The effect of narrowed gastric conduits on anastomotic leakage following minimally invasive oesophagectomy

Risk factors for esophageal anastomotic stricture after esophagectomy: a meta-analysis

BACKGROUND

The aim of this study was to assess the risk factors for anastomotic stricture in esophageal cancer patients undergoing esophagectomy. Esophageal anastomotic stricture is the most common long-term complication for esophagectomy. The risk factors for esophageal anastomotic stricture still remain controversial.

METHODS

MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for esophageal anastomotic stricture after esophagectomy. A meta-analysis was conducted to investigate the impact of various risk factors on esophageal anastomotic stricture. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels.

RESULTS

This review included 14 studies evaluating 5987 patients.The meta-analysis found that anastomotic leakage (odds ratio [OR]: 2.75; 95% confidence interval[CI]:2.16-3.49), cardiovascular disease [OR:1.62; 95% CI: 1.22-2.16],diabete [OR: 1.62; 95% CI: 1.20-2.19] may be risk factors for esophageal anastomotic stricture.There were no association between neoadjuvant therapy [OR: 0.78; 95% CI:0.62-0.97], wide gastric conduit [OR:0.98; 95% CI: 0.37-2.56],mechanical anastomosis [OR: 0.84; 95% CI:0.47-1.48],colonic interposition[OR:0.20; 95% CI: 0.12-0.35],and transhiatal approach[OR:1.16; 95% CI:0.81-1.64],with the risk of esophageal anastomotic stricture.

CONCLUSIONS

This meta-analysis provides some evidence that anastomotic leakage,cardiovascular disease and diabete may be associated with higher rates of esophageal anastomotic stricture.Knowledge about those risk factors may influence treatment and procedure-related decisions,and possibly reduce the anastomotic stricture rate.

Association of conduit dimensions with perioperative outcomes and long-term quality of life after esophagectomy for malignancy

Objective

The impact of conduit dimensions and location of esophagogastric anastomosis on long-term quality of life after esophagectomy remains unexplored. We investigated the association of these parameters with surgical outcomes and patient-reported quality of life at least 18 months after esophagectomy.

Methods

We identified all patients who underwent esophagectomy for cancer from 2018 to 2020 in our institution. We reviewed each patient's initial postoperative computed tomography scan measuring the gastric conduit's greatest width (centimeters), linear staple line length (centimeters), and relative location of esophagogastric anastomosis (vertebra). Quality of life was ascertained using patient-reported outcome measures. Perioperative complications, length of stay, and mortality were collected. Multivariate regressions were performed.

Results

Our study revealed that a more proximal anastomosis was linked to an increased risk of pulmonary complications, a lower recurrence rate, and greater long-term insomnia. Increased maximum intrathoracic conduit width was significantly associated with trouble enjoying meals and reflux long term after esophagectomy. A longer conduit stapled line correlated with fewer issues related to insomnia, improved appetite, less dysphagia, and significantly enhanced "social," "role," and "physical'" aspects of the patient's long-term quality of life.

Conclusions

The dimensions of the gastric conduit and the height of the anastomosis may be independently associated with outcomes and long-term quality of life after esophagectomy for cancer.

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial

BACKGROUND

The purpose of this randomized controlled trial was to determine if enhanced recovery after surgery (ERAS) would improve outcomes for three-stage minimally invasive esophagectomy (MIE).

METHODS

Patients with esophageal cancer undergoing MIE between March 2016 and August 2018 were consecutively enrolled, and were randomly divided into 2 groups: ERAS+group that received a guideline-based ERAS protocol, and ERAS- group that received standard care. The primary endpoint was morbidity after MIE. The secondary endpoints were the length of stay (LOS) and time to ambulation after the surgery. The perioperative results including the Surgical Apgar Score (SAS) and Visualized Analgesia Score (VAS) were also collected and compared.

RESULTS

A total of 60 patients in the ERAS+ group and 58 patients in the ERAS- group were included. Postoperatively, lower morbidity and pulmonary complication rate were recorded in the ERAS+ group (33.3% vs. 51.7%; p = 0.04, 16.7% vs. 32.8%; p = 0.04), while the incidence of anastomotic leakage remained comparable (11.7% vs. 15.5%; p = 0.54). There was an earlier ambulation (3 [2-3] days vs. 3 [3-4] days, p = 0.001), but comparable LOS (10 [9-11.25] days vs. 10 [9-13] days; p = 0.165) recorded in ERAS+ group. The ERAS protocol led to close scores in both SAS (7.80 ± 1.03 vs. 8.07 ± 0.89, p = 0.21) and VAS (1.74 ± 0.85 vs. 1.78 ± 1.06, p = 0.84).

CONCLUSIONS

Implementation of an ERAS protocol for patients undergoing MIE resulted in earlier ambulation and lower pulmonary complications, without a change in anastomotic leakage or length of hospital stay. Further studies on minimizing leakage should be addressed in ERAS for MIE.

Circular Stapler Method for Avoiding Stricture of Cervical Esophagogastric Anastomosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Advantages of McKeown minimally invasive oesophagectomy for the treatment of oesophageal cancer: propensity score matching analysis of 169 cases

BACKGROUND

Oesophagectomy, the gold standard for oesophageal cancer treatment, causes significantly high morbidity and mortality. McKeown minimally invasive oesophagectomy (MIE) is preferred for treating oesophageal malignancies; however, limited studies with large sample sizes focusing on the surgical and oncological outcomes of this procedure have been reported. We aimed to compare the clinical safety and efficacy of McKeown MIE with those of open oesophagectomy (OE).

PATIENTS AND METHODS

Overall, 338 oesophageal cancer patients matched by gender, age, location, size, and T and N stages (McKeown MIE: 169 vs OE: 169) were analysed. The clinicopathologic features, operational factors, postoperative complications, and prognoses were compared between the groups.

RESULTS

McKeown MIE resulted in less bleeding (200 mL vs 300 mL, p<0.01), longer operation time (335.0 h vs 240.0 h, p<0.01), and higher number of harvested lymph nodes (22 vs 9, p<0.01) than OE did. Although the rate of recurrent laryngeal nerve injury in the two groups was not significantly different, incidence of anastomotic leakage (8 vs 24, p=0.003) was significantly lower in the McKeown MIE group. In addition, patients who underwent McKeown MIE had higher 5-year overall survival than those who underwent OE (69.9% vs 40.4%, p<0.001).

CONCLUSION

McKeown MIE is proved to be feasible and safe to achieve better surgical and oncological outcomes for oesophageal cancer compared with OE.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of Complications After Esophagectomy

Esophagectomy is a complex operation with many potential complications. Early recognition of postoperative complications allows for the best chance for patient survival. Diagnosis and management of conduit complications, including leak, necrosis, and conduit-airway fistulae, are reviewed. Other common complications, such as chylothorax and recurrent laryngeal nerve injury, also are discussed.

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

T-shaped linear-stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy: a pilot study

BACKGROUND

Minimally invasive esophagectomy (MIE) has become a good option in the surgical treatment of esophageal cancer. Cervical esophagogastric anastomoses (CEGA) are widely used during esophagectomy. However, CEGA are related with a higher incidence of anastomotic complications. In the present study, a new procedure of T-shaped linear-stapled cervical esophagogastric anastomosis was used during MIE and the short-term outcomes are presented.

METHODS

From May 2014 to December 2018, 32 consecutive patients with esophageal cancer who underwent total MIE followed by T-shaped linear-stapled cervical esophagogastric anastomosis were included. Postoperative outcomes were analyzed.

RESULTS

Fifteen men and 17 women were included this pilot study. The histology of all cases was squamous cell carcinoma. Mean operation time of T-shaped linear-stapled cervical esophagogastric anastomosis was 17.6 minutes. There were no early or late mortalities. A minor cervical anastomotic leakage occurred in 1 patient. No complications of anastomotic stenosis occurred in this study.

CONCLUSION

The T-shaped linear-stapled cervical esophagogastric anastomosis is efficient, reliable, easy to perform, and associated with lower postoperative complication rate.

Neoadjuvant chemoradiotherapy followed by minimally invasive esophagectomy: is it a superior approach for locally advanced resectable esophageal squamous cell carcinoma?

Background

Few studies reported the outcomes of minimally invasive esophagectomy (MIE) in treating patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant chemoradiotherapy (nCRT). The aim of the study was to investigate the feasibility and efficacy of nCRT plus MIE (RM) strategy in treating locally advanced resectable ESCC.

Methods

This retrospective study included 175 patients with ESCC undergoing surgical resection after neoadjuvant therapy in our institution from 2010 to 2016. Patients were stratified into three groups: RM, [neoadjuvant chemotherapy (nCT) plus MIE] (CM) and [nCT plus open esophagectomy (OE)] (CO).

Results

Seventy-six (43.4%), 42 (24%) and 57 (32.6%) patients received RM, CM and CO approach, respectively. Compared with CO approach, RM or CM approach had shorter operation duration (188±39, 185±37 vs. 209±45 minutes, P=0.004, P=0.009) and less blood loss (124±88, 122±79 vs. 166±92 mL, P=0.001, P=0.003). There was a trend with lower risk of postoperative non-surgical complications in RM and CM approach [odds ratio (OR) 0.45, 0.200-1.040; P=0.062; OR 0.41, 0.150-1.160; P=0.093]. There were no differences in 30- and 90-day mortality among all groups. RM approach was more likely to achieve pathological complete regression (27.6% vs. 4.8%, 1.8%, P=0.001, P=0.001) and fewer lymph node metastasis (25.0% vs. 57.1%, 61.4%, P=0.001, P=0.001) than CM or CO approach. Survival analysis revealed a potential trend towards improved overall survival in RM approach compared with CM or CO approach (P=0.098, P=0.166).

Conclusions

RM approach was a safe and efficient strategy in treating locally advanced resectable ESCC.

Failure to rescue patients from early critical complications of oesophagogastric cancer surgery

'Failure to rescue' is a significant cause of mortality in gastrointestinal surgery. Differences in mortality between high and low-volume hospitals are not associated with large difference in complication rates but to the ability of the hospital to effectively rescue patients from the complications. We reviewed the critical complications following surgery for oesophageal and gastric cancer, their prevention and reasons for failure to rescue. Strategies focussing on perioperative optimization, the timely recognition and management of complications may be essential to improving outcome in low-volume hospitals.

A comparison of short-term outcomes between Ivor-Lewis and McKeown minimally invasive esophagectomy

BACKGROUND

Only few comparative studies have been reported on the outcomes of minimally invasive esophagectomy (MIE) with intrathoracic anastomosis (MIE Ivor-Lewis) and MIE with cervical anastomosis (MIE McKeown) for patients with mid and lower esophageal cancer. The objective of this study is to compare the safety, feasibility, and short-term outcomes between two groups.

METHODS

Clinical and surgical data of patients with esophageal cancer who underwent either MIE Ivor-Lewis or MIE McKeown between January 2013 and October 2014 were retrospectively analyzed. Demographic characteristics, pathological data, operative procedures, and perioperative outcomes and survival in patients were compared between both groups.

RESULTS

Of the 72 patients included in this retrospective analysis, 32 underwent MIE Ivor-Lewis and 40 underwent MIE McKeown. Demographics, pathologic data, inpatient mortality, and surgical morbidity in both cohorts were almost identical. A significant difference was observed in Pulmonary complication (18.8% vs. 42.5%, P=0.032), Anastomotic leakage (9.4% vs. 30%, P=0.032), Anastomotic stenosis (12.5% vs. 35%, P=0.028), recurrent laryngeal nerve (RLN) injury (6.3% vs. 22.5%, P=0.034) between MIE Ivor-Lewis and MIE McKeown groups; however, no difference in operative time (312.6±82.0 vs. 339.4±80.0, P=0.249), blood loss (246.3±82.4 vs. 272.9±136.3, P=0.443), lymph nodes harvested (19.3±8.1 vs. 20.2±7.2, P=0.655) and 90-day mortality (3.1% vs. 5%, P=0.692) was observed between two groups.

CONCLUSIONS

The procedure of MIE Ivor-Lewis for esophageal cancer possesses advantages in perioperative outcomes and less complications compared with MIE McKeown.