Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis

Risk factors for and treatment of anastomotic strictures after Ivor Lewis esophagectomy

INTRODUCTION

Anastomotic strictures following esophagectomy occur frequently and impact on nutrition and quality of life. Although strictures are often attributed to ischemia and anastomotic leaks, the role of anastomosis size and pyloroplasty is not well evaluated. Our study aims to assess the rate of and risk factors for anastomotic stricture following esophagectomy, and the impact of treatment with regular endoscopic balloon dilatations.

METHODS

Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, surgical outcomes and anastomotic strictures were recorded. Relationship of anastomotic strictures with circular stapler size, pyloroplasty and anastomotic leak was analyzed. Treatment of strictures with endoscopic balloon dilatation was reviewed and percentage weight loss at 1 year was evaluated.

RESULTS

Anastomotic strictures occurred in 17.4% of patients. Patient demographics between those with and without stricture were similar. Stricture rate was similar in patients with or without pyloroplasty (13.9% vs 21.7%, respectively, p = 0.14) and in those with or without an anastomotic leak (25.0% vs 16.6%, respectively, p = 0.345). Stricture risk increased with smaller sized stapler (25 mm = 33.3%, 28 mm = 15.3%, 31 mm = 4.8%; p = 0.027). The median number of dilatations required to fully treat strictures was 2 (IQR: 1-3). The median length of time from surgery to first dilatation was 2.9 months (IQR: 2.0-4.7) and to last dilatation was 6.1 months (IQR: 4.8-10.0). Median maximum dilatation diameter was 20 mm (IQR: 18.0-20.0). There were no complications from dilatations. Percentage weight loss at 1 year in patients with strictures was similar to those without strictures (8.7% vs 11.1%, respectively, p = 0.090).

CONCLUSIONS

Post-esophagectomy anastomotic strictures are common and not necessarily related to anastomotic leaks or absence of pyloroplasty. Smaller anastomosis size was strongly linked with stricture formation. A driven approach with regular endoscopic balloon dilation is safe and effective in treating these strictures with no excess weight loss at 1 year once treated.

Risk factors for esophageal anastomotic stricture after esophagectomy: a meta-analysis

BACKGROUND

The aim of this study was to assess the risk factors for anastomotic stricture in esophageal cancer patients undergoing esophagectomy. Esophageal anastomotic stricture is the most common long-term complication for esophagectomy. The risk factors for esophageal anastomotic stricture still remain controversial.

METHODS

MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for esophageal anastomotic stricture after esophagectomy. A meta-analysis was conducted to investigate the impact of various risk factors on esophageal anastomotic stricture. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels.

RESULTS

This review included 14 studies evaluating 5987 patients.The meta-analysis found that anastomotic leakage (odds ratio [OR]: 2.75; 95% confidence interval[CI]:2.16-3.49), cardiovascular disease [OR:1.62; 95% CI: 1.22-2.16],diabete [OR: 1.62; 95% CI: 1.20-2.19] may be risk factors for esophageal anastomotic stricture.There were no association between neoadjuvant therapy [OR: 0.78; 95% CI:0.62-0.97], wide gastric conduit [OR:0.98; 95% CI: 0.37-2.56],mechanical anastomosis [OR: 0.84; 95% CI:0.47-1.48],colonic interposition[OR:0.20; 95% CI: 0.12-0.35],and transhiatal approach[OR:1.16; 95% CI:0.81-1.64],with the risk of esophageal anastomotic stricture.

CONCLUSIONS

This meta-analysis provides some evidence that anastomotic leakage,cardiovascular disease and diabete may be associated with higher rates of esophageal anastomotic stricture.Knowledge about those risk factors may influence treatment and procedure-related decisions,and possibly reduce the anastomotic stricture rate.

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis

BACKGROUND

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy.

METHODS

A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test.

RESULTS

A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation.

CONCLUSION

Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Advantages of Totally Stapled Collard Over Circular Stapled Technique for Cervical Esophagectomy Anastomosis

BACKGROUND

The quality of life between the totally stapled Collard (TSC) and circular stapled (CS) techniques from the patient's perspective has not been assessed. This longitudinal patient-reported outcome and objective data assessment study aimed to compare the effects of TSC vs CS for cervical anastomosis with minimally invasive esophagectomy (MIE) on the quality of life.

METHODS

This single-center, retrospective study included patients with esophageal cancer who underwent MIE and cervical anastomosis between April 2019 and February 2021; of whom, 105 and 216 patients received TSC and CS anastomosis, respectively. The objective metrics were evaluated based on postoperative complications. Patient-reported outcomes instruments using the European Organization for Research and Treatment of Cancer modules were assessed preoperatively. The Quality of Life Questionnaire (QLQ) Core 30 and the QLQ-Oesophagus Module 18 assessed the quality of life. Mixed-effects models examined changes in questionnaire scores.

RESULTS

The stenosis rate in the TSC group was significantly lower than that in the CS group. There were no significant differences in other postoperative complications between the groups. In the QLQ Core 30 scale, the TSC group had better emotional function, less fatigue, less appetite loss, and better function than the CS group, with significant differences in different time points between the groups. QLQ-Oesophagus Module 18 revealed that the TSC group had significantly less appetite loss, dysphagia, dry mouth, pain, and obstruction, and better eating and speech than the CS group.

CONCLUSIONS

TSC has significant advantages over the CS technique in lowering postoperative symptom burden and improving quality of life for cervical anastomosis on patient-reported outcomes.

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Anastomotic Stricture After Minimally Invasive Esophagectomy

BACKGROUND

Despite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America.

METHODS

We performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models.

RESULTS

Of 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001).

CONCLUSIONS

After controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Postoperative complications analysis of circular stapled versus linear stapled anastomosis for patients undergoing esophagectomy: a systematic review and meta-analysis

BACKGROUND

The choice of anastomosis technique after esophagectomy is closely associated with the postoperative complications. Whether circular stapled or linear stapled anastomosis is the optimal technique has not been established. Therefore, we conducted this meta-analysis to show the latest and most comprehensive published assessment of circular stapled anastomosis in comparison with linear stapled anastomosis in postoperative complications.

METHODS

Databases (PubMed, Embase, Web of science, Cochrane Library) were searched for all randomized controlled trials and comparative studies comparing circular stapled anastomosis with linear stapled anastomosis after esophagectomy. The odd ratio and mean difference with 95% confidence interval were calculated. We used the Higgins I² statistics to assess the statistical heterogeneity between studies. Review manager (version 5.4) software was used in this analysis.

RESULTS

Sixteen studies with 2322 patients were included in our study. The study demonstrated that the use of linear stapled technique after esophagectomy could reduce the risk of both anastomotic leakage (P = 0.0003) and stricture (P < 0.00001) compared with circular stapled technique. Stratification by anastomotic site showed that no matter what kind of anastomotic site (cervical or thoracic anastomosis) was used, linear stapled anastomosis could effectively reduce the anastomotic stricture in comparison with circular stapled anastomosis. Moreover, linear stapled anastomosis could decrease the risk of thoracic anastomotic leakage. There were no significant differences between circle stapled anastomosis and linear stapled anastomosis in reflux esophagitis (P = 0.17), pneumonia (P = 0.91), operation time (P = 0.41) and hospital stay (P = 0.38).

CONCLUSIONS

The study suggested that linear stapled anastomosis could be considered to be an optimal treatment associated with a reduced risk of anastomotic leakage and stricture in comparison with circular stapled anastomosis.

Endoscopic Stricturotomy in the Treatment of Refractory Esophageal Anastomotic Strictures

Refractory esophageal anastomotic strictures are a frequent challenge for endoscopists. The current therapeutic strategies have a significant restenosis rate, and patients usually require repeated sessions and suffer from dysphagia. Therefore, we propose a modified method named endoscopic stricturotomy (ES) to treat refractory esophageal anastomotic strictures. The patients diagnosed with refractory esophageal anastomotic strictures were enrolled in the cohort study. The method of ES is to incise longitudinally only a single strip of mucosa at the most prominent part of fibrotic scar and completely cut fibrotic tissues under the mucosa. The primary endpoint was the times of endoscopic therapies. The secondary endpoints include the effective rate, success rate, recurrence rate, endoscopic treatment intervals, complications, length of hospital stay, and surgical cost. The patients were followed up for at least 6 months after ES. The median anastomotic diameter of 12 patients was 2 mm (range 1 to 4 mm). Dysphagia were dramatically relieved in all patients (dysphagia grade from 3 to 1), the effective rate was 100%. During the follow-up, the 12 patients received a total number of 38 sessions, and the median number of ES sessions was 2.5 (1-9), and the success rate were 83%. Nine of the patients (75%) developed restenosis during follow-up, with a median interval of 38 days (15-315 days). No complications occurred during treatment and following up. The median hospital stay was 2 days (2-2.9 days), and the hospitalization costs was 3887.4 RMB (3632.8 RMB-4116.9 RMB). ES seems to be an effective treatment modality for refractory esophageal anastomotic strictures. Large prospective clinical trials are needed to confirm its utility and its place in the management of refractory esophageal anastomotic strictures (ChiCTR2000032997).

Impact of pre-diabetes, well-controlled diabetes, and poorly controlled diabetes on anastomotic leakage after esophagectomy for esophageal cancer: a two-center retrospective cohort study of 1901 patients

BACKGROUND

Diabetes is known to be associated with anastomotic leakage (AL) after esophagectomy. However, it is unknown whether well-controlled diabetes is also associated with AL.

METHODS

We conducted a two-center retrospective cohort database study of patients who underwent oncological esophagectomy (2011-2019). Patients were divided into four groups: normoglycemia, pre-diabetes, well-controlled diabetes (hemoglobin A1c [HbA1c] < 7.0%), and poorly controlled diabetes (HbA1c ≥ 7.0%). The occurrence of AL and length of stay were compared between groups using multivariable analyses. The relationship between categorical HbA1c levels and AL was also investigated in patients stratified by diabetes medication before admission.

RESULTS

Among 1901 patients, 1114 (58.6%) had normoglycemia, 480 (25.2%) had pre-diabetes, 180 (9.5%) had well-controlled diabetes, and 127 (6.7%) had poorly controlled diabetes. AL occurred in 279 (14.7%) patients. Compared with normoglycemia, AL was significantly associated with both well-controlled diabetes (odds ratio 1.83, 95% confidence interval [CI] 1.22-2.74) and poorly controlled diabetes (odds ratio 1.95, 95% CI 1.23-3.09), but not with pre-diabetes. Preoperative HbA1c levels showed a J-shaped association with AL in patients without diabetes medication, but no association in patients with diabetes medication. Compared with normoglycemia, only poorly controlled diabetes was significantly associated with longer hospital stay after surgery, especially in patients with operative morbidity (unstandardized coefficient 14.9 days, 95% CI 5.6-24.1).

CONCLUSIONS

Diabetes was associated with AL after esophagectomy even in well-controlled patients, but pre-diabetes was not associated with AL. Operative morbidity, including AL, in poorly controlled diabetes resulted in prolonged hospital stays compared with normoglycemia.

Totally mechanical Collard versus circular stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy

BACKGROUND

Previous studies have proposed that the totally mechanical Collard (TMC) method may reduce anastomotic leakage and stricture. This study aimed to compare the TMC method and the circular stapled (CS) method for cervical anastomosis after minimally invasive esophagectomy (MIE) for esophageal cancer.

METHODS

From May 2017 to September 2020, 308 patients (165 in the CS group and 143 in the TMC group) were included in this study. The primary endpoints were anastomotic leakage and anastomotic stricture within 12 months. Propensity score matching was used to control potential selection bias.

RESULTS

Anastomotic leak, anastomotic stricture, and refractory stricture (≥ 3 dilations) occurred in 30 (9.7%), 28 (9.1%), and 18 (5.8%) patients, respectively. The rate of anastomotic leak was similar in the CS and TMC methods (9.7 vs. 9.8%; P = 0.978), but anastomotic stricture (3.5 vs. 13.9%; P = 0.001) and refractory stricture (2.8 vs. 9.1%, P = 0.022) occurred less frequently in the TMC method. Propensity score matching yielded 128 patient pairs and confirmed these results. Multivariable analyses found that CS method, anastomotic leakage, and diabetes were independent predictors for both anastomotic stricture and refractory stricture. Subgroup analysis revealed that for patients with anastomotic leakage, the postoperative hospital stay in the TMC group was significantly longer than that in the CS group.

CONCLUSION

In cervical anastomosis after MIE, the TMC method is superior to the CS method regarding anastomotic stricture and refractory stricture formation. However, compared to the CS method, the TMC method cannot lower the probability of anastomotic leakage, and anastomotic leakage with the TMC method requires a longer healing time.

Which Anastomotic Techniques Is the Best Choice for Cervical Esophagogastric Anastomosis in Esophagectomy? A Bayesian Network Meta-Analysis

INTRODUCTION

The optimal choice of anastomotic techniques for cervical esophagogastric anastomosis in esophagectomy remains unclear.

METHODS

An electronic literature search of PubMed, Embase, and Web of Science (data up to April 2022) was conducted and screened to compare hand sewn (HS), circular stapling (CS), side-to-side linear stapling (LS), and triangulating stapling (TS) for cervical esophagogastric anastomosis. Anastomotic leak, pulmonary complications, anastomotic stricture, and reflux esophagitis of the 4 anastomotic techniques were evaluated using a Bayesian network meta-analysis by R.

RESULT

Twenty-nine studies were ultimately included, with a total of 5,020 patients from 9 randomized controlled trials, 7 prospect cohort studies, and 13 retrospective case-control studies in the meta-analysis. The present study demonstrates that the incidence of anastomotic leakage is lower in TS than HS and CS (TS vs. HS: odds ratio (OR) = 0.32, 95% CI: 0.1 to 0.9; TS vs. CS: OR = 0.37, 95% CI: 0.13 to 1.0), and the incidence of anastomotic stricture is lower in TS than in HS and CS (TS vs. HS: OR = 0.32, 95% CI: 0.11 to 0.86; TS vs. CS: OR = 0.23, 95% CI: 0.08 to 0.58). TS ranks best in terms of anastomotic leakage, pulmonary complication, anastomotic stricture, and reflux esophagitis.

CONCLUSION

TS for cervical esophagogastric anastomosis of esophagectomy had a lower incidence of anastomotic leakage and stricture. TS should be preferentially recommended. Large-scale RCTs will be needed to provide more evidence in future studies.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer

BACKGROUND

Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS).

METHODS

We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery.

RESULTS

Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001).

CONCLUSIONS

The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Identifying a core symptom set triggering radiological and endoscopic investigations for suspected recurrent esophago-gastric cancer: a modified Delphi consensus process

BACKGROUND

There is currently a lack of evidence-based guidelines regarding surveillance for recurrence after esophageal and gastric (OG) cancer surgical resection, and which symptoms should prompt endoscopic or radiological investigations for recurrence. The aim of this study was to develop a core symptom set using a modified Delphi consensus process that should guide clinicians to carry out investigations to look for suspected recurrent OG cancer in previously asymptomatic patients.

METHODS

A web-based survey of 42 questions was sent to surgeons performing OG cancer resections at high volume centers. The first section evaluated the structure of follow-up and the second, determinants of follow-up. Two rounds of a modified Delphi consensus process and a further consensus workshop were used to determine symptoms warranting further investigations. Symptoms with a 75% consensus agreement as suggestive of recurrent cancer were included in the core symptom set.

RESULTS

27 surgeons completed the questionnaires. A total of 70.3% of centers reported standardized surveillance protocols, whereas 3.7% of surgeons did not undertake any surveillance in asymptomatic patients after OG cancer resection. In asymptomatic patients, 40.1% and 25.9% of centers performed routine imaging and endoscopy, respectively. The core set that reached consensus, consisted of eight symptoms that warranted further investigations included; dysphagia to solid food, dysphagia to liquids, vomiting, abdominal pain, chest pain, regurgitation of foods, unexpected weight loss and progressive hoarseness of voice.

CONCLUSION

There is global variation in monitoring patients after OG cancer resection. Eight symptoms were identified by the consensus process as important in prompting radiological or endoscopic investigation for suspected recurrent malignancy. Further randomized controlled trials are necessary to link surveillance strategies to survival outcomes and evaluate prognostic value.

Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer

Simple Summary

Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments.

Abstract

Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.

Mucosal Congestion on the First Day Following Endoscopy Predicts Anastomotic Stricture After Esophagectomy

BACKGROUND

Anastomotic stricture is a relatively common postoperative complication after esophagectomy. Previous studies have indicated that impaired perioperative blood perfusion at the anastomosis is associated with the occurrence of stricture. Therefore, we analyzed the association between endoscopically assessed blood perfusion during the early postoperative period and anastomotic stricture.

METHODS

This retrospective study evaluated patients who underwent esophagectomy at Tokyo Medical and Dental University between 2010 and 2015. The patients had undergone nasal endoscopy on the 1st and 8th postoperative days. The findings were used to evaluate blood perfusion at the anastomosis and gastric tube, which was classified based on mucosal color as ischemia (white) or congestion (blue or black). Univariate and multivariable logistic regression analyses were performed to identify risk factors for anastomotic stricture.

RESULTS

The study included 197 patients and anastomotic stricture was observed in 60 patients (30.4%). The multivariable analysis revealed that postoperative gastric tube congestion was a risk factor for stricture (odds ratio [OR]: 6.440, 95% confidence interval [CI]: 2.660-15.600; p < 0.001). Lower risks of anastomotic stricture were associated with pathological stage III-IV disease (OR: 0.325, 95% CI: 0.161-0.656; p = 0.002).

CONCLUSION

This study revealed that endoscopically detected congestion at the anastomosis on the first postoperative day was a risk factor for anastomotic stricture.

Anastomotic stricture after Ivor Lewis esophagectomy: An evaluation of incidence, risk factors, and treatment

BACKGROUND

Anastomotic stricture is a recognized complication after esophagectomy. It can impact the patient's quality of life and may require recurrent dilatations. Thus, the aim of this study was to evaluate the frequency of strictures, contributing factors, and long-term outcomes of management in patients undergoing esophagectomy with thoracic anastomosis using a standardized circular stapled technique.

METHODS

All patients who underwent a 2-stage transthoracic esophagectomy with curative intent between January 2010 and December 2019 at NOGU, Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded.

RESULTS

Overall, 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, 2, and 3 dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients, respectively. Multivariable analysis identified the occurrence of an anastomotic leak (odds ratio 1.906, 95% confidence interval 1.088-3.341, P = .024) and circular staple size <28 mm (odds ratio 1.462, 95% confidence interval 1.033-2.070, P = .032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs 4.7%, odds ratio 3.089, 95% confidence interval 1.349-7.077, P = .008).

CONCLUSION

This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures.

Circular stapled technique versus modified Collard technique for cervical esophagogastric anastomosis after esophagectomy: A randomized controlled trial

OBJECTIVE

This study was performed to investigate the efficacy of the modified Collard (MC) technique for reducing anastomotic stricture after esophagectomy compared with the circular stapled (CS) technique.

SUMMARY BACKGROUND DATA

The currently available techniques of anastomosis after esophagectomy are associated with a significant risk of anastomotic complications. However, the optimal anastomotic technique after esophagectomy has not yet been established.

METHODS

We randomly allocated patients to either the CS group or the MC group. The primary endpoint was the incidence of anastomotic stricture. The secondary endpoints included the incidence of postoperative complications (including anastomotic leakage) and quality of life (QOL). All anastomoses were performed after indocyanine green evaluation for objective homogenization of blood flow to the gastric conduit between the two techniques.

RESULTS

Among 100 randomized patients (CS group, n = 50; MC group, n = 50), anastomotic strictures were observed in 18 (42%) patients in the CS group and in no patients in the MC group. There were no significant between-group differences in anastomotic leakage (CS group, 7% vs. MC group, 8%; p = 0.94). QOL domains of dysphagia and choking when swallowing at 3 months after surgery were significantly better in the MC group than in the CS group.

CONCLUSIONS

The MC technique reduces the incidence of anastomotic stricture and improves postoperative QOL. Furthermore, the incidence of anastomotic leakage is comparable between the two techniques based on accurate comparison under objective homogenization of the gastric conduit condition.

Anastomosis behind the sternoclavicular joint is associated with increased incidence of anastomotic stenosis in retrosternal reconstruction with a gastric conduit after esophagectomy

Anastomotic stenosis after esophagectomy is a major cause of long-term morbidity because it leads to poor dietary intake and malnutrition that markedly reduces the quality of life. The aim of this study was to test the hypothesis that anastomosis behind the sternoclavicular (SC) joint in retrosternal reconstruction is associated with an increased risk of anastomotic stenosis compared with anastomosis deviated from the joint. Among 226 patients who underwent esophagectomy for esophageal cancer between April 2010 and March 2019, we selected 114 patients who underwent retrosternal reconstruction using a gastric conduit for this study. They were classified into two groups according to the location of the anastomosis as determined by axial sections on postoperative computed tomography scans: anastomosis located behind the SC joint (Group B; n = 71) and anastomosis deviated from the joint (Group D; n = 43). The primary endpoint was the difference in the incidence of anastomotic stenosis between the two groups. Whether the occurrence of anastomotic leak affected the likelihood of anastomotic stenosis was also investigated. The incidence of anastomotic stenosis was significantly higher in Group B than in Group D (71.8% [n = 51] vs. 18.6% [n = 8]; P < 0.0001). The incidence of stenosis in patients who developed an anastomotic leak was significantly higher in Group B than in Group D (88.0% vs. 41.7%; P = 0.0057), although the findings were similar in patients who did not develop anastomotic leak (63.0% and 9.7%, respectively; P < 0.0001). We conclude that anastomosis located behind the SC joint in retrosternal reconstruction with a gastric conduit after esophagectomy is associated with an increased risk of anastomotic stenosis regardless of the development of anastomotic leak.

The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia

Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.

Totally Mechanical Collard Technique for Cervical Esophagogastric Anastomosis Reduces Stricture Formation Compared with Circular Stapled Anastomosis

BACKGROUND

The optimal technique for cervical esophagogastric anastomosis in esophagectomy has not yet been established. Using circular stapled (CS) technique effectively reduces the incidence of anastomotic leakage and shortens the operating time; however, anastomotic stricture has been reported to be more common. The present study was performed to compare the clinical outcomes of the recently developed totally mechanical Collard (TMC) and CS anastomosis.

METHODS

We retrospectively reviewed consecutive esophageal cancer cases who are undergoing transthoracic extended esophagectomy with gastric conduit reconstruction using cervical CS or TMC anastomosis from December 2013 to December 2016. Propensity score matching and multivariate regression were used to adjust for differences in baseline characteristics.

RESULTS

Among 313 patients, 93 underwent CS anastomosis and 220 underwent TMC anastomosis. Stricture formation occurred in 59 patients (18.8%), significantly more often with the CS than TMC anastomosis (30.1% vs. 14.1%, p = 0.001). No significant differences were observed in the refractory stricture rate (9.7% vs. 5.0%, p = 0.134) or the anastomotic leakage rate (11.8% vs. 10.9%, p = 0.845) between the two groups. The propensity score matching cohort study including 86 pairs of patients confirmed a significantly lower stricture formation rate with the TMC than CS technique (27.9% vs. 14.0%, p = 0.038). In the multivariable analysis, anastomotic leakage, the CS technique, and a body mass index of ≥25 mg/m² were independently associated with a risk of stricture formation.

CONCLUSION

TMC technique contributed to a reduced rate of stricture formation compared with CS technique in cervical esophagogastric anastomosis.

Initial management of esophageal anastomotic strictures after transhiatal esophagectomy for esophageal cancer with dilations up to 18-20 mm

INTRODUCTION

Esophageal anastomotic stricture is a well-known complication after transhiatal esophagectomy (THE), but there is limited data regarding the initial management and subsequent outcomes after stricture dilation. There is concern that dilating to larger diameters upon the initial encounter, specifically with high-grade strictures, will lead to increased risk for complications. We therefore reviewed one surgeon's experience with esophageal dilations after THE and provided data and treatment recommendations based upon these findings.

METHODS

A retrospective review of patients who underwent esophageal dilations ≥ 18 mm up to 20 mm after THE between 2006 and 2019 at our institution was performed. Patient demographics were n = 97, age = 70, 81 males.

RESULTS

For all cases, the mean location, length, diameter of the stricture, and number of days from surgery and initial dilation were 20 cm, 1.9 cm, 6.7 mm, and 106 days, respectively. Most dilations (79%) occurred within 2 weeks to 3 months from surgery. 29.9% were dilated up to 18 mm, 10.3% were dilated up to 19 mm, and 59.8% were dilated up to 20 mm upon initial dilation. Even 1-mm-diameter lesions could be safely dilated upon 18-20 mm. In this study group there were no complications after endoscopic dilation that required hospitalization or further surgical or endoscopic interventions.

CONCLUSION

These results suggest that early aggressive endoscopic management of esophageal anastomotic strictures after THE can be safely performed.

Esophageal stent migration to the transverse colon, entrapped within a hiatal hernia status post esophagectomy

Self-expandable metal stents are used in both benign and malignant esophageal conditions for the treatment of strictures, leaks and perforations. With this intervention, the most common complication is stent migration. Those in whom migration occurs are subject to additional procedures with significant risk. We present a unique case of stent migration in a 61-year-old male who underwent transhiatal esophagectomy secondary to esophageal adenocarcinoma. Postoperatively, two covered stents were applied to relieve anastomotic stricture and proximal esophageal occluding web. Several months thereafter, the initial stent was found to have migrated to the transverse colon subsequently entrapped in a hiatal hernia defect. Fortunately, the migrated stent was amenable to colonoscopic retrieval. As endoscopic stent use grows, it is important to recognize that covered stents may migrate through anatomic narrowing’s such as pylorus and ileocecal valve, but can also become entrapped in nonanatomic narrowing’s such as a hernia leading to further complications.

Risk factors and therapeutic measures for postoperative complications associated with esophagectomy

Esophageal cancer is one of the most common cancers associated with the high mortality rate. Timely diagnosis and treatment are important to manage the disease and prevent comorbidities. Surgical resection of the tumor and lymph nodes is usually practiced either with or without chemo or chemoradiotherapy. Despite advancements in surgical methods and skills, complex nature of the esophagus and invasiveness of the surgery can lead to serious complications in these patients. In order to predict postoperative outcomes, preoperative examination of the patients, in addition to risk factors, should be conducted. Conclusion: Lastly, early detection of adverse postoperative events may help faster recovery, reduce hospital stay and prevent other morbidities.

Unmet supportive care needs and associated factors among Chinese discharged patients with esophageal cancer after esophagectomy: A cross-sectional study

PURPOSE

After esophagectomy, patients experience a series of problems that severely affect their quality of life. Understanding their unmet needs could help medical staff provide better supportive care. The aim of this study was to investigate the supportive care needs of discharged patients with esophageal cancer after esophagectomy and explore the factors associated with these needs.

METHOD

A total of 167 discharged patients with esophageal cancer after esophagectomy were recruited from a University Cancer Center in China and investigated using a self-designed demographic and clinical characteristics questionnaire, the 34-item Supportive Care Needs Survey, and the M.D. Anderson Symptom Inventory Gastrointestinal Cancer Module.

RESULTS

Approximately 95.2% of the patients had ≥1 unmet need(s). The overall level of supportive care needs of patients after esophagectomy was mild to medium. Most of the top 10 moderate-to-severe unmet needs were identified in the health and information domains. Age (β = -0.157, p = 0.011), dysphagia (β = -0.178, p = 0.005), recurrence (β = 0.175, p = 0.005), time since diagnosis (β = -0.150, p = 0.018), and symptom interference (β = 0.488, p < 0.001) were significantly associated with supportive care needs.

CONCLUSIONS

Discharged patients with esophageal cancer after esophagectomy had a wide range of unmet supportive care needs. It is essential to combine the associated factors to accurately evaluate patient needs. We should pay more attention to propose comprehensive measures for these patients and provide more individualized supportive care during the lengthy recovery period.

Meta-Analysis of Two Different Methods for Cervical Esophagogastric Anastomosis: Triangulating Versus Circular Stapling

Background: The standard treatment for esophageal carcinoma is extensive resection of the tumor and esophagogastric anastomosis despite the high incidence of related anastomotic complications, such as stricture and leakage. Thus, the choice of the cervical esophagogastric anastomotic method-triangulating stapling (TS) versus circular stapling (CS)-is a critical decision for the surgeon. Aim: To compare the incidence of major adverse outcomes between TS and CS in patients with resectable thoracic esophageal cancer. Methods: For this meta-analysis, PubMed, Embase, Wiley Online Library, Google Scholar, Wanfang, and China National Knowledge Infrastructure databases were searched for subject-relevant studies by using a rigorous study protocol established according to the recommendations of the Cochrane Handbook. Anastomotic leakage, anastomotic stricture, and postoperative pulmonary complications were the primary endpoints used for comparison. Relative risk (RR) with 95% confidence intervals (CI) were calculated to assess the strength of association. Results: Six studies were selected by our inclusion/exclusion criteria and represented a total of 739 patients in our meta-analysis of TS (n = 376) versus CS (n = 363). The TS group showed a lower incidence of anastomotic stricture (RR: 0.23 [95% CI: 0.08-0.63]; P = .004) and pulmonary complications (RR: 0.57 [95% CI: 0.37-0.87]; P = .01). However, the incidence of anastomotic leakage was similar for the two groups (RR: 0.66 [95% CI: 0.41-1.09]; P = .1). Subgroup analysis of four studies in which the surgical methods were minimally invasive demonstrated the TS group to have a lower incidence of lung complications (RR: 0.55 [95% CI: 0.35-0.87]; P = .01), anastomotic leakage (RR: 0.36 [95% CI: 0.18-0.74]; P = .005), and anastomotic stricture (RR: 0.23 [95% CI: 0.05-0.98]; P = .05). Conclusion: The TS method for cervical esophagogastric anastomosis after esophagectomy had a lower incidence of anastomotic stricture and postoperative lung complications.

T-shaped linear-stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy: a pilot study

BACKGROUND

Minimally invasive esophagectomy (MIE) has become a good option in the surgical treatment of esophageal cancer. Cervical esophagogastric anastomoses (CEGA) are widely used during esophagectomy. However, CEGA are related with a higher incidence of anastomotic complications. In the present study, a new procedure of T-shaped linear-stapled cervical esophagogastric anastomosis was used during MIE and the short-term outcomes are presented.

METHODS

From May 2014 to December 2018, 32 consecutive patients with esophageal cancer who underwent total MIE followed by T-shaped linear-stapled cervical esophagogastric anastomosis were included. Postoperative outcomes were analyzed.

RESULTS

Fifteen men and 17 women were included this pilot study. The histology of all cases was squamous cell carcinoma. Mean operation time of T-shaped linear-stapled cervical esophagogastric anastomosis was 17.6 minutes. There were no early or late mortalities. A minor cervical anastomotic leakage occurred in 1 patient. No complications of anastomotic stenosis occurred in this study.

CONCLUSION

The T-shaped linear-stapled cervical esophagogastric anastomosis is efficient, reliable, easy to perform, and associated with lower postoperative complication rate.

21- versus 25-mm Circular Staplers for Cervical Anastomosis: A Propensity-Matched Study

BACKGROUND

The use of a small circular stapler (CS) has been reported to increase the incidence of benign anastomotic stricture of the intrathoracic anastomosis after esophagectomy, but no study has evaluated the effects of the CS size on cervical esophagogastrostomy. Based on a propensity-matched comparison, the present study was designed to determine whether the perioperative outcomes differ between 21- and 25-mm CSs after minimally invasive esophagectomy with cervical anastomosis.

METHODS

From January 2015 to December 2017, 162 patients who received CS cervical esophagogastric anastomosis after minimally invasive esophagectomy for esophageal cancer were identified from our surgical database. A propensity-matched analysis was used to compare the outcomes between the 21- and 25-mm CS groups. Endpoints included anastomotic leak, dysphagia, reflux, stricture, and other major postoperative outcomes within 6 postoperative months.

RESULTS

There were 69 and 93 patients in the 21- and 25-mm CS groups, respectively. Propensity matching produced 57 patients in each group. The two groups were not remarkably different in benign anastomotic stricture rate (P = 0.528). All strictures were resolved by balloon dilatation. The 25-mm CS group had a significantly longer operative time in cervical anastomosis than the 21-mm group (P = 0.005). No statistically significant differences in anastomotic leak rates, dysphagia scores, reflux scores, or other postoperative complications were noted between the two groups.

CONCLUSIONS

The use of a 21-mm CS in minimally invasive esophagectomy with cervical esophagogastric anastomosis did not result in greater anastomotic stricture as compared with a 25-mm CS. The 21-mm CS was associated with a significantly shorter operative time.

Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy

BACKGROUND

Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler.

METHODS

Perioperative data were extracted from a contemporaneously collected database of all consecutive esophagectomies for cancer with intrathoracic anastomoses performed in the Trent Oesophago-Gastric Unit between January 2015 and April 2018. Anastomotic techniques: circular stapled versus semi-mechanical, were evaluated and outcomes were compared. The primary outcome was anastomotic leak rate. Secondary outcomes included anastomotic stricture, overall complication rates, length of stay (LOS) and 30 day all-cause mortality.

RESULTS

One hundred and fifty-nine consecutive esophagectomies with intrathoracic anastomosis were performed during the study period. There were no significant differences between the two groups in terms of age, American Society of Anaesthesiologists score, Charlson comorbidity index and neoadjuvant therapies received. Circular stapled anastomoses were performed in 85 patients, while 74 patients received a semi-mechanical anastomosis. Clavien-Dindo complications II or more were higher in the circular stapled group (p = 0.02). There were 16 (10%) anastomotic leaks overall, three (4%) in semi-mechanical group versus 13 (15%) in the circular stapled group (p < 0.019). There was no statistically significant difference between the two groups in terms of LOS, 30-day mortality or the need for endoscopic dilatation of the anastomosis at 3 months follow-up.

CONCLUSION

The move from a circular stapled to a semi-mechanical intrathoracic anastomosis has been associated with a reduced postoperative anastomotic leak rate following esophagectomy for esophageal cancer.

Minimally invasive surgical management of spontaneous esophageal perforation (Boerhaave's syndrome)

BACKGROUND

Spontaneous esophageal perforation (Boerhaave's syndrome) is a highly morbid condition traditionally associated with poor outcomes. The Pittsburgh perforation severity score (PSS) accurately predicts risk of morbidity, length of stay (LOS) and mortality. Operative management is indicated among patients with medium (3-5) or high (> 5) PSS; however, the role of minimally invasive surgery remains uncertain.

METHODS

Consecutive patients presenting with Boerhaave's syndrome with intermediate or high PSS managed via a thoracoscopic and laparoscopic approach from 2012 to 2018 were reviewed. Demographics, clinical presentation, management, and outcomes were analyzed.

RESULTS

Ten patients (80% male) with a mean age of 61.3 years (range 37-81) were included. Two patients had intermediate and eight had high PSS (7.9 ± 2.8, range 4-12). The mean time from onset of symptoms to diagnosis was 27 ± 12 h and APACHE II score was 13.6 ± 4.9. Thoracoscopic debridement and primary repair was performed in eight cases, with two perforations repaired primarily over a T-tube. Laparoscopic feeding jejunostomy was performed in all patients. Critical care LOS was 8.7 ± 6.8 days (range 3-26), while inpatient LOS was 23.1 ± 12.5 days (range 14-46). Mean comprehensive complications index was 42.1 ± 26.2, with grade IIIa and IV morbidity in 60% and 10%, respectively. One patient developed dehiscence at the primary repair, which was managed non-operatively. In-hospital and 90-day mortality was 10%.

CONCLUSION

Minimally invasive surgical management of spontaneous esophageal perforation with medium to high perforation severity scores is feasible and safe, with outcomes which compare favorably to the published literature.

Risk factors for loss of bone mineral density after curative esophagectomy

Micronutrient and fat malabsorption and altered enteroendocrine signaling occur after esophagectomy for cancer; however, the impact of malnutrition on bone health in this cohort has not been previously investigated. In this study, the prevalence of osteoporosis increased after curative surgery, associated with disease-specific, treatment-related, and population risk factors.

PURPOSE

Improved oncologic outcomes in esophageal cancer (EC) have resulted in increased survivorship and a focus on long-term quality of life. Malnutrition and micronutrient malabsorption are common among patients with EC, but the effect on bone metabolism is not known. The aim of this study was to characterize changes in bone mineral density (BMD) following curative esophagectomy.

METHODS

Consecutive disease-free patients who underwent esophagectomy with gastric conduit for pathologically node-negative disease from 2000 to 2014 were included. BMD was assessed at vertebral levels T12-L5 by computed tomography using a simple trabecular region-of-interest attenuation technique, and serum markers of nutritional status and bone metabolism were examined. Independent risk factors for osteoporosis were identified by multivariable logistic regression.

RESULTS

Seventy-five consecutive patients were studied. Osteoporosis was present in 25% at diagnosis. BMD declined at 1 and 2 years postoperatively (144.3 ± 45.8 versus 128.6 ± 46.2 and 122.7 ± 43.5 Hounsfield Units (HU), P < 0.0001), with increased osteoporosis prevalence to 38% and 44% (P = 0.049), respectively. No significant postoperative change in vitamin D, calcium, or phosphate was observed, but alkaline phosphatase increased significantly (P < 0.001). While female sex (P = 0.004) and ASA grade (P = 0.043) were independently associated with osteoporosis at diagnosis, age (P = 0.050), female sex (P = 0.023), smoking (P = 0.024), and pathologic T stage (P = 0.023) were independently predictive of osteoporosis at 1 year postoperatively.

CONCLUSIONS

Osteoporosis is prevalent among disease-free patients post-esophagectomy for EC, associated with disease-specific, treatment-related, and population risk factors. Strategies which minimize BMD decline should be considered to avoid fragility fractures in this cohort.

Comparison of the modified Collard and hand-sewn anastomosis for cervical esophagogastric anastomosis after esophagectomy in esophageal cancer patients: A propensity score-matched analysis

BACKGROUND

Several studies have reported that modified Collard anastomosis is useful for cervical anastomosis after esophagectomy for thoracic esophageal cancer. However, no large-scale study has confirmed the efficacy of the modified Collard anastomosis.

METHODS

Between 2008 and 2016, 398 consecutive esophageal cancer patients who underwent esophagectomy and cervical anastomosis were enrolled in this study. Patients with a short remnant cervical esophagus were excluded. We investigated the utility of the modified Collard anastomosis by comparing the results of postoperative complications using a propensity score-matched analysis between the hand-sewn method (HS) and the modified Collard anastomosis (MC) for esophagogastric anastomosis of the neck after esophagectomy in thoracic esophageal cancer patients.

RESULTS

Of the 398 patients, 127 were included in the MC group and 127 were included in the HS group after propensity score matching. Clinical characteristics did not differ between the two groups. Frequency of anastomotic leakage tended to be lower in the MC group than in the HS group (3% vs. 7%, P = 0.127). Frequency of anastomotic stenosis was significantly lower in the MC group than in the HS group (13% vs. 59%, P < 0.001). Multivariate logic analysis showed that anastomotic technique (HS) and performance status were independent factors associated with anastomotic stenosis (odds ratio, 12.24 and 2.52; P-value <0.001 and 0.047, respectively).

CONCLUSION

In cervical esophagogastric anastomosis after esophagectomy, the modified Collard anastomosis is more suitable than hand-sewn anastomosis in terms of reducing the frequency of anastomotic stenosis.

An analysis of the risk factors of anastomotic stricture after esophagectomy

PURPOSE

Anastomotic stricture after esophagectomy is a major cause of long-term morbidity and a poor quality of life. The aim of this study was to identify the risk factors for the development of anastomotic stricture after esophagectomy.

METHODS

The study subjects were 213 patients who underwent esophagectomy for squamous cell carcinoma of the esophagus between 2012 and 2014. Anastomotic stricture was defined as stenosis at the site of anastomosis that required endoscopic dilation. Refractory stricture was defined as that requiring more than four sessions of dilations. Univariate and multivariate logistic regression analyses were used to identify the potential risk factors for the development of anastomotic stricture.

RESULTS

In this retrospective study, 29 patients (13.6%) developed anastomotic stricture within a median period of 108 postoperative days and required a median of 2 dilations. Tumors located in the upper part of the esophagus (p = 0.004), the presence of cardiovascular disease (p = 0.024) and anastomotic leakage (p = 0.002) were identified as independent risk factors for the development of anastomotic stricture. The time to the diagnosis of refractory stricture (85 ± 33 days) was significantly shorter than that of non-refractory stricture (171 ± 22 days, p = 0.038).

CONCLUSIONS

Patients with squamous cell carcinoma in the upper esophagus with cardiovascular disease who develop postoperative anastomotic leakage should be carefully monitored to prevent the development of benign anastomotic stricture.

Sarcopenia: Prevalence, and Impact on Operative and Oncologic Outcomes in the Multimodal Management of Locally Advanced Esophageal Cancer

OBJECTIVE

The aim of this article was to study the prevalence and significance of sarcopenia in the multimodal management of locally advanced esophageal cancer (LAEC), and to assess its independent impact on operative and oncologic outcomes.

SUMMARY OF BACKGROUND DATA

Sarcopenia in cancer may confer negative outcomes, but its prevalence and impact on modern multimodal regimens for LAEC have not been systematically studied.

METHODS

Two hundred fifty-two consecutive patients were studied. Lean body mass (LBM), skeletal muscle index (SMI), and fat mass (FM) were determined pre-treatment, preoperatively, and 1 year postoperatively. Sarcopenia was defined by computed tomography (CT) at L3 as SMI < 52.4 cm/m for males and SMI < 38.5 cm/m for females. All complications were recorded prospectively, including comprehensive complications index (CCI), Clavien-Dindo complication (CDC), and pulmonary complications (PPCs). Multivariable linear, logistic, and Cox regression analysis was performed.

RESULTS

In-hospital mortality was 1%, and CCI was 21 ± 19. Sarcopenia increased (P = 0.02) from 16% at diagnosis to 31% post-neoadjuvant therapy, with loss of LBM (-3.0 ± 5.4 kg, P < 0.0001), but not FM (-0.3 ± 2.7 kg, P= 0.31) during treatment. On multivariable analysis, preoperative sarcopenia was associated with CCI (P = 0.043), and CDC ≥IIIb (P = 0.003). PPCs occurred in 36% nonsarcopenic versus 55% sarcopenic patients (P = 0.01). Sarcopenia did not impact disease-specific (P = 0.14) or overall survival (P = 0.11) after resection. At 1 year, 35% had sarcopenia, significantly associated with pre-treatment BMI (P = 0.013) but not complications (P = 0.20).

CONCLUSIONS

Sarcopenia increases through multimodal therapy, is associated with an increased risk of major postoperative complications, and is prevalent in survivorship. These data highlight a potentially modifiable marker of risk that should be assessed and targeted in modern multimodal care pathways.