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Aiolfi A, Griffiths EA, Sozzi A, Manara M, Bonitta G, Bonavina L, Bona D. Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination. Ann Surg Oncol 2023; 30:5564-5572. [PMID: 37210447 DOI: 10.1245/s10434-023-13670-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Anastomotic leak (AL) is a serious complication after esophagectomy. It is associated with prolonged hospital stay, increased costs, and increased risk for 90-day mortality. Controversy exists concerning the impact of AL on survival. This study was designed to investigate the effect of AL on long-term survival after esophagectomy for esophageal cancer. METHODS PubMed, MEDLINE, Scopus, and Web of Science were searched through October 30, 2022. The included studies evaluated the effect of AL on long-term survival. Primary outcome was long-term overall survival. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. RESULTS Thirteen studies (7118 patients) were included. Overall, 727 (10.2%) patients experienced AL. The RMSTD analysis shows that at 12, 24, 36, 48, and 60 months, patients not experiencing AL live an average of 0.7 (95% CI 0.2-1.2; p < 0.001), 1.9 (95% CI 1.1-2.6; p < 0.001), 2.6 (95% CI 1.6-3.7; p < 0.001), 3.4 (95% CI 1.9-4.9; p < 0.001), and 4.2 (95% CI 2.1-6.4; p < 0.001) months longer compared with those with AL, respectively. The time-dependent HRs analysis for AL versus no AL shows a higher mortality hazard in patients with AL at 3 (HR 1.94, 95% CI 1.54-2.34), 6 (HR 1.56, 95% CI 1.39-1.75), 12 (HR 1.47, 95% CI 1.24-1.54), and 24 months (HR 1.19, 95% CI 1.02-1.31). CONCLUSIONS This study seems to suggest a modest clinical impact of AL on long-term OS after esophagectomy. Patients who experience AL seem to have a higher mortality hazard during the first 2 years of follow-up.
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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.
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - 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
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 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
| | - Luigi Bonavina
- I.R.C.C.S. Ospedale Galeazzi - Sant'Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 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
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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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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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Su Q, Yin C, Liao W, Yang H, Ouyang L, Yang R, Ma G. Anastomotic leakage and postoperative mortality in patients after esophageal cancer resection. J Int Med Res 2021; 49:3000605211045540. [PMID: 34590915 PMCID: PMC8489786 DOI: 10.1177/03000605211045540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Objective Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. This study aimed to investigate the risk factors of cervical anastomotic leakage and postoperative mortality. Methods In this retrospective, observational study, we recruited 1010 patients with esophageal cancer. Cox regression analysis was performed to identify factors affecting anastomotic leakage and postoperative mortality. After propensity score matching, the Kaplan–Meier curve was used to evaluate the effect of leakage on postoperative mortality. Results The number of patients with cervical anastomotic leakage, in-hospital mortality, 30-day postoperative mortality, and 60-day postoperative mortality was 194 (19.2%), 13 (1.3%), 12 (1.2%), and 16 (1.6%), respectively. The total length of hospital stay and hospital stay postoperatively were 29.7 ± 21.1 and 21.3 ± 20.3 days, respectively. Diabetes, stage IV, and an upper thoracic tumor were significant risk factors for leakage. Leakage and diabetes were significant risk factors for postoperative mortality. After propensity score matching, leakage also significantly affected postoperative mortality. Conclusions Patients with tumors in the upper thoracic segment of the esophagus may be more prone to developing anastomotic leakage compared with those with tumors in the middle or lower thoracic segment. Anastomotic leakage may prolong the length of hospital stay and increase postoperative mortality.
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Affiliation(s)
- Quanguan Su
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Chenxi Yin
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Wei Liao
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Haoxian Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Liying Ouyang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Rong Yang
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Gang Ma
- Intensive Care Unit, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
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5
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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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6
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Gujjuri RR, Kamarajah SK, Markar SR. Effect of anastomotic leaks on long-term survival after oesophagectomy for oesophageal cancer: systematic review and meta-analysis. Dis Esophagus 2021; 34:5902816. [PMID: 32901259 DOI: 10.1093/dote/doaa085] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 07/14/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Long-term survival after curative surgery for oesophageal cancer surgery remains poor, and the prognostic impact of anastomotic leak (AL) remains unknown. A meta-analysis was conducted to investigate the impact of AL on long-term survival. METHODS A systematic electronic search for articles was performed for studies published between 2001 and 2020 evaluating the long-term oncological impact of AL. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute hazard ratios and 95% confidence intervals. RESULTS Nineteen studies met the inclusion criteria, yielding a total of 9885 patients. Long-term survival was significantly reduced after AL (HR: 1.79, 95% CI: 1.33-2.43). AL was associated with significantly reduced overall survival in studies within hospital volume Quintile 1 (HR: 1.35, 95% CI: 1.12-1.63) and Quintile 2 (HR: 1.83, 95% CI: 1.35-2.47). However, no significant association was found for studies within Quintile 3 (HR: 2.24, 95% CI: 0.85-5.88), Quintile 4 (HR: 2.59, 95% CI: 0.67-10.07), and Quintile 5 (HR: 1.29, 95% CI: 0.92-1.81). AL was significantly associated with poor long-term survival in patients with associated overall Clavien Dindo Grades 1-5 (HR: 2.17, 95% CI: 1.31-3.59) and severe Clavien Dindo Grades 3-5 (HR: 1.42, 95% CI: 1.14-1.78) complications. CONCLUSIONS AL has a negative prognostic impact on long-term survival after restorative resection of oesophageal cancers, particularly in low-volume centers. Future efforts must be focused on strategies to minimize the septic and immunological response to AL with early recognition and treatment thus reducing the impact on long-term survival.
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Affiliation(s)
- Rohan R Gujjuri
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sivesh K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - Sheraz R Markar
- Department of Surgery & Cancer, Imperial College London, London, UK
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Lindenmann J, Fink-Neuboeck N, Porubsky C, Fediuk M, Anegg U, Kornprat P, Smolle M, Maier A, Smolle J, Smolle-Juettner FM. A nomogram illustrating the probability of anastomotic leakage following cervical esophagogastrostomy. Surg Endosc 2020; 35:6123-6131. [PMID: 33106886 PMCID: PMC8523496 DOI: 10.1007/s00464-020-08107-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 10/16/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND Early diagnosis of anastomotic dehiscence following cervical esophagogastrostomy may become difficult. Estimation of an individual probability could help to establish preventive and diagnostic measures. The predictive impact of epidemiological, surgery-related data and laboratory parameters on the development of anastomotic dehiscence was investigated in the immediate perioperative period. METHODS Retrospective study in 412 patients with cervical esophagogastrostomy following esophagectomy. Epidemiological data, risk factors, underlying disease, pre-treatment- and surgery-related data, C-reactive protein and albumin levels pre-and post-operatively were evaluated. We applied univariable and multivariable logistic regression analysis and developed a nomogram for individual risk assessment. RESULTS There were 345 male, 67 female patients, mean aged 61.5 years; 284 had orthotopic, 128 retrosternal gastric pull-up; 331 patients had carcinoma, 81 non-malignant disease. Mean duration of operation was 184 min; 235 patients had manual, 113 mechanical and 64 semi-mechanical suturing; 76 patients (18.5%) developed anastomotic dehiscence clinically evident at mean 11.4 days after surgery. In univariable testing young age, retrosternal conduit transposition, manual suturing, high body mass index, high ASA and high postoperative levels of C-reactive protein were predictors for anastomotic leakage. These six parameters which had yielded a p < 0.1 in the univariable analysis, were entered into a multivariable analysis and a nomogram allowing the determination of the patient's individual risk was created. CONCLUSION By using the nomogram as a supportive measure in the perioperative management, the patient's individual probability of developing an anastomotic leak could be quantified which may help to take preventive measures improving the outcome.
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Affiliation(s)
- Joerg Lindenmann
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria.
| | - Nicole Fink-Neuboeck
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Christian Porubsky
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Melanie Fediuk
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Udo Anegg
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Peter Kornprat
- Department of General Surgery, Medical University of Graz, Graz, Austria
| | - Maria Smolle
- Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria
| | - Alfred Maier
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
| | - Josef Smolle
- Institute of Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Freyja Maria Smolle-Juettner
- Division of Thoracic Surgery and Hyperbaric Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29/3, 8036, Graz, Austria
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8
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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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9
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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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Kamarajah SK, Lin A, Tharmaraja T, Bharwada Y, Bundred JR, Nepogodiev D, Evans RPT, Singh P, Griffiths EA. Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis. Dis Esophagus 2020; 33:5709700. [PMID: 31957798 DOI: 10.1093/dote/doz089] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 06/07/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, University of Newcastle, Newcastle Upon Tyne, UK
| | - Aaron Lin
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Thahesh Tharmaraja
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Yashvi Bharwada
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - James R Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Dmitri Nepogodiev
- Department of Academic Surgery and College of Medical and Dental Sciences, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | - Richard P T Evans
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, City Hospital Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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11
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Author's Reply: Comparison of Outcomes with Semi-mechanical and Circular Stapled Intrathoracic Esophagogastric Anastomosis following Esophagectomy. World J Surg 2019; 44:321-322. [PMID: 31641834 DOI: 10.1007/s00268-019-05247-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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12
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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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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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Mishra PK, Shah H, Gupta N, Varshney V, Patil NS, Jain A, Saluja SS. Stapled versus hand-sewn cervical esophagogastric anastomosis in patients undergoing esophagectomy: A Retrospective Cohort Study. Ann Med Surg (Lond) 2016; 5:118-24. [PMID: 27222711 PMCID: PMC4866531 DOI: 10.1016/j.amsu.2015.12.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/31/2015] [Accepted: 12/31/2015] [Indexed: 02/07/2023] Open
Abstract
Introduction Anastomotic leak is one of the main causes of morbidity following esophageal resection for carcinoma of the esophagus and gastroesophageal junction. We compared hand sewn and stapled cervical esophagogastric anastomotic techniques in terms of postoperative complications. Methods All patients who underwent esophagectomy with cervical esophagogastric anastomosis at a single academic center from 2004 to 2014 were included in the study. Both early and late complications were analyzed. Results 153 patients underwent resection for carcinoma of the esophagus and gastroesophageal junction. Of these 140 patients had esophagectomy with cervical esophagogastric anastomosis. 66 patients underwent a hand sewn anastomosis and 74 patients had a side-to-side stapled anastomosis fashioned. Both groups were comparable with respect to preoperative characteristics. There was no difference in the operative blood loss and T and N stage of the disease. The overall morbidity and mortality was 32.8% and 6.4%, respectively. Overall leak rate was 17%. There was no difference in the leak rates among two groups (12 in the hand-sewn group & 12 in the Stapled stapled group; p = 0.82). The rate of anastomotic stricture was significantly higher for the hand sewn group (16.1% vs 4.3%; p = 0.03) at median follow up of 30 months. Conclusion Both hand sewn and stapled anastomotic techniques are equally effective way of performing a cervical esophagogastric anastomosis. However, patients having anastomotic leak develop anastomotic stricture more often in those having hand-sewn anastomosis compared to stapled anastomosis. We analyzed & compared the outcomes of cervical esophagogastric anastomosis between hand sewn and partial side to side stapled technique. Both hand sewn and stapled techniques are equally effective way of performing a cervical esophagogastric anastomosis. Anastomotic leak results in anastomotic stricture more often with hand-sewn anastomosis than stapled.
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Affiliation(s)
- Pramod Kumar Mishra
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Harsh Shah
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Nikhil Gupta
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Vaibhav Varshney
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Nilesh Sadashiv Patil
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Amit Jain
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
| | - Sundeep Singh Saluja
- Department of Gastrointestinal Surgery, G B Pant Hospital & Maulana Azad Medical College, New Delhi, 110002, India
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Harustiak T, Pazdro A, Snajdauf M, Stolz A, Lischke R. Anastomotic leak and stricture after hand-sewn versus linear-stapled intrathoracic oesophagogastric anastomosis: single-centre analysis of 415 oesophagectomies. Eur J Cardiothorac Surg 2015; 49:1650-9. [PMID: 26574497 DOI: 10.1093/ejcts/ezv395] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/06/2015] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES There seems to be a decreased anastomotic leak rate and a late stricture formation after linear-stapled (LS) cervical oesophagogastric anastomosis compared with hand-sewn (HS) technique. The aim of our study was to compare the surgical outcomes of intrathoracic side-to-side LS and end-to-end HS anastomosis after transthoracic oesophagectomy. METHODS We conducted a retrospective review of all patients undergoing Ivor Lewis oesophagectomy with LS or HS anastomosis for neoplasia at our institution from 2005 to 2012. Anastomotic leak was radiologically and clinically graded as minor or major. End-points included overall and major leak rate, morbidity, mortality, length of hospital stay and endoscopically identified late anastomotic stricture. A propensity score-matched analysis was done to compensate for the differences in baseline characteristics between HS and LS groups. Multivariable analyses of the associations of anastomotic technique and other preoperative and pathological variables with anastomotic leak and stricture were performed. RESULTS There were 415 patients, 134 with HS and 281 with LS anastomoses. Anastomotic leak occurred in 56 patients (13.5%), significantly more after HS than LS technique (20.9 vs 10.0%; P = 0.002). Major leak rate was not significantly different (9.0 vs 5.7%; P = 0.216, respectively). Overall morbidity (54.7%), in-hospital mortality (3.9%) and length of hospital stay (median 12 days) were not affected by the anastomotic technique. A follow-up endoscopic evaluation was available in 248 patients (59.8%). An anastomotic stricture was detected in 24 patients (9.7%), significantly more after HS than LS technique (20.3 vs 6.3%; P = 0.002). The propensity score-matched analysis of 105 patient pairs confirmed a significantly decreased overall leak rate (11.4 vs 22.9%; P = 0.045) and stricture formation (7.5 vs 18.2%; P = 0.041) in LS technique compared with HS technique. The multivariable analyses found obesity and HS anastomotic technique associated with an increased overall leak rate, chronic hepatopathy and diabetes associated with major leak and HS technique, female sex and the absence of arterial hypertension associated with increased stricture formation. CONCLUSIONS Our non-randomized study showed that side-to-side LS technique is the preferred method of intrathoracic oesophagogastric anastomosis due to a decreased overall anastomotic leak rate and anastomotic stricture formation compared with HS technique.
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Affiliation(s)
- Tomas Harustiak
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alexandr Pazdro
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Martin Snajdauf
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Alan Stolz
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
| | - Robert Lischke
- 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic
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Deng XF, Liu QX, Zhou D, Min JX, Dai JG. Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: A meta-analysis. World J Gastroenterol 2015; 21:4757-4764. [PMID: 25914488 PMCID: PMC4402326 DOI: 10.3748/wjg.v21.i15.4757] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/30/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of hand-sewn (HS) and linearly stapled (LS) esophagogastric anastomosis for esophageal cancer.
METHODS: Before beginning this study, a rigorous protocol was established according to the recommendations of the Cochrane Collaboration. Databases and references were searched for all randomized controlled trials and comparative clinical studies that compared LS with HS esophagogastric anastomosis for esophageal cancer. The primary outcomes compared were anastomotic leak and stricture. Subgroup analyses were performed according to site of anastomosis.
RESULTS: Fifteen studies were used, comprising 3203 patients (n = 2027 LS and 1176 HS). Primary outcome analysis revealed a significant decrease in anastomotic leakage (RR = 0.51, 95%CI: 0.41-0.65; P < 0.00001) associated with LS anastomosis. A significantly reduced rate of anastomotic stricture associated with LS was also found (RR = 0.56, 95%CI: 0.49-0.64; P < 0.00001). A subgroup analysis according to the site of anastomosis revealed a significantly reduced rate of anastomotic stricture (P < 0.00001). Although there was no significant difference in the decrease in thoracic anastomotic leakage, there was a significant decrease in cervical anastomotic leakage associated with LS (P < 0.00001).
CONCLUSION: This meta-analysis indicates that the LS technique contributes to a reduced rate of leakage and stricture compared with the HS method.
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Liu QX, Min JX, Deng XF, Dai JG. Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis. World J Gastroenterol 2014; 20:17218-17226. [PMID: 25493038 PMCID: PMC4258594 DOI: 10.3748/wjg.v20.i45.17218] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/24/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.
METHODS: A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electronic database search, hand search, and reference search were used to retrieve all randomized controlled trials that compared hand-sewn and mechanical esophagogastric anastomoses.
RESULTS: This study included 15 randomized controlled trials with a total of 2337 patients. The results revealed that there was no significant difference in the incidence of anastomotic leakage between the methods [relative risk (RR) = 0.77, 95% confidence interval (CI): 0.57-1.04; P = 0.09], but a subgroup analysis yielded a significant difference for the sutured layer and year of publication (Ps < 0.05). There was also no significant difference in the incidence of postoperative mortality (RR = 1.52, 95%CI: 0.97-2.40; P = 0.07). However, the anastomotic strictures rate was increased in the stapler group compared with the hand-sewn group (RR = 1.45, 95%CI: 1.11-1.91; P < 0.01) in the end-to-side subgroup, while the incidence of anastomotic strictures was decreased (RR = 0.34, 95%CI: 0.16-0.76; P < 0.01) in the side-to-side subgroup.
CONCLUSION: The stapler reduces the anastomotic leakage rate compared with hand sewing. End-to-side stapling increases the risk of anastomotic strictures, but side-to-side stapling decreases the risk.
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Salih AEA, Bass GA, D’Cruz Y, Brennan RP, Smolarek S, Arumugasamy M, Walsh TN. Extending the reach of stapled anastomosis with a prepared OrVil™ device in laparoscopic oesophageal and gastric cancer surgery. Surg Endosc 2014; 29:961-71. [DOI: 10.1007/s00464-014-3768-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 07/25/2014] [Indexed: 12/29/2022]
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19
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Bolton JS, Conway WC, Abbas AE. Planned delay of oral intake after esophagectomy reduces the cervical anastomotic leak rate and hospital length of stay. J Gastrointest Surg 2014; 18:304-9. [PMID: 24002761 DOI: 10.1007/s11605-013-2322-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Accepted: 08/12/2013] [Indexed: 02/07/2023]
Abstract
Cervical anastomotic leak rates are high after esophagectomy. We examined the effect of a purposeful delay in institution of oral diet after esophagectomy on the leak rate and hospital length of stay. A retrospective analysis of 120 patients submitted to esophagectomy with cervical esophagogastric anastomosis was conducted. Eighty-seven resumed diet within 7 days of surgery (early eaters), and 33 had delayed diet until a mean of 12 days after surgery (late eaters). Mean age was 62.3 years; 98 patients were male. One hundred one resections were for cancer, and 49 % of cancer patients received neoadjuvant therapy. The overall leak rate was 17.5 %, and hospital length of stay was 10.9 days. Anastomotic leak rate was 3 % for late eaters versus 23 % for early eaters (OR of 9.57, p = 0.010). Hospital length of stay was 6 days for late eaters versus 11.8 days for early eaters (p < 0.001). Anastomotic leak was significantly associated with increased length of stay (p < 0.001), adding an average of 7.6 days to hospital stay. Respiratory complications (p < 0.001) and delayed gastric emptying (p = 0.014) were also independent predictors of increased length of stay, but early eater status was not. Delayed resumption of oral diet after esophagectomy significantly reduces cervical anastomotic leak rate and avoids the increased length of stay associated with leak.
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Affiliation(s)
- John S Bolton
- Department of Surgery, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA, 70121, USA,
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20
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Abstract
This review gives an overview of the esophageal anastomosis. The history, various techniques and substitution organs, their advantages and disadvantages, healing mechanism, complications, and actual trend of this essential part of esophageal surgery are described. The history of the esophageal anastomosis extending from the first anastomosis in 1901 to today has undergone more than one century. In the early days, the success rate of the anastomosis was extremely low. As the technology progressed, the anastomosis got significant achievement. Various anastomotic techniques are currently being used. However, controversies exist on the choice of anastomotic method concerning the success rate, postoperative complication and quality of life. How to choose the method, no one can give the best answer. We searched the manuscripts about the esophageal anastomoses in recent years and studied the controversy questions about the anastomosis. Performing an esophageal anastomosis is a technical matter, and suture healing is independent of the patient's biologic situation. Every anastomosis technique has its own merit, but the outcomes were different if it was performed by different surgeons, and we also found that the complication rate of the anastomosis was mainly associated with the surgeons. So the surgeons should learn from their previous experience and others to avoid technical errors.
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Affiliation(s)
- Y Yuan
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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21
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Kayani B, Garas G, Arshad M, Athanasiou T, Darzi A, Zacharakis E. Is hand-sewn anastomosis superior to stapled anastomosis following oesophagectomy? Int J Surg 2013; 12:7-15. [PMID: 24239928 DOI: 10.1016/j.ijsu.2013.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 10/17/2013] [Accepted: 11/02/2013] [Indexed: 12/19/2022]
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was: In patients undergoing oesophagectomy is stapled anastomosis (STA) superior to hand-sewn anastomosis (HSA) with respect to post-operative outcomes. In total, 82 papers were found suitable using the reported search and 14 of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that STA is associated with reduced time to anastomotic construction and decreased intra-operative blood loss but increased risk of benign stricture formation compared to HSA. There is no difference between HSA and STA with respect to cardiac or respiratory complications, anastomotic leakage, duration of hospital admission or 30-day mortality. In HSA, increasing surgical experience and intra-operative air leakage testing after anastomotic creation are associated with reduced risk of anastomotic leakage. Further adequately powered studies will enable identification of other local and systemic factors influencing anastomotic healing, which will lead to improved patient and anastomotic technique selection for optimal surgical outcomes.
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Affiliation(s)
- Babar Kayani
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK.
| | - George Garas
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Mubarik Arshad
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Emmanouil Zacharakis
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK.
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22
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Bronson NW, Luna RA, Hunter JG. Tailoring esophageal cancer surgery. Semin Thorac Cardiovasc Surg 2013; 24:275-87. [PMID: 23465676 DOI: 10.1053/j.semtcvs.2012.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 12/15/2022]
Abstract
Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patient's clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patient's chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.
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Affiliation(s)
- Nathan W Bronson
- Department of Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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Vakalopoulos KA, Daams F, Wu Z, Timmermans L, Jeekel JJ, Kleinrensink GJ, van der Ham A, Lange JF. Tissue adhesives in gastrointestinal anastomosis: a systematic review. J Surg Res 2013; 180:290-300. [PMID: 23384970 DOI: 10.1016/j.jss.2012.12.043] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 11/24/2012] [Accepted: 12/20/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anastomotic leakage in gastrointestinal (GI) surgery remains a major problem. Although numerous studies have been undertaken on the role of tissue adhesives as GI anastomotic sealants, no clear overview has been presented. This systematic review aims to provide a clear overview of recent experimental and clinical research on the sealing of different levels of GI anastomosis with tissue adhesives. METHODS We searched MEDLINE and Embase databases for clinical and experimental articles published after 2000. We included articles only if these addressed a tissue adhesive applied around a GI anastomosis to prevent anastomotic leakage or decrease leakage-related complications. We categorized results according to level of anastomosis, category of tissue adhesive, and level of evidence. RESULTS We included 48 studies: three on esophageal anastomosis, 13 on gastric anastomosis, four on pancreatic anastomosis, eight on small intestinal anastomosis, and 20 on colorectal anastomosis; 15 of the studies were on humans. CONCLUSIONS Research on ileal and gastric/bariatric anastomosis reveals promising results for fibrin glue sealing for specific clinical indications. Sealing of pancreatico-enteric anastomosis does not seem to be useful for high-risk patients; however, research in this field is limited. Ileal anastomotic sealing was promising in every included study, and calls for clinical evaluation. For colorectal anastomoses, sealing with fibrin glue sealing seems to have more positive results than with cyanoacrylate. Further research should concentrate on the clinical evaluation of promising experimental results as well as on new types of tissue adhesives. This research field would benefit from a systematic experimental approach with comparable methodology.
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Randomized trial comparing side-to-side stapled and hand-sewn esophagogastric anastomosis in neck. J Gastrointest Surg 2012; 16:1287-95. [PMID: 22528571 DOI: 10.1007/s11605-012-1885-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 04/03/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leak from cervical esophagogastric anastomosis (CEGA) following esophagectomy is associated with morbidity and poor functional outcome. To address this issue, we conducted a randomized trial comparing "hand-sewn" with "stapled side-to-side" CEGA. METHODS Of 174 patients who underwent esophageal resection and CEGA between 2004 and 2010, 87 each were randomized to "hand-sewn" and "stapled side-to-side" CEGA [ www.Clinical Trials.gov: NCT00497549]. The primary outcome measure was anastomotic leak rate. The secondary outcome measures included CEGA construction time and occurrence of anastomotic stricture during follow up. RESULTS The overall anastomotic leak rate was 17.2% (major leaks: 8 %). The leak rate was similar among the two groups (hand-sewn: 14/87, stapled: 16/87; p=0.33). The stapled anastomotic technique was faster (25 ±.5 min vs. 27 ± 5.5 min; p=0.02). The overall operative mortality and morbidity rates were 6.3 % and 40.8 %, respectively. At a median follow up of 12 (6-42) months, anastomotic stricture occurred in 24 (14.7 %) patients and was significantly more common in the "hand-sewn" group (17/82 vs. 7/81; p=0.045). CONCLUSION There were no differences in the leak rates and postoperative outcome between the two CEGA techniques. At follow up, anastomotic strictures occurred less frequently following stapled CEGA. The ideal CEGA technique remains elusive.
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An Early Experience Using the Technique of Transoral OrVil EEA Stapler for Minimally Invasive Transthoracic Esophagectomy. Ann Thorac Surg 2011; 92:1862-9. [DOI: 10.1016/j.athoracsur.2011.07.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 07/07/2011] [Accepted: 07/12/2011] [Indexed: 12/29/2022]
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Palmes D, Brüwer M, Bader FG, Betzler M, Becker H, Bruch HP, Büchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N. Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 2011; 396:857-66. [PMID: 21713594 DOI: 10.1007/s00423-011-0818-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 06/07/2011] [Indexed: 12/16/2022]
Abstract
PURPOSE Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year. MATERIALS AND METHODS The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement). RESULTS Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy. CONCLUSION The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.
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Affiliation(s)
- Daniel Palmes
- Department of General and Visceral Surgery, University of Münster, Waldeyerstrasse 1, 48149 Münster, Germany.
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Xu QR, Wang KN, Wang WP, Zhang K, Chen LQ. Linear stapled esophagogastrostomy is more effective than hand-sewn or circular stapler in prevention of anastomotic stricture: a comparative clinical study. J Gastrointest Surg 2011; 15:915-21. [PMID: 21484495 DOI: 10.1007/s11605-011-1490-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 03/14/2011] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of this study was to retrospectively compare the operative effects of linear stapled intrathoracic esophagogastrostomy with hand-sewn or circular stapled anastomosis in prevention of anastomotic stricture. METHOD Between October 2007 and October 2009, 293 patients with esophageal or gastric cardia cancer underwent a curative intent resection. Patients received either a linear stapled (LS group, n = 166), conventional hand-sewn (HS group, n = 59), or circular stapled intrathoracic esophagogastric anastomosis (CS group, n = 68). The patients were followed-up and compared at 3 months after the operation. RESULT Three groups of patients were comparable on clinical baseline characteristics. There was one operative death in the HS group. The operative complications were documented in 15 patients (5.1%), with no difference among three groups (χ(2) = 2.215, P = 0.330). The follow-up rate was 96.9%. The anastomotic diameter was 1.6 ± 0.4 cm in the LS group, 1.2 ± 0.3 cm in the HS group, and 1.0 ± 0.4 cm in the CS group, respectively (F = 58.110, P < 0.001). The anastomotic stricture rates were 1.9% (3/162) in the LS group, 9.3% (5/54) in the HS group, and 20.9% (14/67) in the CS group, respectively (χ(2) = 24.095, P < 0.001). The reflux score in LS group was lower than other two groups (H = 6.995, P = 0.030). CONCLUSION The linear stapled esophagogastrostomy could decrease anastomotic stricture without increasing gastroesophageal reflux.
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Affiliation(s)
- Qi-Rong Xu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, No. 37, Guoxue Alley, Chengdu, Sichuan, 610041, China
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Abstract
BACKGROUND Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development. METHODS A Pubmed search was performed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses. CONCLUSIONS There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.
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Affiliation(s)
- K Schwameis
- Universitätsklinik für Chirurgie, Medizinische Universität Wien, AKH Wien, Österreich
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Safranek PM, Cubitt J, Booth MI, Dehn TCB. Review of open and minimal access approaches to oesophagectomy for cancer. Br J Surg 2010; 97:1845-53. [PMID: 20922782 DOI: 10.1002/bjs.7231] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2010] [Indexed: 12/14/2022]
Abstract
BACKGROUND Minimally invasive approaches to oesophagectomy are being used increasingly, but there remain concerns regarding safety and oncological acceptability. This study reviewed the outcomes of totally minimally invasive oesophagectomy (MIO; 41 patients), hybrid procedures (partially minimally invasive; 34) and open oesophagectomy (46) for oesophageal cancer from a single unit. METHODS Demographic and clinical data were entered into a prospective database. MIO was thoracoscopic-laparoscopic-cervical anastomosis, hybrid surgery was thoracoscopic-laparotomy or laparoscopic gastric mobilization-thoracotomy, and open resections were left thoracoabdominal (LTA), Ivor Lewis (IL) or transhiatal oesophagectomy (THO). RESULTS There were 118 resections for carcinoma (23 squamous cell carcinoma, 95 adenocarcinoma) and three for high-grade dysplasia. MIO took longer than open surgery (median 6·5 h versus 4·8 h for THO, 4·7 h for IL and LTA). MIO required less epidural time (P < 0·001 versus IL and LTA, P = 0·009 versus thorascopic hybrid, P = 0·014 versus laparoscopic IL). Despite a shorter duration of single-lung ventilation with MIO compared with IL and LTA (median 90 versus 150 min; P = 0·013), respiratory complication rates and duration of hospital stay were similar. There were seven anastomotic leaks after MIO, four after hybrid procedures and one following open surgery. Mortality rates were 2, 6 and 2 per cent respectively. Lymph node harvests were similar between all groups, as were rates of complete (R0) resection in patients with locally advanced tumours. CONCLUSION MIO is technically feasible. It does not reduce pulmonary complications or length of stay. Oncological outcomes appear equivalent.
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Affiliation(s)
- P M Safranek
- Department of Upper Gastrointestinal Surgery, Addenbrooke's Hospital, Cambridge, UK
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Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 2010; 101:527-33. [PMID: 20401920 DOI: 10.1002/jso.21510] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Anastomotic complications are responsible for significant morbidity and mortality following esophagectomy for cancer. Conflicting reports exist regarding the superiority of hand-sewn versus stapled techniques. This systematic review identified eight randomized clinical trials examining this issue. None of the studies reported significant differences in leak rate or early mortality. One study demonstrated a difference in stricture rates, with fewer for hand-sewn anastomoses. There is insufficient evidence to recommend one anastomotic technique over the other.
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Affiliation(s)
- Roger H Kim
- Division of Surgical Oncology, Department of Surgery, Louisiana State University Health Sciences Center in Shreveport, Feist-Weiller Cancer Center, Shreveport, Louisiana 71130-3932, USA.
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Hitch your wagon to a star-shaped incision? A closer look at electro-incision for benign gastroesophageal anastomotic strictures. Gastrointest Endosc 2009; 70:856-9. [PMID: 19879401 DOI: 10.1016/j.gie.2009.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 04/12/2009] [Indexed: 12/21/2022]
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Abstract
BACKGROUND The purpose of this prospectively collected database is to evaluate the safety, efficacy, and utility of postoperative jejunostomy feeding in terms of achieving nutritional goals and evaluating gastrointestinal and mechanical complications in patients undergoing esophagectomy. METHODS The study included 204 consecutive patients who underwent esophagectomy for various benign and malignant conditions. All patients underwent Witzel feeding jejunostomy at the time of laparotomy. Patients were followed prospectively to record nutritional intake, type of feed administered, rate progression, tolerance, and complications either mechanical or gastrointestinal. RESULTS Feeding jejunostomy could be performed in 99.5% patients; 6.0% of the patients had a blocked catheter during the course of feeding. The target calorie requirement could be achieved in 78% of patients by third day. In all, 95% of patients could be successfully fed exclusively by jejunostomy catheter during the postoperative period. Minor gastrointestinal complications developed in 15% of the patients and were managed by slowing the rate of infusion or administering medication. Patients spent a mean of 16.67 +/- 22.00 days (range 0-46 days) on jejunostomy feeding after surgery; however, 13% required prolonged jejunostomy feeding beyond 30 days. Altogether, 64% of the patients with an anastomotic leak and 50% of the patients with postoperative complications required catheter jejunostomy feeding beyond 30 days. The mean duration for which jejunostomy tube feeding was used was significantly higher for patients who developed anastomotic disruptions (33.05 +/- 16.24 vs. 14.69 +/- 19.04 days; p = 0.000) and postoperative complications (26.67 +/- 25.56 vs. 14.52 +/- 18.64 days; p = 0.000) when compared to those without disruption or complications. There were no serious complications related to the feeding catheter that required reintervention. There was no difference in the mean body weight or weight deficit at the end of 10 days and at 1 month in patients who developed complications or anastomotic disruption when compared to their counterparts. No patient died as a result of a complication related to the feeding jejunostomy. CONCLUSIONS Tube jejunostomy feeding is an effective method for providing nutritional support in patients undergoing esophagectomy, and it allows home support for the subset who fail to thrive. Prolonged tube feeding was continued in patients developing anastomotic disruptions and postoperative complications. Feeding jejunostomy has a definitive role to play in the management of the patients undergoing esophagectomy.
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