Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-analysis

Update on clinical impact, documentation, and management of complications associated with esophagectomy

The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.

Clinical application of mucosal valve technique for anastomosis during esophagogastrostomy

BACKGROUND

The study aims to compare the efficacy in prevention of anastomotic complications using layer-to-layer mucosal valve technique versus circular stapled technique for esophagogastric intrathoracic anastomosis after resection for esophageal and gastric cardiac carcinoma.

METHODS

From January 2005 to December 2010, 136 patients received layer-to-layer mucosal valve technique (LM group), 219 received circular stapled anastomosis (CS group) after curative intent resection for esophageal and gastric cardiac carcinoma. The technique details were reported and the clinical results were analyzed.

RESULTS

The two groups were comparable on clinical baseline characteristics. The average duration of operation was longer with LM technique by 16 min, but without statistical significance (P = 0.073). There was no anastomotic leakage in the LM group, while in the CS group, leakage occurred in seven patients (3.2 %, P = 0.047). Both the incidence and grade of postoperative dysphagia were significantly lower in the LM group (P < 0.05). Significantly fewer patients experienced stricture after LM technique (3.8 %) compared with CS anastomosis (18.2 %, P < 0.001). CS anastomosis was associated with a significantly higher incidence of persistent stricture requiring more dilatation (P < 0.001). Symptoms of reflux were better controlled by LM technique; 82.7 % of patients were asymptomatic with respect to reflux compared to 58.9 % in the CS group, P < 0.001. And there was a significant reduction in the incidence of esophagitis in remnant esophagus in the LM group (P = 0.001).

CONCLUSIONS

The layered mucosal valve anastomosis could significantly diminish the incidence of anastomotic complications and could be used as an alternative for esophagogastric anastomosis after resection of esophageal and gastric cardiac carcinoma.

Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis

BACKGROUND

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.

METHODS

Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.

RESULTS

No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005).

CONCLUSIONS

A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.

Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database

BACKGROUND

Anastomotic leak is an important cause of morbidity and mortality after esophagectomy. Few studies have targeted risk factors for the development of leak after esophagectomy. The purpose of this study is to use The Society of Thoracic Surgeons Database to identify variables associated with leak after esophagectomy.

METHODS

The Society of Thoracic Surgeons Database was queried for patients treated with esophagectomy for esophageal cancer between 2001 and 2011. Univariate and multivariate analysis of variables associated with an increased risk anastomotic leak was performed.

RESULTS

There were 7,595 esophagectomies, with 804 (10.6%) leaks. Thirty-day mortality and length of stay were higher for patients with anastomotic leak. Mortality in patients requiring surgical management was 11.6% (38 of 327) compared with 4.4% (20 of 458) in medically managed leaks (p < 0.001). The leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomoses, 12.3% versus 9.3%, respectively (p = 0.006). There was no difference in leak-associated mortality between the two approaches. Factors associated with leak on univariate analysis include obesity, heart failure, coronary disease, vascular disease, hypertension, steroids, diabetes, renal insufficiency, tobacco use, procedure duration greater than 5 hours, and type of procedure (p < 0.05). Multivariable regression analysis associated heart failure, hypertension, renal insufficiency, and type of procedure as risk factors for the development of leak (p < 0.05).

CONCLUSIONS

Anastomotic leak after esophagectomy is an important cause of postoperative mortality and increased length of stay. We have identified important risk factors for the development of esophageal anastomotic leak after esophagectomy. Further studies aimed at risk reduction are warranted.

Current status of minimally invasive esophagectomy for patients with esophageal cancer

Technical advancements and development of endoscopic equipment in thoracoscopic surgery have resulted in increase in the popularity of minimally invasive esophagectomy (MIE). However, advantages with regard to short-term outcome and oncological feasibility of MIE have not been adequately established. To date, a number of single-institution studies and several meta-analyses have demonstrated acceptable short-term outcomes of thoracoscopic esophagectomy for esophageal cancer, and the outcomes are comparable to those of conventional open esophagectomy (OE). A study group recently reported the results of the first multicenter randomized controlled trial (RCT) that compared MIE and OE. The incidence of pulmonary infection after surgery was markedly lower in the MIE group than in the OE group. Additional benefits of MIE included less operative blood loss, better postoperative patients' quality of life, and shorter hospital stay. However, the oncological benefit to patients undergoing MIE has not been scientifically proven because there have been no RCTs to verify the equivalency in long-term survival of patients undergoing MIE compared with that of patients undergoing OE. If future prospective studies indicate oncological benefits, MIE could truly become the standard care for patients with esophageal cancer.

Embedded cervical esophagogastrostomy: a simple and convenient method using a circular stapler after esophagectomy for esophageal carcinomas

Background

Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.

Methods

In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.

Results

A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.

Conclusions

Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.

Surgical quality of care in esophageal malignancies

Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high. Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: ‘esophagectomy’, ‘esophagus’, ‘neoplasm’ and ‘cancer’ to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care. Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients. Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons’ practice.

Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis

OBJECTIVE

To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection.

BACKGROUND DATA

Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined.

METHODS

A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration.

RESULTS

Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66-1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95-2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16-2.42), and (3) reduced the length of the operation time (mean: -15.3 minutes, range: -28.1 to -2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration.

CONCLUSION

The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.

Tubular stomach or whole stomach for esophagectomy through cervico-thoraco-abdominal approach: a comparative clinical study on anastomotic leakage

BACKGROUND

Esophagectomy through cervico-thoraco-abdominal approach is a useful surgical technique in treating patients with esophageal cancer. However, the cervical reconstruction is also known to have a high rate of anastomotic leakage, as well as anastomotic stricture, intrathoracic stomach syndrome, reflux esophagitis and other complications, thereby influencing postoperative recovery and quality of life.

AIMS

The objective of this study was to investigate whether tubular stomach is superior to whole stomach in reducing anastomotic leakage for esophageal reconstruction through the cervico-thoraco-abdominal (3-field) approach.

METHODS

A total of 850 patients undergoing the 3-field esophagectomy were retrospectively included in this study and divided into a tubular stomach reconstruction group (Group A, n=453) and a whole stomach reconstruction group (Group B, n=397). All patients underwent esophagectomy through right thorax, left cervical part, abdominal triple incisions and done in esophageal reconstruction by hand-sewn two-layer anastomosis.

RESULTS

Results revealed that in comparison with whole stomach, esophageal reconstruction with tubular stomach had a lower incidence of anastomotic leakage (5.5 vs. 9.3%, P<0.05), less manifestation of intrathoracic syndrome (3.3 vs. 9.8%, P<0.001) and less occurence of reflux esophagitis (5.1 vs. 11.1%, P<0.01). However, for the incidence of anastomotic stricture, there was no significant difference between the two groups (9.3 vs. 9.8%).

CONCLUSIONS

This observation study suggests that for esophageal cancer patients undergoing the 3-field esophagectomy tubular stomach is better than whole stomach for esophageal reconstruction as reflected by a reduced postoperative anastomotic leakage, intrathoracic syndrome and reflux esophagitis.

Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.

Complications of esophagectomy

Esophagectomy remains the gold standard curative therapy for the treatment of esophageal cancer. Despite 125 years of evolution, esophagectomy remains a demanding procedure associated with a 5% to 10% mortality and a 50% morbidity rate. Knowledge of the multitude of techniques possible for performing this complex procedure, as well as the host of associated complications, is vital for the practitioner aspiring to treat this challenging disease.

Intrathoracic versus cervical anastomosis after resection of esophageal cancer: a matched pair analysis of 72 patients in a single center study

Background

The aim of this study was to analyze the early postoperative outcome of esophageal cancer treated by subtotal esophageal resection, gastric interposition and either intrathoracic or cervical anastomosis in a single center study.

Methods

72 patients who received either a cervical or intrathoracic anastomosis after esophageal resection for esophageal cancer were matched by age and tumor stage. Collected data from these patients were analyzed retrospectively regarding morbidity and mortality rates.

Results

Anastomotic leakage rate was significantly lower in the intrathoracic anastomosis group than in the cervical anastomosis group (4 of 36 patients (11%) vs. 11 of 36 patients (31%); p = 0.040). The hospital stay was significantly shorter in the intrathoracic anastomosis group compared to the cervical anastomosis group (14 (range 10–110) vs. 26 days (range 12 – 105); p = 0.012). Wound infection and temporary paresis of the recurrent laryngeal nerve occurred significantly more often in the cervical anastomosis group compared to the intrathoracic anastomosis group (28% vs. 0%; p = 0.002 and 11% vs. 0%; p = 0.046). The overall In-hospital mortality rate was 6% (4 of 72 patients) without any differences between the study groups.

Conclusions

The present data support the assumption that the transthoracic approach with an intrathoracic anastomosis compared to a cervical esophagogastrostomy is the safer and more beneficial procedure in patients with carcinoma of the lower and middle third of the esophagus due to a significant reduction of anastomotic leakage, wound infection, paresis of the recurrent laryngeal nerve and shorter hospital stay.

Transthoracic resection versus non-transthoracic resection for gastroesophageal junction cancer: a meta-analysis

BACKGROUND

The aim of this meta-analysis is to evaluate the impact of transthoracic resection on long-term survival of patients with GEJ cancer and to compare the postoperative morbidity and mortality of patients undergoing transthoracic resection with those of patients who were not undergoing transthoracic resection.

METHOD

Searches of electronic databases identifying studies from Medline, Cochrane Library trials register, and WHO Trial Registration etc were performed. Outcome measures were survival, postoperative morbidity and mortality, and operation related events.

RESULTS

Twelve studies (including 5 RCTs and 7 non-RCTs) comprising 1105 patients were included in this meta-analysis, with 591 patients assigned treatment with transthoracic resection. Transthoracic resection did not increase the 5-y overall survival rate for RCTs and non-RCTs (HR = 1.01, 95% CI 0.80- 1.29 and HR = 0.89, 95% CI 0.70- 1.14, respectively). Stratified by the Siewert classification, our result showed no obvious differences were observed between the group with transthoracic resection and group without transthoracic resection (P>0.05). The postoperative morbidity (RR = 0.69, 95% CI 0.48- 1.00 and OR = 0.55, 95% CI 0.25- 1.22) and mortality (RD = -0.03, 95% CI -0.06- 0.00 and RD = 0.00, 95% CI -0.05- 0.05) of RCTs and non-RCTs did not suggest any significant differences between the two groups. Hospital stay was long with thransthoracic resection (WMD = -5.80, 95% CI -10.38- -1.23) but did not seem to differ in number of harvested lymph nodes, operation time, blood loss, numbers of patients needing transfusion, and reoperation rate. The results of sensitivity analyses were similar to the primary analyses.

CONCLUSIONS

There were no significant differences of survival rate and postoperative morbidity and mortality between transthoracic resection group and non-transthoracic resection group. Both surgical approaches are acceptable, and that one offers no clear advantage over the other. However, the results should be interpreted cautiously since the qualities of included studies were suboptimal.

Robot-assisted transhiatal esophagectomy: a 3-year single-center experience

Minimally invasive esophagectomy has emerged as an important procedure for disease management in esophageal cancer (EC) with clear margin status, less morbidity, and shorter hospital stays compared with open procedures. The experience with transhiatal approach robotic esophagectomy (RE) for dissection of thoracic esophagus and associated morbidity is described here. Between March 2007 and November 2010, 40 patients with resectable esophageal indications underwent transhiatal RE at the institute. Clinical data for all patients were collected prospectively. Of 40 patients undergoing RE, one patient had an extensive benign stricture, one had high-grade dysplasia, and 38 had EC. Five patients were converted from robotic to open. Median operative time and estimated blood loss were 311 minutes and 97.2 mL, respectively. Median intensive care unit stay was 1 day (range, 0-16), and median length of hospital stay was 9 days (range, 6-36). Postoperative complications frequently observed were anastomotic stricture (n= 27), recurrent laryngeal nerve paresis (n= 14), anastomotic leak (n= 10), pneumonia (n= 8), and pleural effusion (n= 18). Incidence rates of laryngeal nerve paresis (35%) and leak rate (25%) were somewhat higher in comparison with that reported in literature. However, all vocal cord injuries were temporary, and all leaks healed following opening of the cervical incision and drainage. None of the patients died in the hospital, and 30-day mortality was 2.5% (1/40). Median number of lymph nodes removed was 20 (range, 3-38). In 33 patients with known lymph node locations, median of four (range, 0-12) nodes was obtained from the mediastinum, and median of 15 (range, 1-26) was obtained from the abdomen. R0 resection was achieved in 94.7% of patients. At the end of the follow-up period, 25 patients were alive, 13 were deceased, and 2 patients were lost to follow-up. For patients with EC, median disease-free survival was 20 months (range, 3-45). Transhiatal RE, by experience, is a feasible albeit evolving oncologic operation with low hospital mortality. The benefits include minimally invasive mediastinal dissection without thoracotomy or thoracoscopy. A reasonable operative time with minimal blood loss and postoperative morbidity can be achieved, in spite of the technically demanding nature of the procedure. Broader use of this technology in a setting of high-volume comprehensive surgical programs will almost certainly reduce the complication rates. Robotic tanshiatal esophagectomy with the elimination of a thoracic approach should be considered an option for the appropriate patient population in a comprehensive esophageal program.

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

Novel thoracoscopic intrathoracic esophagogastric anastomosis technique for patients with esophageal cancer

BACKGROUND

This article describes a novel, easy, and secure thoracoscopic intrathoracic esophagogastric anastomosis procedure that uses a circular stapler with transoral placement of the anvil for patients with esophageal cancer who underwent thoracoscopic esophagectomy.

METHODS

After the thoracoscopic esophagectomy, the esophagus was transected obliquely at the level of the upper posterior mediastinum using a linear stapler. The Orvil™ (Autosuture, Norwalk, CT) anvil was placed at the edge of the staple line of the esophageal stump, which was relatively at an acute angle to the stump. Next the gastric conduit was pulled through the esophageal hiatus into the right thoracic cavity. The shaft of a 25-mm circular stapler was inserted and placed into the gastric conduit from the gastrotomy. Circular stapling was undertaken in a conventional manner. The access opening on the stump of the gastric conduit was closed with a linear stapler intracorporeally.

RESULTS

The anastomotic procedure was completed in 20 patients. Intraoperative complications or conversions to open surgery from thoracoscopic surgery were not observed in any patient. There were no severe postoperative complications, such as anastomotic leaks or gastric conduit necrosis.

CONCLUSION

The present study revealed that our novel thoracoscopic intrathoracic esophagogastric anastomosis was technically easy and safe with minimal morbidity.

Cigarette smoke exposure promotes arterial thrombosis and vessel remodeling after vascular injury in apolipoprotein E-deficient mice

BACKGROUND

Cigarette smoking is a major risk factor for the development of cardiovascular disease. However, in terms of the vessel wall, the underlying pathomechanisms of cigarette smoking are incompletely understood, partly due to a lack of adequate in vivo models.

METHODS

Apolipoprotein E-deficient mice were exposed to filtered air (sham) or to cigarette mainstream smoke at a total particulate matter (TPM) concentration of 600 microg/l for 1, 2, 3, or 4 h, for 5 days/week. After exposure for 10 +/- 1 weeks, arterial thrombosis and neointima formation at the carotid artery were induced using 10% ferric chloride.

RESULTS

Mice exposed to mainstream smoke exhibited shortened time to thrombotic occlusion (p < 0.01) and lower vascular patency rates (p < 0.001). Morphometric and immunohistochemical analysis of neointimal lesions demonstrated that mainstream smoke exposure increased the amount of alpha-actin-positive smooth muscle cells (p < 0.05) and dose-dependently increased the intima-to-media ratio (p < 0.05). Additional analysis of smooth muscle cells in vitro suggested that 10 microg TPM/ml increased cell proliferation without affecting viability or apoptosis, whereas higher concentrations (100 and 500 microg TPM/ml) appeared to be cytotoxic.

CONCLUSIONS

Taken together, these findings suggest that cigarette smoking promotes arterial thrombosis and modulates the size and composition of neointimal lesions after arterial injury in apolipoprotein E-deficient mice.