be reduced without a reduction of blood flow in the anastomotic region by preventive measures [31,90]. For anastomotic stenosis, balloon dilatation is currently available as the “gold standard” treatment option.
In the context of PDGE, the introduction of impedance planimetry (Endoflip™) may result in significant advances for the therapy of this complication. This system allows accurate diagnosis and verification of therapeutic success, can be used repeatedly, and may also help to identify patients at risk for the development of PDGE later on [93,94].
This entry is adapted from the peer-reviewed paper 10.3390/cancers14040980
This entry is offline, you can click here to edit this entry!