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Goto H, Oshikiri T, Koterazawa Y, Sawada R, Ikeda T, Harada H, Urakawa N, Hasegawa H, Kanaji S, Yamashita K, Matsuda T, Kakeji Y. The totally mechanical Collard technique for cervical esophagogastric anastomosis reduces anastomotic stricture compared with triangular anastomosis in minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route: a propensity score-matched study. Esophagus 2024:10.1007/s10388-024-01088-2. [PMID: 39269559 DOI: 10.1007/s10388-024-01088-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 09/02/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Cervical esophagogastric anastomosis is conventionally performed using the McKeown esophagectomy. However, an optimal anastomotic technique has not yet been established. This study aimed to compare the clinical outcomes of triangular anastomosis (TA) and totally mechanical Collard anastomosis (TMCA) for cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route. METHODS In this matched- cohort study, 117 patients who underwent minimally invasive esophagectomy between 2019 and 2024 were divided into TA and TMCA groups. The TA technique was performed between September 2019 and December 2021, and the TMCA technique was performed between January 2022 and January 2024. We then compared the surgical outcomes and postoperative complications (pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, and stricture) between the two groups. RESULTS Propensity score matching revealed that 40 patients were included in both the TA and TMCA groups. The rates of pneumonia, recurrent laryngeal nerve palsy, and anastomotic leakage were not significantly different between the two groups. However, the rate of anastomotic stricture was lower in the TMCA than in the TA group (2.5% vs. 27.5%, respectively, P = 0.003). CONCLUSIONS Compared with the TA technique, the TMCA technique reduced the rate of anastomotic stricture when performing cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.
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Affiliation(s)
- Hironobu Goto
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery and Surgical Oncology, Graduate School of Medicine, Ehime University, Shitsukawa 454, Toon, Ehime, 791-0295, Japan
| | - Yasufumi Koterazawa
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Ryuichiro Sawada
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Taro Ikeda
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hitoshi Harada
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Naoki Urakawa
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Takeru Matsuda
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
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Huang Y, Xie Q, Wei X, Shi Q, Zhou Q, Leng X, Miao Y, Han Y, Wang K, Fang Q. Enhanced Recovery Protocol Versus Conventional Care in Patients Undergoing Esophagectomy for Cancer: Advantages in Clinical and Patient-Reported Outcomes. Ann Surg Oncol 2024; 31:5706-5716. [PMID: 38833056 DOI: 10.1245/s10434-024-15509-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 05/09/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND This study was designed to compare the clinical and patient-reported outcomes (PROs) between the enhanced recovery after surgery (ERAS) protocol and conventional care in patients undergoing esophagectomy for cancer, which have not previously been compared. METHODS This single-center retrospective study included prospective PRO data from August 2019 to June 2021. Clinical outcomes included perioperative complications and postoperative length of stay (PLOS). Patient-reported outcomes were assessed by using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (QLQ-C30) and esophagus-specific module (QLQ-OES18) preoperatively to 6 months postoperatively. Mixed-effects models were used to longitudinally compare quality of life (QOL) scores between the two modes. RESULTS Patients undergoing conventional care and ERAS were analyzed (n = 348 and 109, respectively). The ERAS group had fewer overall complications, pneumonia, arrhythmia, and a shorter PLOS than the conventional group, and outperformed the conventional group in five functional QLQ-C30 domains and five symptom QLQ-OES18 domains, including less dysphagia (p < 0.0001), trouble talking (p = 0.0006), and better eating (p < 0.0001). These advantages persisted for 3 months postoperatively. For the cervical circular stapled anastomosis, the initial domains and duration of benefit were reduced in the ERAS group. CONCLUSIONS The ERAS protocol has significant advantages over conventional care in terms of clinical outcomes, lowering postoperative symptom burden, and improving functional QOL in patients who have undergone esophagectomy. Selection of the optimal technique for cervical anastomosis is a key operative component of ERAS that maintains the symptom domains and duration of the advantages of PROs.
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Affiliation(s)
- Yixuan Huang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Qin Xie
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Xing Wei
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Qiuling Shi
- School of Public Health, Chongqing Medical University, Chongqing, China
| | - Qiang Zhou
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Xuefeng Leng
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Yan Miao
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Yongtao Han
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China
| | - Kangning Wang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China.
| | - Qiang Fang
- Department of Thoracic Surgery, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of the University of Electronic Science and Technology of China, Chengdu, China.
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Lin J, Rooney DM, Yang SC, Antonoff M, Jaklitsch MT, Pickens A, Ha JS, Sudarshan M, Bribriesco A, Zapata D, Weiss K, Johnson C, Hennigar D, Orringer MB. Multi-institutional beta testing of a novel cervical esophagogastric anastomosis simulator. JTCVS Tech 2024; 25:254-263. [PMID: 38899103 PMCID: PMC11184443 DOI: 10.1016/j.xjtc.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/21/2023] [Accepted: 12/10/2023] [Indexed: 06/21/2024] Open
Abstract
Objective A novel simulator developed to offer hands-on practice for the stapled side-to-side cervical esophagogastric anastomosis was tested previously in a single-center study that supported its value in surgical education. This multi-institutional trial was undertaken to evaluate validity evidence from 6 independent thoracic surgery residency programs. Methods After a virtual session for simulation leaders, learners viewed a narrated video of the procedure and then alternated as surgeon or first assistant. Using an online survey, perceived value was measured across fidelity domains: physical attributes, realism of materials, realism of experience, value, and relevance. Objective assessment included time, number of sutures tearing, bubble test, and direct inspection. Comparison across programs was performed using the Kruskal-Wallis test. Results Surveys were completed by 63 participants as surgeons (17 junior and 20 senior residents, 18 fellows, and 8 faculty). For 3 of 5 tasks, mean ratings of 4.35 to 4.44 correlated with "somewhat easy" to "very easy" to perform. The interrupted outer layer of the anastomosis rated lowest, suggesting this task was the most difficult. The simulator was rated as a highly valuable training tool. For the objective measurements of performance, "direct inspection" rated highest followed by "time." A total of 90.5% of participants rated the simulator as ready for use with only minor improvements. Conclusions Results from this multi-institutional study suggest the cervical esophagogastric anastomosis simulator is a useful adjunct for training and assessment. Further research is needed to determine its value in assessing competence for independent operating and associations between improved measured performance and clinical outcomes.
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Affiliation(s)
- Jules Lin
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | - Deborah M. Rooney
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Mich
| | - Stephen C. Yang
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | - Mara Antonoff
- Department of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, Tex
| | | | - Allan Pickens
- Department of Thoracic Surgery, Vanderbilt University Hospital, Nashville, Tenn
| | - Jinny S. Ha
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | | | | | - David Zapata
- Division of Cardiothoracic Surgery, University of Maryland, Baltimore, Md
| | - Kathleen Weiss
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Christopher Johnson
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md
| | | | - Mark B. Orringer
- Section of Thoracic Surgery, University of Michigan Medical School, Ann Arbor, Mich
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Qureshi S, Khan S, Waseem HF, Shafique K, Abdul Jalil H, Quraishy MS. Three-staged minimally invasive esophagectomy with end-to-end esophago-gastric anastomosis for thoracic esophageal cancers: An experience from a low middle-income country. Asian J Surg 2024; 47:425-432. [PMID: 37777408 DOI: 10.1016/j.asjsur.2023.09.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 08/16/2023] [Accepted: 09/14/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Esophageal cancer is on a steady rise and carries significant mortality and morbidity. Depending upon the clinical stage at presentation, either chemotherapy, radiotherapy with or without surgical resection is the treatments in practice. Traditionally, open esophagectomy was performed but over time, the importance of minimally invasive esophagectomy has been established. In this study, we aimed to report our data of totally minimally invasive esophagectomies performed for thoracic esophageal cancers in last four years. METHODOLOGY A prospective cross-sectional study was conducted at the Department of Upper GI Surgery, Dow University of Health Sciences, Karachi. All diagnosed cases of esophageal carcinoma undergoing minimally invasive esophagectomy, from 2019 to 2022 were included in this study. Outcomes measured were operative time, intra operative complications, conversion rate to open, postoperative complications, number of lymph nodes harvested, margin clearance, in-hospital mortality and 90-days mortality. RESULTS A total of 53 cases were included in the study, the most prevalent histological type was squamous cell carcinoma 42(79.2%) as compared to adenocarcinoma 8(15.1%). Most common tumor site was lower thoracic esophagus (30-38 cm) in 20 (56.6%) cases. Neo-adjuvant chemotherapy was given in all 53(100%) cases, whereas neo-adjuvant radiation therapy was offered to 49(92.5%) patients. There was a significant and favorable patient response to the neo-adjuvant treatment in 37(69.8%) cases, leading to a decrease in tumor size. Laparoscopic McKeown Esophagectomies were performed in 44 (83.0%) and 9(17.0%) were Robot-assisted Minimally Invasive esophagectomy (RAMIE). Intraoperative injuries (i.e., lung parenchymal injury and bleeding) were reported in only 2(3.8%) patients. Post-operative complications were recorded in 12(22.6%) patients. Margin clearance was observed in 53 (100%) of the patients. The 90-day mortality rate was 3(5.7%), one due to bleeding and other two mortalities were due to COVID related respiratory complications. CONCLUSION Minimally invasive esophagectomy was found to be safe and feasible technique with encouraging results in terms of decreased intraoperative and post operative complications as well as achieving the standard oncological surgery with acceptable lymph node yield and margin clearance and in hospital and 90 days mortality.
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Affiliation(s)
- Sajida Qureshi
- Dow Medical College, Dow University of Health Sciences, Pakistan.
| | - Sumayah Khan
- Dow Medical College, Dow University of Health Sciences, Pakistan.
| | | | - Kashif Shafique
- School of Public Health, Dow University of Health Sciences (DUHS) Director, Office of Research, Innovation & Commercialization, DUHS Dow University of Health Sciences, Pakistan.
| | - Hira Abdul Jalil
- Department of Surgery Dow Medical College, Dow University of Health Sciences, Pakistan.
| | - M Saeed Quraishy
- Dow Medical College, Dow University of Health Sciences, Pakistan.
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Laios K, Apostolou KG, Vavlas A, Ntousopoulos A, Chrysikos D, Troupis T, Karamanou M, Schizas D. The history of esophageal surgery. Acta Chir Belg 2023; 123:712-723. [PMID: 37667664 DOI: 10.1080/00015458.2023.2254604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/29/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Esophageal surgery has always been considered extremely demanding, given the surgical experience and skills required, due to the anatomic location of the esophagus as well as the impact of such extensive operations on patients' homeostasis. The intention of the present study is to review all historical time points of esophageal surgery, from its inception to the modern era of minimally invasive esophageal surgery. METHODS The first clear description of esophageal surgery is dated back to 1738, in an attempt to remove a foreign body from the thoracic esophagus. However, the high morbidity and mortality rates of esophageal surgical operations led to the invention and application of less invasive surgical procedures. RESULTS Esophageal surgery has evolved from extensive surgical operations to minimally invasive esophagectomies, aiming exclusively to reduce perioperative morbidity and mortality, while maintaining surgical effectiveness. Despite the fact that benign esophageal pathologies were the main stimulus for this evolution, minimally invasive esophageal surgery is now applied even in patients with esophageal cancer, with outcomes comparable to those of traditional surgical approaches. CONCLUSION It would be interesting to see how all these new surgical techniques may evolve, altering further the current status of esophageal surgery in the future.
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Affiliation(s)
- Konstantinos Laios
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Konstantinos G Apostolou
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Alexios Vavlas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Aggelos Ntousopoulos
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimosthenis Chrysikos
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Troupis
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Karamanou
- Department of History of Medicine and Medical Ethics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Gu HY, Luo J, Qiang Y. Postoperative complications analysis of circular stapled versus linear stapled anastomosis for patients undergoing esophagectomy: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:242. [PMID: 37559141 PMCID: PMC10413733 DOI: 10.1186/s13019-023-02309-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 06/28/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The choice of anastomosis technique after esophagectomy is closely associated with the postoperative complications. Whether circular stapled or linear stapled anastomosis is the optimal technique has not been established. Therefore, we conducted this meta-analysis to show the latest and most comprehensive published assessment of circular stapled anastomosis in comparison with linear stapled anastomosis in postoperative complications. METHODS Databases (PubMed, Embase, Web of science, Cochrane Library) were searched for all randomized controlled trials and comparative studies comparing circular stapled anastomosis with linear stapled anastomosis after esophagectomy. The odd ratio and mean difference with 95% confidence interval were calculated. We used the Higgins I² statistics to assess the statistical heterogeneity between studies. Review manager (version 5.4) software was used in this analysis. RESULTS Sixteen studies with 2322 patients were included in our study. The study demonstrated that the use of linear stapled technique after esophagectomy could reduce the risk of both anastomotic leakage (P = 0.0003) and stricture (P < 0.00001) compared with circular stapled technique. Stratification by anastomotic site showed that no matter what kind of anastomotic site (cervical or thoracic anastomosis) was used, linear stapled anastomosis could effectively reduce the anastomotic stricture in comparison with circular stapled anastomosis. Moreover, linear stapled anastomosis could decrease the risk of thoracic anastomotic leakage. There were no significant differences between circle stapled anastomosis and linear stapled anastomosis in reflux esophagitis (P = 0.17), pneumonia (P = 0.91), operation time (P = 0.41) and hospital stay (P = 0.38). CONCLUSIONS The study suggested that linear stapled anastomosis could be considered to be an optimal treatment associated with a reduced risk of anastomotic leakage and stricture in comparison with circular stapled anastomosis.
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Affiliation(s)
- Hao-Yu Gu
- Medical College, Nantong University, Nantong City, Nantong, 226000, Jiangsu, P.R. China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Nanjing Jinling Hospital, East Region Military Command General Hospital, Nanjing, 210000, Jiangsu, P.R. China.
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Nanjing Jinling Hospital, East Region Military Command General Hospital, Nanjing, 210000, Jiangsu, P.R. China.
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Martre P, Chati R, Schwarz L, Wood G, Logeay M, Grognu A, Tuech JJ, Huet E. Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients. J Visc Surg 2023; 160:196-202. [PMID: 36333184 DOI: 10.1016/j.jviscsurg.2022.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy. METHODS This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis. RESULTS Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality. CONCLUSION The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.
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Affiliation(s)
- P Martre
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - R Chati
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - L Schwarz
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - G Wood
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - M Logeay
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - A Grognu
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
| | - J-J Tuech
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France.
| | - E Huet
- Digestive Surgery Department, CHU Rouen, 76031 Rouen cedex, France
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Na B, Kang CH, Na KJ, Park S, Park IK, Kim YT. Risk Factors of Anastomosis Stricture After Esophagectomy and the Impact of Anastomosis Technique. Ann Thorac Surg 2023; 115:1257-1264. [PMID: 36739069 DOI: 10.1016/j.athoracsur.2023.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/03/2022] [Accepted: 01/08/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Anastomosis complications after esophagectomy are related to postoperative survival and quality of life. This is a retrospective observational study to identify risk factors for anastomotic stricture after esophageal cancer surgery and the effect of different anastomosis techniques on stricture development. METHODS This study included 737 patients who underwent esophagectomy for esophageal cancer that used stomach conduits. Four types of anastomoses were used: manual sewing (n = 221, 30%), circular stapling (n = 172, 23%), hybrid linear stapling with a 45-mm stapler (HLS; n = 155, 21%), and triangular linear stapling with 60-mm staplers (TLS; n = 189, 26%). Multivariate analysis was performed to evaluate the risk factors for stricture. RESULTS Strictures that required endoscopic dilatation within 1 year after surgery occurred in 105 patients (14%), and 13% of the strictures were related to leakage. Multivariate analysis revealed that chronic obstructive pulmonary disease (hazard ratio [HR] 1.726, P = .017), leakage (HR 2.502, P = .015), and anastomosis techniques other than TLS (manual sewing: HR 9.588; circular stapling: HR 6.516; HLS HR 5.462, all P < .001) were significant risk factors for stricture. TLS significantly reduced the stricture rate (3.2%) compared with other techniques (manual sewing: 22.2%; circular stapling:, 14.5%; HLS: 16.1%; P < .001). Stricture rate was lower in the TLS group in patients without leakage (P < .001); however, the effect disappeared with leakage. CONCLUSIONS Anastomosis stricture occurred in 14% of esophagectomy patients. Chronic obstructive pulmonary disease, leakage, and anastomosis technique are risk factors for stricture. A large anastomosis area with the TLS technique using 60-mm length linear staplers prevented stricture, especially when leakage was not observed.
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Affiliation(s)
- Bubse Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea; Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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9
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Totally mechanical Collard versus circular stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy. Surg Endosc 2023; 37:891-901. [PMID: 36038647 DOI: 10.1007/s00464-022-09551-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
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.
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10
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Chen B, Xia P, Tang W, Huang S. Which Anastomotic Techniques Is the Best Choice for Cervical Esophagogastric Anastomosis in Esophagectomy? A Bayesian Network Meta-Analysis. J Gastrointest Surg 2023; 27:422-432. [PMID: 36417036 DOI: 10.1007/s11605-022-05482-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 09/24/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The optimal choice of anastomotic techniques for cervical esophagogastric anastomosis in esophagectomy remains unclear. METHODS An electronic literature search of PubMed, Embase, and Web of Science (data up to April 2022) was conducted and screened to compare hand sewn (HS), circular stapling (CS), side-to-side linear stapling (LS), and triangulating stapling (TS) for cervical esophagogastric anastomosis. Anastomotic leak, pulmonary complications, anastomotic stricture, and reflux esophagitis of the 4 anastomotic techniques were evaluated using a Bayesian network meta-analysis by R. RESULT Twenty-nine studies were ultimately included, with a total of 5,020 patients from 9 randomized controlled trials, 7 prospect cohort studies, and 13 retrospective case-control studies in the meta-analysis. The present study demonstrates that the incidence of anastomotic leakage is lower in TS than HS and CS (TS vs. HS: odds ratio (OR) = 0.32, 95% CI: 0.1 to 0.9; TS vs. CS: OR = 0.37, 95% CI: 0.13 to 1.0), and the incidence of anastomotic stricture is lower in TS than in HS and CS (TS vs. HS: OR = 0.32, 95% CI: 0.11 to 0.86; TS vs. CS: OR = 0.23, 95% CI: 0.08 to 0.58). TS ranks best in terms of anastomotic leakage, pulmonary complication, anastomotic stricture, and reflux esophagitis. CONCLUSION TS for cervical esophagogastric anastomosis of esophagectomy had a lower incidence of anastomotic leakage and stricture. TS should be preferentially recommended. Large-scale RCTs will be needed to provide more evidence in future studies.
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Affiliation(s)
- Boyang Chen
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Putian University, Putian, 351100, China.
| | - Ping Xia
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardiothoracic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Weifeng Tang
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardiothoracic Surgery, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, China
| | - Shijie Huang
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Putian University, Putian, 351100, China
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11
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Flamey N, Lesaffer J, De Loof H, Lissens P, Mandeville Y. Centralisation of oesophageal cancer services: experiences and outcomes of the first year of implementation at a Belgian non-academic teachinghospital. Acta Chir Belg 2023; 123:31-35. [PMID: 33990166 DOI: 10.1080/00015458.2021.1930460] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Oesophageal surgery recently became centralised in Belgium. This study aims to evaluate surgical outcomes and service delivered one year after implementation of centralisation. PATIENTS AND METHODS All patients undergoing an oesophagectomy between the start of the centralisation; 1st of June 2019 and 31st of May 2020, were included from a prospectively maintained database. RESULTS 53 patients (41 male, 12 female) underwent an oesophagectomy during the study period. Most oesophagectomies were performed through an open left thoracoabdominal approach (64.2%), 30.2% via a minimally invasive approach and hybrid approaches were carried out in 5.7% of patients. In this study population, the 30 day mortality rate was 0% and the 90 day mortality rate was 3.8%, equating to 2 deaths. The overall 30 day readmission rate was 7.5%. Clinically significant anastomotic leaks occurred in 4 patients, (7.5%). Pneumonia and atrial fibrillation were the most frequent complications, both having a prevalence of 32.1%. The median length of stay was 11 days (IQR 9.5-14.5). CONCLUSION The results from our centre are comparable to those from international registers which demonstrate that centralisation of complex cancer services can be safely implemented.
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Affiliation(s)
- Nicolas Flamey
- Department of Abdominal Surgery, AZ Delta, Roeselare, Belgium
| | - Jan Lesaffer
- Department of Abdominal Surgery, AZ Sint Jan, Bruges, Belgium
| | - Hans De Loof
- Department of Abdominal Surgery, AZ Delta, Roeselare, Belgium
| | - Peter Lissens
- Department of Abdominal Surgery, Sint-Andriesziekenhuis, Tielt, Belgium
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12
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Fujimoto D, Taniguchi K, Takashima J, Miura F, Kobayashi H. Hybrid esophagogastric tube anastomosis after minimally invasive McKeown esophagectomy to prevent stenosis in patients with esophageal cancer. Langenbecks Arch Surg 2023; 408:7. [PMID: 36597004 DOI: 10.1007/s00423-022-02743-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 10/27/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE The use of a small circular stapler has been reported to increase the incidence of benign anastomotic stenosis in reconstruction. In circular stapling anastomosis after esophagectomy, the anastomotic lumen is dependent on the size of the esophagus and the replacement organ. We developed a new and foolproof method to prevent stenosis in esophagogastric tube anastomosis for patients with esophageal cancer that is not dependent on operator skill. METHODS Seven patients with esophageal squamous cell carcinoma underwent minimally invasive McKeown esophagectomy in our hospital. Esophagogastric tube anastomosis was tried for all patients using the novel "hybrid esophagogastric tube anastomosis" technique. A 21-mm circular stapler was applied to perform an end-to-side anastomosis between the cervical esophagus and the posterior wall of the gastric tube. Then, a 30-mm linear stapler was positioned in the esophagogastric anastomosis formed by the 21-mm circular stapler with the anvil fork inserted into the esophagus and the cartridge fork inserted into the gastric tube. A supplementary side-to-side anastomosis of appropriately 15 mm was created. Afterward, the entry hole was closed with a linear stapler. RESULTS The hybrid esophagogastric tube anastomosis was successful in all seven patients receiving it between June 2020 and March 2022. No postoperative complications related to this anastomosis were observed in any of the patients. Five patients underwent follow-up gastrointestinal endoscopy at 6 months after esophagectomy. No patient had an anastomotic stenosis. CONCLUSIONS Hybrid esophagogastric tube anastomosis can be performed easily and safely and can reduce the complications associated with anastomosis.
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Affiliation(s)
- Daisuke Fujimoto
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan.
| | - Keizo Taniguchi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
| | - Junpei Takashima
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
| | - Fumihiko Miura
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
| | - Hirotoshi Kobayashi
- Department of Surgery, Teikyo University Hospital, Mizonokuchi, 5-1-1 Futako, Takatsu-Ku, Kawasaki-City, Kanagawa, 213-8507, Japan
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13
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Takeoka T, Miyata H, Sugimura K, Kanemura T, Sugase T, Yamamoto M, Shinno N, Hara H, Fujii Y, Mukai Y, Asukai K, Mikamori M, Hasegawa S, Akita H, Haraguchi N, Nishimura J, Wada H, Matsuda C, Omori T, Yasui M, Ohue M, Yano M. Modified Collard technique is more effective than circular stapled for cervical esophagogastric anastomosis in prevention of anastomotic stricture: a propensity score-matched study. Dis Esophagus 2022; 36:6835329. [PMID: 37122247 DOI: 10.1093/dote/doac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/21/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022]
Abstract
Abstract
The anastomotic technique after esophagectomy is of great interest in the prevention of anastomotic complications that adversely affect postoperative recovery. This study aimed to compare the clinical outcomes of modified Collard (MC) and circular stapled (CS) anastomoses after esophagectomy. A total of 504 consecutive patients with thoracic esophageal cancer who underwent esophagectomy and cervical esophagogastric CS or MC anastomosis from January 2013 to December 2019 were enrolled. Out of 504 patients, 134 and 370 underwent CS and MC anastomoses. The frequency of anastomotic leakage and stricture was significantly lesser in the MC group than in the CS group (3.0 vs. 10.5%, P = 0.0014 and 11.1 vs. 34.3%, P < 0.001, respectively). CS anastomosis was an independent risk factor for anastomotic stricture (odds ratio, 4.89; P < 0.001). Oral intake was significantly higher in the group without anastomotic stricture than in the group with anastomotic stricture at 2, 3, and 6 months postoperatively (P < 0.001, P = 0.013, and P < 0.001, respectively). The percentage body weight loss (%BWL) was −12.2% in the group with anastomotic stricture and −7.5% in the group without anastomotic stricture at 3 months postoperatively (P = 0.0012). Anastomotic stricture was an independent factor associated with %BWL (odds ratio, 4.86; P = 0.010). Propensity score-matched analysis, which included 88 pairs of patients, confirmed a significantly lower anastomotic stricture rate in the MC group than in the CS group (10.2 vs. 35.2%, P < 0.001). MC anastomosis is better than CS anastomosis for reducing the frequency of anastomotic stricture, which may be useful for maintaining early postoperative nutritional status.
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Affiliation(s)
- Tomohira Takeoka
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Miyata
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Keijiro Sugimura
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Takashi Kanemura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takahito Sugase
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Yamamoto
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naoki Shinno
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hisashi Hara
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yoshiaki Fujii
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yosuke Mukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Kei Asukai
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Manabu Mikamori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Shinichiro Hasegawa
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hirofumi Akita
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Naotsugu Haraguchi
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroshi Wada
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Takeshi Omori
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayoshi Yasui
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masayuki Ohue
- Department of Gastroenterological Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Masahiko Yano
- Department of Surgery, Suita Municipal Hospital, Suita, Osaka, Japan
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14
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Aiolfi A, Sozzi A, Bonitta G, Lombardo F, Cavalli M, Cirri S, Campanelli G, Danelli P, Bona D. Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:3297-3309. [PMID: 36242619 DOI: 10.1007/s00423-022-02706-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). CONCLUSIONS LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.
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Affiliation(s)
- Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy. .,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy. .,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy.
| | - Andrea Sozzi
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Francesca Lombardo
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Marta Cavalli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Silvia Cirri
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Giampiero Campanelli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Piergiorgio Danelli
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
| | - Davide Bona
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, Milan, Italy.,Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.,Department of General Surgery, Luigi Sacco University Hospital, Milan, Italy
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15
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Obitsu T, Kiyozaki H, Saito M, Fukai S, Abe I, Ichida K, Muto Y, Rikiyama T. Minimally invasive esophagectomy in the semi-prone position for corrosive esophagitis: a case report. J Surg Case Rep 2022; 2022:rjac218. [PMID: 35919698 PMCID: PMC9341224 DOI: 10.1093/jscr/rjac218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Treatment strategies for corrosive esophagitis include conservative treatment, such as balloon dilatation at the stenosis site, and surgical treatment. Esophagectomy for corrosive esophagitis is usually performed through the transthoracic or transhiatal approaches. Herein, we report a case of corrosive esophagitis treated with thoracoscopic esophagectomy with the patient in the semi-prone position. The patient was a 48-year-old woman who developed corrosive esophagitis due to accidental ingestion of an alkaline agent. Surgical intervention was required for esophageal stenosis. Therefore, thoracoscopic esophagectomy was performed with the patient in the semi-prone position with bilateral pulmonary ventilation. In our hospital, good operative outcomes have been obtained using thoracoscopic esophagectomy for esophageal cancer with the patient in the semi-prone position with bilateral pulmonary ventilation. This technique is also considered effective for the treatment of corrosive esophagitis.
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Affiliation(s)
- Tamotsu Obitsu
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Hirokazu Kiyozaki
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Masaaki Saito
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Shota Fukai
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Iku Abe
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Kosuke Ichida
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Yuta Muto
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
| | - Toshiki Rikiyama
- Department of Surgery , Saitama Medical Center, , Saitama , Japan
- Jichi Medical University , Saitama Medical Center, , Saitama , Japan
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16
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Shishido Y, Matsunaga T, Makinoya M, Miyauchi W, Shimizu S, Miyatani K, Uejima C, Morimoto M, Murakami Y, Hanaki T, Kihara K, Yamamoto M, Tokuyasu N, Takano S, Sakamoto T, Saito H, Hasegawa T, Fujiwara Y. Circular stapling anastomosis with indocyanine green fluorescence imaging for cervical esophagogastric anastomosis after thoracoscopic esophagectomy: a propensity score-matched analysis. BMC Surg 2022; 22:152. [PMID: 35488244 PMCID: PMC9052471 DOI: 10.1186/s12893-022-01602-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 04/18/2022] [Indexed: 12/24/2022] Open
Abstract
Background Thoracoscopic esophagectomy has been extensively used worldwide as a curative surgery for patients with esophageal cancer; however, complications such as anastomotic leakage and stenosis remain a major concern. Therefore, the objective of this study was to evaluate the efficacy of circular stapling anastomosis with indocyanine green (ICG) fluorescence imaging, which was standardized for cervical esophagogastric anastomosis after thoracoscopic esophagectomy. Methods Altogether, 121 patients with esophageal cancer who underwent thoracoscopic esophagectomy with radical lymph node dissection and cervical esophagogastric anastomosis from November 2009 to December 2020 at Tottori University Hospital were enrolled in this study. Patients who underwent surgery before the anastomotic method was standardized were included in the classical group (n = 82) and patients who underwent surgery after the anastomotic method was standardized were included in the ICG circular group (n = 39). The short-term postoperative outcomes, including anastomotic complications, were compared between the two groups using propensity-matched analysis and the risk factors for anastomotic leakage were evaluated using logistic regression analyses. Results Of the 121 patients, 33 were included in each group after propensity score matching. The clinicopathological characteristics of patients did not differ between the two groups after propensity score matching. In terms of perioperative outcomes, a significantly higher proportion of patients who underwent surgery using the laparoscopic approach (P < 0.001) and narrow gastric tube (P = 0.003), as well as those who had a lower volume of blood loss (P = 0.009) in the ICG circular group were observed after matching. Moreover, the ICG circular group had a significantly lower incidence of anastomotic leakage (39% vs. 9%, P = 0.004) and anastomotic stenosis (46% vs. 21%, P = 0.037) and a shorter postoperative hospital stay (30 vs. 20 days, P < 0.001) than the classical group. According to the multivariate analysis, the anastomotic method was an independent risk factor for anastomotic leakage after thoracoscopic esophagectomy (P = 0.013). Conclusions Circular stapling anastomosis with ICG fluorescence imaging is effective in reducing complications such as anastomotic leakage and stenosis.
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Affiliation(s)
- Yuji Shishido
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan.
| | - Tomoyuki Matsunaga
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Masahiro Makinoya
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Wataru Miyauchi
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Shota Shimizu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Kozo Miyatani
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Chihiro Uejima
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Masaki Morimoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Yuki Murakami
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Takehiko Hanaki
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Kyoichi Kihara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Manabu Yamamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Naruo Tokuyasu
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Shuichi Takano
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Teruhisa Sakamoto
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Hiroaki Saito
- Department of Surgery, Japanese Red Cross Tottori Hospital, 117 Shotoku-cho, 680- 8517, Tottori, Japan
| | - Toshimichi Hasegawa
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
| | - Yoshiyuki Fujiwara
- Division of Gastrointestinal and Pediatric Surgery, Department of Surgery, School of Medicine, Tottori University Faculty of Medicine, 36-1 Nishi-cho, 683-8504, Yonago, Japan
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17
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Robot-assisted minimally invasive esophagectomy (RAMIE) with side-to-side semi-mechanical anastomosis: analysis of a learning curve. Updates Surg 2022; 74:907-916. [DOI: 10.1007/s13304-022-01284-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
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18
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Circular Stapler Method for Avoiding Stricture of Cervical Esophagogastric Anastomosis. J Gastrointest Surg 2022; 26:725-732. [PMID: 35138510 DOI: 10.1007/s11605-022-05266-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/25/2022] [Indexed: 01/31/2023]
Abstract
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.
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Akutsu T, Fujita T, Kajiyama D, Ozaki A, Sato K, Fujiwara H, Kojima T, Daiko H. Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer. Thorac Cancer 2022; 13:844-852. [PMID: 35088520 PMCID: PMC8930463 DOI: 10.1111/1759-7714.14332] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background The first choice of an esophageal substitute after esophagectomy for cancer is the stomach. However, the colon must be considered for reconstruction in specific situations. The purpose of this study was to clarify the frequency and clinical features of patients who underwent colon interposition in thoracic esophagectomy and to investigate the postoperative complications and survival. Methods We conducted a retrospective case–control study in the National Cancer Center Hospital East, Japan. Patients who underwent colon interposition after esophagectomy for cancer between 2010 and 2020 were analyzed. Results Eighty‐eight patients underwent esophagectomy with colon interposition; 53.2% received preoperative treatment and 52.3% underwent thoracoscopic surgery. Clavien–Dindo grade >III postoperative complications occurred in 42% of the patients; anastomotic leakage was the most common complication, occurring in 26.1% of the cases. Univariate analysis of the factors associated with Clavien–Dindo grade <III complications showed that the period 2015–2020 and totally mechanical Collard anastomosis were significant factors, with odds ratios (OR) of 0.264 and 0.267 (p = 0.00327 and p = 0.00335), respectively. Totally mechanical Collard anastomosis was associated with a lower risk of anastomotic leakage by univariate and multivariate analysis (OR, 0.257, p = 0.00566 and OR, 0.285, p = 0.133, respectively). Three‐year overall survival was 54.2%. Univariate and multivariate analysis of overall survival showed that older age was a risk factor (OR, 1.08) for complications. Conclusion In colon reconstruction after esophageal cancer resection, totally mechanical Collard anastomosis for cervical anastomosis may reduce the risk of Clavien–Dindo grade >III complications.
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Affiliation(s)
- Tomohiro Akutsu
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Daisuke Kajiyama
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Asako Ozaki
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Kazuma Sato
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Hisashi Fujiwara
- Division of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Takashi Kojima
- Division of Gastrointestinal Oncology, National Cancer Center Hospital East, Chiba, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
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Moons J, Depypere L, Lerut T, van Achterberg T, Coosemans W, Van Veer H, Mandeville Y, Nafteux P. Impact of the introduction of an enhanced recovery pathway in esophageal cancer surgery: a cohort study and propensity score matching analysis. Dis Esophagus 2021; 34:6141530. [PMID: 33598683 DOI: 10.1093/dote/doab007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/10/2020] [Accepted: 12/24/2020] [Indexed: 12/11/2022]
Abstract
Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P<0.0001 and 17% vs. 12%; P<0.0001, respectively) and postoperative blood transfusion (26.7%-11%; P<0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10-23) in TC compared with 10 days (IQR 8-14) in ERP patients (P<0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P=0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P=0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P=0.0001), anastomotic leak (P=0.047), several infectious complications (P=0.01-0.034), blood transfusion (P=0.001), Comprehensive Complications Index (P=0.01), and length of stay (P=0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates.
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Affiliation(s)
- J Moons
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - L Depypere
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T Lerut
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - T van Achterberg
- Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | - W Coosemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - H Van Veer
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
| | - Y Mandeville
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - P Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven, Belgium
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Ishii K, Tsubosa Y, Mayanagi S, Inoue M, Haneda R. Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series. J INVEST SURG 2021; 35:809-813. [PMID: 34542377 DOI: 10.1080/08941939.2021.1968080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masazumi Inoue
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryoma Haneda
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Circular stapled technique versus modified Collard technique for cervical esophagogastric anastomosis after esophagectomy: A randomized controlled trial. Ann Surg 2021; 276:30-37. [PMID: 34417369 DOI: 10.1097/sla.0000000000005185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study was performed to investigate the efficacy of the modified Collard (MC) technique for reducing anastomotic stricture after esophagectomy compared with the circular stapled (CS) technique. SUMMARY BACKGROUND DATA The currently available techniques of anastomosis after esophagectomy are associated with a significant risk of anastomotic complications. However, the optimal anastomotic technique after esophagectomy has not yet been established. METHODS We randomly allocated patients to either the CS group or the MC group. The primary endpoint was the incidence of anastomotic stricture. The secondary endpoints included the incidence of postoperative complications (including anastomotic leakage) and quality of life (QOL). All anastomoses were performed after indocyanine green evaluation for objective homogenization of blood flow to the gastric conduit between the two techniques. RESULTS Among 100 randomized patients (CS group, n = 50; MC group, n = 50), anastomotic strictures were observed in 18 (42%) patients in the CS group and in no patients in the MC group. There were no significant between-group differences in anastomotic leakage (CS group, 7% vs. MC group, 8%; p = 0.94). QOL domains of dysphagia and choking when swallowing at 3 months after surgery were significantly better in the MC group than in the CS group. CONCLUSIONS The MC technique reduces the incidence of anastomotic stricture and improves postoperative QOL. Furthermore, the incidence of anastomotic leakage is comparable between the two techniques based on accurate comparison under objective homogenization of the gastric conduit condition.
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Bonavina L. Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:907. [PMID: 34164541 PMCID: PMC8184442 DOI: 10.21037/atm.2020.03.66] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The esophagogastric anastomosis is most commonly performed to restore digestive tract continuity after esophagectomy for cancer. Despite a long history of clinical research and development of high-tech staplers, this procedure is still feared by most surgeons and associated with a 10% leakage rate. Among specific factors that may contribute to failure of the esophageal anastomosis are the absence of serosa layer, longitudinal orientation of muscle fibers, and ischemia of the gastric conduit. It has recently been suggested that the gut microbiome may influence the healing process of the anastomosis through the presence of collagenolytic bacterial strains, indicating that suture breakdown is not only a matter of collagen biosynthesis. The esophagogastric anastomosis can be performed either in the chest or neck, and can be completely hand-sewn, completely stapled (circular or linear stapler), or semi-mechanical (linear stapler posterior wall and hand-sewn anterior wall). Because of the lack of randomized clinical trials, no conclusive evidence is available, and the debate between the hand-sewn and the stapling technique is still ongoing even in the present era of robotic surgery. Centralization of care has improved the overall postoperative outcomes of esophagectomy, but the esophagogastric anastomosis remains the Achille’s heel of the procedure. More research and network collaboration of experts is needed to improve safety and clinical outcomes.
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Affiliation(s)
- Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese (Milano), Italy
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Kurahashi Y, Ishida Y, Kumamoto T, Nakanishi Y, Hojo Y, Igeta M, Takemura M, Shinohara H. Anastomosis behind the sternoclavicular joint is associated with increased incidence of anastomotic stenosis in retrosternal reconstruction with a gastric conduit after esophagectomy. Dis Esophagus 2021; 34:5912915. [PMID: 32995867 DOI: 10.1093/dote/doaa089] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/27/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Yasunori Kurahashi
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshinori Ishida
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tsutomu Kumamoto
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yasutaka Nakanishi
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yudai Hojo
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Masataka Igeta
- Department of Biostatistics, Hyogo College of Medicine, Nishinomiya, Japan
| | | | - Hisashi Shinohara
- Upper G.I. Division, Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
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iTriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy. World J Surg 2021; 45:1828-1834. [PMID: 33611662 DOI: 10.1007/s00268-021-05997-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
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.
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Sasikumar K, Kalayarasan R, Gnanasekaran S, Chandrasekar S, Pottakkat B. Minimally invasive oesophagectomy with a total two-field lymphadenectomy after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of the oesophagus: A prospective study. J Minim Access Surg 2021; 17:49-55. [PMID: 31929228 PMCID: PMC7945645 DOI: 10.4103/jmas.jmas_242_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: In the era of neoadjuvant chemoradiotherapy (NACTRT), the safety and clinical significance of radical lymphadenectomy specifically lymphadenectomy along the recurrent laryngeal nerve (RLN) has been questioned. Furthermore, the compliance to NACTRT with the CROSS regimen has not been well studied in the Indian population. This prospective study aimed to determine the compliance with CROSS regimen, feasibility and short-term outcomes of minimally invasive oesophagectomy (MIE) with a total two-field lymphadenectomy after NACTRT. Methods: A prospective study (January 2014 to December 2018) of patients with locally advanced oesophageal squamous cell carcinoma (SCC) eligible for NACTRT (cT1-4a, N0-1, M0) with CROSS regimen followed by MIE with total two-field lymphadenectomy. The compliance rate, post-operative complications and the pathological response rate were assessed. Results: Of the 166 patients with locally advanced SCC, 76 (45.8%) were eligible for NACTRT and 34 completed NACTRT followed by MIE with a total two-field lymphadenectomy (study group). Twenty-nine (38.1%) patients did not complete NACTRT due to complications or poor compliance. Median (range) blood loss was 125 (50–450) ml and the median (range) operation time for the thoracoscopic phase was 205 (155–325) min. Total median (range) lymph node count and mediastinal lymph node counts were 20 (11–33) and 12, (8–21) respectively. Most common post-operative complications were pneumonia (n = 12, 35.3%) followed by RLN palsy (n = 10, 29.4%). Of the 22 patients who had a complete pathological response of the primary tumour, 7 (31.8%) patients had a node-positive disease. Conclusion: NACTRT followed by MIE is feasible in patients with locally advanced SCC. The nodal disease is common even in patients with the complete pathological response of the primary tumour. The dropout rate with NACTRT using the CROSS regimen is high in the present study.
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Affiliation(s)
- Kuppusamy Sasikumar
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Sandip Chandrasekar
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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Shestakov AL, Tadzhibova IM, Cherepanin AI, Bezaltynnykh AA, Shakhbanov ME. MECHANICAL ESOPHAGEAL ANASTOMOSES. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-29-35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article gives an overview of mechanical esophageal anastomosis. The results of the esophageal anastomoses formation by using circular and linear stitching devices (staplers) by Russian and foreign authors are presented in chronological order. The faults of staplers, complications associated with them are described. The importance of the problem related to the choice of anastomotic technique to reduce the risks of specific complications such as leakage and stricture of esophageal anastomosis was remarked by authors. The advantages and disadvantages of the currently known esophageal anastomotic methods have been analyzed. It was noted that mechanical side-to-side anastomoses are associated with low frequency of leakage, stricture, postoperative mortality, that’s why they have become preferable, especially in the mini-invasive reconstructive surgery. The authors concluded that the question about the feasibility of mechanical esophageal anastomoses formation is not answered, the evaluation of the properties of modern staplers and the search for the best esophageal anastomotic method are relevant for modern surgery.
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Affiliation(s)
| | | | - A. I. Cherepanin
- Federal State Institution «Federal Clinical Center of High Medical Technologies of the Federal Medical and Biological Agency»
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Orringer MB, Hennigar D, Lin J, Rooney DM. A novel cervical esophagogastric anastomosis simulator. J Thorac Cardiovasc Surg 2020; 160:1598-1607. [DOI: 10.1016/j.jtcvs.2020.02.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/10/2020] [Accepted: 02/29/2020] [Indexed: 01/01/2023]
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Nederlof N, Tilanus HW, de Vringer T, van Lanschot JJB, Willemsen SP, Hop WCJ, Wijnhoven BPL. A single blinded randomized controlled trial comparing semi-mechanical with hand-sewn cervical anastomosis after esophagectomy for cancer (SHARE-study). J Surg Oncol 2020; 122:1616-1623. [PMID: 32989770 PMCID: PMC7821322 DOI: 10.1002/jso.26209] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The aim was to compare leak rate between hand-sewn end-to-end anastomosis (ETE) and semi-mechanical anastomosis (SMA) after esophagectomy with gastric tube reconstruction. BACKGROUND DATA The optimal surgical technique for creation of an anastomosis in the neck after esophagectomy is unclear. METHODS Patients with esophageal cancer undergoing esophagectomy with gastric tube reconstruction and cervical anastomosis were eligible for participation after written informed consent. Patients were randomized in 1:1 ratio. Primary endpoint was anastomotic leak rate defined as external drainage of saliva from the site of the anastomosis or intra-thoracic manifestation of leak. Secondary endpoints included anastomotic stricture rate at one year follow up, number of endoscopic dilatations, dysphagia-score, hospital stay, morbidity, and mortality. Patients were blinded for intervention. RESULTS Between August 2011 and July 2014, 174 patients with esophageal cancer underwent esophagectomy. Ninety-three patients were randomized to ETE (n = 44) or SMA (n = 49). Anastomotic leak occurred in 9 of 44 patients (20%) in the ETE group and 12 of 49 patients (24%) in the SMA group (absolute difference 4%, 95% CI -13% to +21%; p = .804). There was no significant difference in dysphagia at 1 year postoperatively (ETE 25% vs. SMA 20%; p = .628), in stricture rate (ETE 25% vs. 19% in SMA, p = .46), nor in median hospital stay (17 days in the ETE group, 13 days in the SMA group), morbidity (82% vs. 73%, p = .460) or mortality (0% vs. 4%, p = .175) between the groups.
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Affiliation(s)
- Nina Nederlof
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Hugo W Tilanus
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Tahnee de Vringer
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Jan J B van Lanschot
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Sten P Willemsen
- Department of Biostatistics, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Wim C J Hop
- Department of Biostatistics, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC-Erasmus University Medical Centre, Rotterdam, The Netherlands
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Li XK, Xu Y, Cong ZZ, Luo J, Zhou H, Ji SG, Diao YF, Wu WJ, Qiang Y, Qian JJ, Shen Y. Modified Collard versus end-to-side hand-sewn anastomosis for cervical anastomosis after McKeown esophagectomy. Thorac Cancer 2020; 11:2909-2915. [PMID: 32833352 PMCID: PMC7529547 DOI: 10.1111/1759-7714.13630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022] Open
Abstract
Background According to previously published studies, esophagectomy with modified Collard anastomosis has been reported to have low incidences of anastomotic leak and stricture. However, the optional anastomotic method after esophagectomy is still controversial. We conducted this study to compare the incidence of postoperative anastomotic stricture formation and dysphagia over three years after an esophagectomy with modified Collard anastomosis (MC) or end‐to‐side (ETS) hand‐sewn anastomosis. Meanwhile, the early postoperative anastomotic leakage and other complications, hospital stay and 30‐ and 90‐day mortality were also evaluated. Methods The clinical data of 905 patients undergoing McKeown esophagectomy were retrospectively reviewed. The rate of postoperative stricture formation after three years was demonstrated by stricture‐free survival which is the primary end‐point of this study. The incidence of dysphagia, first time of onset of stricture and number of dilatations were also recorded during follow‐up. Results The incidence of anastomotic leak tended to be higher in the MC group compared with that in the ETS group (13.0% vs. 8.7%, P = 0.064). The rates of anastomotic stricture in the MC group were significantly less than in the ETS group (P = 0.004). The number of dilatations in the MC group were significantly greater than those in the ETS group (2.34 vs. 2.46, P = 0.011). Conclusions A modified Collard cervical esophagogastric anastomosis was associated with lower rates of anastomotic stricture and dysphagia, compared with ETS hand‐sewn anastomosis. However, the modified Collard anastomosis is accompanied by an increased anastomotic leakage rate.
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Affiliation(s)
- Xiao-Kun Li
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yang Xu
- Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhuang-Zhuang Cong
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Hai Zhou
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Sai-Guang Ji
- Department of Thoracic Surgery, Nanjing Second Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi-Fei Diao
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Wen-Jie Wu
- Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jian-Jun Qian
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China
| | - Yi Shen
- Department of Cardiothoracic Surgery, Jingling Hospital, School of Medicine, Southeast University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardiothoracic Surgery, Jingling Hospital, School of Clinical Medicine, Nanjing Medical University, Nanjing, China.,Department of Clinical Medicine, School of Medicine, Southeast University, Nanjing, China
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Totally Mechanical Collard Technique for Cervical Esophagogastric Anastomosis Reduces Stricture Formation Compared with Circular Stapled Anastomosis. World J Surg 2020; 44:4175-4183. [PMID: 32783124 DOI: 10.1007/s00268-020-05729-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND The optimal technique for cervical esophagogastric anastomosis in esophagectomy has not yet been established. Using circular stapled (CS) technique effectively reduces the incidence of anastomotic leakage and shortens the operating time; however, anastomotic stricture has been reported to be more common. The present study was performed to compare the clinical outcomes of the recently developed totally mechanical Collard (TMC) and CS anastomosis. METHODS We retrospectively reviewed consecutive esophageal cancer cases who are undergoing transthoracic extended esophagectomy with gastric conduit reconstruction using cervical CS or TMC anastomosis from December 2013 to December 2016. Propensity score matching and multivariate regression were used to adjust for differences in baseline characteristics. RESULTS Among 313 patients, 93 underwent CS anastomosis and 220 underwent TMC anastomosis. Stricture formation occurred in 59 patients (18.8%), significantly more often with the CS than TMC anastomosis (30.1% vs. 14.1%, p = 0.001). No significant differences were observed in the refractory stricture rate (9.7% vs. 5.0%, p = 0.134) or the anastomotic leakage rate (11.8% vs. 10.9%, p = 0.845) between the two groups. The propensity score matching cohort study including 86 pairs of patients confirmed a significantly lower stricture formation rate with the TMC than CS technique (27.9% vs. 14.0%, p = 0.038). In the multivariable analysis, anastomotic leakage, the CS technique, and a body mass index of ≥25 mg/m2 were independently associated with a risk of stricture formation. CONCLUSION TMC technique contributed to a reduced rate of stricture formation compared with CS technique in cervical esophagogastric anastomosis.
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Kim HR. Stricture Following Esophageal Reconstruction. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:222-225. [PMID: 32793456 PMCID: PMC7409887 DOI: 10.5090/kjtcs.2020.53.4.222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/08/2020] [Accepted: 07/14/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, University of Ulsan College of Medicine, Seoul, Korea
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33
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Mazza E, Strignano P, Fop F, Patrono D, Catalano G, Salizzoni M, Romagnoli R. Semimechanical anastomosis during oesophagectomy reduces leaks and stenosis: a propensity score matched analysis. Interact Cardiovasc Thorac Surg 2020; 31:182-190. [PMID: 32530036 DOI: 10.1093/icvts/ivaa065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/04/2020] [Accepted: 03/12/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique. METHODS Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998-September 2015), when both TM and SM techniques were used, and a validation period (October 2015-April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding. RESULTS The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P < 0.001) and stricture rate (0% vs 7%; P = 0.005). After propensity score matching, the difference in leak (0% vs 14%; P = 0.013) and stricture rate (0% vs 10%; P = 0.022) was confirmed. During the validation period, which included 100 oesophagectomies performed with SM anastomosis, 1 leak (1%) and 1 stricture (1%) were observed. CONCLUSIONS SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.
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Affiliation(s)
- Elena Mazza
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Paolo Strignano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Fabrizio Fop
- Renal Transplant Unit, Nephrology, Dialysis and Renal Transplant Division, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Giorgia Catalano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Mauro Salizzoni
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
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Rasihashemi SZ, Ramouz A, Beheshtirouy S, Amini H. Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study. BMC Gastroenterol 2020; 20:250. [PMID: 32736599 PMCID: PMC7393709 DOI: 10.1186/s12876-020-01393-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 07/21/2020] [Indexed: 02/08/2023] Open
Abstract
Background Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients. Methods This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation. Results Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02). Conclusion Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.
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Affiliation(s)
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, Heidelberg, Germany
| | - Samad Beheshtirouy
- Department of Cardiothoracic Surgery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Amini
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Department of General Surgery, Imam Reza Hospital, Tabriz University of Medical Sciences, Tabriz, Iran.
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35
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Sato S, Nakatani E, Higashizono K, Nagai E, Taki Y, Nishida M, Watanabe M, Oba N. Size of the thoracic inlet predicts cervical anastomotic leak after retrosternal reconstruction after esophagectomy for esophageal cancer. Surgery 2020; 168:558-566. [PMID: 32611514 DOI: 10.1016/j.surg.2020.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although an anastomotic leak after esophagectomy is one of the most common postoperative complications, it is not well understood whether specific anatomic factors of the different route of reconstruction can predispose to the development of anastomotic leak after esophagectomy. This study aimed to clarify whether various factors related to the size of the thoracic inlet are independent predictors of anastomotic leak after esophagectomy. METHODS We reviewed 248 patients who underwent esophagectomy with retrosternal reconstruction of the gastric conduit between January 2013 and March 2019. Various factors related to the size of the thoracic inlet were measured using computed tomography. Multivariate logistic regression was used to analyze the association between various measurements and anastomotic leak. RESULTS Anastomotic leak occurred in 38 patients (15.3%). On univariate analysis, the thickness of the sternum, the thickness of the clavicle, the sternum-trachea distance, the ratio of the sternum-trachea distance/sternum-vertebral body distance, sex, body mass index, and method of anastomosis were statistically significantly associated with anastomotic leak. On multivariate analysis, the ratio of the sternum-trachea distance/sternum-vertebral body distance and the method of anastomosis were the independent risk factors for anastomotic leak. CONCLUSION The ratio of the sternum-trachea distance/sternum-vertebral body distance is associated with cervical anastomotic leak after retrosternal gastric conduit reconstruction after esophagectomy. Measurement of the thoracic inlet space may contribute to preoperative planning, such as for the route of the conduit for reconstruction and anastomotic site.
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Affiliation(s)
- Shinsuke Sato
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan.
| | - Eiji Nakatani
- Division of Statistical Analysis, Research Support Center, Shizuoka General Hospital, Japan
| | - Kazuya Higashizono
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
| | - Erina Nagai
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
| | - Yusuke Taki
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
| | - Masato Nishida
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
| | - Masaya Watanabe
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
| | - Noriyuki Oba
- Department of Gastroenterological Surgery, Shizuoka General Hospital, Japan
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36
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Kamarajah SK, Bundred JR, Singh P, Pasquali S, Griffiths EA. Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis. BJS Open 2020; 4:563-576. [PMID: 32445431 PMCID: PMC7397345 DOI: 10.1002/bjs5.50298] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 04/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Current evidence on the benefits of different anastomotic techniques (hand‐sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes. Methods This was a systematic review and network meta‐analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non‐randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta‐analysis of postoperative anastomotic leaks and strictures was performed. Results Of 4192 articles screened, 15 randomized and 22 non‐randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001). Conclusion LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.
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Affiliation(s)
- S K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - J R Bundred
- College of Medical and Dental Sciences, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - P Singh
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Regional Oesophago-Gastric Unit, Royal Surrey NHS Foundation Trust, Guildford, UK
| | - S Pasquali
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - E A Griffiths
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Propensity Score–Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy. Ann Surg 2020; 271:128-133. [DOI: 10.1097/sla.0000000000002982] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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38
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Valmasoni M, Capovilla G, Pierobon ES, Moletta L, Provenzano L, Costantini M, Salvador R, Merigliano S. A Technical Modification to the Circular Stapling Anastomosis Technique During Minimally Invasive Ivor Lewis Procedure. J Laparoendosc Adv Surg Tech A 2019; 29:1585-1591. [PMID: 31580751 DOI: 10.1089/lap.2019.0461] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background: The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophagogastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient, and highly reproducible; however, the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog-ears and, therefore, increase the risk of anastomotic leak (AL). We describe a simple modification of the CS technique that consists of folding the linear esophageal transection line with a stitch around the anvil shaft, to include the staple line in the resection during the EEA™ firing. Methods: We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Feasibility has been evaluated as the percentage of cases in which the modified anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure-related complications. Results: MIE was performed in 10 patients using our modified CS technique. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complications. Only one patient developed a postoperative AL that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusion: Our modified CS technique is feasible and did successfully prevent the occurrence of clinically relevant ALs in this small case series of patients.
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Affiliation(s)
- Michele Valmasoni
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Elisa Sefora Pierobon
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Luca Provenzano
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Renato Salvador
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastroenterological Sciences, University Hospital of Padova Center for Esophageal Diseases, University of Padova, Padova, Italy
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Yanni F, Singh P, Tewari N, Parsons SL, Catton JA, Duffy J, Welch NT, Vohra RS. Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy. World J Surg 2019; 43:2483-2489. [PMID: 31222637 DOI: 10.1007/s00268-019-05057-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Several techniques have been described for esophagogastric anastomosis following esophagectomy. This study compared the outcomes of circular stapled anastomoses with semi-mechanical technique using a linear stapler. METHODS Perioperative data were extracted from a contemporaneously collected database of all consecutive esophagectomies for cancer with intrathoracic anastomoses performed in the Trent Oesophago-Gastric Unit between January 2015 and April 2018. Anastomotic techniques: circular stapled versus semi-mechanical, were evaluated and outcomes were compared. The primary outcome was anastomotic leak rate. Secondary outcomes included anastomotic stricture, overall complication rates, length of stay (LOS) and 30 day all-cause mortality. RESULTS One hundred and fifty-nine consecutive esophagectomies with intrathoracic anastomosis were performed during the study period. There were no significant differences between the two groups in terms of age, American Society of Anaesthesiologists score, Charlson comorbidity index and neoadjuvant therapies received. Circular stapled anastomoses were performed in 85 patients, while 74 patients received a semi-mechanical anastomosis. Clavien-Dindo complications II or more were higher in the circular stapled group (p = 0.02). There were 16 (10%) anastomotic leaks overall, three (4%) in semi-mechanical group versus 13 (15%) in the circular stapled group (p < 0.019). There was no statistically significant difference between the two groups in terms of LOS, 30-day mortality or the need for endoscopic dilatation of the anastomosis at 3 months follow-up. CONCLUSION The move from a circular stapled to a semi-mechanical intrathoracic anastomosis has been associated with a reduced postoperative anastomotic leak rate following esophagectomy for esophageal cancer.
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Affiliation(s)
- Fady Yanni
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK.
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Nilanjana Tewari
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Simon L Parsons
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham, UK
| | - James A Catton
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - John Duffy
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Neil T Welch
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Ravinder S Vohra
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham City Hospital, Hucknall Road, Nottingham, NG5 1PB, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham , Nottingham, UK
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40
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Anand S, Kalayarasan R, Chandrasekar S, Gnanasekaran S, Pottakkat B. Minimally Invasive Esophagectomy with Thoracic Duct Resection Post Neoadjuvant Chemoradiotherapy for Carcinoma Esophagus-Impact on Lymph Node Yield and Hemodynamic Parameters. J Gastrointest Cancer 2019; 50:230-235. [PMID: 29344808 DOI: 10.1007/s12029-018-0051-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Neoadjuvant therapy followed by surgery is the current recommended treatment for locally advanced esophageal carcinoma. Thoracic duct (TD) resection was indicated for radical mediastinal lymphadenectomy. However, TD resection can cause hemodynamic disturbances. The presence of metastasis in TD has not been previously studied. METHODS Twenty-two patients who underwent minimally invasive esophagectomy with D2 lymphadenectomy after neoadjuvant chemoradiotherapy for esophageal squamous cell carcinoma were analyzed. Ten patients had their TD resected from thoracic inlet till the esophageal hiatus. Multiple histopathological sections of the TD were examined for evidence of tumor spread. Intraoperative and immediate (48 h) postoperative hemodynamic parameters, lymph node yield, and postoperative morbidity were compared between TD-resected and TD-preserved groups. RESULTS The median postoperative day 1 fluid requirement (3310 mL vs. 2875 mL, P = 0.059) and the median postoperative day 2 pulse rate were higher in the TD-resected group (111/min vs. 95/min, P = 0.043). There was no significant difference in the intraoperative fluid infusion, blood loss, urine output, mean blood pressure, pulse rate, postoperative urine output, and mean blood pressure between two groups. Median (range) mediastinal lymph node count was similar in TD-resected and TD-preserved groups [15(11-32) vs. 14(9-31), P = 0.283]. Pathological examination of TD did not reveal tumor cells in any of the patients. There was no significant difference in the postoperative morbidity between two groups except for cervical anastomotic dehiscence (P = 0.007). CONCLUSIONS Minimally invasive esophagectomy with TD resection causes minor hemodynamic changes in the immediate postoperative period, without adversely affecting the postoperative outcome. In the setting of neoadjuvant chemoradiotherapy, TD resection does not increase lymph node yield.
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Affiliation(s)
- Santosh Anand
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Raja Kalayarasan
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India.
| | - Sandip Chandrasekar
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Senthil Gnanasekaran
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
| | - Biju Pottakkat
- Department of Surgical Gastroenterology, JIPMER, Room no 551, Fourth floor, Superspeciality block, Puducherry, 605006, India
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Krishnamurthy A. Cervical esophagogastric anastomosis using a modified linear cutter stapler technique in esophageal cancers following neoadjuvant chemoradiation. Indian J Cancer 2019; 56:278-279. [PMID: 31389397 DOI: 10.4103/ijc.ijc_665_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wang Y, Zhang X, Jiang Y, Ma G, Wang Z, Xue X, Sang S, Zhang L. Comparison of hand-sewn versus mechanical esophagogastric anastomosis in esophageal cancer: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15676. [PMID: 31169669 PMCID: PMC6571278 DOI: 10.1097/md.0000000000015676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many studies have been conducted to compare the hand-sewn and mechanical staples in esophageal cancer (EC) patients who received esophagogastric anastomosis. However, the results remain controversial. Hence, the purpose of the meta-analysis is to evaluate the impact of different anastomosis methods on the early and long-term outcomes. METHODS We will perform a systematic electronic search of the PubMed, Embase, Cochrane Library, Web of Science for relevant articles published in English language. Pooled odds ratios will be calculated for the effect on discrete variables including anastomotic leakage, anastomotic strictures, 30-day mortality, quality of life, cardiac and pulmonary complications. The weighted mean difference was calculated for the effect size on continuous variables such as operative time and bleeding amount. We will use the software Review Manager 5.3 and STATA 14.0 to perform the meta-analysis to calculate the data synthesis. RESULTS The review will provide a high-quality synthesis of current evidence of the impact of different anastomosis methods on postoperative course in ECs after esophagectomy. The results will be published in a peer-reviewed journal. CONCLUSION This systematic review and meta-analysis will compare the different anastomosis methods in EC patients. The results will better offer some specific suggestions for esophagogastric anastomosis. PROSPERO REGISTRATION NUMBER This systematic review protocol has been registered in the PROSPERO network (No. CRD 42019109523).
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Affiliation(s)
| | - Xiangwei Zhang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Yuanzhu Jiang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Guoyuan Ma
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Zhaoyang Wang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Xianbiao Xue
- Department of Thoracic Surgery, Juye County People's Hospital, Juye
| | - Shaowei Sang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Lin Zhang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
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Minimally Invasive and Robotic Esophagectomy: A Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2019; 13:391-403. [PMID: 30543576 DOI: 10.1097/imi.0000000000000572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
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The Impact of Circular Stapler Size on the Incidence of Cervical Anastomotic Stricture After Esophagectomy. World J Surg 2019; 43:1746-1755. [DOI: 10.1007/s00268-019-04938-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Tsuji T, Ojima T, Nakamori M, Nakamura M, Katsuda M, Hayata K, Kitadani J, Maruoka S, Shimokawa T, Yamaue H. 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. Trials 2019; 20:83. [PMID: 30691515 PMCID: PMC6350379 DOI: 10.1186/s13063-019-3201-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 01/16/2019] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Toshiaki Tsuji
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Mikihito Nakamori
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Masaki Nakamura
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Masahiro Katsuda
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Keiji Hayata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Junya Kitadani
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Shimpei Maruoka
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan
| | - Toshio Shimokawa
- Clinical Study Center, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama, 641-8510, Japan.
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Sugimura K, Miyata H, Matsunaga T, Asukai K, Yanagimoto Y, Takahashi Y, Tomokuni A, Yamamoto K, Hirofumi A, Nishimura J, Motoori M, Wada H, Takahashi H, Yasui M, Omori T, Ohue M, Yano M. Comparison of the modified Collard and hand-sewn anastomosis for cervical esophagogastric anastomosis after esophagectomy in esophageal cancer patients: A propensity score-matched analysis. Ann Gastroenterol Surg 2019; 3:104-113. [PMID: 30697615 PMCID: PMC6345657 DOI: 10.1002/ags3.12220] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/04/2018] [Accepted: 10/11/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Several studies have reported that modified Collard anastomosis is useful for cervical anastomosis after esophagectomy for thoracic esophageal cancer. However, no large-scale study has confirmed the efficacy of the modified Collard anastomosis. METHODS Between 2008 and 2016, 398 consecutive esophageal cancer patients who underwent esophagectomy and cervical anastomosis were enrolled in this study. Patients with a short remnant cervical esophagus were excluded. We investigated the utility of the modified Collard anastomosis by comparing the results of postoperative complications using a propensity score-matched analysis between the hand-sewn method (HS) and the modified Collard anastomosis (MC) for esophagogastric anastomosis of the neck after esophagectomy in thoracic esophageal cancer patients. RESULTS Of the 398 patients, 127 were included in the MC group and 127 were included in the HS group after propensity score matching. Clinical characteristics did not differ between the two groups. Frequency of anastomotic leakage tended to be lower in the MC group than in the HS group (3% vs. 7%, P = 0.127). Frequency of anastomotic stenosis was significantly lower in the MC group than in the HS group (13% vs. 59%, P < 0.001). Multivariate logic analysis showed that anastomotic technique (HS) and performance status were independent factors associated with anastomotic stenosis (odds ratio, 12.24 and 2.52; P-value <0.001 and 0.047, respectively). CONCLUSION In cervical esophagogastric anastomosis after esophagectomy, the modified Collard anastomosis is more suitable than hand-sewn anastomosis in terms of reducing the frequency of anastomotic stenosis.
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Affiliation(s)
- Keijiro Sugimura
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Miyata
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Tomoyuki Matsunaga
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kei Asukai
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | | | - Yusuke Takahashi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Akira Tomokuni
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Kazuyoshi Yamamoto
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Akita Hirofumi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Junichi Nishimura
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masaaki Motoori
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hiroshi Wada
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Hidenori Takahashi
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayoshi Yasui
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Takeshi Omori
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masayuki Ohue
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
| | - Masahiko Yano
- Department of Digestive SurgeryOsaka International Cancer InstituteOsakaJapan
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Hagen JA. A novel intrathoracic esophagogastric anastomotic technique: Potential benefit for patients undergoing a robotic-assisted minimally invasive esophagectomy. J Thorac Cardiovasc Surg 2018; 156:1746-1747. [DOI: 10.1016/j.jtcvs.2018.05.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 11/15/2022]
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Shridhar R, Takahashi C, Huston J, Doepker MP, Meredith KL. Anastomotic leak and neoadjuvant chemoradiotherapy in esophageal cancer. J Gastrointest Oncol 2018; 9:894-902. [PMID: 30505592 DOI: 10.21037/jgo.2018.04.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Anastomotic leaks (AL) cause significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (UFS) and NCR patients. Methods An esophagectomy database was queried for UFS and NCR patients treated between 1996 and 2015. Predictors of AL rate were identified using univariate and multivariate (MVA) analysis and propensity score matching (PSM). Results We identified 820 patients (UFS, 288; NCR, 532). Overall AL rate was 5.4%. Decreased AL rate was observed in NCR patients on MVA (8.0% vs. 4.1%; P=0.02) but no difference was seen after PSM (7.7% vs. 4.2%; P=0.14). MVA of factors associated with decreased AL in UFS patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic. Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM. MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. Conclusions There is no difference in the AL rate between UFS and NCR patients. Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.
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Affiliation(s)
- Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA
| | | | - Jamie Huston
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Matthew P Doepker
- Department of Surgery, University of South Carolina, Columbia, SC, USA
| | - Kenneth L Meredith
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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Patel PK, Shah M, Patni S, Saini S. Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer. Indian J Cancer 2018; 54:669-672. [PMID: 30082555 DOI: 10.4103/ijc.ijc_381_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Anastomosis in gastrointestinal (GI) surgery is a commonly performed procedure. Irrelevant various methods of intestinal anastomosis were followed - recent advance is the use of a stapler as a device for GI anastomosis. Due to the use of staplers, technical failures are a rarity, anastomosis is more consistent and can be used at difficult locations. MATERIALS AND METHODS : Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy or video-assisted thoracoscopic surgery with linear stapler anastomosis. RESULTS The average follow-up was approximately 9 months. Anastomotic leakage was observed in three patients. On follow-up, two patients presented with difficulty in swallowing, and on upper GI endoscopy, they were found to have anastomotic site stricture. There was no perioperative mortality. CONCLUSION The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. As in this technique only two linear staplers are used in comparison to other techniques where three or more staplers are used, it is also cost-effective. The procedure deserves more attention and further application.
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Affiliation(s)
- Parth Kanaiyalal Patel
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Mishal Shah
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Sanjeev Patni
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Shashikant Saini
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
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Kesler KA, Ramchandani NK, Jalal SI, Stokes SM, Mankins MR, Ceppa D, Birdas TJ, Vardas PN, Rieger KM. Outcomes of a novel intrathoracic esophagogastric anastomotic technique. J Thorac Cardiovasc Surg 2018; 156:1739-1745.e1. [PMID: 30033105 DOI: 10.1016/j.jtcvs.2018.05.088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel "side-to-side: staple line-on-staple line" (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide-diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institution's initial 6-year experience. METHODS An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications. RESULTS There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end-stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P = .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge. CONCLUSIONS We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.
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Affiliation(s)
- Kenneth A Kesler
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind.
| | - Neal K Ramchandani
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Shadia I Jalal
- Medical Oncology Division, Department of Medicine, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Samatha M Stokes
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Mark R Mankins
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - DuyKhanh Ceppa
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Thomas J Birdas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Panos N Vardas
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
| | - Karen M Rieger
- Division of Cardiothoracic Surgery, Department of Surgery, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Ind
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