Triangulating stapling technique for esophagogastrostomy after minimally invasive esophagectomy

Predictive factors for refractory anastomotic stricture after cervical triangular anastomosis with gastric conduit reconstruction through the posterior mediastinum in minimally invasive esophagectomy

BACKGROUND

After esophagectomy, anastomotic strictures disturb food passage and increase the incidence of aspiration pneumonia. Multiple endoscopic balloon dilatations are required for stricture treatment. Therefore, long-term quality of life and nutritional status may be adversely affected. This study aimed to identify risk factors for strictures after cervical triangular anastomosis using a gastric conduit among patients who underwent minimally invasive esophagectomy (MIE).

METHODS

A total of 188 patients who underwent MIE for esophageal cancer between 2010 and 2020 at Kobe University Hospital were retrospectively examined. The incidence of strictures, number of dilatations for stricture, and time to stricture diagnosis were evaluated. Next, the potential independent risk factor for refractory strictures requiring more than 5 endoscopic balloon dilatations was clarified.

RESULTS

The study included 188 patients who satisfied the inclusion criteria. Anastomotic strictures were observed in 44 patients (23%). Neoadjuvant chemotherapy was significantly more common in patients with stricture than in patients without stricture (75% vs 58%, respectively; P = .041). The median number of endoscopic balloon dilatations was 5 (IQR, 1-31). Of note, 30 patients (68%) underwent their first dilatation within 3 months after MIE. In univariate and multivariate analyses, < 69 days from surgery to first endoscopic balloon dilatation was an independent risk factor for stricture requiring more than 5 endoscopic balloon dilatations after cervical triangular anastomosis in MIE (hazard ratio, 9.483; 95% CI, 2.220-54.274; P = .002).

CONCLUSION

Early postoperative anastomotic stricture might become refractory, and an appropriate treatment plan should be developed.

Evaluation of the Usefulness of Contrast-Enhanced Computed Tomography for the Early Detection of Anastomotic Leakage After Esophagectomy

OBJECTIVE

Anastomotic leakage is one of the most severe complications after esophagectomy. However, a diagnostic gold standard for anastomotic leakage has not been established yet. This retrospective cohort study aimed to evaluate the potential use of routine postoperative contrast-enhanced computed tomography findings as an early predictor of anastomotic leakage in patients who underwent esophagectomy for esophageal cancer.

METHODS

This study included 75 patients who underwent Mckeown esophagectomy, of whom 22 developed anastomotic leakage after surgery. The computed tomography findings for this patient cohort were categorized into 3 grades based on mural enhancement patterns observed at the anastomotic site. Both semiquantitative and quantitative analyses were performed, and the interobserver agreement between the 2 experienced radiologists was assessed.

RESULTS

It was found that poor enhancement in both the early and portal venous phases (grade 2) had a robust association with the occurrence of anastomotic leakage. The computed tomography enhancement ratio that is used to estimate wall degeneration and ischemia was significantly higher in patients with anastomotic leakage.

CONCLUSIONS

Routine postoperative contrast-enhanced computed tomography could be beneficial for the early detection of anastomotic leakage, even in asymptomatic patients, after esophagectomy.

Efficacy and Postoperative Outcomes of Laparoscopic Retrosternal Route Creation for the Gastric Conduit: Propensity Score-Matched Comparison to Posterior Mediastinal Reconstruction

BACKGROUND

Retrosternal reconstruction has lower risks for severe postoperative morbidities, such as gastro-tracheal fistula or esophageal hiatal hernia. We have previously reported the laparoscopic retrosternal route creation (LRRC) method, but its safety and efficacy remain unclear.

METHODS

In total, 374 patients with esophageal carcinoma who underwent minimally invasive McKeown esophagectomy in the prone position between 2010 and 2021 were retrospectively reviewed. We performed a propensity score-matched analysis with the simple, nearest-neighbor method and no calipers to compare postoperative outcomes and reconstructed gastric conduit functionality between patients who underwent LRRC and counterparts who underwent posterior mediastinal reconstruction.

RESULTS

After matching, 62 patients were included in the laparoscopic retrosternal group (LR group) or posterior mediastinal group (PM group). No significant differences were observed between the groups, apart from the number of robot-assisted surgeries, the extent of lymph node dissection, and the method of cervical anastomosis. There were no significant differences in the incidence of Clavien-Dindo grade ≥ 2 complications. Gastro-tracheal fistula (n = 1) and esophageal hiatal hernia (n = 2) occurred in the PM group but not in the LR group. There were no differences in the incidence of pulmonary embolism between the groups (5% vs. 5%). The postoperative anastomotic stenosis rate was similar (16% vs. 27%, p = 0.192). Endoscopic findings of reflux esophagitis (modified Los Angeles classification ≥ M) at 1 year after surgery were significantly better in the LR group (p = 0.037).

CONCLUSIONS

LRRC for gastric conduit reconstruction is safe and valuable. It is associated with good reconstructed gastric conduit function.

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.

Initial Learning Curve and Stereotypical Use of Extra Arm During da Vinci Chest Procedures of McKeown Esophagectomy

Objective: McKeown esophagectomy facilitates extensive lymphadenectomy for the optimal management of esophageal cancer. Robot-assisted esophagectomy (RAE) was introduced in an attempt to reduce the incidence of postoperative complications. The da Vinci System has 3 active robotic arms in addition to the camera scope, and an extra robotic arm (ERA) is generally used to maintain a fine and stable operative field. However, the optimal use of an ERA has not been documented. In addition, the learning curve of the RAE using the da Vinci System remains controversial. In this study, we aimed to determine the optimal use of an ERA in association with the initial learning curve of robotic McKeown esophagectomy with extremely extensive lymphadenectomy. Methods: We reviewed 81 consecutive patients who underwent RAE. To determine whether stereotypical use of an ERA after establishment of its optimal use accounted for the learning curve, we measured the duration of 14 steps and the duration when performed with optimal use of an ERA in the corresponding step by reviewing video-recorded procedures. We then calculated the ratio as the degree of stereotypical use of the ERA during the da Vinci chest procedures. Results: The cumulative sum method showed that the learning curve required 27 cases of RAE. In addition, stereotypical use of the ERA was significantly associated with the learning curve of RAE. Conclusions: Establishment of optimal use of an ERA could help to accelerate the learning curve in da Vinci chest procedures during McKeown esophagectomy with extensive lymphadenectomy.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy (MT), with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of MT anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which MT anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

14 patients were included, with a mean age of 63 years. The mean operative time was 436 min (360-581), being diagnosed of anastomotic leak (AL) 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis (AS). The median stay was 20 days, without any death in the series.

DISCUSSION

Multiple publications suggest the superiority in terms of AL and AS of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

McKeown esophagectomy with concomitant median arcuate ligament release in a case of esophageal cancer with celiac artery stenosis

BACKGROUND

The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor-Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release.

CASE PRESENTATION

A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter.

CONCLUSIONS

Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.

Laparoscopic creation of a retrosternal route for gastric conduit reconstruction

BACKGROUND

Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route.

METHODS

We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts.

RESULTS

Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction.

CONCLUSION

Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

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.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy, with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of triangular esophagogastrostomy anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which triangular esophagogastrostomy anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

A total of 14 patients were included, with a mean age of 63 years. The mean operative time was 436minutes (360-581), being diagnosed of anastomotic leak 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis. The median stay was 20 days, without any death in the series.

CONCLUSIONS

Multiple publications suggest the superiority in terms of anastomotic leak and anastomotic stenosis of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

iTriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy

BACKGROUND

We herein report the feasibility and safety of cervical end-to-end anastomosis by the iTriangular stapling technique (iTST), which was developed as an extension of the triangular stapling technique (TST) after minimally invasive esophagectomy (MIE).

METHODS

A total of 45 patients with thoracic esophageal cancer who underwent reconstruction with cervical esophagogastric anastomosis by iTST using a linear stapler after MIE between January 2016 and January 2019 were retrospectively reviewed. We modified and improved upon the TST by adding a 1- to 2-cm vertical incision on the anterior wall of the remnant esophageal stump to enlarge the anastomotic lumen and thereby reduce the risk of anastomotic stenosis. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.

RESULTS

The median operating time was 686 (range, 319-1110) minutes, and the median blood loss was 170 (range, 5-1180) ml. There were no cases of anastomotic stenosis in this study, although 2 patients (4.4%) developed minor anastomotic leakage. A case (2.2%) of tracheal fistula due to the apex of the triangular anastomosis was resolved simply by delaying the patient's oral intake. The mean length of the hospitalization was 21 days.

CONCLUSIONS

The iTST provides a larger lumen unlimited by the size of the esophagus in cervical esophagogastric anastomosis. This technique is feasible, and sufficient short-term results have been achieved. Further studies with the accumulation of more cases will be required to prove the benefits of iTST for reconstruction after MIE.

Comparison of circular stapling, triangulating stapling and T-shape stapling for cervical anastomosis with minimally invasive esophagectomy

Background

The triangulating stapling (TST) and T-shape stapling (TS) methods have been proposed to decrease the incidence of anastomotic leakage after esophagectomy, but few studies have compared them to the circular stapling technique (CS). This retrospective study aimed to compare the efficacy and safety of three cervical anastomosis methods after esophagectomy.

Methods

Squamous cell carcinoma patients who underwent minimally invasive esophagectomy (MIE) with CS, TST or TS anastomosis between April 2010 and June 2012 were recruited. Their clinical characteristics and short-term outcome were analyzed. Kaplan-Meier analyses compared with log-rank test were used to calculate the effect of the three types of cervical anastomosis on overall survival (OS) and disease-free survival (DFS).

Results

The incidence of anastomotic leakage was 21.8% in the CS group, 7.7% in the TS group and 11.9% in the TST group (P=0.029). There were significant differences in the incidence of gastroesophageal reflux among the three groups (P<0.001). Rates of anastomotic stenosis, pulmonary infection, chylothorax and hoarseness were not different among the groups. There were significant differences in anastomotic time, operation time and hospitalization time (all P<0.001), but there was no significant difference in albumin content at 1 month after operation (P=0.226). There was no differences in long-term surgical effects of the three types of anastomosis

Conclusions

Cervical esophagogastric anastomosis by TST or TS can be considered feasible and safe and with improved short-term outcome.

Postoperative hiatal hernia after minimally invasive esophagectomy for esophageal cancer

Background

Minimally invasive esophagectomy (MIE) can reduce various complications compared with conventional thoracotomic esophagectomy. However, several reports suggested that MIE promoted incidence of post-operative hiatal hernia (HH). In current reports, we retrospectively analyzed incidence and risk factors of HH development after MIE.

Methods

A total of 113 patients undergoing MIE (McKeown esophagectomy) at our institute from April 2009 to December 2015 were included in this study. Patients with clinical stage II and III received neoadjuvant chemotherapy (NAC).

Results

Eleven of 113 patients (9.7%) undergoing MIE developed HH. Four of them were female and the ratio of female among the patient with HH was higher than that among the patient without HH after MIE (36.4% vs. 13.7%, P=0.05). Sixty-six patients (58.4%) during the study period were administered NAC and 10 of 11 patients with HH (90.9%) received NAC according to the clinical stage, which was significantly more than in the non-HH group (P=0.02). Type and route of graft organ were not related to HH development. Moreover, the fixation of the conduit organ at the hiatus does not contribute to post-operative HH.

Conclusions

In the current study, we showed that NAC was a major risk factor of HH development after MIE.

Intrathoracic side-to-side esophagogastrostomy with a linear stapler and barbed suture in robot-assisted Ivor Lewis esophagectomy

Background

The side‐to‐side anastomosis was considered a promising approach to create an intrathoracic esophagogastrostomy in the minimally invasive esophagectomy, with advantages over the side‐to‐end anastomosis with aspects of no need for additional mini‐thoracotomy and lower occurrence of stenosis. The hand‐sewing anterior aspect of the anastomosis is technically challenging in the thoracoscopic Ivor Lewis esophagectomy. Here we introduced our initial experience to facilitate this approach by using the surgical robot and barbed suture.

Methods

A retrospective study of all patients underwent robot‐assisted Ivor Lewis esophagectomy with side‐to‐side esophagogastrostomy from February 2016 to September 2018 was performed. The technical details are described in this paper.

Results

A total of 37 patients (35 male and 2 female, median age of 62.7 years) were successfully treated with completely robot‐assisted Ivor Lewis esophagectomy. The median total surgical time was 340 minutes including 65 minutes to perform the anastomosis. Median estimated blood loss was 120 mL and the length of hospital stay was 10 days. There was no 90‐day mortality. Three patients suffered anastomotic leakage (8.1%,3/37), who were successfully treated without reoperation.

Conclusion

Our initial results imply that it is technically feasible to perform intrathoracic gastroesophageal anastomosis by taking advantage of a robotic system and knotless suturing.

Mesenteric excision of upper esophagus: a concept for rational anatomical lymphadenectomy of the recurrent laryngeal nodes in thoracoscopic esophagectomy

BACKGROUND

The recurrent laryngeal nerve (RLN) lymph nodes are among the most frequently involved lymph nodes in esophageal cancer. Surgical removal of these lymph nodes is considered beneficial for postoperative prognosis, especially in patients with squamous cell carcinoma. Unfortunately, the precise surgical anatomy of the upper mediastinum is not well understood and no distinct high-resolution images are currently available.

METHODS

In this article, we provide a simple intuitive concept of upper mediastinal surgical anatomy that could facilitate rational anatomical lymphadenectomy of the RLN lymph nodes. The essential concept of this mesenteric excision is to mobilize mesoesophagus including RLN in an en bloc fashion and to save RLN laterally by incising visceral sheath. This is applicable identically to both right and left upper mediastinum.

RESULTS

Between January 2009 and December 2017, thoracoscopic esophagectomy with upper mediastinal lymphadenectomy for primary esophageal cancer was performed in 189 patients. Median thoracoscopic procedure time was 297 (range 205-568) min and median intraoperative blood loss was 70 ml (range unmeasurable up to 2545 ml). Median number of harvested upper mediastinal lymph nodes was 12. Postoperative complication of Clavien-Dindo classification grade III or higher events was observed in 14% of patients. RLN palsy of grade II or higher occurred in 20 patients (11%).

CONCLUSION

The mesoesophagus in the upper mediastinum is an anatomical unit surrounded by fibrous connective tissue containing the esophagus, trachea, tracheoesophageal vessels, lymphatic tissue, and RLNs. Thus, mesenteric excision of esophagus is defined to resect this area by sparing trachea and RLNs for rational anatomical lymphadenectomy. We believe that this concept makes upper mediastinal lymphadenectomy safer and more appropriate.

Anastomotic leakage following retrosternal pull-up

PURPOSE

Narrow thoracic inlet might be associated with increased incidence of cervical anastomotic leakage (AL) after esophagectomy with retrosternal reconstruction. We retrospectively evaluated the relationship of the length from the suprasternal notch to the trachea (LST) and AL using computed tomography.

METHODS

In this retrospective study including 121 patients with esophageal cancer who underwent subtotal esophagectomy with retrosternal reconstruction between 2008 and 2016, clinicopathological characteristics, including the LST, surgical procedures, and perioperative outcomes, were compared between the AL and non-AL groups.

RESULTS

AL occurred in 19 of the 121 patients (15.7%). There were no associations between AL development and age, sex, body mass index, tumor location, TNM stage, histological type, surgical approach, or type of the anastomotic procedure. Surgery duration was longer in the AL group than in the non-AL group (p = 0.004). Other surgical factors such as intra-operative blood loss and anastomotic technique were not associated with AL. LST was significantly shorter in the AL group than in the non-AL group (p < 0.001). Multivariate analysis revealed that LST was a significant predictor of AL (p < 0.001).

CONCLUSION

LST is a simple and useful predictor of AL after esophagectomy with retrosternal reconstruction.

Triangulating stapling vs functional end-to-end stapling for cervical esophagogastric anastomosis after esophagectomy for thoracic esophageal cancer: study protocol for a randomized controlled trial

Background

Several studies have reported that the triangulating stapling method decreases the incidence of anastomotic stricture after esophagectomy. Our previous randomized controlled trial, however, could not confirm the superiority of the triangulating stapling (TS) method over the circular stapling (CS) method in terms of postoperative anastomotic stricture rate. Recently, the functional end-to-end stapling (FEES) method for cervical anastomosis after esophagectomy was developed, and lower anastomotic stricture rates with FEES have been reported than for our previously experienced anastomotic methods. To investigate the optimal anastomotic method, we now compare the TS method with the FEES method for cervical anastomosis regarding decrease in anastomotic stricture after esophagectomy for thoracic esophageal cancer.

Methods

This is a randomized, single-center clinical trial designed to examine the superiority of the FEES method over the TS method for esophageal cancer patients. The primary endpoint is reduction of anastomotic stricture of cervical esophagogastric anastomosis within 12 months after esophagectomy. Secondary endpoints include overall postoperative morbidity within the first 12 months after esophagectomy, incidence of anastomotic leakage, aspiration pneumonia, or reflux esophagitis, and quality of life assessment as measured by the FACT-E at 12 months after esophagectomy. The incidence rate of anastomotic stricture of the TS method was 20% and this rate of the FEES method was estimated to be 4% in our preliminary study. We calculated sample size with a beta error of 0.20 and an alpha error of 0.05. We have been enrolling 125 patients in this trial to either the TS group or the FEES group since January 2017.

Discussion

This study should help to define the optimal anastomotic method for cervical esophagogastric anastomosis after esophagectomy in patients with esophageal cancer.

The FEES method, if proven to be superior to the TS method, can be implemented routinely for esophageal cancer patients with gastric-conduit reconstruction after esophagectomy.

Trial registration

University Hospital Medical Information Network Clinical Trial Registry (UMIN 000025632). Registered on 13 January 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3201-2) contains supplementary material, which is available to authorized users.

Impact of the Kocher maneuver on anastomotic leak after esophagogastrostomy in combined thoracoscopic-laparoscopic esophagectomy

OBJECTIVES

Anastomotic leak is a common complication after esophagectomy for esophageal cancer. This study evaluated the impact of the Kocher maneuver on the incidence of anastomotic leak following esophagogastrostomy using a 3-cm-wide gastric conduit.

METHODS

This single-institution, retrospective, cohort study included 43 patients who underwent thoraco-laparoscopic esophagectomy. The Kocher maneuver was not performed in the first half of the study period between April 2014 and May 2015 (first half group, n=14), but was performed in the second half between May 2015 and January 2017 (second half group, n=29). Primary endpoint was the incidence of anastomotic leak. Metrological values of the gastric conduit were postoperatively assessed on computed tomography. Blood perfusion of the gastric conduit was prospectively examined using the indocyanine green fluorescence method.

RESULTS

The incidence of anastomotic leak was 14%; the incidence was significantly lower in the second half group than in the first half group (3.4% vs. 35.7%, p=0.01). The Kocher maneuver was the only significant independent risk factor associated with anastomotic leak (OR 0.064, 95% CI 0.007-0.625, p=0.018). The postoperative length of the entire gastric conduit was significantly shorter in the second half group than in the first half group. A more anal location of the 3-cm-wide gastric conduit was associated with better blood perfusion.

CONCLUSIONS

The Kocher maneuver may enable shortening of the gastric conduit, leading to better blood perfusion of the tip of the gastric conduit, and a significant reduction in the occurrence of anastomotic leak.

Successful repair using thymus pedicle flap for tracheoesophageal fistula: a case report

Background

Treatment for tracheoesophageal fistula (TEF), a life-threatening complication after esophagectomy, is challenging.

Case presentation

A 75-year-old man with thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the post-mediastinal root after neoadjuvant chemotherapy. Owing to postoperative anastomotic leakage, an abscess formed at the anastomotic region. Sustained inflammation from the abscess caused refractory TEF between the esophagogastric anastomotic site and membrane of the trachea, and several conservative therapies for TEF failed. Hence, the patient underwent surgery including division of the fistula, direct suturing of the leakage sites, and reinforcement with the flap of the thymus pedicle. As a result, the abscess and TEF disappeared after surgery and the patient was immediately administered an oral diet and discharged home 103 days after initial surgery.

Conclusions

Although pedicle flaps for the reinforcement of TEF are usually obtained from muscle or pericardium, these flaps need enough lengths to overcome moving distance. We are the first in the existing literature to have successfully treated TEF with surgical repair using a thymus flap located close to TEF. The thymus pedicle might be another candidate for the reinforcement flap in TEF.

A novel technique for cervical gastro-oesophageal anastomosis during minimally invasive oesophagectomy

BACKGROUND

Anastomotic leakage, fibrous stricture and gastro-oesophageal reflux are three major complications of gastro-oesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to traditional side-to-side anastomosis (SS) and end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux.

METHODS

A total of 390 patients with thoracic oesophageal cancer underwent minimally invasive oesophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. A detailed description of the surgical procedure is provided, and the major postoperative complications, including postoperative leakage, stricture and reflux, were compared using a three-armed controlled study.

RESULTS

The anastomotic method was an independent risk factor for anastomotic leakage, as well as stricture and reflux. The rate of anastomotic leakage of the NA group (1.0%) was significantly lower than that in the SS group (8.8%, P = 0.025) and in the CS group (8.5%, P = 0.001). The rate of anastomotic stricture in the NA group was not significantly different than that in the SS group (1.5% vs. 2.9%, P = 0.368) but was significantly lower than that in the CS group (1.5% vs. 18.9%, P < 0.001). The incidence of gastro-oesophageal reflux in the NA group was significantly lower than that in the SS group and the CS group (5.7% vs. 23.5% and 18.3%, P = 0.003 and 0.001, respectively).

CONCLUSION

Jiang's anastomosis technique remarkably reduces the incidence of gastro-oesophageal anastomotic leakage, stricture and reflux, and it is a safe and effective technique for minimally invasive oesophagectomy.

Triple-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis

BACKGROUND

Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far.

METHODS

The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap.

RESULTS

The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680-320 min). The intraoperative blood loss volume was 104.4 mL (range 240-30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II.

CONCLUSIONS

TRIQ can be performed easily and safely, and good short-term outcome can be expected.

Circular stapling versus triangulating stapling for the cervical esophagogastric anastomosis after esophagectomy in patients with thoracic esophageal cancer: A prospective, randomized, controlled trial

BACKGROUND

Several studies have reported that the triangulating stapling method decreases the incidence of anastomotic stricture after esophagectomy, but no randomized, controlled trial has confirmed the efficacy of the triangulating stapling method for cervical esophagogastrostomy. We compared triangulating stapling and circular stapling for cervical esophagogastric anastomosis regarding the decrease in anastomotic stricture after esophagectomy for thoracic esophageal cancer.

METHODS

Between August 2010 and April 2014, 100 patients enrolled in this randomized, controlled trial at the Wakayama Medical University Hospital were allocated randomly to either the circular stapling group (n = 49) or the triangulating stapling group (n = 51). The primary end point was the incidence of anastomotic stricture within 12 months postoperatively. This randomized, controlled trial was registered with the University Hospital Medical Information Network Clinical Trial Registry (UMIN000004848).

RESULTS

There were no differences between the circular stapling and triangulating stapling groups in terms of clinical data. The amount of time required for esophagogastric anastomosis was slightly greater for the triangulating stapling group (22 minutes) than for the circular stapling group (18 minutes) (P = .028). Anastomotic stricture occurred in 8 patients (17%) in the circular stapling group and 9 patients (19%) in the triangulating stapling group (P = .935). The rate of anastomotic leakage was 11% for the circular stapling group and 2% for the triangulating stapling group (P = .073).

CONCLUSION

The triangulating stapling method for cervical anastomosis for thoracic esophageal cancer does not decrease the incidence of anastomotic stricture compared with the circular stapling method within 12 postoperative months but may affect the rate of anastomotic leakage.

A comparison of cervical delta-shaped anastomosis and circular stapled anastomosis after esophagectomy

Background

The delta-shaped anastomosis has been reported to reduce anastomotic complications for a decade. However, little has been written comparing this technique with the circular stapler technique. The objective of this retrospective study was to assess the safety and efficacy of cervical delta-shaped anastomosis after esophagectomy.

Methods

Medical records of patients with esophageal squamous cell carcinoma who underwent McKeown (three-incision) esophagectomy between September 2013 and June 2015 were reviewed. Either circular stapled anastomosis (CSA) or delta-shaped anastomosis (DSA) was performed at the cervical stage. The clinical characteristics and short-term outcome were retrospectively assessed to identify the differences between the two groups.

Results

A total of 81 patients were included in this study. The clinical characteristics were similar between the two groups. Cervical anastomotic leakage occurred in 3 (7.7%) of 39 patients in the DSA group and in 8 (19%) of 42 patients in the CSA group (P = 0.197). The average anastomotic orifice width was 16.1 ± 4.9 mm and 11.7 ± 2.2 mm, respectively (P < 0.001). The incidence of anastomotic stenosis was 2.6% (1/39) and 23.5% (10/42) in the DSA and CSA groups, respectively (P = 0.007). There was no significant difference in surgical duration, blood loss, pulmonary complication, postoperative mortality, time of hospitalisation and time of ICU stay between the two groups.

Conclusions

Delta-shaped anastomosis may be an effective alternative method for gastroesophageal anastomosis after esophagectomy, with lower incidence of leakage and stenosis.

Outcomes of cervical end-to-side triangulating esophagogastric anastomosis with minimally invasive esophagectomy

BACKGROUND

Esophagogastric anastomosis after esophagectomy has been performed with a variety of techniques during the past decade. However, anastomotic leakage and stricture are still important clinical problems after esophagogastric anastomosis, causing burdensome symptoms and poor quality of life. Herein, we describe a novel cervical end-to-side triangulating esophagogastric anastomoasis using linear stapler.

METHODS

A total of 90 patients (85 % male; mean age 63 years) with thoracic esophageal cancer who underwent cervical end-to-side esophagogastric triangular anastomosis using a linear stapler after minimally invasive esophagectomy between November 2006 and April 2013 were retrospectively reviewed.

RESULTS

The median operation time was 602 min (range 424-936 min). The volume of blood loss during the entire operative procedure was 127 ml (range 0-700 ml). There were no cases of anastomotic leakage in this study, although four patients (4.4 %) developed dysphagia associated with benign anastomotic stricture formation. All patients with a benign anastomotic stricture underwent balloon dilation, which resulted in improvement in their symptoms.

CONCLUSIONS

Considering the absence of anastomotic leakage and low rate of anastomotic stricture formation in this study, our modified triangular esophagogastric anastomosis technique appears promising and may contribute to reduced morbidity and mortality rates following esophagectomy.

Cervical triangulating stapled anastomosis: technique and initial experience

OBJECTIVE

To explore the safety and efficacy of modified cervical triangulating stapled anastomosis (TSA) for gastroesophageal anastomosis (GEA) in minimally invasive esophagectomy (MIE).

METHODS

From January 2013 to November 2013, eighty-four patients who underwent three-stage MIE was enrolled. During the cervical stage, either circular stapled (CS) or triangulating stapled (TS) anastomosis was applied for GEA. Clinical features were collected and compared to identify the differences between the two groups.

RESULTS

A total of 84 patients were included in this study. The clinical characteristics were close between the two groups. Intra-operatively, the duration of GEA was close between the two groups (18±3.4 vs. 17±2.7 min, P=0.139). Post-operatively, Cervical anastomotic leakage occurred in one (3.0%) of the 33 TS patients, but in six (11.8%) of the 51 CS patients (P=0.312). The incidence of anastomotic stenosis was 0.0% and 13.7% in the TS and CS groups, respectively (P=0.069). The overall incidence of postoperative complications was significantly lower in TS than that in CS (15.2% vs. 35.3%, P=0.043). There was no difference in the median length of hospital stay or perioperative mortality rate between the two groups.

CONCLUSIONS

TSA is a safe and effective alternative for GEA, which would probably lower the incidence of leakage and stenosis following MIE. Further studies based on larger volumes are required to confirm these findings.