Hybrid trans-thoracic esophagectomy with side-to-side stapled intra-thoracic esophagogastric anastomosis for esophageal cancer

Evaluation of the blood flow in reconstructed gastric tube and its relation to anastomosis leakage

OBJECTIVES

Anastomotic leakage in esophageal cancer surgery may be reduced by evaluating the blood flow to the reconstructed organ, but quantitative evaluation of arterial and venous blood flow is difficult. This study aimed to quantitatively assess blood flow using a new technique, as well as determine the relationship between the blood flow in the gastric tube and anastomotic leakage using near-infrared spectroscopy.

METHODS

This single-center, observational study included 50 patients aged 51-82 years who underwent radical esophagectomy with gastric tube reconstruction for esophageal cancer between June 2022 and January 2023. Regional tissue oxygen saturation was measured at the antrum (point X), the anastomotic point (point Z), and the midpoint between points X and Z (point Y) before and after gastric tube formation. These three points of oxygen saturation were investigated in relation to anastomotic leakage.

RESULTS

When comparing the presence of leakage to its absence, regional tissue oxygen saturation at points X and Z after gastric tube formation was significantly lower (X: p = 0.03, Z: p = 0.02), with the decreasing rate significantly higher at point Z (p = 0.01). There was no significant difference in the decreasing rate of regional tissue oxygen saturation between points X and Y (X: p = 0.052, Y: p = 0.83).

CONCLUSION

Regional tissue oxygen saturation levels may be useful for measuring blood flow and could be a predictor of anastomotic leakage.

Esophageal Achalasia: Evaluation and Treatment of Recurrent Symptoms

BACKGROUND

Esophageal achalasia is a primary esophageal motility disorder of unknown origin. Treatment is palliative and its goal is to decrease the resistance posed by a non-relaxing and often hypertensive lower esophageal sphincter. This goal can be accomplished by different treatment modalities such as pneumatic dilatation, laparoscopic myotomy or peroral endoscopic myotomy. In some patients, however, symptoms tend to recur overtime.

METHODS

A comprehensive literature search was performed on PubMed focused on the management of recurrent achalasia.

RESULTS

The available treatment modalities can be used, alone or in combination. The goal of treatment is to resolve/improve symptoms, avoiding an esophagectomy, an operation linked to significant morbidity.

CONCLUSIONS

The treatment of these patients is often very challenging, and the best results are obtained in centers where a multidisciplinary team-radiologists, gastroenterologists, and surgeons-is present.

Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series

BACKGROUND

One cause of anastomotic leakage after radical esophagectomy is blood flow insufficiency at the cervical anastomosis site. .

METHODS

Eighteen patients, who underwent radical esophagectomy with gastric tube reconstruction, were studied. The regional tissue oxygen saturation (rSO2) was measured at the tip (point pre 0) and 2, 4, and 6 cm on the distal side of the tip (point pre 1, pre 2, and pre 3, respectively) before the gastric tube was raised to the cervical site through the retrosternal route. After that, rSO2 was measured at the tip, 2 and 4 cm on the distal side of the tip (points post 0, post 1, and post 2), the actual anastomotic site (point AN), and the chest skin as an indicator of whole-body oxygenation. The relationship between rSO2 scores and the rate of anastomotic leakage was determined.

RESULTS

The mean rSO2 at pre 0, pre 1, pre 2, and pre 3 were 48.9%, 52.3%, 54.8%, and 56.9%, respectively (p < 0.05). The mean rSO2 at post 0, post 1, and post 2 were 47.8%, 50.5%, and 52.3%, respectively, and the rSO2 at point AN was 52.1%.Anastomotic leakage was found in 6 patients. The rSO2 at points pre 0, pre 1, and pre 2, post 0 and point AN were significantly lower in patients with anastomosis leakage than those without (p < 0.05).

CONCLUSION

Tissue oxygen saturation monitoring was a useful indicator of blood flow insufficiency in the gastric tube during radical esophagectomy.

The evaluation of the gastric tube blood flow by indocyanine green fluorescence angiography during esophagectomy: a multicenter prospective study

OBJECTIVE

We determined the anastomotic site during gastric tube reconstruction in esophagectomy according to the "90-to 60-s rule" using indocyanine green (ICG) fluorescence angiography. We evaluated its safety and efficacy in a prospective multicenter setting.

METHODS

We enrolled 129 patients who underwent subtotal esophagectomy for esophageal cancer. ICG fluorescence angiography was performed after making a wide gastric tube, and the time from the initial enhancement of the right gastroepiploic artery to the tip of the gastric tube was used as a parameter. Esophago-gastro anastomosis was made at the area that was enhanced within 90 s (preferably within 60 s). The enhancement time and the incidence of anastomotic leakage were compared.

RESULTS

In all cases, anastomosis was made at the site enhanced within 90 s. Anastomotic leakage was found in only 4 (3.1%) of 129 cases; specifically, it was detected in 3 (2.4%) of 126 cases whose anastomotic site was enhanced within 60 s and in 1 (33.3%) of 3 cases where the enhancement time exceeded 60 s (p = 0.09).

CONCLUSIONS

Determining the anastomotic site using the 90-to 60-s rule with ICG imaging in gastric tube reconstruction helps reduce the rate of anastomotic leakage.

Hybrid Esophagectomy: How I Do It?

The hybrid esophagectomy is a procedure that combines an initial laparoscopic approach in which the gastric conduit is prepared preserving the right gastroepiploic artery, followed by a right thoracotomy for resection of the esophagus, gastric pull-up into the chest, and esophagogastric anastomosis. Critical surgical steps should be carefully respected to perform a safe operation.

The evaluation of the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy

OBJECTIVE

We herein evaluated the hemodynamics of a gastric tube in esophagectomy using a new noninvasive blood flow evaluation device utilizing near-infrared spectroscopy.

METHODS

Thirty-two cases of subtotal esophagectomy and gastric tube reconstruction for esophageal cancer were studied. The new device measures the regional tissue saturation of oxygen (rSO₂: 0-99%) and total hemoglobin index (T-HbI: 0-1.0) with a small sensor. We measured these values at the antrum (point A), final branch of the right gastroepiploic artery (point B) and planned anastomotic point (point C) before and after gastric tube formation. The values at the three points were compared, and the gradients at the three points from before to after gastric tube formation were compared.

RESULTS

The mean values of rSO₂ at point A, B, and C before gastric tube formation were 57.2%, 57.8% and 56.0%, and those after formation were 54.6%, 58.0% and 55.8%, respectively. There was no significant difference in the comparison of the rSO₂ gradient before and after formation (p = 0.167). The mean values of T-HbI at point A, B, and C before formation were 0.126, 0.178 and 0.211, and those after formation were 0.167, 0.247 and 0.292, respectively. There was no significant difference in the gradient of the increase before and after formation (p = 0.461).

CONCLUSION

A new device has shown that the gastric tube used in our facility is one that maintains tissue saturation of oxygen and does not cause excessive congestion at anastomosis.

A new technology for reducing anastomotic fistula in the neck after esophageal cancer surgery

Background

To explore the risk factors and prevention methods of cervical mechanical anastomotic fistula and stenosis after the radical resection of esophageal cancer.

Methods

From March 2018 to November 2018, 128 patients undergoing mechanical anastomosis of esophageal cancer were selected from the Department of Thoracic Surgery of The First Affiliated Hospital of Zhengzhou University. All the enrolled patients were operated on using the Mckeown method, and a retrospective study was conducted. Data for preoperative and postoperative test indices, intraoperative embedding materials, postoperative complications, and preoperative and postoperative treatment were collected, and the relationship between various factors and the incidence of cervical anastomotic fistula and stenosis was analysed. Univariate analysis was conducted using t tests or Fisher's exact probability method, and multivariate analysis was conducted using logistic regression models.

Results

All 128 patients successfully underwent surgery without dying. The enrolled patients were evaluated using the Stooler classification, with 28 patients having grade 0, 41 patients having grade 1, 34 patients having grade 2, 21 patients having grade 3, and 4 patients having grade 4 stenosis. Patients with stenosis of grade 3 or above had obvious choking sensation, which could only be relieved by balloon dilation. Symptoms in all patients with stenosis were relieved by balloon dilation. There were no significant differences between the two groups regarding embedding materials, preoperative choking history, history of alcohol consumption, history of hypertension, history of coronary heart disease, history of diabetes, postoperative calcium concentration, average albumin concentration, average platelet concentration, body mass index, anastomotic fistula, preoperative chemotherapy, postoperative chemotherapy, or postoperative cough (P>0.05). There were significant differences in postoperative reflux (χ²=11.338, P<0.05) and scar constitution (χ²=12.497, P<0.05). The effects of embedding materials in patients with anastomotic fistula were significantly different (χ²=4.372, P<0.05).

Conclusions

Postoperative reflux and scar constitution may be risk factors for postoperative anastomotic stenosis after resection of esophageal cancer. There was almost no difference in the effects on esophageal anastomotic stenosis between embedding materials and the omentum majus, but Neoveil^® may have certain advantages in preventing cervical anastomotic fistula, and thus may have certain clinical application value.

Prevalence of anastomotic leak and the impact of indocyanine green fluorescein imaging for evaluating blood flow in the gastric conduit following esophageal cancer surgery

BACKGROUNDS AND AIM

Anastomotic leak (AL) following esophagectomy for esophageal cancer (EC) remains an important cause of prolonged hospitalization and impaired quality of life. Recently, indocyanine green (ICG) fluorescein imaging has been used to evaluate the gastric conduit blood supply during EC surgery. Although several factors have been reported to be associated with AL, no studies have evaluated the relationships between risk factors for AL, including ICG fluorescein imaging. The purpose of this study was to investigate the risk factors associated with AL following esophagectomy and to evaluate the impact of ICG fluorescein imaging of the gastric conduit during EC surgery.

METHODS

One hundred and twenty patients undergoing esophagectomy with esophagogastric anastomosis for EC were enrolled in this retrospective study. Clinicopathological factors, preoperative laboratory variables, and surgical factors, including ICG fluorescence imaging, were analyzed to determine their association with AL. Univariate and multivariate logistic regression analysis was used to evaluate the impact of each of these factors on the incidence of AL.

RESULTS

Among the 120 patients enrolled in the study, 10 (8.3%) developed AL. Univariate analysis demonstrated an increased risk of AL in patients with a high-neutrophil-to-lymphocyte ratio (p = 0.0500) and in patients who did not undergo ICG fluorescein imaging (p = 0.0057). Multivariate analysis revealed that the absence of ICG imaging was an independent risk factor for AL (p = 0.0098).

CONCLUSIONS

Using ICG fluorescein imaging to evaluate blood flow in the gastric conduit might decrease the incidence of AL following EC surgery.

Prevention of Perioperative Anastomotic Healing Complications: Anastomotic Stricture and Anastomotic Leak

The anastomotic healing complications of postoperative leak and stricture continue to plague surgeons despite many broadly targeted interventions. Evaluation of preventive measure efficacy is difficult due to inconsistent definitions and reporting of these complications. Few interventions have been shown to impact rates of leakage or stricture. However, new evidence is emerging that the intestinal microbiota can play an important role in the development of anastomotic complications. A more holistic approach to understanding the mechanisms of anastomotic complications is needed in order to develop tailored interventions to reduce their frequency. Such an approach may require a more complete definition of the role of the microbiota in anastomotic healing.