Anastomotic stricture complicating esophagectomy

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.

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.

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).

AGREEMENT BETWEEN UDD APPTM & PROVIDER EVALUATION OF ESOPHAGECTOMY SYMPTOMS IN A MOBILE APP TOOL

BACKGROUND

The objective of this study was to assess the criterion validity of score thresholds for Upper Digestive Disease (UDD) App^TM.

METHODS

From 12/15/2017-12/15/2020, patients presenting after esophagectomy were offered the UDD App^TM concurrent with a provider visit. This tool consists of 67 questions including five novel domains. Score thresholds were used to classify patient as good, moderate, or poor based on domain scores. Providers were given performance descriptions for each domain and asked to classify patients based on their clinical evaluation. The weighted kappa statistic was used to determine the magnitude of agreement between classifications based on the patients' UDD App^TM scores and providers' clinical evaluation.

RESULTS

Fifty-nine patients in the study (76% male), median age 63 [IQR 57, 72] reported outcomes utilizing the UDD app. Providers reviewed between 1-10 patients at a median time of 296.5 days [IQR 50, 975] post-esophagectomy. The magnitude of agreement between patients and providers was moderate for dysphagia (κ= 0.52, p<0.001) and reflux (κ= 0.42, p<0.001). Dumping-related hypoglycemia (κ= 0.03, p=0.148), gastrointestinal complaints (κ= 0.02, p=0.256) and pain (κ= 0.05, p<0.184), showed minimal agreement, with providers underestimating the symptoms and problems reported by patients in these domains.

CONCLUSIONS

Although there was agreement between UDD App^TM assessment and provider evaluation of dysphagia and reflux following esophagectomy, there was discordance of scoring for dumping-related symptoms and pain. Future research is needed to determine whether thresholds for pain and dumping domains need to be revised and/or whether additional provider education on performance descriptions is needed.

Circular Stapler Method for Avoiding Stricture of Cervical Esophagogastric Anastomosis

BACKGROUND

This study was performed to verify the superiority of a new "non-tensioning method" for avoiding stricture of the cervical esophagogastric anastomosis by circular stapling compared with the conventional method.

METHODS

In total, 395 consecutive patients who underwent McKeown esophagectomy with gastric conduit (GC) reconstruction were reviewed. A 4 cm-wide GC was created and pulled up at the cervical site through the retrosternal route. The esophagogastrostomy site of the GC was planned as far caudally as possible on the greater curvature side. In the conventional technique, the stapler was fired while pulling the GC to avoid tissue slack. In the non-tensioning technique, the stapler was fired through the natural thickness of the stomach wall. The length of the blind end was changed from 4 to 2 cm in the non-tensioning technique. Anastomotic leakage and stricture formation were compared between the two techniques, and adjustment was performed using propensity score matching.

RESULTS

The conventional group comprised 315 patients, and the non-tensioning group comprised 80 patients. Anastomotic leakage occurred in 22 (7%) and 2 (2.5%) patients, respectively (P = 0.134) [and in 9 (2.9%) and 2 (2.5%) patients, respectively, if leakage at the blind end was excluded]. Anastomotic stricture occurred in 92 (29.2%) and 3 (3.8%) patients, respectively (P < 0.001). The propensity score-matching analysis including 79 pairs of patients confirmed a lower stricture rate in the non-tensioning than conventional group (2.5% vs. 29.1%, P < 0.001).

CONCLUSIONS

The non-tensioning technique significantly reduced the incidence of anastomotic stricture compared with the conventional technique.

Functional syndromes and symptom-orientated aftercare after esophagectomy

BACKGROUND

Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life.

PURPOSE

The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare.

CONCLUSIONS

Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.

Comparison of the outcomes between total eversion and conventional triangulating stapling technique in cervical esophagogastric anastomosis after esophagectomy: a propensity score-matched analysis

BACKGROUND

Anastomotic leakage and stenosis remain major problems after esophageal reconstruction. This study evaluated the clinical outcomes between the total eversion (TE) triangulating stapling technique (TST) and conventional (C) TST.

METHODS

The study included 404 consecutive patients with esophageal cancer who underwent cervical esophagogastrostomy by TST between January 2013 and December 2018. The postoperative outcomes were compared between TE-TST and C-TST using propensity score-matched analysis.

RESULTS

Before matching, the cT stage and the cTNM stage were different between the groups. After matching, each group consisted of 128 patients. The patients' background characteristics were similar between the groups. Although the incidence of anastomotic leakage was similar between the groups (p = 0.216), anastomotic stricture occurred in 19 (14.8%) and 7 (5.5%) patients in the C-TST and the TE-TST groups, respectively (p = 0.021).

CONCLUSIONS

The incidence of anastomotic stenosis was significantly lower in the TE-TST group than in the C-TST group. TE-TST decreases the incidence of anastomotic stricture and can improve the quality of life in patients undergoing esophagectomy.

Stricture Following Esophageal Reconstruction

Owing to varying clinical definitions of anastomotic stricture following esophageal reconstruction, its reported incidence rate varies from 10% to 56%. Strictures adversely impact patients’ quality of life. Risk factors, such as the anastomosis method, leakage, ischemia, neoadjuvant chemoradiotherapy, and underlying disease have been mentioned, but conflicting information has been reported. Balloon dilation is regarded as a safe and effective treatment method for patients with benign anastomotic strictures. Reoperations are seldom required. The etiology and management of anastomotic strictures are reviewed in this article.

Wide Gastric Conduit Increases the Risk of Benign Anastomotic Stricture After Esophagectomy

BACKGROUND

To identify the association between the width of the gastric conduit and the benign anastomotic stricture (BAS) after esophagectomy with end-to-side cervical anastomosis for esophageal cancer.

METHODS

Patients with esophageal cancer who underwent esophagectomy between July 2013 and July 2014 were included in this study. The gastric conduit was used for reconstruction in all patients and end-to-side cervical anastomosis were performed using a circular stapler. The patients were divided into a narrow group (3-5 cm) and a wide group (>5 cm) based on the gastric conduit width. Univariate and multivariate logistic regressions were used to analyze the possible factors (patients' age, gender, preoperative comorbidities, neoadjuvant chemotherapy, gastric conduit width, anastomotic leakage) that could affect the incidence of BAS.

RESULTS

Two-hundred and one patients were included in this study. The median follow-up period was 29 months (17-58 months). Seven cases (3.5%) showed anastomotic leakage in the postoperative period and 38 patients (18.9%) developed BAS; all within the first year of follow-up. In univariate analysis, the width of the gastric conduit was the only risk factor for the development of BAS (odds ratio [OR] = 3.36, P = .005). In multivariate logistic regression analysis, the wide group was an independent significant risk factor for the development of BAS developing compared with the narrow group (OR = 2.84, P = .02).

CONCLUSIONS

A wide gastric conduit width (>5 cm) is an independent risk factor for the development of BAS after esophagectomy and stapled cervical end-to-side anastomosis for esophageal cancer.

Totally mechanical linear stapled anastomosis for minimally invasive Ivor Lewis esophagectomy: Operative technique and short-term outcomes

BACKGROUND

Anastomosis is one of the important factors affecting anastomotic complications after esophagectomy, and multiple reports have compared anastomotic complications among various techniques. However, there is insufficient evidence in the literature to definitively recommend one anastomotic technique over another.

METHOD

We retrospectively evaluated 34 consecutive patients who underwent an improved totally mechanical side-to-side: posterior-to-posterior linear stapled (TM-STS) technique for minimally invasive Ivor Lewis esophagogastric anastomosis, performed by a single surgeon between February 2015 to November 2017. The operative techniques and short-term outcomes are analyzed in this study.

RESULTS

There were no conversions to an open approach and a complete resection was achieved in all patients undergoing this improved procedure. During the first half of the series, the median operation time was 355 minutes, ranging from 257 to 480 minutes. Over the second half of this series, the median operation time was reduced to 256 minutes. There were no mortalities or serious postoperative complications. Only one patient (2.9%) had an anastomotic leak, which resolved without intervention. Another patient (2.9%) experienced transient, delayed conduit emptying which upper gastrointestinal radiography determined was due to a mechanical obstruction caused by an abnormally long gastric tube in the chest cavity.

CONCLUSIONS

The results of our study suggest that this improved TM-STS technique is safe and effective for minimally invasive Ivor Lewis esophagectomy, and can be considered as one of the alternative procedure for patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma.

Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device

BACKGROUND

Benign oesophageal strictures carry a significant level of morbidity, causing burdensome symptoms impacting on quality of life. Post-oesophagectomy anastomotic stricture rates as high as 41% have been reported in the literature. These can require endoscopic dilatation, often multiple times to relieve dysphagia. The aim of the present study was to determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.

AIM

To determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.

METHODS

We performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesophagectomy performed from 2004-2018 to determine the stricture rate. The database comprised a single-surgeon series of open, two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis. Tumour location, histology, neoadjuvant chemotherapy, stapler size, T-stage and R-status were analysed to see if they could predict stricture formation. Stricture was defined as dysphagia requiring endoscopic dilatation. Patients with anastomotic leaks were excluded on the basis they would develop an anastomotic stricture.

RESULTS

One hundred and seventy patients were collected in the database. Nineteen were excluded on the basis of anastomotic leak, perioperative death and early recurrence. One hundred and fifty-four patients (119 males, 35 females) with a mean age of 64 ± 10 years were eligible for analysis. A total of 15 patients developed strictures a median of 99 d (interquartile range: 84-133) after surgery, giving a Kaplan-Meier estimated stricture rate of 10% at one year. None of the factors considered were found to be significantly associated with strictures.

CONCLUSION

In this study the stricture rate was 10%, with the majority occurring in the first 100 d after surgery. No significant independent factors were found in the development of strictures.

Long-term quality of life after endovac-therapy in anastomotic leakages after esophagectomy

Background

Endoluminal vacuum therapy (EVT) has been successfully established with promising survival rates in the treatment of anastomotic leakages after esophagectomy. It is still unclear how this therapy affects health related quality of life (HRQOL).

Methods

HRQOL was prospectively assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30) questionnaire. Assessment was carried out prior to surgery, after discharge, 6 months and 12 months after surgery. We compared HRQOL after EVT (n=23) to patients without anastomotic leakages as a control group (n=50). Investigated parameters included age, sex, and localization of anastomosis, number of EVT sessions, length of ICU and hospital stay, therapy failure, anastomotic stricture, tumour stage, neoadjuvant and adjuvant treatment, sepsis.

Results

After esophagectomy HRQOL increased within 12 months. Compared to patients without leakages the EVT-group showed significantly better HRQOL-scores for pain, social and emotional functioning after discharge and 6 months after surgery. In the long-term follow up HRQOL was comparable between the groups. After EVT age, advanced tumour stage, tumour recurrence, anastomotic strictures, length of ICU and hospital stay and length of EVT had a significant influence on HRQOL.

Conclusions

EVT is a promising therapeutic option in leakages after esophagectomy. In the long-term, HRQOL of EVT-treated patients is comparable to patients, who did not suffer from postsurgical leakages.

Comparison of OrVil™ and RPD in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) is frequently performed for treating patients with gastric cancer; however, the absence of anastomotic techniques with greater superiority has impaired its popularization. We have compared two types of anastomotic techniques with regard to technical perspectives and clinical outcomes.

METHODS

We reviewed 43 patients with gastric cancer who underwent LTG. Two types of anastomotic techniques have been applied after LTG-the trans-orally inserted anvil (OrVil™) and the reverse puncture device (RPD). Data on the type of anastomosis, blood loss, operation time, anastomosis time, location of tumors, distance between the top border of tumors and top resection margin, diameter of tumor, length of postoperative hospital stay, early and late postoperative complications, and total cost of surgical consumables were obtained by reviewing patient medical records and analyzed thereafter.

RESULTS

We included 32 men and 11 women (mean age 61 years). The loss to follow-up rate was 13.2%. The median survival time for the OrVil™ and RPD groups was 23 and 22 months, respectively. The total rate of complications was 9.3%. The difference in the anastomosis times between the groups was statistically significant. OrVil™ required more time than RPD and cost more than RPD.

CONCLUSIONS

Both the OrVil™ and RPD techniques showed good safety and applicability in LTG. RPD showed an advantage with regard to lesser operative complexity and lower cost.

[Management of delayed complications after esophagectomy]

Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.

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.

The effect of disc-shaped gastric resection of anastomosis site on reducing postoperative dysphagia and stricture after esophagogastric anastomosis in patients with esophageal cancer

Background: Esophagectomy remains the most reliable technique for managing esophageal cancer, but anastomotic complications including postoperative leak, ischemia and stricture negatively affect outcomes of this specific surgery. The aim of this study was to evaluate the effects of a novel method of esophagogastric anastomosis for reducing postoperative dysphagia and stricture formation.

Methods: Eighty patients who were scheduled for esophagectomy due to esophageal cancer were randomly assigned into two groups: intervention and control (40 each). In the control group, the esophagogastric anastomosis was performed with a linear gastric incision, whilst in the intervention group a new method of disc-shaped gastric resection for anastomosis was applied. Postoperative outcomes were compared between the two groups.

Results: The incidence of postoperative dysphagia and anastomotic stricture was significantly lower in the disc-shaped resection group (dysphagia 45% vs 75%, P = 0.02; stricture 12.5% vs 32.5%, P = 0.03), whilst the length of stay in an intensive care unit (ICU), anastomotic leakage and other complications were not significantly different between the two groups (all P > 0.05).

Conclusion: Anastomotic complications can be reduced by improving surgical techniques. The decreased incidence of postoperative dysphagia and anastomotic stricture in our study may be partly due to providing the proper diameter for the site of anastomosis when using the disc-shaped gastric resection method. Hence, this new method can improve the clinical outcomes of patients who undergo esophagectomy with esophagogastric anastomosis.

Comparison of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis

Objective

In this meta-analysis, we conducted a pooled analysis of clinical studies comparing Linear Stapled (LS) versus Circular Stapled (CS) esophagogastric anastomosis for esophageal cancer.

Methods

According to the recommendations of the Cochrane Collaboration, we established a rigorous study protocol. We performed a systematic electronic search of the PubMed, Embase, Cochrane Library, Web of Science, and Chinese Biomedical databases as well as Chinese scientific journals to identify articles to include in our meta-analysis. The primary outcomes compared were anastomotic leak, anastomotic stricture and 3-month mortality.

Results

Five controlled trials comprising 840 patients (523 LS vs. 317 CS) were included. Primary outcomes revealed a statistically significant decrease in anastomotic strictures [risk ratio (RR): 0.26, 95 % confidence interval (CI): 0.11–0.60, P = 0.002] compared with linear stapled anastomosis. However, there were no significant differences between the two groups with respect to anastomotic leakage [risk ratio (RR): 0.80, 95 % confidence interval (CI): 0.40–1.58, P = 0.52] and 3-month mortality [risk ratio (RR): 0.94, 95 % confidence interval (CI): 0.47–1.87, P = 0.85].

Conclusion

There were no statistical differences in the rate of 3-month mortality or anastomotic leakage between the two groups. However, the LS method contributed to a reduced rate of anastomotic strictures. This meta-analysis may offer some specific suggestions for esophagogastric anastomosis.

A prospective randomized controlled trial of semi-mechanical versus hand-sewn or circular stapled esophagogastrostomy for prevention of anastomotic stricture

BACKGROUND

Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture.

METHODS

Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤ 0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter.

RESULTS

The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar.

CONCLUSIONS

Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.

The novel use of intraoperative laser-induced fluorescence of indocyanine green tissue angiography for evaluation of the gastric conduit in esophageal reconstructive surgery

BACKGROUND

Esophagectomy with reconstruction using a gastric conduit is associated with a relatively high rate of anastomotic leakage. We used indocyanine green tissue angiography to evaluate the gastric conduit intraoperatively before gastroesophageal anastomosis to identify ischemia.

METHODS

We performed an institutional review board-approved retrospective review of all esophagectomies performed from 2010 to the beginning of 2011. Patient histories and perioperative outcomes were reviewed retrospectively. Postoperative morbidity and 30-day mortality were determined.

RESULTS

Eleven patients had an esophagectomy performed using this technology. All had adequate perfusion on gross examination. All but 1 had good perfusion with tissue angiography, and there were 2 anastomotic leakages leaks including this patient. There were no mortalities at 30 days.

CONCLUSIONS

We report preliminary results using this imaging system in esophageal reconstructive surgery. Larger randomized controlled studies are needed to determine if surgical outcomes can be improved using this technology.

Cell reactions in gastric tube and colon transplants in stenoses of esophageal anastomosis

We studied morphological and cell characteristics of stenosis of esophagogastric and esophagocolonic anastomosis. It was demonstrated that sclerogenesis in the gastric transplants is associated with hypertrophy of leiomyocytes, hyperelastosis foci, degenerative and atrophic modifications of the glands, and foveolar cell hypersecretion. In colonic transplant, collagen synthesis predominates in the esophageal anastomosis and can be associated with proliferation of blood capillaries; hyperplastic reactions of leiomyocytes and elastic fibers are minor, colonocytes exhibit high secretory activity. Differences in the cell reactions of the transplants reflect complex character of the formation of esophageal anastomosis stenosis.

Linear-stapled versus circular-stapled laparoscopic gastrojejunal anastomosis in morbid obesity: meta-analysis

BACKGROUND

The study aims to provide a pooled analysis of individual small trials comparing linear-stapled versus circular-stapled laparoscopic gastrojejunal (GJ) anastomosis in morbid obesity surgery.

METHODS

A systematic literature search of Medline, Embase, and Cochrane library databases was performed. Primary outcomes were GJ leak and stricture. Secondary outcomes were operative time, length of hospital stay, postoperative bleeding, wound infection, marginal ulcers, and estimated weight loss. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes.

RESULTS

Nine trials were included comprising 9374 patients (2946 linear vs. 6428 circular). Primary outcome analysis revealed a statistically significant increase in the rate of GJ stricture associated with circular-stapled anastomosis. A significantly reduced rate of wound infection, bleeding, and operative time associated with linear stapling was also found. No significant differences appeared for the other outcomes.

CONCLUSIONS

This pooled analysis recommends the preferential use of the linear stapling technique over circular stapling.

Impact of anastomotic leak on outcomes after transhiatal esophagectomy

BACKGROUND

The development of anastomotic leaks and/or strictures can be associated with considerable morbidity and impairment of quality of life. In the current study, we evaluated the outcomes of patients who developed anastomotic complications after esophagectomy to elucidate the impact of these events on morbidity, mortality, and subsequent need for dilation.

METHODS

We analyzed retrospectively the clinical course of 235 patients who underwent transhiatal esophagectomy for cancer from 2001 to 2009. Patients with confirmed anastomotic leaks were identified and classified with the following scale: class 1: Radiographic leak only, no intervention; class 2: leak requiring opening of the wound, cervical and/or percutaneous drainage; class 3: disruption of anastomosis (10-50% circumference) with perianastomotic abscess requiring video-assisted thoracoscopic surgery or thoracotomy; and class 4: gastric tip necrosis with anastomotic separation (>50% circumference).

RESULTS

Anastomotic leaks were encountered in 30 patients (13%). Anastomotic leaks were associated with greater morbidity (70% vs 47%; P = .02) and stricture formation (57% vs 19%; P = .0001). Mortality was not different. Increasing leak class was associated with an increased need for postoperative anastomotic dilations (P = .016).

CONCLUSION

Anastomotic integrity after esophagectomy has a substantial impact on perioperative course and long-term swallowing. A more formal radiographic and endoscopic leak classification system seems justified.

Comparison of anastomotic leakage and stricture formation following layered and stapler oesophagogastric anastomosis for cancer: a prospective randomized controlled trial

The objective of this prospective, randomized, controlled trial, conducted from May 2002 to December 2007, was to compare post-operative anastomotic leakage and stricture formation following layered manual versus stapler oesophagogastric anastomosis in patients who underwent resection of oesophageal or gastric cardia carcinoma. Patients (n = 516) were randomized to receive either layered manual or circular stapled oesophagogastric anastomosis. Mean follow-up time was > 12 months. Anastomotic leakage occurred in one (0.4%) patient in the layered group and six (2.2%) in the stapler group; no statistically significant between-group difference. After operation, two (0.8%) patients in the layered group and 13 (5.0%) in the stapler group developed a benign oesophageal stricture; the difference between the groups was statistically significant. Compared with stapler anastomosis, layered manual anastomosis may significantly reduce the incidence of anastomotic strictures. This method is easy to apply and could be used as an alternative procedure for oesophagogastric anastomosis after resection for oesophageal or cardia carcinoma.

Outcomes after esophagectomy in patients with prior antireflux or hiatal hernia surgery

BACKGROUND

Esophagectomy is indicated occasionally for the treatment of patients with refractory gastroesophageal reflux disease (GERD) or recurrent hiatus hernia. The purpose of this study was to evaluate the impact of previous gastroesophageal operations on outcomes after esophagectomy for recurrent GERD or hiatus hernia.

METHODS

Using a prospectively accumulated database, a retrospective review was performed to identify patients undergoing esophagectomy for complicated GERD or hiatus hernia. Mortality, perioperative and functional outcomes, and need for reoperation were evaluated, assessing esophagectomy patients who had undergone prior operations for GERD or hiatus hernia.

RESULTS

Of 258 patients with GERD or hiatus hernia undergoing esophagectomy, 104 had undergone a previous operation, with a median interval to esophagectomy of 28 months. Transhiatal resection was accomplished in fewer patients undergoing reoperation (87 of 104 versus 151 of 154; p<0.005). A gastric conduit was used as an esophageal replacement in fewer patients with previous operation(s) (89 of 104 versus 150 of 154; p<0.005). Esophagectomy patients with a history of prior gastroesophageal surgery, as compared with those without, sustained more blood loss and were more likely to require reoperation, and fewer reported good to excellent swallowing function (p<0.05). There was no difference in the occurrence of anastomotic leak.

CONCLUSIONS

Esophagectomy in patients who have undergone prior operations for either GERD or hiatus hernia can be accomplished without thoracotomy and with satisfactory intermediate-term quality of life. Such patients should be evaluated and prepared for the use of alternative conduits should the remobilized stomach prove to be an unsatisfactory esophageal substitute at the time of esophagectomy.

Circular- vs. linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Different surgical techniques have been developed for the gastrojejunostomy (GJS) in laparoscopic Roux-en-Y gastric bypass (LRYGBP) with the anastomosis performed in a circular-stapled, linear-stapled, or totally hand-sewn way. No technique seems superior to the other as no consistent data on weight loss or complication rates were described.

METHODS

A matched-pair study was conducted including a total of 150 patients, who underwent primary antegastric, antecolic LRYGBP between August 2003 and February 2007. Early weight loss and the incidence of GJS strictures or leaks and wound infections were compared between circular-stapled anastomosis (CSA) and linear-stapled anastomosis (LSA). Both groups were matched for age, sex, and body mass index.

RESULTS

Excess weight loss at 3 months was slightly better with the CSA (p = 0.002) and comparable thereafter. Percentage of excess weight loss at 6, 12, and 24 months was 55.9 +/- 17.5% vs. 51.2 +/- 14.5%, 69.5 +/- 20.9% vs. 71.4 +/- 22.6%, and 70.8 +/- 22.4% vs. 73.2 +/- 23.4%, respectively (CSA vs. LSA). Strictures at the GJS were found only in the CSA group (n = 4), and leaks were found in one patient of the CSA group. More wound infections were observed in patients of the CSA group (ten vs. one).

CONCLUSIONS

CSA and LSA lead to comparable early weight loss in LRYGB. Thus, the technique is the surgeon's choice. In CSA, a higher incidence of GJS strictures and wound infections was observed. As weight regain following LRYGBP is commonly observed after at least 3 years, a longer follow-up is needed to compare the incidence of weight regain in circular- vs. linear-stapled GJS.

Esophagectomy for the treatment of esophageal cancer

Esophageal cancer is an aggressive disease with an overall poor prognosis. Esophagectomy remains a key therapeutic option in treating patients who have this disease. Tailoring the surgical approach to the patient and the nature of his or her malignancy is essential. Over time, advances in staging, preoperative assessment, operative techniques, and postoperative care have resulted in decreased operative mortality and better long-term outcomes.

An exceptional postoperative gastric tube bleeding after esophageal resection for cancer

A case of gastric tube bleeding after an Ivor-Lewis esophagectomy with gastroesophageal anastomosis is reported. During the early postoperative course, the patient had a gastric tube stasis that improved progressively. The subsequent onset of a serious and intermittent hematemesis, which was endoscopically deemed to be the result of a hemorrhagic gastritis, required multiple blood transfusions. The evolution to a severe hemodynamic instability obliged us to reoperate on the patient. During surgery, a band-related obstruction of the first jejunal loop with local signs of vascular hypertension was noted. As soon as the obstruction was solved, the gastric bleeding stopped. The authors discuss the clinical aspects and physiopathology of the gastric tube bleeding and, in particular, they evaluate the influence of the intestinal obstruction with vascular involvement on the development of this exceptional and severe complication.

Management of the cervical esophagogastric anastomotic stricture

Esophagogastric anastomotic stricture following esophagectomy with a gastric esophageal substitute can be a vexing problem for the patient and treating physician. We describe the clinical practice at a single center with extensive experience in esophageal surgery for management of this complication.