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Kollmann L, Flemming S, Lock JF, Wiegering A, Germer CT, Seyfried F. Surgical options in retrosternal oesophageal reconstruction. Langenbecks Arch Surg 2024; 409:238. [PMID: 39096348 PMCID: PMC11297802 DOI: 10.1007/s00423-024-03433-6] [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: 04/26/2024] [Accepted: 07/28/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND Retrosternal oesophageal reconstructions with collar anastomoses can become necessary when the stomach is either unavailable for oesophageal replacement, or orthotopic reconstruction is deemed impractical. Our aim was to analyse our results regarding technical approaches and outcomes. MATERIALS AND METHODS All patients undergoing primary and secondary oesophageal retrosternal reconstructions with collar anastomoses at our centre (2019-2023) were retrospectively analysed and individual surgical reconstruction options were presented. RESULTS Overall, twelve patients received primary (n = 5; 42.7%) or secondary (n = 7; 58.3%) reconstructions; ten with colonic interposition and two with gastric pull-up. Male/female ratio was 4:8; median age 66 years (30-87). Charlson-Comorbidity-Score (CCS) was 5 (1-7); 8/12 patients (67%) had ASA-classification score ≥ 3. We observed no conduit necrosis, but one patient (8.3%) with a leakage of the oesophago-colonostomy which was successfully treated by endoscopic vacuum therapy. Four patients (33.3%) acquired nosocomial pneumonia. Additional drainages for pleural fluid collections were necessary in three patients (25%). Overall comprehensive-complication-index (CCI) was 26.2 (0-44.9). Length-of-stay (LOS) was 22 days median (15-40). There was no 90-days mortality. Overall, CCI during the follow-up (FU) period at median 26 months (16-50) was 33.7 (0-100). 10 out of 12 patients were on sufficient oral nutrition at 12 months FU. CONCLUSION Primary and secondary oesophageal retrosternal reconstructions encompass diverse entities and typically requires tailored decision-making. These procedures, though rare, are feasible with acceptable complication rates and positive functional outcomes when performed in experienced hands.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Sven Flemming
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Johan Friso Lock
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
- Comprehensive Cancer Centre, Wuerzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular, and Paediatric Surgery, University Hospital Wuerzburg, Wuerzburg, Germany.
- Head of Surgery for Upper Gastrointestinal Tract and Metabolic Surgery, Department of General, Visceral, Transplantation, Vascular and Paediatric Surgery, Centre of Operative Medicine (ZOM), University Hospital of Wuerzburg, Wuerzburg, Germany.
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Bartella I, Brunner S, Schiffmann LM, Schiller P, Schmidt T, Fuchs HF, Chon S, Bruns CJ, Schröder W. Clinical utility and applicability of the,Esophagus Complication Consensus Group' (ECCG) classification of anastomotic leakage following hybrid Ivor-Lewis esophagectomy. Langenbecks Arch Surg 2023; 408:258. [PMID: 37391512 DOI: 10.1007/s00423-023-03001-4] [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: 04/17/2023] [Accepted: 06/25/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) remains the leading surgical complication following Ivor-Lewis (IL) esophagectomy. Different treatment options of AL exist but outcome is difficult to compare due to a lack of generally accepted classifications. This retrospective study was conducted to analyze the clinical significance of a recently proposed classification based on the management of AL. PATIENTS AND METHODS A cohort of 954 consecutive patients undergoing hybrid IL esophagectomy (laparoscopy/thoracotomy) was analysed. AL was defined according to the,Esophagus Complication Consensus Group' (ECCG) criteria depending on its treatment: conservative (AL type I), interventional endoscopic (AL type II), and surgical (AL type III). Primary outcome was single or multiple organ failure (Clavien-Dindo IVA/B) associated with AL. RESULTS Overall morbidity was 63.0% and 8.8% (84/954 patients) developed an AL postoperatively. Three patients (3.5%) had an AL type I, 57 patients (67.9%) an AL type II and 24 patients (28.6%) an AL type III. For patients managed surgically, AL was diagnosed significantly earlier (median days: AL type III: 2 vs AL type II: 6, p < 0.001). Associated organ failure (CD IVA/B) was significantly lower for AL type II as compared to AL type III (21.1% versus 45.8%, p < 0.0001). In-hospital mortality was 3.5% for AL type II and 8.3% for AL type III (p = 0.789). There was no difference for re-admission to ICU and overall length of hospital stay. CONCLUSION The proposed ECCG classification is simply to apply and discriminates the post-treatment severity of AL but does not aid to implement a treatment algorithm.
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Affiliation(s)
- Isabel Bartella
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Stefanie Brunner
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Petra Schiller
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Seung Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department of General, Visceral, Cancer and Transplantation Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 32, 50937, Cologne, Germany.
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Walsh TN. The Esophagogastric Anastomosis: The Importance of Anchoring Sutures in Reducing Anastomotic Leak Rates. ANNALS OF SURGERY OPEN 2023; 4:e231. [PMID: 37600864 PMCID: PMC10431275 DOI: 10.1097/as9.0000000000000231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/29/2022] [Indexed: 02/04/2023] Open
Abstract
Background The incidence of anastomotic leakage in gastrointestinal surgery is highest after esophagogastric anastomosis, with leakage rates of 10% to 38% still being reported, but little consensus as to cause or corrective. The role of anastomotic tension from a series of physiological forces acting on the anastomosis from the moment of recovery from anesthesia may be underestimated. It was hypothesized that anchoring the conduit in the mediastinum would provide the greatest protection during the vulnerable healing phase. Patients and Methods A prospectively maintained database was interrogated for anastomotic leakage following the introduction of an anastomotic technique employing anchoring sutures where the gastric conduit was secured to the mediastinal pleura with 3 obliquely inserted load-bearing sutures. A contrast study was performed between days 5 and 7 and all intrahospital mortalities underwent autopsy. Clinical, radiological, and autopsy leaks were recorded. Results Of 146 intrathoracic esophagogastric anastomoses in 144 patients, 81 (55%) of which were stapled, there was 1 clinical leak and 1 patient with an aortoenteric fistula, considered at autopsy to be possibly due to an anastomotic leak, to give an anastomotic leak rate of 2 in 146 (1.37%). Conclusion The low anastomotic leak rate in this series is potentially due to the protective effect of anchoring sutures, the chief difference from an otherwise standard anastomotic technique. These sutures protect the anastomosis from a series of distracting forces during the most vulnerable phase of healing. It is intuitive that the absence of tension would also reduce any risk posed by a minor impairment of blood supply or any imperfection of the technique.
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Affiliation(s)
- Thomas N. Walsh
- From the Royal College of Surgeons in Ireland Department of Surgery, Connolly Hospital Blanchardstown, Dublin, Ireland
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Current Issues and Future Technologies in Esophageal Cancer Surgery. J Clin Med 2022; 12:jcm12010209. [PMID: 36615010 PMCID: PMC9821094 DOI: 10.3390/jcm12010209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/19/2022] [Indexed: 12/29/2022] Open
Abstract
Gastrointestinal surgery has evolved rapidly in recent years, with laparoscopic techniques being implemented as the standard procedure and robotic surgery becoming increasingly important [...].
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Angehrn FV, Neuschütz KJ, Fourie L, Becker P, von Flüe M, Steinemann DC, Bolli M. Continuously sutured versus linear-stapled anastomosis in robot-assisted hybrid Ivor Lewis esophageal surgery following neoadjuvant chemoradiotherapy: a single-center cohort study. Surg Endosc 2022; 36:9435-9443. [PMID: 35854126 PMCID: PMC9652283 DOI: 10.1007/s00464-022-09415-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 06/24/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Esophageal cancer surgery is technically highly demanding. During the past decade robot-assisted surgery has successfully been introduced in esophageal cancer treatment. Various techniques are being evaluated in different centers. In particular, advantages and disadvantages of continuously sutured (COSU) or linear-stapled (LIST) gastroesophageal anastomoses are debated. Here, we comparatively analyzed perioperative morbidities and short-term outcomes in patients undergoing hybrid robot-assisted esophageal surgery following neoadjuvant chemoradiotherapy (nCRT), with COSU or LIST anastomoses in a single center. METHODS Following standardized, effective, nCRT, 53 patients underwent a hybrid Ivor Lewis robot-assisted esophagectomy with COSU (n = 32) or LIST (n = 21) gastroesophageal anastomoses. Study endpoints were intra- and postoperative complications, in-hospital morbidity and mortality. Duration of operation, intensive care unit (ICU) and overall hospital stay were also evaluated. Furthermore, rates of rehospitalization, endoscopies, anastomotic stenosis and recurrence were assessed in a 90-day follow-up. RESULTS Demographics, ASA scores and tumor characteristics were comparable in the two groups. Median duration of operation was similar in patients with COSU and LIST anastomosis (467 vs. 453 min, IQR 420-521 vs. 416-469, p = 0.0611). Major complications were observed in 4/32 (12.5%) and 4/21 (19%) patients with COSU or LIST anastomosis, respectively (p = 0.697). Anastomotic leakage was observed in 3/32 (9.3%) and 2/21 (9.5%) (p = 1.0) patients with COSU or LIST anastomosis, respectively. Pleural empyema occurred in 1/32 (3.1%) and 2/21 (9.5%) (p = 0.555) patients, respectively. Mortality was similar in the two groups (1/32, 3.1% and 1/21, 4.7%, p = 1.0). Median ICU stay did not differ in patients with COSU or LIST anastomosis (p = 0.255), whereas a slightly, but significantly (p = 0.0393) shorter overall hospital stay was observed for COSU, as compared to LIST cohort (median: 20 vs. 21 days, IQR 17-22 vs. 18-28). CONCLUSIONS COSU is not inferior to LIST in the performance of gastroesophageal anastomosis in hybrid Ivor Lewis operations following nCRT.
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Affiliation(s)
- Fiorenzo V Angehrn
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
| | - Kerstin J Neuschütz
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Lana Fourie
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Pauline Becker
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Markus von Flüe
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Daniel C Steinemann
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
| | - Martin Bolli
- Department of Surgery, Clarunis AG - University Center for Gastrointestinal and Liver Diseases, Postfach, 4002, Basel, Switzerland
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Zhang H, Zuo Z, Yan X, Wang F, Yang L, Qiu G, Chen LQ, Wang Y. Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy. Front Surg 2022; 9:957093. [PMID: 35965865 PMCID: PMC9365067 DOI: 10.3389/fsurg.2022.957093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background With the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis. Methods After stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired. Results The clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period. Conclusion Two purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.
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Affiliation(s)
- Hanlu Zhang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Zeping Zuo
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiuji Yan
- Department of Plastic and Burns Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Fuqiang Wang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Lin Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Guanghao Qiu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
- Correspondence: Long-Qi Chen Yun Wang
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
- Correspondence: Long-Qi Chen Yun Wang
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Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy. Surg Endosc 2021; 36:1675-1682. [PMID: 34499220 PMCID: PMC8428217 DOI: 10.1007/s00464-021-08715-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
Background Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. Methods From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. Results The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. Conclusion Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08715-4.
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