Anastomotic leakage: an avoidable complication of Lewis-Tanner oesophagectomy

A single blinded randomized controlled trial comparing semi-mechanical with hand-sewn cervical anastomosis after esophagectomy for cancer (SHARE-study)

OBJECTIVE

The aim was to compare leak rate between hand-sewn end-to-end anastomosis (ETE) and semi-mechanical anastomosis (SMA) after esophagectomy with gastric tube reconstruction.

BACKGROUND DATA

The optimal surgical technique for creation of an anastomosis in the neck after esophagectomy is unclear.

METHODS

Patients with esophageal cancer undergoing esophagectomy with gastric tube reconstruction and cervical anastomosis were eligible for participation after written informed consent. Patients were randomized in 1:1 ratio. Primary endpoint was anastomotic leak rate defined as external drainage of saliva from the site of the anastomosis or intra-thoracic manifestation of leak. Secondary endpoints included anastomotic stricture rate at one year follow up, number of endoscopic dilatations, dysphagia-score, hospital stay, morbidity, and mortality. Patients were blinded for intervention.

RESULTS

Between August 2011 and July 2014, 174 patients with esophageal cancer underwent esophagectomy. Ninety-three patients were randomized to ETE (n = 44) or SMA (n = 49). Anastomotic leak occurred in 9 of 44 patients (20%) in the ETE group and 12 of 49 patients (24%) in the SMA group (absolute difference 4%, 95% CI -13% to +21%; p = .804). There was no significant difference in dysphagia at 1 year postoperatively (ETE 25% vs. SMA 20%; p = .628), in stricture rate (ETE 25% vs. 19% in SMA, p = .46), nor in median hospital stay (17 days in the ETE group, 13 days in the SMA group), morbidity (82% vs. 73%, p = .460) or mortality (0% vs. 4%, p = .175) between the groups.

Comparison of clinical outcomes after conservative and surgical treatment of isolated anastomotic leaks after esophagectomy for esophageal cancer

The clinical course and outcome of isolated anastomotic leaks (IALs) after esophagectomy are significantly different from those of necrotic leaks. The purpose of this study was to investigate the clinical features, diagnosis, treatment, and long-term outcome in patients with IALs after esophagectomy with reconstruction for esophageal cancer. A total of 663 patients underwent esophagectomy with esophageal reconstruction because of esophageal cancer between 2000 and 2010 at the Seoul Asan Medical Center. IALs occurred in 23 patients (3.5%). All patients with IAL were male, with a median age of 61 years. Patients with IAL were divided into three groups based on their clinical course. group A comprised patients who had definite clinical symptoms and/or signs indicating mediastinal contamination or leak before routine contrast esophagography was performed. Groups B and C comprised patients who had no definite clinical symptoms and/or signs of leaks before the routine contrast examination. Furthermore, group B contained those patients who resumed oral intake because no leak was found in the routine contrast examination and was diagnosed some days after resuming oral intake. Group C contained those patients who kept fasting because the leak was found in the routine contrast examination. The median follow-up period was 30 months. The mean time to closure of the IAL was 70.1 ± 96.0 days (range 4-364). There was a 72.7% overall closure rate within 60 days. By univariate analysis, the mean time to closure of the IAL was found to be significantly longer for group A patients or in cases where the patients had an uncontained leak, leukocytosis, or empyema. However, there was no statistically significant differences in age, neoadjuvant treatment, site of anastomosis (cervical vs. thoracic), fever, or treatment of the leak. By multivariate analysis, group A was found to be an independent predictive factor for the time to closure of the IAL. Repeat contrast studies revealed no anastomotic leaks in 18 patients and the formation of contained fistula in four cases (excluding one patient who died in hospital). The four patients with a contained fistula showed no clinical symptoms or signs, and tolerated resumed oral intake. IALs were resolved in most cases with low leak-related mortality, and resolution of the leaks occurred within 2 months in the majority of patients.

Prognostic indicators of surgery for esophageal cancer: a 5 year experience

BACKGROUND/AIM

To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer.

MATERIALS AND METHODS

This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSS R for Windows.

RESULTS

Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl (P < 0.05) and Geansler's index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant (P = 0.051) on multivariate analysis.

CONCLUSION

Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler's index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer.

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10-year period (median age 61 [31-79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2-year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02-1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16-9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long-term survival was unaffected.

Surgical factors influence the outcome after Ivor-Lewis esophagectomy with intrathoracic anastomosis for adenocarcinoma of the esophagogastric junction: a consecutive series of 240 patients at an experienced center

BACKGROUND

Despite a considerable number of randomized studies, the surgical approach to locally advanced adenocarcinoma of the esophagogastric junction (AEG) I and II is still discussed controversially. Thus, we evaluated the surgical risk and outcome after an abdominothoracic esophagectomy (Ivor-Lewis) with intrathoracic anastomosis as standard procedure.

METHODS

Between 1998 and 2006, a total of 240 consecutive patients underwent standardized right thoracoabdominal esophagectomy with two-field lymphadenectomy and intrathoracic anastomosis (Ivor-Lewis operation) for AEG I (n = 206) or AEG II (n = 34). A total of 157 patients (65.4%) had neoadjuvant chemotherapy.

RESULTS

Postoperative morbidity occurred in 17.9% (43 of 240). Overall mortality was 3.8% (9 of 240). The majority of patients (4 of 9) died because of severe pulmonary complications (44.4%) irrespective of surgical complications. Neoadjuvant chemotherapy did not increase morbidity or mortality. The median overall survival was 51 months. Multivariate analysis including age >75 years, clinical response to chemotherapy, complications, R-category and N-category revealed R-category (P = .005; relative risk [RR] 0.32, 95% confidence interval [95% CI] 0.14-0.70) and complications (P < .001, RR 0.16, 95% CI 0.08-0.35) as independent prognostic factors for all patients. Complications was the only independent prognostic factor (P < .001, RR 0.09, 95% CI 0.08-0.35) for the R0 resected patients.

CONCLUSIONS

At an experienced center, Ivor-Lewis resection is a safe surgical procedure. Outcome of patients was significantly influenced by surgical factors such as complete resection and complications. Neoadjuvant chemotherapy did not lead to higher morbidity and mortality. The high mortality from non-surgery-related complications emphasizes the importance of careful preoperative evaluation of comorbidities and patient selection.

The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.

Laparoscopic partial gastric transection and devascularization in order to enhance its flow

Background

Esophagogastric fistula following an esophagectomy for cancer is very common. One of the most important factors that leads to its development is gastric isquemia. We hypothesize that laparoscopic gastric devascularization and partial transection is a safe operation that will enhance the vascular flow of the fundus of the stomach.

Method

Our study included eight pigs. Each animal had two operations. In the first one, a laparoscopic gastric devascularization and mobilization took place. Vascular flow was measured previous to the procedure and immediately after it with a laser doppler (endoscopic probe). After three weeks, a second operation took place. We re-measured the vascular flow and sent a sample of gastric fundus for histopathologic evaluation.

Results

The gastric fundus showed signs of neovascularization after both macroscopic and microscopic evaluation. These findings correlated with laser doppler measurements.

Conclusion

Laparoscopic gastric devascularization and partial transection is a safe procedure that increases the vascular flow of the stomach in a three week period. This finding can have a positive impact in terms of decreasing fistula formation.

Prospective trial comparing contrast swallow, computed tomography and endoscopy to identify anastomotic leak following oesophagogastric surgery

BACKGROUND

Anastomotic leaks are a major complication of oesophagogastric surgery. We compare contrast swallow fluoroscopy, computed tomography (CT) with oral contrast and endoscopy in identifying anastomotic leaks following oesophagogastric surgery.

METHODS

A prospective trial of 38 patients undergoing oesophagogastric resection was undertaken with informed consent and institutional review board (ethics committee) approval. Patients underwent all three investigations (over 24 hours) 1 week postoperatively.

RESULTS

Eight (21%) had clinically apparent leaks. Three pseudo-leaks were suggested on contrast swallow but were confirmed normal on CT and endoscopy. Contrast swallow and CT missed one anastomotic leak each. Endoscopy identified anastomotic defects in three patients, in whom CT and contrast swallow were either normal or conflicting.

CONCLUSIONS

Routine tests of anastomotic integrity are unnecessary. When clinically suspected, contrast swallow or CT with oral contrast will identify most leaks. Endoscopy is useful in cases where there are incongruous results.

Self-expandable metallic stents in the treatment of post-esophagogastrostomy/post-esophagoenterostomy fistula

Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4-27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5-8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed - covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators.

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Progressive gastric perfusion in rats: role of ischemic conditioning

Occult ischemia of the mobilized stomach is usually related to the dehiscence of an esophagogastric anastomosis. The principle of ischemic conditioning was studied to verify its clinic use. This study aims to evaluate progressively the tissue perfusion of the stomach in ischemic conditioning, establishing the best moment for gastric transposition. Twenty-four male EPM-1 Wistar rats were used, which also underwent partial desvacularization of the stomach by ligature of the left gastric vessels. Tissue perfusion was measured through flowmetry by laser Doppler (tissue perfusion unit; TPU) in the antrum (10 mm distal from the cardiac region). This measurement was done before (baseline) and immediately after the ligature, and on different postoperative days (POD) (days 3, 7, 10, and 14). A statistical analysis was done with nonparametric tests (P <or= 0.05). The mean value (+/-SD) of the gastric perfusion, during the whole study period, was 88 +/- 6 (baseline), 23 +/- 5 (postligature), 31 +/- 5 (3rd POD), 55 +/- 4 (7th POD), 71 +/- 16 (10th POD), and 84 +/- 6 (14th POD), respectively. Perfusion immediately after the artery ligature was significantly lower (74%) than the baseline of the gastric perfusion; therefore, in the following days, tissue perfusion increased progressively (35%, 63%, 81%, and 96%, respectively). The flowmetry of the stomach reached basal values in the 14th POD of desvascularization, suggesting that this would the best day to perform a gastric transposition. However, on the 10th POD, good tissue perfusion was observed. The extrapolation from these data to the clinic could improve the results of esophagogastric anastomosis.

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management

BACKGROUND

Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management.

STUDY DESIGN

From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications.

RESULTS

Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n= 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications.

CONCLUSIONS

Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.

Diagnosis and management of a mediastinal leak following radical oesophagectomy

BACKGROUND

The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis.

METHODS

Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy.

RESULTS

Nineteen patients (6.5 per cent) developed a proven mediastinal leak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died.

CONCLUSION

Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.

Tratamento cirúrgico das complicações da anastomose esôfago-visceral cervical

A anastomose esôfago-visceral cervical apresenta como complicações a fístula e a estenose, que podem necessitar de reintervenção cirúrgica para sua correção. Com o objetivo de avaliar as táticas para abordagem operatória dessas complicações e seus resultados, os autores estudaram retrospectivamente nove pacientes, que demandaram esta conduta, num período de 17 anos. Foram operadas duas fístulas e sete estenoses da anastomose esôfago-visceral cervical, sendo a via de acesso inicial a cervicotomia em todos os pacientes. Em quatro casos, houve necessidade de ampliação para esternotomia mediana total, que facilitou significativamente a reconstrução, porém com mortalidade de 75%. As táticas adotadas foram a reanastomose em cinco casos, a sutura do orifício da fístula em um caso e a plastia em três casos. A ressutura teve mau resultado. As plastias evoluíram satisfatoriamente, e os doentes submetidos a reanastomose sem ésternotomia também evoluíram satisfatoriamente. A plastia da anastomose demonstrou ser uma boa tática para o tratamento da estenose cervical, enquanto a reanastomose parece ter a melhor indicação nas fístulas, devendo-se evitar a esternotomia total mediana.

Gastric conditioning

The etiology of esophagogastric anastomotic leaks is often multifactorial. However, occult ischemia of the gastric fundus is an important cause. In gastric conditioning, preliminary partial gastric devascularization is carried out 2-3 weeks before construction of the esophagogastric anastomoses. Gastric vascularity improves over this time. In animal studies, gastric conditioning has reduced the incidence of anastomotic leaks. Clinically, the concept of gastric conditioning can be used in several ways. Esophagectomy can be done at one stage, then a cervical esophagogastric anastomosis can be completed as a second-stage procedure. Pre-esophagectomy angiographic gastric artery embolization is another method of gastric conditioning. Finally, laparoscopic partial gastric devascularization can be done at the time of laparoscopic cancer staging. For gastric conditioning to be clinically useful, the benefit from reduction in leaks must be greater than the costs and morbidity of the conditioning procedure itself.

Revascularization using the short gastric vessels of the gastric tube after subtotal esophagectomy for intrathoracic esophageal carcinoma

BACKGROUND

Maintaining sufficient blood flow to the substitutive organ after esophagectomy is essential to decrease the risk of anastomotic leakage.

STUDY DESIGN

Forty-one patients underwent subtotal esophagectomy for intrathoracic esophageal carcinoma and reconstruction using the gastric tube. Additional vascular anastomosis between the short gastric vessels and the vessels in the neck was performed in 15 patients. Tissue blood flow was measured by laser Doppler flowmetry before and after vascular anastomosis. The incidence of anastomotic leakage in the revascularization group was compared with that in the remaining 26 patients.

RESULTS

Venous anastomosis was performed in 14 patients and arterial anastomosis in 9. There was a significant increase in tissue blood flow after venous anastomosis alone (mean percent increase: 36%; p < 0.01), and after arterial and venous anastomoses (mean percent increase: 108%; p < 0.01). No anastomotic leakage was observed in the revascularization group; six patients (23.1%) in the control group had leakage (p < 0.05). Patients in the revascularization group started taking a meal 10.0 +/- 0.4 days postoperatively, compared with 15.1 +/- 1.8 days in the control group (p < 0.05).

CONCLUSIONS

Additional vascular anastomosis in esophageal reconstruction after subtotal esophagectomy achieved good results. This procedure can reduce the risk of anastomotic leakage and may be useful for esophageal reconstruction.

[Late morbidity after esophagectomy for cancer: is partial esophagectomy preferred?]

PURPOSE

The aim of this study is to report late postoperative complications occurring after oesophagectomy for cancer over a 12-month period and to compare the incidence of these complications according to the level of the anastomosis.

PATIENTS AND METHOD

This study included 106 consecutive patients 51% with subtotal oesophagectomy (thoracic anastomosis), and 49% with total oesophagectomy (cervical anastomosis). The two groups were comparable for age, mean weight loss before surgery, life expectancy, number of positive margins, TNM grading, size and tumour differentiation.

RESULTS

Late morbidity concerned 67.9% of the 106 patients. Predominant complications were dysphagia (32.1% of the 106), gastro-esophageal reflux (25.5% of the 106), and diarrhoea (18.8% of the 106). Among all the factors causing dysphagia, evaluated by logistic regression, the level of anastomosis was only found significant with a 20.4% occurrence for thoracic anastomosis and 44.2% for cervical anastomosis (P = 0.012). All the other complications were similar in the two groups.

CONCLUSION

Functional results of oesophagectomy for cancer are poor. As partial oesophagectomy morbidity is lower, total oesophagectomy should not be proposed in all cases of oesophageal cancer.

Diagnosis and conservative management of intrathoracic leakage after oesophagectomy

BACKGROUND

Although intrathoracic leakage is a major complication of oesophagectomy, precise data concerning diagnostic features and results of conservative treatment are lacking.

METHODS

From 1986 to 1994, 409 oesophagectomies with stapled oesophagogastrostomy were performed, including 358 Lewis-Tanner and 51 Sweet procedures. A water-soluble contrast swallow was routinely performed on day 7 or later, before oral intake was begun. All patients except one received conservative non-surgical treatment, including nutritional support and perianastomotic drainage.

RESULTS

Leaks were diagnosed in 38 patients (9.3 per cent). The leakage rate was 7.8 per cent after the Lewis-Tanner procedure and 20 per cent after the Sweet procedure (P < 0.01). Eleven patients had no symptoms. Seven of the 27 patients with symptoms had a contrast swallow that was normal, and subsequently developed a confirmed fistula after the onset of oral intake. Five patients had to undergo reoperation. All asymptomatic patients and 18 symptomatic patients recovered. Nine patients died, mainly from multiple organ failure, including three who had reoperation for resection of the gastroplasty.

CONCLUSION

The potential presence of clinically silent fistula and the deleterious role of oral intake still justify routine detection of leakage after oesophageal resection. Conservative treatment results in survival with preservation of the gastroplasty in most patients, unless multiple organ failure occurs.

Esophagogastric anastomotic leaks: the importance of gastric ischemia and therapeutic applications of gastric conditioning

The etiology of esophagogastric anastomotic leaks is often multifactorial. However, occult ischemia of the gastric fundus is an important cause. In gastric conditioning, preliminary partial gastric devascularization is done 2-3 weeks before construction of the esophagogastric anastomoses. Gastric vascularity improves over this time. In animal studies, gastric conditioning has reduced the incidence of anastomotic leaks. Clinically, the concept of gastric conditioning can be used in several ways. Esophagectomy can be done at one stage, and then a cervical esophagogastric anastomosis can be completed as a second-stage procedure. Preesophagectomy angiographic gastric artery embolization is another method of gastric conditioning. Finally, laparoscopic partial gastric devascularization can be done at the time of laparoscopic cancer staging. For gastric conditioning to be clinically useful, the benefit from reduction in leaks must be greater than the costs and morbidity of the conditioning procedure itself.

Comparison of stapled and hand-sewn esophagogastric anastomoses

BACKGROUND

Esophagogastric anastomotic leaks continue to be a major source of morbidity and mortality after esophagectomy. Leaks usually result from technical errors or occult ischemia of the mobilized gastric fundus. The introduction of stapled esophagogastric anastomoses was initially very promising; leak rates appeared to be reduced.

DATA SOURCES

The English language medical literature was searched for publications comparing stapled and hand-sewn esophagogastric anastomoses. We reviewed data from four randomized trials and seven nonrandomized comparative studies to determine if stapling was superior to hand suturing for esophagogastric anastomoses.

RESULTS

Pooled data from randomized trials comparing stapled with hand-sewn esophagogastric anastomoses showed no significant difference for leaks (stapled 9%, hand-sewn 8%, P <0.67), but a higher incidence of strictures in stapled anastomoses (stapled 27%, hand-sewn 16%, P < 0.02). In nonrandomized studies, stapled anastomoses had a lower leak rate (stapled 6%, hand-sewn 11%, P < 0.0001), but strictures were more frequent (stapled 31%, hand-sewn 16%, P < 0.0001). A major source of bias in the nonrandomized studies was the comparison of contemporary stapled experience and earlier hand-sewn experience. This bias was not present in three of seven nonrandomized studies that featured prospective data collection. Pooled data from these three studies showed no difference in anastomotic leak rate (stapled 4%, hand-sewn 6%, P < 0.28).

CONCLUSIONS

Stapled and hand-sewn esophagogastric anastomotic techniques have equivalent anastomotic leak rates, but strictures are more common in stapled anastomoses. Irrespective of which technique is used, surgical experience and meticulous attention to detail are required to prevent anastomotic complications. Anastomotic technical modifications alone are unlikely to eliminate the problem of leaks, since they do not address the problem of gastric fundal ischemia.

Postoperative analgesia reduces mortality and morbidity after esophagectomy

BACKGROUND

To study the influence of postoperative analgesia on morbidity and mortality after esophagectomy.

METHODS

The outcomes of 578 patients who underwent one-stage resection between 1986 and 1995 were analyzed. Patients who received either epidural morphine, patient-controlled analgesia, or continuous intravenous morphine infusion supervised by an anesthesiology-based acute pain service (group APS, n = 299) were compared with those for whom conventional intramuscular meperidine injections were used (group CON, n = 279).

RESULTS

For patients who underwent transthoracic esophagectomy, group APS (n = 226) had a lower incidence of pulmonary complications (13% versus 25%, P = 0.002), cardiovascular complications (21% versus 43%, P < 0.001), and hospital mortality (8% versus 14%, P = 0.038) when compared with group CON (n = 189). No similar difference was demonstrated in patients who underwent esophagectomy without thoracotomy. The hospital stay (days) was shorter in group APS than in group CON for both transthoracic esophagectomy (22 +/- 20 versus 30 +/- 37, P = 0.005) and nontransthoracic esophagectomy patients (19 +/- 13 versus 25 +/- 21, P = 0.029).

CONCLUSION

Adequate postoperative analgesia is associated with lower cardiopulmonary complications, lower mortality and reduced cost in patients undergoing transthoracic esophagectomy.

Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space

BACKGROUND

The management of postoperative leaks into the mediastinum or pleural cavities after esophageal surgery yields unsatisfactory results. A recently described method, drainage of the mediastinum or pleural cavity through suture line defects, has been used in our department with eight patients.

METHODS

A suction tube was advanced over an endoscopically placed guide wire into the abscess from inside the esophagus, and gentle aspiration was used to remove saliva and secretions. Intravenous antibiotics and total parenteral nutrition were also given.

RESULTS

The sepsis was rapidly controlled, and the abscess cavity progressively collapsed in all cases. Seven patients recovered and were discharged 34 to 61 days after operation; one died of concomitant complications.

CONCLUSIONS

This method seems promising for the management of intrathoracic esophageal leaks.

Stapler design and strictures at the esophagogastric anastomosis

An apparent reduction in the rate of benign anastomotic stricture after stapled esophagogastrectomy prompted us to review the results obtained with different stapling devices since 1988. We present a retrospective review of 125 consecutive patients undergoing esophageal resection for malignancy with stapled intrathoracic anastomoses. Benign anastomotic stricture was deemed present when a patient required endoscopic dilatation to treat postoperative dysphagia. We found no difference in risk factors not related to stapler size (tumor histologic characteristics, adjuvant therapy) between patients with stricture and patients without stricture. Event-free survival was compared for different stapler diameters as well as for different stapler designs. We found that staplers of smaller diameter were associated with significantly more strictures (p < 0.005). In a comparison of different designs of 25 mm stapler, the newer CDH device (Ethicon Ltd., Edinburgh, United Kingdom) was associated with a similar stricture rate to that associated with other designs (ILP [Ethicon] and EEA [Autosuture Company Division, United States Surgical Corp., Norwalk, Conn.]). For a given stapler diameter, it appears that different stapler designs have no effect on stricture rate.

Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review

PURPOSE

To summarize the most current information about the etiology, pathophysiology, clinical presentation, treatment, and outcome of esophagogastrostomy leaks following esophagectomy.

METHOD

The English language literature was searched by manual methods and MEDLINE for original articles reporting results and complications of esophagectomy.

RESULTS

Esophagogastrostomy anastomotic leaks cause considerable morbidity and mortality after esophagectomy. Their major etiologic factors are ischemia of the gastric fundus and errors in surgical technique. The clinical presentation of postoperative anastomotic leak ranges from an asymptomatic radiographic finding to a necrotizing thoracic infection. Severity of illness is largely dependent on four factors: gastric viability, the site (thorax or neck) and time of the leak, and its containment by surrounding tissues. Cervical anastomoses have a higher leak rate than thoracic anastomoses, but leaks from thoracic anastomoses are more morbid.

CONCLUSION

Leaks from thoracic anastomoses require aggressive surgical treatment. Cervical anastomotic leaks that are truly confined to the neck can usually be managed at the bedside with wound drainage and packing. However, the seriousness of cervical anastomotic leaks should not be underestimated. Some leaks from anastomoses constructed in the neck are, in reality, mediastinal leaks. Selected patients with radiologically detected asymptomatic leaks can be managed conservatively.

Role of gastrografin study in the assessment of anastomotic leaks from cervical oesophagogastric anastomosis

Gastric pull-up with cervical oesophagogastric anastomosis is a common procedure after oesophageal resection. Contrast studies are used by many surgeons for detection of anastomotic leaks but may be unnecessary. A prospective study was undertaken to compare gastrografin study and test feeding using water for detection of cervical anastomotic leaks. In 25 patients, gastrografin study showed three leaks, two of which were clinically silent and patients did not have any problems. One patient had aspiration of contrast and the study could not be completed. Two of the leaks detected clinically were missed by contrast study (one because of an incomplete study and the other was a satisfactory study). Delayed leaks occurred in two patients. All leaks healed spontaneously. A contrast study may thus be unnecessary for evaluation of a cervical oesophagogastric anastomosis and can be replaced with the simpler and safer technique of 'test feeding' using water.

Does esophagectomy cure a resectable esophageal cancer?

During the years 1978-1990, 401 patients with esophageal cancer were evaluated for curative resection. A retrospective study was undertaken to estimate the efficacy of surgery and select criteria for long-term survival. After investigation, 187 patients (47%) underwent surgery. To evaluate the long-term results, 101 curative esophageal resections classified into stage I (11 patients), II (24 patients), and III, pathological TNM (66 patients), with at least 2 years' follow-up, were considered. Esophagogastrectomy was performed in 91% of the cases and gastric transposition was achieved in 96% of the patients. The anastomoses were intrathoracic (98%) and at the apex of the right thorax for tumors of the middle third of the esophagus. Staplers were used in 76% of sutures. Postoperative hospital mortality was 5.9%. Specific morbidity included strictures 11%, esophagitis 12%, and anastomotic leak 2%. Actuarial 5-year survival was 90.9% in stage I, 52.3% in stage II, and 17.7% in stage III. The overall 5-year survival rate was 34.2%, 64.8% for the N0 patients, and decreased to 17.7% when node involvement was observed. Five- to 8-year survival is also considered. It is concluded from this study that esophagectomy is actually the appropriate treatment in patients with nonmetastatic resectable carcinoma with an overall 34.2% 5-year survival. The operation can be performed with a low morbidity and mortality rate if done in experienced centers.

Esophagogastrectomy: reoperation for complications

From 1961 to 1991, a total of 1,452 esophagectomies were performed for esophageal cancer at Memorial Sloan-Kettering Cancer Center. Of these patients, 40 (2.7%) developed complications requiring a second operation during the same hospitalization. The majority of the carcinomas were located in the midesophagus or the gastroesophageal junction. The pathologic diagnosis was squamous cell carcinoma in two-thirds of the patients. Few comorbid factors could be identified. Twenty-nine patients (72%) had a standard Ivor-Lewis resection, 5 (12%) had a transhiatal resection, 5 (12%) had a transabdominal approach, and 1 (3%) had a cervical approach only. Complications requiring reoperation were the following: respiratory failure in 13 patients, anastomotic leak in 6, bowel obstruction in 5, major bleeding in 4, wound dehiscence in 4, tracheo-esophageal fistula in 3, feeding tube malposition in 2, empyema in 1, chyle leak in 1, a positive margin in 1. Twelve of these same patients had a persistent or second complication and required a third operation. Among the 40 patients in this study, the mortality was 40%.

Endoscopic drainage of esophageal suture line leaks

Suture line leaks after esophageal or gastric surgery are associated with high morbidity and mortality rates. We report a new approach to the management of this problem, which has been used successfully in the treatment of nine patients with such leaks who were treated at or referred to our unit. The suture line defect is first visualized by endoscopy, after which a sump nasogastric tube is advanced down the esophagus and out through the defect into the abscess cavity. The tubes are irrigated intermittently to achieve patency and maintained with continuous suction. Separate pleural or subphrenic collections are drained by conventional techniques. After the injection of contrast down the tube, serial radiologic studies are used to monitor progress and to guide the slow withdrawal of the tube as the cavity collapses.

Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition

Following esophagectomy, restoration of swallowing by gastric tube interposition with cervical esophagogastric anastomosis reduces morbidity and mortality associated with intrathoracic anastomoses at the expense of an increased incidence of both anastomotic leak and stricture formation. A retrospective study of 165 patients with either squamous cell carcinoma or adenocarcinoma of the distal esophagus or gastric cardia undergoing esophagogastrectomy with gastric tube interposition and cervical anastomosis at Vancouver, British Columbia, or London, Ontario, was undertaken. Forced-entry multiple logistic regression analysis of factors believed to influence anastomotic outcome was performed. Anastomotic leak occurred in 17% of patients; statistically significant correlation with low preoperative serum albumin (p = 0.005), running suture technique (p = 0.029), high intraoperative blood loss (p = 0.038), and the occurrence of postoperative delayed gastric emptying (p = 0.045) was found. Anastomotic strictures occurred in 31% of patients; a statistically significant correlation was found with preceding anastomotic leak (p = 0.001) and intraoperative blood loss (p = 0.042). Factors including preoperative radiotherapy and diabetes mellitus were not found to be significant.

Postoperative analgesia for oesophageal surgery: a comparison of three analgesic regimens

Sixty-four patients undergoing oesophageal surgery were randomly allocated to receive either a continuous lumbar epidural infusion of morphine or fentanyl, or, intramuscular morphine for postoperative analgesia. There was no statistical difference in analgesic requirements between the patients who underwent a thoracotomy for their procedure (n = 50) and those who did not (n = 14), as assessed by the total dose of opioid administered, visual analogue scale (VAS) and pain score (PS) comparison. However, by these criteria, epidural morphine infusion provided the most satisfactory analgesia (P less than 0.05). Despite the variable quality of analgesia achieved with the three regimens, the postoperative lung function tests were similar for all groups, and we conclude that routine lung function tests are not an appropriate method of comparing analgesic efficacy. Prophylactic administration of loratadine to 15% of our patients was not shown to be effective in diminishing the incidence of pruritus.

A comparison of two-lung high frequency positive pressure ventilation and one-lung ventilation plus 5 cm H2O non-ventilated lung CPAP, in patients undergoing anaesthesia for oesophagectomy

A randomised prospective controlled study was conducted during a one-year period on patients scheduled for oesophagectomy via a right thoracotomy approach. Twenty-two patients received one-lung ventilation (OLV group) and twenty patients received high frequency positive pressure ventilation (HFPPV group). Episodic hypoxaemia (SaO2 less than 90% for greater than 30 seconds, FiO2 1.0) occurred in eleven patients in the OLV group and six patients in the HFPPV group. No patient in the HFPPV group had a severe desaturation episode (SaO2 less than 80%, FiO2 1.0) compared with nine patients in the OLV group (P less than 0.05). The mean peak inspiratory pressure and average mean airway pressure were significantly lower in the HFPPV group 28.8 (SD 7.7) and 7.2 (SD 2.4) cm H2O respectively, compared with the OLV group, 40.0 (SD 9.9) and 11.9 (SD 4.9) cm H2O (P less than 0.05). Two-lung high frequency positive pressure ventilation has some advantages over one-lung ventilation during the thoracotomy phase of oesophagectomy because it is easy to administer, does not significantly compromise the surgical exposure and is associated with fewer severe undesirable physiological disturbances.

Safety of EEA staplers for anastomosis between upper esophagus and the gastric tube

The EEA stapling devices used for intrathoracic anastomosis between the upper esophagus and the gastric tube in patients with carcinoma of the thoracic esophagus were evaluated, and the results were compared with those of an antesternally reconstructed esophagus. These approaches were both used by the same surgical team. An intrathoracic anastomosis using the EEA stapler was made in 53 patients with carcinoma of the thoracic esophagus. Minor anastomotic leakage occurred in five patients (9.4%). Good results were obtained with total parenteral nutrition for 2 weeks. Intrathoracic anastomotic complications were never fatal. Among another 106 patients with antesternally reconstructed esophagus, with the EEA stapler there were 28 patients with anastomotic leakage (26.4%) and two operative mortalities (1.9%). Intrathoracic anastomosis with the EEA stapler is recommended because it is secure and the operative procedure is simple and time-saving. For successful use of the instrument, proper technical procedures must be followed.