Intrathoracic versus cervical anastomosis and predictors of anastomotic leakage after oesophagectomy for cancer

Prediction of esophagogastric anastomotic leakage by nomogram combined with preoperative nutritional status and clinical factors: a retrospective study of 775 patients

AIM

The purpose was to explore the independent risk factors for esophagogastric anastomotic leakage (EGAL) and establish a nomogram.

METHODS

Patients who underwent esophagectomy were enrolled and randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The differences between the two groups of factors were analyzed by difference analysis, and multivariate regression analysis was subsequently performed. A nomogram was established, and the feasibility of the nomogram was verified by analyzing the discrimination, calibration, and decision curves.

RESULTS

A total of 775 patients were enrolled, including 532 in the training cohort and 223 in the validation cohort. Multivariate regression analysis revealed that age, smoking history, drinking history, nutritional indicators, and anastomotic location were independent risk factors. In terms of discrimination, in the training group, the area under the curve was 0.757 (P = 0.025). In the calibration curve, the curves and fitting lines before and after correction in the training group and the validation group were basically the same. The results of the Hosmer-Lemeshow test showed that the chi-square value of the training cohort was 5.48 (P = 0.791). In the decision curve analysis of the training set, when the threshold probability was in the range of 5-63%, the net benefit of patients was greater than that of the two extreme curves.

CONCLUSION

Preoperative malnutrition is an independent risk factor for EGAL. A diagnostic model, developed on age, anastomotic location, smoking status, and drinking history, was a reliable noninvasive tool to timely predict the occurrence of AL.

Predicting anastomotic leak in patients with esophageal squamous cell cancer treated with neoadjuvant chemoradiotherapy using a nomogram based on CT radiomic and clinicopathologic factors

BACKGROUND

Anastomotic leak (AL) is a common complication in patients with operable esophageal squamous cell carcinoma (ESCC) treated with neoadjuvant chemoradiotherapy (NCRT) and radical esophagectomy. Therefore, this study aimed to establish and validate a nomogram to predict the occurrence of AL.

METHODS

Between March 2016 and December 2022, ESCC patients undergoing NCRT and radical esophagectomy were retrospectively collected in China. Clinicopathologic and radiomics characteristics were included in the univariate logistic regression analysis, and statistically significant factors were enrolled to develop the nomogram, which was evaluated by the area under the curve (AUC) of the receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA).

RESULTS

231 eligible patients were divided into training (n = 159) and validation cohorts (n = 72). Univariate and multivariate analyses revealed that dose at the anastomosis ≥ 24 Gy, gross tumor volume ≥ 60 cm3, postoperative albumin < 35 g/L, comorbidities, duration of surgery ≥ 270 min, and computed tomography-based radiomics characteristics were independent predictors of AL. The nomogram AUC in the training and validation cohorts was 0.845 (95% confidence interval [CI]: 0.770-0.920) and 0.839 (95% CI: 0.718-0.960), respectively, indicating good discriminatory ability. The calibration curves showed good agreement between the predicted and actual AL occurrence and the DCA demonstrated favorable clinical outcomes.

CONCLUSIONS

We developed and validated a nomogram based on radiomics and clinicopathologic characteristics. This predictive model could be a powerful tool to predict AL occurrence in patients with ESCC treated with NCRT.

Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis

One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.

Long-term outcomes of intrathoracic versus cervical anastomosis after esophagectomy: A large-scale propensity score matching analysis

BACKGROUND

Esophageal squamous cell carcinoma is a prevalent and aggressive gastrointestinal tumor, particularly in East Asia. However, there is a lack of consensus on the long-term survival outcomes of intrathoracic anastomosis and cervical anastomosis following esophagectomy. This study aims to provide a comprehensive summary of the long-term survival outcomes of these 2 anastomosis techniques.

METHODS

We employed data drawn from the Sichuan Cancer Hospital and Institute Esophageal Cancer Case Management Database from January 2010 to December 2017. Patients were stratified into 2 distinct groups according to the anatomical location of anastomosis following esophagectomy: those who underwent intrathoracic anastomosis (IA) (IA group) and those who underwent cervical anastomosis (CA) (CA group). To account for potential confounding factors and baseline imbalances between the 2 groups, propensity score matching was employed.

RESULTS

The CA group exhibited longer overall survival compared with the IA group, with a median overall survival of 49.10 months versus 35.87 months (hazard ratio, 1.118; 95% CI, 1.118-1.412; P < .001). Additionally, survival rates at 1, 3, and 5 years were higher in the CA group (87%, 59%, and 48%, respectively) compared with the IA group (86%, 50%, and 39%, respectively). The significance persisted even after propensity score matching (hazard ratio, 1.164; 95% CI, 1.013-1.336; P < .001), inverse probability of treatment weighting, and overlap weighting were applied. The survival difference between CA and IA was attributed to varying extents of lymph node dissection, particularly in the upper mediastinal zone (P < .001).

CONCLUSIONS

Our study suggests that there could be the potential survival advantage of CA over IA in patients undergoing esophagectomy for esophageal squamous cell carcinoma.

Major coronary artery calcifications as predictors of postoperative complications in Ivor Lewis esophagectomies: a five-year retrospective analysis

BACKGROUND

This study aimed to determine the relationship between preoperative arterial calcifications and postoperative outcomes after Ivor Lewis esophagectomies.

METHODS

This was a single-center retrospective review of Ivor Lewis esophagectomies from 2013 to 2018. Preoperative CT imaging was reviewed, and arterial calcifications were graded (absent, minor, or major) in various locations. The primary outcome included major complications (defined by the Clavien-Dindo classification III-V) and the secondary outcomes were 90-day reoperations, readmissions, and mortality. Significant associations (p < 0.05) between calcifications and outcomes on univariable analysis were evaluated using a multivariable logistic regression model (odds ratios, OR; 95% confidence intervals, CI).

RESULTS

One hundred patients underwent esophagectomies from 2013 to 2018 (79% male, 90% White, median age 68 years), and 85% were classified as ASA III. Ninety-four patients had accessible preoperative imaging. Arterial calcifications in specific areas were observed: 82 in coronary arteries (major in 33 patients), 54 in the aortic valve, 78 in supra-aortic arteries, 79 in the thoracic aorta, 82 in the abdominal aorta, and 71 in common iliac. Furthermore, 60 patients exhibited celiac axis calcifications, with 40 patients classified as major. Twenty-five patients experienced major complications. Anastomotic leak occurred in two patients, and graft necrosis occurred in one patient. Ninety-day readmission was 10%, reoperation was 12%, and mortality was 4%. On univariable analysis, major coronary artery calcifications were significantly associated with major complications (OR 4.04; 95% CI 1.34-12.16; p = 0.02) and 90-day readmissions (OR 8.20; 95% CI 1.01-68.47; p = 0.04). However, no significant associations were identified between 90-day reoperations or mortality and arterial calcifications.

CONCLUSIONS

This study demonstrated that preoperative coronary calcifications increase the risk of postoperative complications, as this may be a surrogate of overall health. Nonetheless, the correlation between splanchnic calcifications and postoperative outcomes needs further exploration.

Esophagectomy after definitive chemoradiation in esophageal cancer: a safe therapeutic strategy

The standard treatment regimen for esophageal cancer is chemoradiation followed by esophagectomy. However, the use of neoadjuvant chemoradiotherapy damages the surrounding tissue, which potentially increases the risk of postoperative complications, including anastomotic leakage. The impact of definitive chemoradiotherapy (dCRT, 50.4 Gy radiotherapy) compared to the standard neoadjuvant scheme (nCRT, 41.4 Gy radiotherapy) prior to surgery on the incidence of anastomotic leakage remains poorly understood. To study this, all patients who received dCRT between 2011 and 2021 followed by esophagectomy were included. For each patient, two patients who received nCRT were selected as matched controls. Outcomes included postoperative anastomotic leakage, pulmonary and other complications, anastomotic stenosis, pulmonary and other postoperative complications (Clavien Dindo Classification ≥1), and overall survival. One hundred and eight patients were included with a median follow-up of 28 months. The time between neoadjuvant treatment and surgery was longer in the dCRT group compared to the nCRT group (65 vs. 48 days, P < 0.001). Postoperatively, significantly more patients in the dCRT group suffered from anastomotic leakage (11% vs. 1%, P = 0.04) and anastomotic stenosis (42% vs. 17%, P < 0.01). No differences were found for other complications or overall survival between both groups. In conclusion, preoperative dCRT is associated with a higher risk of anastomotic leakage and stenosis. These complications, however, can be treated effectively. Therefore, esophagectomy after dCRT is considered to be an appropriate treatment strategy in a selected patient group.

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

A case report of colon interposition radical surgery performed via unilateral thoracotomy in a patient with esophageal cancer after billroth II gastrectomy

Introduction

When a gastric tube cannot be used as a substitute for the esophagus, the colon offers several advantageous features for esophageal replacement. However, this procedure remains complex and necessitates patients to have a favorable nutritional status. In this study, we investigated the viability of intrathoracic colonic interposition anastomosis through a single thoracic incision, with the goal of mitigating surgical challenges and nutritional requirements.

Case description

We conducted a colectomy and reconstructed the esophageal-colonic-gastric tract via the esophageal bed into the left thoracic cavity for a 68-year-old male patient with compromised nutritional status following 30 years post-Billroth II (BII) gastrectomy. Under normal circumstances, this patient would not have been deemed an appropriate candidate for a conventional colonic interposition procedure. The patient resumed a soft diet through the normal digestive tract two weeks after the surgery and was discharged 20 days later.

Conclusion

Patients who have previously received a Billroth II Gastrectomy and subsequently developed early-stage esophageal cancer, characterized by the absence of lymph node metastasis, are suitable candidates for Colon Interposition Radical Surgery via left thoracotomy.

Evaluation of the gastric conduit perfusion using indocyanine green in thoracoscopic esophagectomy for esophageal cancer

Objective

Indocyanine green has been used in the assessment of the gastric conduit perfusion in thoracoscopic esophagectomy to prevent malperfusion-associated anastomotic leak. This study aims to evaluate the initial results of investigating the gastric conduit perfusion with indocyanine green in the surgical treatment of esophageal cancer.

Patients and methods

This cross-sectional descriptive study was carried out on 54 esophageal cancer patients undergoing thoracoscopic esophagectomy and gastric conduit reconstruction. The blood flow in the gastric conduit was observed using an infrared camera and indocyanine green after completion of the conduit and after tunneling the conduit through the mediastinum to the neck.

Results

The gastric conduit width and length were 5.2 ± 0.3 cm, and 31.5 ± 1.6 cm, respectively. The length of the gastric conduit from the junction between the right and left gastroepiploic to the point where the distal end of the gastric conduit still has a vascular pulse was 11.9 ± 4.3 cm. Seventeen patients (31.5%) had poor blood supply at the distal end of the gastric conduit, with indocyanine green appearance time ⩾ 60 s, in whom anastomotic leaks occurred in five patients (9.3%). The lack of connection between the right and left gastroepiploic vessels was associated with poor blood supply of the distal gastric conduit (p = 0.04). Multivariable logistic regression analysis showed association between the time of indocyanine green appearance at the distal gastric conduit and the risk of anastomotic leak (OR = 1.99, 95% CI = 1.10-3.60, p = 0.02).

Conclusion

Investigation of gastric conduit perfusion using indocyanine green in gastric conduit reconstruction detected 31.5% of patients with poor blood supply at the distal end of the conduit, in whom 9.3% had anastomotic leak. The longer indocyanine green appearance time in the distal gastric conduit (segment BC), was associated with the higher rate of the anastomotic leak.

Early postoperative endoscopy for predicting anastomotic leakage after minimally invasive esophagectomy: A large-volume retrospective study

BACKGROUND

Anastomotic leakage is one of the most severe adverse events of minimally invasive esophagectomy for esophageal cancer. Early postoperative endoscopy is considered to be the most objective means to diagnose anastomotic leakage, but its safety is questioned by clinicians. This study aimed to evaluate the safety and effectiveness of early postoperative endoscopy in predicting anastomotic leakage.

METHODS

Patients who underwent minimally invasive esophagectomy (from January 2017 to June 2021) in our center were identified and divided into early postoperative endoscopy and control groups according to whether they underwent early postoperative endoscopy within 72 hours after surgery. Propensity score matching was used to balance baseline characteristics. The incidence of postoperative adverse events was compared between the 2 groups, risk variables for anastomotic leakage were identified using logistic regression, and abnormal endoscopic findings related to anastomotic leakage occurrence were explored.

RESULTS

A total of 436 patients were enrolled, of whom 134 underwent early postoperative endoscopy. One hundred and thirty-two pairs were matched by propensity score matching, and baseline characteristics were well-balanced. Both before and after propensity score matching, early postoperative endoscopy did not increase the incidence of postoperative adverse events (chyle leak, hypoproteinemia, pneumonia, etc) and in-hospital mortality. Notably, the incidence of anastomotic leakage (9.8% vs 22.7%) and the length of mean postoperative hospital stay (17.6 vs 20.9 days) was significantly decreased in the early postoperative endoscopy group. Finally, based on the findings under early postoperative endoscopy, we found that gastric graft ischemia is related to a higher incidence of anastomotic leakage (P = .023).

CONCLUSION

Early postoperative endoscopy does not increase postoperative adverse events after minimally invasive esophagectomy and may guide early prediction and intervention strategies for anastomotic leakage in patients undergoing minimally invasive esophagectomy.

High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy

OBJECTIVES

Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy.

METHODS

A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching.

RESULTS

After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002).

CONCLUSIONS

For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.

Efficacy and Quality of Life with the Modified Versus the Traditional Thoraco-Laparoscopic McKeown Procedure for Esophageal Cancer: A Multicenter Propensity Score-Matched Study

BACKGROUND

This study aimed to compare the efficacy and postoperative quality of life for patients with esophageal cancer treated by either the modified or the traditional thoracolaparoscopic McKeown procedure.

METHODS

This retrospective case-control study included 269 patients with esophageal cancer admitted to three medical centers in China from February 2020 to August 2022. The patients were divided according to surgical method into the layered hand-sewn end-to-end invagination anastomosis group (modified group) and the traditional hand anastomosis group (traditional group). Propensity score-matching (PSM) was used to maintain balance and comparability between the two groups.

RESULTS

The differences in age and tumor location between the patients in the traditional and modified groups were statistically significant. After PSM, the aforementioned factors were statistically insignificant. After PSM, each group had 101 patients. The modified group showed the greater advantage in terms of postoperative hospital stay (P = 0.036), incidence of anastomotic leak (P = 0.009), and incidence of gastroesophageal reflux (P < 0.001), and the difference was statistically significant. The results of the Quality of Life Questionnaire Core 30 (QLQ-C30) and Quality of Life Questionnaire Oesophageal Cancer Module 18 (QLQ-OES18) scales showed that the modified group also had the advantage over the traditional group in terms of physical function, overall health status, loss of appetite, eating, reflux, obstruction, and loss of appetite scores at the first and third months after surgery.

CONCLUSION

The modified thoraco-laparoscopic McKeown procedure is a safe and effective surgical approach that can significantly reduce the incidence of postoperative anastomotic leak and gastroesophageal reflux, shorten the postoperative hospital stay, and improve the postoperative quality of life for patients with esophageal cancer.

Implementing the first program of minimally invasive esophagectomy for cancer in Israel: shifting the paradigm in a high-volume center - a cohort study

BACKGROUND

Esophagectomy is associated with significant perioperative morbidity. Limited data are available on the process of implementation of minimally invasive techniques in esophagectomy and related outcomes. The authors sought to describe implementation processes and outcomes following the implementation of the first minimally invasive esophagectomy (MIE) program at a high-volume center in Israel under the mentorship of American early adopters.

METHODS

Patients who underwent esophagectomy for esophageal carcinoma 2011-2022 were included. Early and late cohorts were created for learning curve analysis. Secondary analysis included patients who underwent open esophagectomy 1997-2011.

RESULTS

Overall, 300 patients underwent MIE: three-field MIE (3F-MIE) was performed in 242 (80.7%) patients, two-field MIE (2F-MIE) in 58 (19.3%) patients. Following program implementation in 2012, the number of MIE performed increased during the first 3 years ( n =33, 86.8% in 2015). Among 3F-MIE patients, a higher number of retrieved lymph nodes was reported during later cases (median, IQR1-3 17, 12-23 vs. 12, 8-12, P <0.001) while surgeries required a longer time (median, IQR1-3 300 min, 261-355 vs. 262.5, 239-300, P <0.001). Among 2F-MIE patients, the late cohort had lower rates of prolonged ICU admissions than earlier counterparts ( n =2, 6.9% vs. n =9, 31%, P =0.041), overall and severe 30-day complications ( n =12, 41.4% vs. n =23, 79.3%, P <0.001 and n =7, 24.1% vs. n =23, 79.3%, P =0.003).

CONCLUSIONS

MIE was safely implemented. Nodal yield was higher among MIE patients than open esophagectomy. During the study years, open approach was gradually abandoned in favor of 3F-MIE procedures, while 2F-MIE increased over the course of the last years.

Effect of Intrathoracic or Cervical Anastomosis After Esophagectomy on Quality of Life

PURPOSE

We aimed to perform serial quality-of-life (QoL) evaluations and comparisons in patients after esophagectomy with intrathoracic anastomosis (IA) or cervical anastomosis (CA).

METHODS

Between November 2012 and March 2015, patients who underwent esophagectomy with IA or CA for mid-esophageal to distal esophageal or gastroesophageal junction cancer were followed up. QoL was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30) and esophagus-specific questionnaire (EORTC QLQ-OES18) before surgery, at discharge, and at 1, 6, 12, and 24 months after discharge. Linear mixed-effect models were used to assess the mean score differences (MDs) of each QoL scale between the two techniques, and changes in QoL over time. Potential confounders were adjusted.

RESULTS

In total, 219 patients were analyzed (IA, n = 127; CA, n = 92). All patients' QoL decreased immediately after esophagectomy. Global QoL and most functioning and symptom scales exhibited a return to baseline levels within 2 years of discharge, except for physical functioning and several symptoms (dyspnea, diarrhea, dysphagia, and reflux). There was no difference in overall health score between the two groups (MD 2, 95% confidence interval [CI] - 1 to 6). Compared with IA, patients with CA reported more trouble with taste (MD - 12, 95% CI - 19 to - 4) and talking (MD - 11, 95% CI - 19 to 2) at discharge. No differences in long-term QoL were found between groups.

CONCLUSIONS

CA was associated with more trouble with taste and talking in the short term than IA. The long-term QoL did not differ between the two approaches.

Laparoscopic ischemic conditioning prior esophagectomy in selected patients: the ISCON trial

Anastomotic leakage (AL) after esophagectomy is the most impactful complication after esophagectomy. Ischemic conditioning (ISCON) of the stomach >14 days prior to esophagectomy might reduce the incidence of AL. The current trial was conducted to prospectively investigate the safety and feasibility of laparoscopic ISCON in selected patients. This international multicenter feasibility trial included patients with esophageal cancer at high risk for AL with major calcifications of the thoracic aorta or a stenosis in the celiac trunk. Patients underwent laparoscopic ISCON by occlusion of the left gastric and the short gastric arteries followed by esophagectomy after an interval of 12-18 days. The primary endpoint was complications Clavien-Dindo ≥ grade 2 after ISCON and before esophagectomy. Between November 2019 and January 2022, 20 patients underwent laparoscopic ISCON followed by esophagectomy. Out of 20, 16 patients (80%) underwent neoadjuvant treatment. The median duration of the laparoscopic ISCON procedure was 45 minutes (range: 25-230). None of the patients developed intraoperative or postoperative complications after ISCON. Hospital stay after ISCON was median 2 days (range: 2-4 days). Esophagectomy was completed in all patients after a median of 14 days (range: 12-28). AL occurred in three patients (15%), and gastric tube necrosis occurred in one patient (5%). In hospital, the 30-day and 90-day mortalities were 0%. Laparoscopic ISCON of the gastric conduit is feasible and safe in selected esophageal cancer patients with an impaired vascular status. Further studies have to prove whether this innovative strategy aids to reduce the incidence of AL.

Prediction model using risk factors associated with anastomotic leakage after minimally invasive esophagectomy

Objective

To explore the risk factors of anastomotic leakage after minimally invasive esophagectomy (MIE) and to build a prediction model of the probability of postoperative anastomotic leakage.

Methods

Clinical data of patients undergoing MIE, admitted in the Fourth Hospital of Hebei Medical University from March 2018 to March 2022, were retrospectively selected, and risk factors of anastomotic leakage after MIE were analyzed by univariate and multivariate logistic regression. A prediction nomogram model was established based on the independent risk factors, and its prediction effect was evaluated.

Results

A total of 308 patients were included. Thirty patients had postoperative anastomotic leakage, with an incidence of 9.74%. Logistic regression analysis showed that age, postoperative delirium, pleural adhesion, postoperative pulmonary complications, high postoperative white blood cell count and low lymphocyte count were risk factors for postoperative anastomotic leakage. A nomograph prediction model was constructed based on these risk factors. The predicted probability of occurrence of the nomograph model was consistent with the actual probability of occurrence. The calculated C-index value (Bootstrap method) was 0.9609, indicating that the nomograph prediction model had a good discrimination ability. By drawing the receiver operating characteristic (ROC) curve, we showed that the area under the curve (AUC) of the nomograph prediction model was 0.9609 (95%CI: 0.937-0.985), which indicated a good prediction efficiency of the model.

Conclusions

The nomograph prediction model based on the independent risk factors of anastomotic leakage after MIE can accurately predict the probability of postoperative anastomotic leakage.

Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study

PURPOSE

Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL.

METHODS

Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors.

RESULTS

A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL.

CONCLUSION

Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.

Development of nomogram for predicting major complications in patients with esophageal cancer in the early postoperative period

PURPOSE

To investigate the predictive value of the Prognostic Nutrition Index (PNI) in major complications after esophagectomy for esophageal cancer and to develop a Nomogram risk prediction model.

METHOD

The clinical data of 386 patients who underwent radical esophageal cancer surgery from May 2019 to March 2022 were retrospectively analyzed. Logistic regression analysis was performed to screen independent risk factors associated with major postoperative complications. A nomogram risk prediction model for major postoperative complications was developed based on the predictors, and the clinical utility of the model was assessed by decision curve analysis(DCA).

RESULT

In this study logistic univariate regression analysis found that age, preoperative radiotherapy, American Society of Anesthesiologists physical status (ASA score), length of surgery, and PNI may be associated with the development of major postoperative complications. logistic multifactorial analysis showed that the above risk factors were independent risk factors for the development of major postoperative complications in esophageal cancer. Nomogram was developed by incorporating the above risk factors with ASA classification. The calibration curves showed that the model had a good agreement. The decision curves showed that the model has good clinical application.

CONCLUSION

Individualized nomograms based on PNI combined with clinical indicators can be used to predict major complications in the early postoperative period and help to enhance perioperative management.

Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy

Purpose

In minimally invasive esophagectomy (MIE), it is important to reduce the rate of anastomotic leakage to ensure its safety. At our institute, the double-ligation method (DLM) has been introduced to insert and fix the anvil of the circular stapler for intracorporeal circular esophagojejunostomy in gastric surgery. We adopted this method for intrathoracic anastomosis (IA) in MIE. The aim of this study was to investigate the safety of IA with DLM in MIE.

Methods

In this study, 48 patients diagnosed with primary middle or lower third segment thoracic esophageal carcinoma with clinical stage I, II, III or IV disease were retrospectively evaluated. Postoperative outcomes were assessed.

Results

Among the 48 patients, 42 patients underwent laparo-thoracoscopic esophagectomy and IA using a circular stapler with the DLM. The average total operation time and thoracoscopic operation time were 433 and 229 minutes, respectively. The average purse-string suturing time was 4.7 minutes. The rates of anastomotic leakage and stenosis were 2.4% and 14.3%, respectively. The overall incidence of postoperative complications (Clavien-Dindo grade of ≥III) was 16.7%. The average postoperative stay was 16 days.

Conclusion

The procedure of IA using a circular stapler with the DLM in MIE was safe and provided a low rate of anastomotic leakage.

Application of reversely connecting circular stapler technique in cervical esophagogastric anastomosis

Introduction

The incidence of anastomotic leakage is relatively high (6-26%) in esophagogastrocervical anastomosis. The traditional anastomotic mode has high tissue tension in the process of anastomosis, which can easily cause tissue tear in the anastomotic area and increase the incidence of anastomotic leakage.

Aim

To investigate the usefulness of reversely connecting circular stapler technique for reducing anastomotic tension and injury of the esophageal and gastric wall, preventing anastomotic leakage in minimally invasive McKeown esophagectomy.

Material and methods

A total of 133 patients with esophageal cancer who underwent minimally invasive McKeown esophagectomy from January 2021 to December 2021 were collected. Characteristics, surgical data, and outcomes of patients were recorded and retrospectively analyzed. There were 83 patients in the reverse order connecting circular stapler group and 50 patients in the conventional order connecting group.

Results

Anastomotic leakage was observed in 2 (2.4%) cases in the reverse order connecting circular stapler group. Compared with the conventional connection group, the reverse connecting group had lower incidence of anastomotic leakage, shorter anastomotic time, shorter hospital stay, and lower incidence of pulmonary and chest infections and hoarseness.

Conclusions

The reversely connecting circular stapler technique could reduce the incidence of anastomotic leakage. The technique is simple to perform and easy to learn. Therefore, it is useful for the prevention of anastomotic leakage.

Five-year Survival after McKeown Compared to Ivor-Lewis Esophagectomy for Esophageal Cancer: A Population-based Nationwide Study in Finland

OBJECTIVE

The aim of study was to compare overall 5-year survival of esophageal cancer patients undergoing transthoracic esophagectomy with either neck or intrathoracic anastomosis, that is, McKeown and Ivor-Lewis esophagectomy.

BACKGROUND

No national studies comparing long-term survival after McKeown and ivor-Lewis esophagectomies in the West exist.

METHODS

This population-based nationwide study included all curatively intended transthoracic esophagectomies for esophageal adenocarcinoma or squamous cell carcinoma in Finland in 1987 to 2016, with follow-up until December 31, 2019. Cox proportional hazard models provided hazard ratios (HR) with 95% confidence intervals (ci) of all-cause 5-year mortality. The results were adjusted for age, sex, year of the operation, comorbidities, histology, stage, and neoadjuvant treatment. Adjusted model 2 included also tumor location and lymph node yield.

RESULTS

A total of 990 patients underwent McKeown (n = 278) or Ivor-Lewis (n = 712) esophagectomy The observed overall 5-year survival was 43.1% after McKeown, and 45.9% after Ivor-Lewis esophagectomy. McKeown esophagectomy was not associated with the overall 5-year mortality (adjusted HR 1.11, 95% CI: 0.89-1.38), compared to Ivor-Lewis esophagectomy. Additional adjustment for tumor location and lymphadenectomy further attenuated the point estimate (HR 1.06, 95% CI: 0.85-1.33). Surgical approach was not associated with 90-day mortality rate (adjusted HR 1.15, 95% CI: 0.67-1.97).

CONCLUSIONS

This population-based nationwide study suggests that overall 5-year survival or 90-day survival with McKeown and Ivor-Lewis esopha-gectomy for esophageal cancer are comparable.

Comparison of hand-sewn and circular stapled esophagogastric anastomoses in the neck after esophagectomy for thoracic esophageal cancer: a propensity score-matched analysis

Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage.

Routine decompression by nasogastric tube after oesophagectomy for oesophageal cancer

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To evaluate the effects of routine nasogastric decompression as compared to no nasogastric decompression after oesophagectomy. In the case of routine decompression, we will also aim to assess the effects of early versus late removal of the nasogastric tube.

Ulcer Scarring in the Gastric Conduit Is a Risk Factor for Anastomotic Leakage After Esophagectomy for Esophageal Cancer

BACKGROUND

Anastomotic leakage (AL) is a serious complication after esophagectomy for esophageal cancer. The objective of this study was to identify the risk factors for AL.

METHODS

Patients with esophageal cancer who underwent curative esophagectomy and cervical esophagogastric anastomosis between 2009 and 2019 (N = 346) and those between 2020 and 2022 (N = 17) were enrolled in the study to identify the risk factors for AL and the study to assess the association between the risk factors and blood flow in the gastric conduit evaluated by indocyanine green (ICG) fluorescence imaging, respectively.

RESULTS

AL occurred in 17 out of 346 patients (4.9%). Peptic or endoscopic submucosal dissection (ESD) ulcer scars were independently associated with AL (OR 6.872, 95% CI 2.112-22.365) in addition to diabetes mellitus. The ulcer scars in the anterior/posterior gastric wall were more frequently observed in patients with AL than in those without AL (75.0% vs. 17.4%, P = 0.042). The median flow velocity of ICG fluorescence in the gastric conduits with the scars was significantly lower than in those without the scars (1.17 cm/s vs. 2.23 cm/s, P = 0.004).

CONCLUSIONS

Peptic or ESD ulcer scarring is a risk factor for AL after esophagectomy in addition to diabetes mellitus. The scars in the anterior/posterior gastric wall are significantly associated with AL, impairing blood flow of the gastric conduit. Preventive interventions and careful postoperative management should be provided to minimize the risk and severity of AL in patients with these risk factors.

Development of nomograms predictive of anastomotic leakage in patients before minimally invasive McKeown esophagectomy

Purpose

The present study aims to identify factors related to anastomotic leakage before esophagectomy and to construct a prediction model.

Methods

A retrospective analysis of 285 patients who underwent minimally invasive esophagectomy (MIE). An absolute shrinkage and selection operator was applied to screen the variables, and predictive models were developed using binary logistic regression.

Results

A total of 28 variables were collected in this study. LASSO regression analysis, combined with previous literature and clinical experience, finally screened out four variables, including aortic calcification, heart disease, BMI, and FEV1. A binary logistic regression was conducted on the four predictors, and a prediction model was established. The prediction model showed good discrimination and calibration, with a C-statistic of 0.67 (95% CI, 0.593-0.743), a calibration curve fitting a 45° slope, and a Brier score of 0.179. The DCA demonstrated that the prediction nomogram was clinically useful. In the internal validation, the C-statistic still reaches 0.66, and the calibration curve has a good effect.

Conclusions

When patients have aortic calcification, heart disease, obesity, and a low FEV1, the risk of anastomotic leakage is higher, and relevant surgical techniques can be used to prevent it. Therefore, the clinical prediction model is a practical tool to guide surgeons in the primary prevention of anastomotic leakage.

Trends in surgical techniques for the treatment of esophageal and gastroesophageal junction cancer: the 2022 update

The aim of this study was to evaluate the current practice in surgical techniques for esophageal and gastroesophageal junction cancer surgery worldwide and to compare the results to the previous surveys in 2007 and 2014. An online survey was sent out among surgical members of the International Society for Diseases of the Esophagus, the World Organization for Specialized Studies on Disease of the Esophagus, the International Gastric Cancer Association, the Association of Upper Gastrointestinal Surgery of Great Britain and Ireland and Dutch gastroesophageal surgeons via the network of the investigators. In total, 260 surgeons completed the survey representing 52 countries and 6 continents; Europe 56%, Oceania 14%, Asia 14%, South-America 9%, North-America 7%. Of the responding surgeons, 39% worked in a hospital that performed >51 esophagectomies per year. Total minimally invasive esophagectomy was the preferred technique (53%) followed by hybrid esophagectomy (26%) of which 7% consisted of a minimally invasive thoracic phase and 19% of a minimally invasive abdominal phase. Total open esophagectomy was preferred by 21% of the respondents. Total minimally invasive esophagectomy was significantly more often performed in high-volume centers compared with non-high-volume centers (P = 0.002). Robotic assistance was used in 13% during the thoracic phase and 6% during the abdominal phase. Minimally invasive transthoracic esophagectomy has become the preferred approach for esophagectomy. Although 21% of the surgeons prefer an open approach, 26% of the surgeons perform a hybrid procedure which may reflect further transition towards the use of total minimally invasive esophagectomy.

Survival after Ivor Lewis versus McKeown esophagectomy for cancer: propensity score matched analysis

It is unknown whether Ivor Lewis (IL) or McKeown (McK) esophagectomy is preferred in patients with potentially curable esophageal or gastro-esophageal junction (GEJ) cancer. Patients with mid- and distal esophageal and GEJ cancer without distant metastases who underwent IL or McK esophagectomy in the Netherlands between 2015 and 2017, were selected from the Netherlands Cancer Registry. Patients were propensity score matched for sex, age, American Society of Anesthesiologist classification, comorbidity, tumor type, tumor location, clinical stage, neoadjuvant treatment and year of diagnosis. The primary outcome was a 3-year relative survival (RS). Secondary outcome parameters were number of lymph nodes examined, number of positive lymph nodes, radical resection rate, tumor regression grade, post-operative complications and mortality. A total of 1627 patients who underwent IL (n = 1094) or McK (n = 533) esophagectomy were included. Patient and tumor characteristics were balanced after propensity score matching, leaving 658 patients to be compared. The 3-year RS was 54% after IL and 50% after McK esophagectomy, P = 0.140. The median number of lymph nodes examined, median number of positive lymph nodes, radical resection rate and tumor regression grade were comparable between both groups. Recurrent laryngeal nerve palsy (2 vs. 5%, P = 0.006) occurred less frequently after IL esophagectomy. No differences were observed in post-operative anastomotic leakage rate, pulmonary complication rate and mortality rates. There was no statistically significant difference in the 3-year RS between IL and McK esophagectomy. Based on these results, both IL and McK esophagectomy can be performed in patients with mid to distal esophageal and GEJ cancer.

Efficacy of sternocleidomastoid muscle flap in reducing anastomotic mediastinal/pleural cavity leak

BACKGROUND

Anastomotic mediastinal/pleural cavity leak (AMPCL) is a life-threatening postoperative complication after esophagectomy. The objective of this study was to find a safe and effective surgical method to reduce the incidence of AMPCL.

METHODS

A total of 223 patients who underwent surgery in Fujian Medical University Union Hospital from May 2020 to October 2021 were enrolled in this study. Data for preoperative and postoperative test indices, postoperative complications, perioperative treatment were collected. After using 1:1 propensity score matching (PSM) to match two cohort (caliper = 0.1), the relationship between various factors and the incidence of AMPCL were analyzed.

RESULTS

209 patients were included for further analysis in the end. There were 95 patients in the sternocleidomastoid muscle flap embedding group (intervention group) and 114 in the routine operation group (control group). There was a significant difference in mean age between two groups. Gender, age, body mass index, diabetes, American society of anesthesiologists score, preoperative neoadjuvant therapy, pathological stage were included in performing 1:1 PSM, and there were no significant differences between two groups. Median operative time was significantly less in intervention group. Anastomotic leak (AL) did not present significant difference between two groups (8 [8.6] vs. 13 [14.0], p = 0.247), however, the AMPCL in intervention group was significantly lower than control group (0 [0] vs. 6 [6.5], p = 0.029).

CONCLUSIONS

The sternocleidomastoid muscle flap embedding could significantly reduce the incidence of AMPCL. This additional procedure is safe, and effective without increase in the occurrence of postoperative complications and hospital expenses.

Application of Amiodarone and Cedilan in the Treatment of Patients with Arrhythmia after Esophageal and Lung Cancer

Objective

To explore the effect of amiodarone and cedilan in the treatment of patients with arrhythmia after esophageal and lung cancer.

Methods

The data of 60 patients with postoperative complications of arrhythmias after esophageal and lung cancer from January 2018 to July 2021 were retrospectively analyzed and divided into an observation group (n = 30) and control group (n = 30) according to the random number grouping principle. The former group was treated with amiodarone, and the latter group received cedilan.

Results

The effective rate of treatment was significantly higher in the observation group than the control group (P < 0.05). The observation group had the drug onset time obviously shorter than the control group (P < 0.001). The average ventricular rate after treatment in the observation group was remarkably lower than the control group (P < 0.001). The observation group exhibited obviously better cardiac function after treatment as compared to the control group (P < 0.05). The incidence of adverse reactions in the observation group was notably lower than the control group (P < 0.05). Moreover, the observation group had less stress after treatment than the control group (P < 0.001). The blood pressure level of the observation group after treatment was significantly better than the control group (P < 0.05).

Conclusion

Amiodarone can relieve stress in patients with arrhythmia following esophageal and lung cancer surgery, stabilize blood pressure, and mitigate arrhythmia symptoms. Our findings are worthy of promotion and application in clinic.

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11 days (range, 6-51 days). 30 day and 90 day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

Comparison of the clinical outcomes after esophagectomy between intrathoracic anastomosis and cervical anastomosis: a systematic review and meta-analysis

OBJECTIVES

Esophageal cancer is a high-mortality disease. Esophagectomy is the most effective method to treat esophageal cancer, accompanied with a high incidence of post-operation complications. The anastomosis has a close connection to many severe post-operation complications. However, it remains controversial about the choice of intrathoracic anastomosis (IA) or cervical anastomosis (CA). The study was conducted to compare the clinical outcomes between the two approaches.

METHODS

We searched databases for both randomized controlled trials (RCTs) and cohort studies comparing post-operation outcomes between IA and CA. Primary outcomes were the incidences of anastomotic leakage and mortality. Secondary outcomes were the incidences of anastomotic stenosis, pneumonia and re-operation.

RESULTS

Twenty studies with a total of 7,479 patients (CA group: n = 3,183; IA group: n = 4296) were included. The results indicated that CA group had a higher incidence of anastomotic leakage than IA group (odds ratio [OR] = 2.05, 95% confidence intervals [CI] = 1.61-2.60, I² = 53.31%, P < 0.01). Subgroup analyses showed that CA group had higher incidences of type I (OR = 2.19, 95%CI = 1.05-4.57, I² = 0.00%, P = 0.04) and type II (OR = 2.75, 95%CI = 1.95-3.88, I² = 1.80%, P < 0.01) anastomotic leakage than IA group. No difference was found in type III anastomotic leakage (OR = 1.23, 95%CI = 0.82-1.86, I² = 20.92%, P = 0.31). The 90-day mortality (OR = 1.66, 95%CI = 1.11-2.47, I² = 0.0%, P = 0.01) in IA group were lower than that in CA group. No difference was found in in-hospital mortality (OR = 1.31, 95%CI = 0.91-1.88, I² = 0.00%, P = 0.15) and 30-day mortality (OR = 1.08, 95%CI = 0.69-1.70, I² = 0.00%, P = 0.74).

CONCLUSIONS

IA might be a better anastomotic approach than CA, with a lower incidence of anastomosis leakage and no increase in short-term mortality. Significant heterogeneity and publication bias might limit the reliability of the results. More high-quality studies are needed to verify and update our findings.

Short-term outcomes of Ivor Lewis vs. McKeown esophagectomy: A meta-analysis

OBJECTIVE

The objective of this article is to assess the rate of anastomotic leak and other perioperative outcomes in patients undergoing esophagectomy with either thoracic or cervical anastomosis.

METHODS

This meta-analysis was conducted by searching relevant literature studies in Web of Science, Cochrane Library, PubMed, and Embase databases. Articles that included patients undergoing esophagectomy and compared perioperative outcomes of McKeown with Ivor Lewis procedures were included. The primary outcome parameter was anastomotic leak, and secondary outcome parameters were grade ≥2 anastomotic leak, chylothorax, recurrent laryngeal nerve injury, hospital length of stay, intensive care unit (ICU) length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined.

RESULTS

A total of eight studies, with 3,291 patients (1,857 Ivor Lewis procedure and 1,434 McKeown procedure) were eligible for analysis. Meta-analysis showed that Ivor Lewis procedure was associated with lower rate of anastomosis leak of all grades [risk ratio (RR), 0.67; 95% confidence interval (CI), 0.55-0.82; P = 0.0001], lower rate of recurrent laryngeal nerve injury (RR, 0.14; 95% CI, 0.08-0.25), and shorter length of hospital stay (weighted mean difference, 0.13; 95% CI, 0.04-0.22). Grade ≥2 anastomotic leak, chylothorax, ICU length of stay, postoperative mortality rate, operative time, blood loss, R0 resection rate, and lymph nodes examined were similar between the two groups.

CONCLUSIONS

Although all grades of anastomotic leak and recurrent laryngeal nerve injury are higher in the McKeown procedure, this meta-analysis supports similar short-term outcomes and oncological efficacy between Ivor Lewis and McKeown esophagectomy.

Health-related quality of life following neoadjuvant chemoradiotherapy versus perioperative chemotherapy and esophagectomy for esophageal cancer: a European multicenter study

Curative treatment for locally advanced esophageal cancer consists of (neo)adjuvant treatment followed by esophagectomy. Both neoadjuvant chemoradiotherapy and perioperative chemotherapy improve the 5-year overall survival rate compared with surgery alone. However, it is unknown whether these treatment strategies are associated with differences in long-term health-related quality of life (HRQL). The aim of this study is to compare long-term HRQL in patients after esophagectomy treated with neoadjuvant chemoradiotherapy or perioperative chemotherapy. Disease-free cancer patients having undergone esophagectomy and (neo)adjuvant treatment in one of the participating lasting symptoms after esophageal resection (LASER) study centers between 2010 and 2016, were identified from the LASER study dataset. Included patients completed the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), EORTC QLQ-OG25, and LASER questionnaires at least 1 year after the completion of treatment. Long-term HRQL was compared between patients treated with neoadjuvant chemoradiotherapy or perioperative chemotherapy, using univariable and multivariable regression and presented as differences in mean score. Among the 565 included patients, 349 (61.8%) received neoadjuvant chemoradiotherapy, and 216 (38.2%) perioperative chemotherapy. Patients treated with perioperative chemotherapy reported more symptomatology for diarrhea (difference in means 5.93), reflux (difference in means 7.40), and odynophagia (difference in means 4.66). The differences did not exceed the 10 points to be of clinical relevance. No significant differences for the LASER key symptoms were observed. The observed differences in long-term HRQL are in favor of patients treated with neoadjuvant chemoradiotherapy compared with patients treated with perioperative chemotherapy; however, the differences were small. Patients need to be informed about long-term HRQL when considering allocation of (neo)adjuvant treatment.

Risk Factors and Effect of Intrathoracic Anastomotic Leakage after Esophagectomy for Underlying Malignancy-A Ten-Year Analysis at a Tertiary University Centre

Aim: Surgical resection remains the treatment of choice for curable esophageal cancer patients. Anastomotic leakage after esophagectomy with an intrathoracic anastomosis is the most feared complication, and is the main cause of postoperative morbidity and mortality. The aim of this study was to identify risk factors associated with anastomotic leakage and its effect on the postoperative outcome. Methods: Between 2012 and 2022, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. We performed a retrospective analysis of 174 patients. The dataset was analyzed to identify risk factors for the occurrence of anastomotic leakage. Results: A total of 174 patients were evaluated. The overall anastomotic leakage rate was 18.96%. The 30-day mortality rate was 8.62%. Multivariate logistic regression analysis identified diabetes (p = 0.0020) and obesity (p = 0.027) as independent risk factors associated with anastomotic leakage. AL had a drastic effect on the combined ICU/IMC and overall hospital stay (p < 0.001. Conclusion: Anastomotic leakage after esophagectomy with intrathoracic anastomosis is the most feared complication and major cause of morbidity and mortality. Identifying risk factors preoperatively can contribute to better patient management.

Effect of Circular Stapler Diameter on Anastomotic Leakage Rate and Stenosis After Open Total Gastrectomy With Esophagojejunostomy: A Substantive Retrospective Propensity Score Matched Series

Background

Anastomotic leakage (AL) and stenosis (AS) are two of the most severe postoperative complications after total gastrectomy with esophagojejunostomy. The stapler diameter can be chosen by the surgeon. Therefore, this study aims to assess the correlation between the stapler size as main independent variable as well as other different risk factors and AL and AS.

Methods

We conducted a retrospective analysis of data from 356 patients who underwent open total gastrectomy between 2000 and 2018, mostly due to gastric cancer (96.9%). After propensity score matching the outcome parameters AL and AS were compared between the two stapler size groups. We also assessed different risk factors for AL and AS in cancer patients using multivariate analysis.

Results

Small circular stapler diameter (21/25 mm; n = 147 vs 28/29/31 mm; n = 209) was identified as a significant risk factor for the occurrence of AL (10% vs 4% for smaller vs larger staplers; P = 0.042). In multivariate analysis for the occurrence of AL an ASA score ≥ 3 could be identified as a risk factor (OR 2.85; 95% CI = 1.13-7.15; P = 0.026). Additionally, smaller stapler size could be identified as a risk factor for AS (OR small 1.00, OR large 0.24; 95% CI: 0.06-0.97; P = 0.045). AL was associated with lower survival (18.1 vs 38.16 months; P = 0.0119).

Conclusion

The application of a larger circular stapler for esophagojejunostomy in open total gastrectomy shows significantly lower rates of AL and stenosis. Therefore, the largest possible stapler diameter should be applied.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy

Background

With the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis.

Methods

After stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired.

Results

The clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period.

Conclusion

Two purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

A New Risk Factor for Cervical Anastomotic Leakage-Role of The Relative Gastric Length in the Surgical Treatment of Esophageal Cancer

BACKGROUND

Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice?

METHODS

Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G).

RESULTS

A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group.

CONCLUSIONS

RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.

Carbon Dioxide Sensing by Immune Cells Occurs through Carbonic Anhydrase 2-Dependent Changes in Intracellular pH

CO₂, the primary gaseous product of respiration, is a major physiologic gas, the biology of which is poorly understood. Elevated CO₂ is a feature of the microenvironment in multiple inflammatory diseases that suppresses immune cell activity. However, little is known about the CO₂-sensing mechanisms and downstream pathways involved. We found that elevated CO₂ correlates with reduced monocyte and macrophage migration in patients undergoing gastrointestinal surgery and that elevated CO₂ reduces migration in vitro. Mechanistically, CO₂ reduces autocrine inflammatory gene expression, thereby inhibiting macrophage activation in a manner dependent on decreased intracellular pH. Pharmacologic or genetic inhibition of carbonic anhydrases (CAs) uncouples a CO₂-elicited intracellular pH response and attenuates CO₂ sensitivity in immune cells. Conversely, CRISPR-driven upregulation of the isoenzyme CA2 confers CO₂ sensitivity in nonimmune cells. Of interest, we found that patients with chronic lung diseases associated with elevated systemic CO₂ (hypercapnia) display a greater risk of developing anastomotic leakage following gastrointestinal surgery, indicating impaired wound healing. Furthermore, low intraoperative pH levels in these patients correlate with reduced intestinal macrophage infiltration. In conclusion, CO₂ is an immunomodulatory gas sensed by immune cells through a CA2-coupled change in intracellular pH.

Minimally invasive oesophagectomy in the prone versus lateral decubitus position: a systematic review and meta-analysis

The thoracic phase of minimally invasive esophagectomy was initially performed in the lateral decubitus position (LDP); however, many experts have gradually transitioned to a prone position (PP) approach. The aim of the present systematic review and meta-analysis is to quantitatively compare the two approaches. A systematic literature search of the MEDLINE, Embase, Google Scholar, Web of Knowledge, China National Knowledge Infrastructure and ClinicalTrials.gov databases was undertaken for studies comparing outcomes between patients undergoing minimally invasive esophageal surgery in the PP versus the LDP. In total, 15 studies with 1454 patients (PP; n = 710 vs. LDP; n = 744) were included. Minimally invasive esophagectomy in the PP provides statistically significant reduction in postoperative respiratory complications (Risk ratios 0.5, 95% confidence intervals [CI] 0.34-0.76, P < 0.001), blood loss (weighted mean differences [WMD] -108.97, 95% CI -166.35 to -51.59 mL, P < 0.001), ICU stay (WMD -0.96, 95% CI -1.7 to -0.21 days, P = 0.01) and total hospital stay (WMD -2.96, 95% CI -5.14 to -0.78 days, P = 0.008). In addition, prone positioning increases the overall yield of chest lymph node dissection (WMD 2.94, 95% CI 1.54-4.34 lymph nodes, P < 0.001). No statistically significant difference in regards to anastomotic leak rate, mortality and 5-year overall survival was encountered. Subgroup analysis revealed that the protective effect of prone positioning against pulmonary complications was more pronounced for patients undergoing single-lumen tracheal intubation. A head to head comparison of minimally invasive esophagectomy in the prone versus the LDP reveals superiority of the former method, with emphasis on the reduction of postoperative respiratory complications and reduced length of hospitalization. Long-term oncologic outcomes appear equivalent, although validation through prospective studies and randomized controlled trials is still necessary.

The ISCON-trial protocol: laparoscopic ischemic conditioning prior to esophagectomy in patients with esophageal cancer and arterial calcifications

Background

Anastomotic leakage is the most important surgical complication following esophagectomy. A major cause of leakage is ischemia of the gastric tube that is used for reconstruction of the gastrointestinal tract. Generalized cardiovascular disease, expressed by calcifications of the aorta and celiac axis stenosis on a pre-operative CT scan, is associated with an increased risk of anastomotic leakage. Laparoscopic ischemic conditioning (ISCON) aims to redistribute blood flow and increase perfusion at the anastomotic site by occluding the left gastric, left gastroepiploic and short gastric arteries prior to esophagectomy. This study aims to assess the safety and feasibility of laparoscopic ISCON in selected patients with esophageal cancer and concomitant arterial calcifications.

Methods

In this prospective single-arm safety and feasibility trial based upon the IDEAL recommendations for surgical innovation, a total of 20 patients will be included recruited in 2 European high-volume centers for esophageal cancer surgery. Patients with resectable esophageal carcinoma (cT1-4a, N0–3, M0) with “major calcifications” of the thoracic aorta accordingly to the Uniform Calcification Score (UCS) or a stenosis of the celiac axis accordingly to the modified North American Symptomatic Carotid Endarterectomy Trial (NASCET) score on preoperative CT scan, who are planned to undergo esophagectomy are eligible for inclusion. The primary outcome variables are complications grade 2 and higher (Clavien-Dindo classification) occurring during or after laparoscopic ISCON and before esophagectomy. Secondary outcomes include intra- and postoperative complications of esophagectomy and the induction of angiogenesis by biomarkers of microcirculation and redistribution of blood flow by measurement of indocyanine green (ICG) fluorescence angiography.

Discussion

We hypothesize that in selected patients with impaired vascularization of the gastric tube, laparoscopic ISCON is feasible and can be safely performed 12–18 days prior to esophagectomy. Depending on the results, a randomized controlled trial will be needed to investigate whether ISCON leads to a lower percentage and less severe course of anastomotic leakage in selected patients.

Trial registration

Clinicaltrials.gov, NCT03896399. Registered 4 January 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09231-x.

Rates of Anastomotic Complications and Their Management Following Esophagectomy: Results of the Oesophago-Gastric Anastomosis Audit (OGAA)

OBJECTIVE

This study aimed to characterize rates and management of anastomotic leak (AL) and conduit necrosis (CN) after esophagectomy in an international cohort.

BACKGROUND

Outcomes in patients with anastomotic complications of esophagectomy are currently uncertain. Optimum strategies to manage AL/CN are unknown, and have not been assessed in an international cohort.

METHODS

This prospective multicenter cohort study included patients undergoing esophagectomy for esophageal cancer between April 2018 and December 2018 (with 90 days of follow-up). The primary outcomes were AL and CN, as defined by the Esophageal Complications Consensus Group. The secondary outcomes included 90-day mortality and successful AL/CN management, defined as patients being alive at 90 day postoperatively, and requiring no further AL/CN treatment.

RESULTS

This study included 2247 esophagectomies across 137 hospitals in 41 countries. The AL rate was 14.2% (n = 319) and CN rate was 2.7% (n = 60). The overall 90-day mortality rate for patients with AL was 11.3%, and increased significantly with severity of AL (Type 1: 3.2% vs. Type 2: 13.2% vs. Type 3: 24.7%, P < 0.001); a similar trend was observed for CN. Of the 329 patients with AL/CN, primary management was successful in 69.6% of cases. Subsequent rounds of management lead to an increase in the rate of successful treatment, with cumulative success rates of 85.4% and 88.1% after secondary and tertiary management, respectively.

CONCLUSION

Patient outcomes worsen significantly with increasing AL and CN severity. Reintervention after failed primary anastomotic complication management can be successful, hence surgeons should not be deterred from trying alternative management strategies.

Dislocation of the gastric conduit reconstructed via the posterior mediastinal route is a significant risk factor for anastomotic disorder after McKeown esophagectomy

BACKGROUND

Anastomotic disorder of the reconstructed gastric conduit is a life-threating morbidity after thoracic esophagectomy. Although there are various reasons for anastomotic disorder, the present study focused on dislocation of the gastric conduit (DGC).

METHODS

The study cohort comprised 149 patients who underwent transthoracic esophagectomy. The relationships between DGC and peri- and postoperative morbidities were analyzed retrospectively. Data were analyzed to determine whether body mass index (BMI) and extension of the gastric conduit were related to DGC. Uni- and multivariate Cox regression analyses were performed to identify the factors associated with anastomotic disorder.

RESULTS

DGC was significantly related to anastomotic leakage (P < .001), anastomotic stricture (P = .018), and mediastinal abscess/empyema (P = .031). Compared with the DGC-negative group, the DGC-positive group had a significantly larger mean preoperative BMI (23.01 ± 3.26 kg/m2 vs. 21.22 ± 3.13 kg/m2, P = .001) and mean maximum cross-sectional area of the gastric conduit (1024.75 ± 550.43 mm2 vs. 619.46 ± 263.70 mm2, P < .001). Multivariate analysis revealed that DGC was an independent risk factor for anastomotic leakage (odds ratio: 4.840, 95% confidence interval: 1.770-13.30, P < .001). Body weight recovery tended to be better in the DGC-negative group than in the DGC-positive group, although this intergroup difference was not significant.

CONCLUSION

DGC reconstructed via the posterior mediastinal route is a significant cause of critical morbidities related to anastomosis. In particular, care is required when performing gastric conduit reconstruction via the posterior mediastinal route in patients with a high BMI.

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

INTRODUCTION

A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear.

OBJECTIVE

This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review.

METHODS

Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed.

RESULTS

All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months.

CONCLUSION

The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.