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

Multifactor analysis of the technique in total laparoscopic gastric cancer

BACKGROUND

Esophageal gastric anastomosis is a common surgical technique used to treat patients with gastric cancer who undergo total gastrectomy. However, using simple anastomosis techniques alone may not meet the needs of patients in some cases and can lead to complications such as anastomotic stenosis and ulceration. In order to overcome these issues and improve patient prognosis, muscle flap reconstruction technique has emerged. Muscle flap reconstruction is a method of improving gastric-esophageal anastomosis by transplanting muscle tissue. By covering the anastomotic site with muscle tissue, it not only enhances the stability of the anastomosis site but also increases blood supply, promoting healing and recovery of the anastomosis. Therefore, the use of muscle flap reconstruction technique in esophageal gastric anastomosis during total gastrectomy for gastric cancer is increasingly widely applied.

AIM

To determine the effectiveness of esophagogastric anastomosis using the muscle flap reconstruction technology in total abdominal gastrectomy for gastric cancer and perform follow-up experiments to understand the factors affecting patients' prognosis.

METHODS

The study subjects were 60 patients with gastric cancer who were admitted to our hospital between October 2018 and January 2022. All patients underwent esophagogastric anastomosis using the double muscle flap reconstruction technology in total abdominal gastrectomy. Perioperative indicators were determined, and patients were followed up for 1 year. Furthermore, patient outcomes were observed within 1 year, followed by patient classification based on different outcomes. Moreover, clinicopathological parameters were observed and relevant factors affecting patient prognosis were analyzed.

RESULTS

The operation time was 318 ± 43 min, the formation time of esophageal double muscle flap anastomosis was 110 ± 13 min, the number of lymph node dissections was 26 ± 6, the incision length was 3 ± 0.6 cm, intraoperative bleeding volume was 48 ± 15 mL, first anal exhaust time was 5.3 ± 1.8 d, first meal time was 6.0 ± 1.6 d, length of hospital stay was 11.8 ± 2.5, and treatment cost was 5.8 ± 0.7 thousand yuan. The patient experienced three postoperative complications: 2 cases of pulmonary infection and 1 case of respiratory discomfort. During 1-year follow-up, 50 patients survived and 10 died. Univariate analysis revealed that histological types, tumor size, tumor-node-metastasis staging, vascular invasion, and postoperative adjuvant radiotherapy and chemotherapy were the main factors affecting the prognosis of surviving patients. Furthermore, Cox regression analysis revealed that postoperative adjuvant radiotherapy and chemotherapy were the main factors affecting patient prognosis. The survival time of the survival group was significantly higher than that of the death group (P < 0.05).

CONCLUSION

Esophagogastric anastomotic using muscle flap reconstruction exhibits good effects on patients who undergo total abdominal gastrectomy for cancer. Postoperative adjuvant radiotherapy and chemotherapy are the main factors affecting patient prognosis.

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.

The Esophagogastric Anastomosis: The Importance of Anchoring Sutures in Reducing Anastomotic Leak Rates

Background

The incidence of anastomotic leakage in gastrointestinal surgery is highest after esophagogastric anastomosis, with leakage rates of 10% to 38% still being reported, but little consensus as to cause or corrective. The role of anastomotic tension from a series of physiological forces acting on the anastomosis from the moment of recovery from anesthesia may be underestimated. It was hypothesized that anchoring the conduit in the mediastinum would provide the greatest protection during the vulnerable healing phase.

Patients and Methods

A prospectively maintained database was interrogated for anastomotic leakage following the introduction of an anastomotic technique employing anchoring sutures where the gastric conduit was secured to the mediastinal pleura with 3 obliquely inserted load-bearing sutures. A contrast study was performed between days 5 and 7 and all intrahospital mortalities underwent autopsy. Clinical, radiological, and autopsy leaks were recorded.

Results

Of 146 intrathoracic esophagogastric anastomoses in 144 patients, 81 (55%) of which were stapled, there was 1 clinical leak and 1 patient with an aortoenteric fistula, considered at autopsy to be possibly due to an anastomotic leak, to give an anastomotic leak rate of 2 in 146 (1.37%).

Conclusion

The low anastomotic leak rate in this series is potentially due to the protective effect of anchoring sutures, the chief difference from an otherwise standard anastomotic technique. These sutures protect the anastomosis from a series of distracting forces during the most vulnerable phase of healing. It is intuitive that the absence of tension would also reduce any risk posed by a minor impairment of blood supply or any imperfection of the technique.

Advances in conduits and anastomotic techniques employed in esophageal cancer resections: A review

Esophageal surgery has evolved significantly since the first esophagectomy, with advancements in diagnosis allowing medicine to keep pace with the disease's increasing incidence. Multimodal treatment improves outcomes, but surgical resection remains imperative for local control, with various techniques in existence but none demonstrating clear superiority. More recently, minimally invasive and robotic surgery have further reduced perioperative morbidity. This review discusses techniques for esophageal resection, with attention to the options available for anastomosis and reconstructive conduits.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis

BACKGROUND

Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy.

METHODS

PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference.

RESULTS

Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42).

CONCLUSIONS

LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Circular vs. linear stapling after minimally invasive and robotic-assisted esophagectomy: a pooled analysis

Purpose

Current data states that most likely there are differences in postoperative complications regarding linear and circular stapling in open esophagectomy. This, however, has not yet been summarized and overviewed for minimally invasive esophagectomy, which is being performed increasingly.

Methods

A pooled analysis was conducted, including 4 publications comparing linear and circular stapling techniques in minimally invasive esophagectomy (MIE) and robotic-assisted minimally invasive esophagectomy (RAMIE). Primary endpoints were anastomotic leakage, pulmonary complications, and mean hospital stay.

Results

Summarizing the 4 chosen publications, no difference in anastomotic insufficiency could be displayed (p = 0.34). Similar results were produced for postoperative pulmonary complications. Comparing circular stapling (CS) to linear stapling (LS) did not show a trend towards a favorable technique (p = 0.82). Some studies did not take learning curves into account. Postoperative anastomotic stricture was not specified to an extent that made a summary of the publications possible.

Conclusions

In conclusion, data is not sufficient to provide a differentiated recommendation towards mechanical stapling techniques for individual patients undergoing MIE and RAMIE. Therefore, further RCTs are necessary for the identification of potential differences between LS and CS. At this point in research, we therefore suggest evading towards choosing a single anastomotic technique for each center. Momentarily, enduring the learning curve of the surgeon has the greatest evidence in reducing postoperative complication rates.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis

BACKGROUND

Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis.

MATERIALS AND METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes.

RESULTS

A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively.

CONCLUSION

HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes

PURPOSE

The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups.

METHODS

We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications.

RESULTS

Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups.

CONCLUSIONS

The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.

Comparison of Two Circular-Stapled Techniques for Esophageal Cancer: A Propensity-Matched Analysis

OBJECTIVE

The optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil™) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil™) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE).

METHODS

The data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage.

RESULTS

In the propensity score-matched analysis, compared with the non-Orvil™ group, the Orvil™ group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p< 0.05).

CONCLUSIONS

Orvil™ anastomosis exhibited better perioperative effects than non-Orvil™ anastomosis after the propensity score-matched analysis. Remarkably, the Orvil™ technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil™ technique.

[Minimally invasive esophagectomy for benign esophageal diseases: results of a two-center study]

OBJECTIVE

To analyze the results of thoracoscopic esophagectomy for benign esophageal diseases.

MATERIAL AND METHODS

The study included 78 patients who underwent thoracoscopic esophagectomy between 2011 and 2019. Peptic and burn strictures of the esophagus were diagnosed in 53 patients, achalasia - in 24 patients. Minimally invasive esophagectomy and esophagoplasty with isoperistaltic gastric tube and esophagogastrostomy on the neck was performed in 68 patients, Ivor Lewis esophagectomy - in 1 patient, coloesophagoplasty - in 9 patients. We used manual technique of anastomosis in 58 patients, stapling device - in 19 patients. In 1 case, surgery was finished with esophagostomy and gastrostomy.

RESULTS

Mean blood loss was 200 ml (10-1200), surgery time - 450 min (265-765 min). Early postoperative complications occurred in 37 patients including anastomotic leakage in 24 cases. In long-term period, anastomotic strictures developed in 9 patients. No mortality was observed.

CONCLUSION

Minimally invasive esophagectomy for benign esophageal diseases ensures favorable clinical outcomes. However, no consensus in the choice of surgical approach and indications, as well as small number of these patients cause challenges in implementation of this technique. There are different opinions regarding technique of anastomosis on the neck and surgical access in thoracoscopic esophagectomy.

Video-Assisted Thoracic Surgery Intrathoracic Anastomosis Technique

The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.

Anastomotic leak following oesophagectomy: research priorities from an international Delphi consensus study

BACKGROUND

The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks.

METHODS

A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income.

RESULTS

In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis.

CONCLUSION

Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.

Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?

BACKGROUND

Robot-assisted surgery for esophageal cancer is increasingly applied. Despite this upsurge, the preferential technique to create a robot-assisted intrathoracic anastomosis has not been established.

DATA SOURCES

Bibliographic databases were searched to identify studies that performed a robot-assisted Ivor Lewis esophagectomy and described the technical details of the anastomotic technique. Out of 1701 articles, 16 studies were included for systematic review.

CONCLUSIONS

This review shows that all technique used to create a thoracoscopic anastomosis can be adopted to robotic surgery. Techniques can be divided into three categories: robotic hand-sewn, circular stapling or linear stapling and robotic hand-sewn closure of the stapler defect. With limited robotic experience, circular stapling might be the preferred technique, however requires a well-trained bedside assistant. The linear stapling technique or hand-sewn technique are more challenging but enable experienced robotic surgeons to perform a controlled anastomosis without bedside support.