Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: A meta-analysis

Gastric conduit reconstruction after esophagectomy

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations.

Application of overlap anastomosis in digestive tract reconstruction during minimally invasive Ivor-Lewis esophagectomy

This study aims to assess the feasibility of the Overlap anastomosis technique in minimally invasive Ivor-Lewis esophagectomy. An accompanying video presentation elucidates our surgical procedures. A retrospective review of 46 patients diagnosed with middle and lower esophageal cancer was conducted. These patients underwent minimally invasive Ivor-Lewis esophagectomy with Overlap anastomosis between January 2019 and December 2020. A consistent team of surgeons performed all procedures. The initial phase involved laparoscopic stomach mobilization, intra-abdominal lymphadenectomies, and preparation of the tubular stomach. Subsequently, with the patient in the left decubitus position, thoracoscopy was used to dissect the esophagus, excise the diseased segment, and conduct mediastinal lymph node dissection. The final stage encompassed the intrathoracic gastroesophageal anastomosis using the Overlap method. All surgeries were completed without converting to an open approach, achieving complete resection. There were no operative fatalities, with an average surgery duration of 259.4 min. Average statistics included intraoperative blood loss of 92.3 ml, 16.2 lymph nodes dissected, and a postoperative hospital stay of 10.3 days. Postoperative complications comprised three instances of hoarseness due to recurrent laryngeal nerve palsy, two cases of aspiration pneumonia, one occurrence of chylothorax, and one gastric emptying disorder. Anastomotic technique-related complications were minimal, with only one patient experiencing an anastomotic leak that resolved spontaneously and two patients facing anastomotic stenosis, which was subsequently alleviated. Our findings posit that the Overlap anastomosis method is safe and efficient for minimally invasive Ivor-Lewis esophagectomy, marked by a notably low rate of anastomosis-related complications. Further evaluation of its long-term implications remains necessary.

Postoperative Outcomes and Quality of Life After Left Thoracoabdominal Esophagogastrectomy: Contrasting Esophagogastrostomy with Esophagojejunostomy

BACKGROUND

Following left thoracoabdominal (LTA) esophagogastrectomy, gastrointestinal continuity can be re-established via esophagogastrostomy or esophagojejunostomy. We explored how the method of reconstruction impacted postoperative outcomes and quality of life (QoL).

METHODS

From January 2007 to January 2022, patients undergoing LTA were identified from a single center's prospectively maintained database. Following esophagogastrectomy or extended total gastrectomy, an esophagogastrostomy (GAS) or Roux-en-Y esophagojejunostomy (R-Y) was fashioned. Postoperative outcomes were compared according to the method of reconstruction. The Functional Assessment of Cancer Therapy-Esophagus (FACT-E) questionnaire compared QoL.

RESULTS

Of the 147 LTA patients identified, 135 (92%) were included-97 GAS (72%) and 38 R-Y patients (28%). R-Y patients had more ypT3/4 lesions (97% vs. 61%, p ≤ 0.001) and a similar incidence of ypN+/M+ disease. Anastomotic leaks were more common among GAS patients (17% vs. 3%, p = 0.023), however grade 3/4 complications (26.6% vs. 19.4%, p = 0.498), reoperation, intensive care admission, hospital representation and readmission were similar. FACT-E data were available for 68/97 (70%) GAS patients and 22/38 (58%) R-Y patients, with scores for 80/21/24/18/23/24 patients at baseline/preoperatively/1 month/3-6 months/1-3 years/3+ years postoperatively, respectively. Comparing between the groups, the scores were similar at each timepoint. FACT-E improved between baseline and preoperatively (79, 34-124 vs. 102, 81-123, p = 0.027). Only at 3+ years were postoperative scores equivalent to preoperative values. GAS patients had more reflux and esophagitis >6 months postoperatively (54% vs. 13%, p = 0.048; 62% vs. 0%, p ≤ 0.001).

CONCLUSION

While the type of reconstruction did not affect QoL, it did affect the postoperative course.

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

[Anastomotic techniques in minimally invasive esophageal and gastric surgery]

In specialized centers minimally invasive surgery has become established as the standard of care for esophageal and gastric surgery. Offering equal oncological outcome, patients benefit with respect to lower postoperative pain and complication rates. The creation of the anastomosis during minimally invasive surgery remains a critical step and the complications are decisive for the immediate postoperative course. So far no clear consensus exists in the literature regarding the recommended techniques for placement of an anastomosis after resections in the upper gastrointestinal tract. This article summarizes and compares the various established anastomotic techniques used in minimally invasive esophageal and gastric surgery.

What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.

Which Anastomotic Techniques Is the Best Choice for Cervical Esophagogastric Anastomosis in Esophagectomy? A Bayesian Network Meta-Analysis

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.

Comparison of Postoperative Outcomes of Hand-Sewn Versus Stapled Esophago-jejunal Anastomosis During Total Gastrectomy for Gastric Cancer in 72 Patients: A Retrospective, Single-Center Study in Poland

BACKGROUND Mechanical stapling is a commonly used alternative to hand-sewn technique for esophago-jejunal anastomosis in total gastrectomy (TG). Some studies report reduction in postoperative complications in the stapler group. This retrospective study aimed to compare short- and long-term surgical outcomes between the groups with stapled and hand-sewn esophago-jejunal anastomosis (EJA) during open TG for gastric cancer. MATERIAL AND METHODS The study included 72 adult patients with gastric cancer who underwent TG in the Department of Digestive Tract Surgery in Katowice between May 2018 and December 2021. The patients were divided into 2 groups according to the technique of EJA: stapled (44 cases) or hand-sewn (28 cases). We compared the groups in terms of the duration of the surgery, length of hospital stay, and occurrence of complications (focusing on anastomotic leakage, stricture and abdominal abscess). RESULTS There were no significant differences in duration of the surgery (P=0.6), blood loss (P=0.7), or length of postoperative hospital stay (P=0.2) among the groups. Early postoperative complications rates were 9.1% (4/44) in the stapler group and 17.9% (5/28) in the hand-sewn group (P=0.27). The most frequent complication was anastomotic leakage, with 2 cases in each group (P=0.76). The mean follow-up time was 1.8±0.9 (0.3-3.6) years. During this period the anastomotic stricture occurred in 7 (15.9%) cases with stapled anastomosis and in 5 (17.9%) cases with hand-sewn anastomosis (P=0.52). CONCLUSIONS In this study there were no significant differences in mortality, morbidity, and surgery duration between stapled and hand-sewn esophago-jejunal anastomosis in total gastrectomy.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer

BACKGROUND

Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS).

METHODS

We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery.

RESULTS

Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001).

CONCLUSIONS

The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Robotic versus thoraco-laparoscopic minimally invasive Ivor Lewis esophagectomy, a matched-pair single-center cohort analysis

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7 days, P < 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis

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.

Circular vs. linear stapling after minimally invasive and robotic-assisted esophagectomy: a pooled analysis

Purpose

Current data states that most likely there are differences in postoperative complications regarding linear and circular stapling in open esophagectomy. This, however, has not yet been summarized and overviewed for minimally invasive esophagectomy, which is being performed increasingly.

Methods

A pooled analysis was conducted, including 4 publications comparing linear and circular stapling techniques in minimally invasive esophagectomy (MIE) and robotic-assisted minimally invasive esophagectomy (RAMIE). Primary endpoints were anastomotic leakage, pulmonary complications, and mean hospital stay.

Results

Summarizing the 4 chosen publications, no difference in anastomotic insufficiency could be displayed (p = 0.34). Similar results were produced for postoperative pulmonary complications. Comparing circular stapling (CS) to linear stapling (LS) did not show a trend towards a favorable technique (p = 0.82). Some studies did not take learning curves into account. Postoperative anastomotic stricture was not specified to an extent that made a summary of the publications possible.

Conclusions

In conclusion, data is not sufficient to provide a differentiated recommendation towards mechanical stapling techniques for individual patients undergoing MIE and RAMIE. Therefore, further RCTs are necessary for the identification of potential differences between LS and CS. At this point in research, we therefore suggest evading towards choosing a single anastomotic technique for each center. Momentarily, enduring the learning curve of the surgeon has the greatest evidence in reducing postoperative complication rates.

Short- and Long-Term Outcomes of Totally Versus Hybrid Minimally Invasive Ivor Lewis Oesophagectomy for Oesophageal Cancer: A Propensity Score-Matched Analysis

Background

Few objective studies have compared totally minimally invasive Ivor Lewis oesophagectomy with hybrid procedure. Here we investigated whether the choice between totally and hybrid minimally invasive Ivor Lewis oesophagectomy influenced short-term outcomes and long-term patient survival.

Methods

Patients who underwent totally or hybrid minimally invasive Ivor Lewis oesophagectomy between January 2014 and December 2017 were propensity score matched in a 1:1 ratio. The short- and long-term outcomes between the two groups were compared before and after matching.

Results

Of 138 totally and 156 hybrid minimally invasive oesophagectomy patients were eligible, 104 patients from each group were propensity score matched. Totally minimally invasive oesophagectomy was associated significantly with less blood loss (median(IQR) 100(60-150) vs 120(120-200) ml respectively; P < 0.001), pneumonia (13.5 vs 25.0%; P = 0.035), pleural effusion (3.8 vs 13.5%; P = 0.014), and chest drainage (7.5(6-9) vs 8(7-9) days; P = 0.009) than hybrid procedure. There was no significant difference in 3-year overall survival rate and 3-year disease-free survival rate between the two group.

Conclusions

Totally minimally invasive Ivor Lewis oesophagectomy may improve short-term outcomes and specifically reduce the incidence of pulmonary complications compared with hybrid procedure. The long-term overall survival and disease-free survival rates between the two groups were similar.

Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer

Background

The first choice of an esophageal substitute after esophagectomy for cancer is the stomach. However, the colon must be considered for reconstruction in specific situations. The purpose of this study was to clarify the frequency and clinical features of patients who underwent colon interposition in thoracic esophagectomy and to investigate the postoperative complications and survival.

Methods

We conducted a retrospective case–control study in the National Cancer Center Hospital East, Japan. Patients who underwent colon interposition after esophagectomy for cancer between 2010 and 2020 were analyzed.

Results

Eighty‐eight patients underwent esophagectomy with colon interposition; 53.2% received preoperative treatment and 52.3% underwent thoracoscopic surgery. Clavien–Dindo grade >III postoperative complications occurred in 42% of the patients; anastomotic leakage was the most common complication, occurring in 26.1% of the cases. Univariate analysis of the factors associated with Clavien–Dindo grade <III complications showed that the period 2015–2020 and totally mechanical Collard anastomosis were significant factors, with odds ratios (OR) of 0.264 and 0.267 (p = 0.00327 and p = 0.00335), respectively. Totally mechanical Collard anastomosis was associated with a lower risk of anastomotic leakage by univariate and multivariate analysis (OR, 0.257, p = 0.00566 and OR, 0.285, p = 0.133, respectively). Three‐year overall survival was 54.2%. Univariate and multivariate analysis of overall survival showed that older age was a risk factor (OR, 1.08) for complications.

Conclusion

In colon reconstruction after esophageal cancer resection, totally mechanical Collard anastomosis for cervical anastomosis may reduce the risk of Clavien–Dindo grade >III complications.

Hybrid transthoracic oesophagectomy due to carcinoma with complications after COVID-19 pneumonia – A case report

Introduction and importance

This case report describes postoperative complications in a patient after hybrid oesophagectomy for oesophageal carcinoma after COVID pneumonia. The global COVID-19 pandemic affected cancer patients indicated for surgery. Covid 19 may worsen the results of oesophageal cancer surgery. More similar studies are needed.

Case presentation

A 69-year-old male was diagnosed with squamous cell carcinoma of the middle oesophagus based on PET/CT without disease generalisation. His stenotic tumour required a nutritive jejunostomy, with subsequent neoadjuvant radiochemotherapy indicated according to the CROSS protocol. The patient developed COVID pneumonia during the cancer therapy. After managing the COVID pneumonia, oncological therapy was completed and a hybrid oesophagectomy was performed 8 weeks later. Serious complications (respiratory failure, septic shock, anastomosis dehiscence) developed during the postoperative period. All complications were managed therapeutically. The patient was type IVb according to the Clavien-Dindo classification.

Clinical discussion

Postoperative complications may develop in any patient operated for oesophageal carcinoma, especially if high-risk predictive factors are present. The question arises as to how much the post-COVID condition affected the onset of these serious complications.

Conclusion

Post-COVID patients are at a risk of developing post-COVID syndrome, which may lead to a wide range of symptoms in the affected organs. Further studies on the relationship between COVID-19 and oesophagectomy for oesophageal carcinoma will be necessary to clarify the relationship between the complications during the postoperative period in patients with oesophageal malignancy.

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Hybrid transthoracic oesophagectomy with complications

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Complications after COVID-19 in patient with oesophageal cancer

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Covid pneumonia complicates oesophagectomy.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

BACKGROUND

Risk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy.

METHODS

First, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed.

RESULTS

We utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases.

CONCLUSION

Our technique of NGT placement is simple, safe, and feasible.

Functional syndromes and symptom-orientated aftercare after esophagectomy

BACKGROUND

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

PURPOSE

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

CONCLUSIONS

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

Video-Assisted Thoracic Surgery Intrathoracic Anastomosis Technique

The extracorporeal anastomosis technique for video-assisted thoracoscopic surgery (VATS) intrathoracic esophagogastric anastomosis is a convenient, easy technique to use in VATS esophagectomy. The surgeon can assess the viability and the status of the gastric conduit, and the introduction of a circular stapler can be easily done under direct vision extracorporeally, enabling easy and simple VATS intrathoracic anastomosis between the esophagus and the gastric conduit.

Modified layered hand-sewn cervical end-to-side anastomosis for minimally invasive McKeown esophagectomy

BACKGROUND

Minimally invasive McKeown esophagectomy (MIE McKeown) with cervical anastomosis is a widely used approach for the treatment of esophageal cancer (EC). Anastomotic leak is one of the most serious complications following esophagectomy. This study aimed to summarize the anastomosis procedure and assess the clinical outcomes of our modified layered hand-sewn cervical end-to-side anastomosis for cervical anastomosis during MIE McKeown.

METHODS

We retrospectively reviewed clinical data of 508 consecutive EC patients who underwent MIE McKeown using the modified layered hand-sewn cervical end-to-side anastomosis between June 2016 and June 2020.

RESULTS

The incidence of anastomotic leakage in our cohort was 2.0%. The postoperative stricture rate was 6.9% and the incidence of other postoperative complications was less than 9.3%. The mean time for setting up MIE McKeown was approximately 211.0 min and the average duration of postoperative hospital stay was 9.1 days.

CONCLUSION

This modified layered hand-sewn cervical end-to-side anastomosis is a safe and effective method for MIE McKeown with a low incidence of anastomotic leakage, anastomotic stricture, or other postoperative complications.

Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer

BACKGROUND

Identifying predictors of anastomotic leakage can contribute to prevention of this common complication after esophagectomy. This study identified predictors for anastomotic leakage and assessed the influence of anastomotic leakage on short-term outcomes and long-term survival.

METHODS

A retrospective cohort study was conducted of consecutive patients who underwent esophagectomy in the Amsterdam University Medical Centers, location Amsterdam Medical Center, between 1993 and 2019. Multilevel logistic and Cox regression models were used to assess predictors for anastomotic leakage and survival, and an operation year-level random effects was considered for the unmeasured characteristics at year of operation.

RESULTS

Included were 1539 patients, and anastomotic leakage developed in 288 (19%). Predictors for developing anastomotic leakage after a transthoracic esophagectomy were a higher body mass index and a cervical anastomosis. Diabetes mellitus type 2 and chronic obstructive pulmonary disease were predictors for anastomotic leakage after a transhiatal esophagectomy. Median intensive care unit and hospital stay was longer for patients with anastomotic leakage than for patients without anastomotic leakage (both P < .001 for transthoracic esophagectomy, P = .010 and P < .001, respectively, for transhiatal esophagectomy). A higher percentage of patients with anastomotic leakage died within 30 days (3.8% vs 1.9%, P = .050). However, anastomotic leakage did not significantly influence long-term survival (hazard ratio, 0.994; 95% CI, 0.849-1.176; P = .994).

CONCLUSIONS

Higher body mass index, cervical anastomosis, diabetes mellitus, and chronic obstructive pulmonary disease are predictors for anastomotic leakage after esophagectomy. Anastomotic leakage is associated with worse short-term outcomes, but long-term survival was not influenced. Future studies should focus on patient optimization, accurate patient selection, and development of tools in risk assessment.

Development and validation of a nomogram to predict anastomotic leakage after esophagectomy for esophageal carcinoma

Background

This study aimed to identify variables associated with anastomotic leakage after esophagectomy and established a tool for anastomotic leakage prediction.

Methods

Twenty-six preoperative and postoperative variables were retrospectively collected from esophageal cancer patients who were treated with radical esophagectomy from January 2018 to June 2020 in the Affiliated Hospital of Qingdao University. SPSS Version 23.0 and Empower Stats software were used for establishing a nomogram after screening relevant variables by univariate and multivariate Logistic regression analyses. The established nomogram was identified by depicting the receiver operating characteristic (ROC) curves and calibration curve, which was verified by 1,000 bootstrap resamples method.

Results

A total of 604 eligible esophageal cancer patients were included, of which 51 (8.4%) patients had anastomotic leakage. Multivariate Logistic regression analysis showed that smoking, anastomotic location, anastomotic technique, prognostic nutritional index (PNI) and ASA score were independent risks of anastomotic leakage. The area under curve (AUC) of ROC in the established nomogram was 0.764 (95% CI, 0.69–0.83). The internal validation confirmed that the nomogram had a great discrimination ability (AUC =0.766). Depicted calibration curve demonstrated a well-fitted prediction and observation probability. In addition, the decision curve analysis concluded that the newly established nomogram is significant for clinical decision-making.

Conclusions

This nomogram provided the individual prediction of anastomotic leakage for esophageal cancer patients after surgery, which might benefit treatment results for patients and clinicians, as well as pre-and postoperative intervention strategy-making.

Robotic-assisted Ivor Lewis esophagectomy, a review of the technique

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

Comparison of a modified one-piece mechanical and double-layer hand-sewn anastomosis in McKeown esophagogastrectomy: A single-institute retrospective study

The present study aimed to introduce a novel method of cervical esophagogastric anastomosis, so-called ‘modified one-piece mechanical anastomosis’ (MOMA) in McKeown esophagogastrectomy and to compare its feasibility, efficacy and safety with those of ‘conventionally double-layer hand-sewn anastomosis’ (CDHA). Between March 2016 and March 2018, 80 consecutive patients with thoracic esophageal squamous cell carcinoma undergoing McKeown esophagogastrectomy with a curative intent were included in the present study. Among them, 40 received MOMA and the other 40 received CDHA. Their medical records, including operation time, anastomotic time, estimated blood loss, postoperative complications within 30 days, as well as survival rate, were retrospectively reviewed, analyzed and compared. Total operation time, anastomotic time and estimated blood loss in the MOMA group were significantly decreased compared with those in the CDHA group (207.73±2.66 vs. 225.40±3.43 min; 10.95±0.44 vs. 23.03±0.47 min; 144.50±21.14 vs. 241.75±23.75 ml; all P<0.01). Anastomotic leakage was present in 1 patient in the CDHA group, but no patients in the MOMA group (P=1.000). Anastomotic stenosis was documented in 4 and 2 patients in the MOMA and CDHA group, respectively (P=0.392). The 30-day operative mortality was 0% and no significant difference was demonstrated in postoperative complications within groups (P>0.05). Furthermore, the disease-free and overall survival was compared by means of Kaplan-Meier survival estimates and log-rank tests and no statistical difference was determined (P=0.5114 and P=0.7875, respectively). McKeown esophagogastrectomy with MOMA may be a feasible, effective and reproducible alternative with relatively satisfactory postoperative outcomes for the treatment of TE-SCC, providing shorter operation and anastomosis times, and less estimated intraoperative blood loss.

Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes

Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50–1000 ml). The median overall length of stay was 13 (7–64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.

Application of mediastinal drainage tube in intrathoracic esophageal anastomotic leakage for early diagnosis and effective treatment: a retrospective study

Background

Intrathoracic esophageal anastomotic leakage (AL) is one of the most fatal complications after esophagectomy. In this study, we placed an additional drainage tube in the esophagus bed and evaluated its effect in early diagnosis and treatment of AL.

Methods

From January 2010 to August 2020, 312 patients with esophageal or cardia carcinoma underwent esophageal resection with intrathoracic esophagogastric anastomosis. A total of 138 patients with only one pleural drainage tube were divided into the “Control Group” and 174 patients with a pleural drainage tube and an additional mediastinal drainage tube (MDT) were divided into the “Tube Group”. For all patients, the incidence of postoperative AL, the time to diagnosis, time to recovery, and patient outcome were analyzed.

Results

No significant differences were observed in the AL rate (P = 0.837) and postoperative pain between two groups. However, in the Tube Group, almost all the patients were diagnosed prior to the appearance of hyperpyrexia, which was considered as the earliest and most common symptom after AL. In the Tube Group, a significant decrease was observed in the incidence of incurable fistula, which required re-operation or variable treatments under gastroscopy when compared to the Control Group (P = 0.032). Finally, patients in the Tube Group showed reduced post AL hospital day (P = 0.015) and a lower mortality, however, when compared to the Control Group, no significant differences were observed (P = 0.188).

Conclusions

Placement of an MDT does not prevent AL, but it is an effective approach for earlier diagnosis of AL and facilitates fistula healing and patient recovery.

iTriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy

BACKGROUND

We herein report the feasibility and safety of cervical end-to-end anastomosis by the iTriangular stapling technique (iTST), which was developed as an extension of the triangular stapling technique (TST) after minimally invasive esophagectomy (MIE).

METHODS

A total of 45 patients with thoracic esophageal cancer who underwent reconstruction with cervical esophagogastric anastomosis by iTST using a linear stapler after MIE between January 2016 and January 2019 were retrospectively reviewed. We modified and improved upon the TST by adding a 1- to 2-cm vertical incision on the anterior wall of the remnant esophageal stump to enlarge the anastomotic lumen and thereby reduce the risk of anastomotic stenosis. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.

RESULTS

The median operating time was 686 (range, 319-1110) minutes, and the median blood loss was 170 (range, 5-1180) ml. There were no cases of anastomotic stenosis in this study, although 2 patients (4.4%) developed minor anastomotic leakage. A case (2.2%) of tracheal fistula due to the apex of the triangular anastomosis was resolved simply by delaying the patient's oral intake. The mean length of the hospitalization was 21 days.

CONCLUSIONS

The iTST provides a larger lumen unlimited by the size of the esophagus in cervical esophagogastric anastomosis. This technique is feasible, and sufficient short-term results have been achieved. Further studies with the accumulation of more cases will be required to prove the benefits of iTST for reconstruction after MIE.

The assessment of intraoperative technique-related risk factors and the treatment of anastomotic leakage after esophagectomy: a narrative review

Anastomotic leakage, including cervical anastomotic leakage and intrathoracic anastomotic leakage, is a serious complication of esophageal cancer and a leading cause of death after esophagectomy. In fact, anastomotic leakage after esophagectomy can be caused by numerous factors in the preoperative, intraoperative, and postoperative periods. Intraoperative technique-related risk factors, including surgical methods, anastomosis sites, anastomosis methods, the type of gastric tube, and reconstruction routes, are the key causes of its occurrence. Anastomotic leakage treatments include both surgical and non-surgical treatments, while surgical treatment has high risks, many complications, and high mortality. Actually, non-surgical methods including naso-leakage drainage, stent, negative pressure therapy, and so on, are also very critical in the treatment of anastomotic leakage. So, the selection of correct and appropriate treatment methods plays an important role in alleviating the suffering of patients, shortening hospitalization time, and reducing mortality. This study undertook a systematic review in which data in the PubMed database were searched and analyzed to assess the safety and efficacy of surgical technique-related factors in esophagectomy, and appropriate treatment of anastomotic leakage after esophagectomy. In conclusion, gastric tube, posterior mediastinal route and stapled anastomosis are safe among esophagectomy surgical techniques, and non-surgical treatment of anastomotic leakage such as naso-leakage drainage is feasible in the majority of cases.

Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy

The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1-3) started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1-10) and ended at 20% (cases 51-60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance.

A single blinded randomized controlled trial comparing semi-mechanical with hand-sewn cervical anastomosis after esophagectomy for cancer (SHARE-study)

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.

Use of vasopressors during esophagectomy is not associated with increased risk of anastomotic leak

Vasopressor use during esophagectomy has been reported to increase the risk of postoperative anastomotic leak and associated morbidity. We sought to assess the association between vasopressor use and fluid (crystalloid and colloid) administration and anastomotic leak following open esophagectomy. Patients who underwent open Ivor Lewis esophagectomy were identified from a prospective institutional database. The primary outcome was postoperative anastomotic leak (any grade) and analyzed using logistic regression models. Postoperative anastomotic leak developed in 52 of 327 consecutive patients (16%) and was not significantly associated with vasopressor use or fluid administered in either univariable or multivariable analyses. Increasing body mass index was the only significant characteristic of both univariable (P = 0.004) and multivariable analyses associated with anastomotic leak (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = 0.007). Of the 52 patients that developed an anastomotic leak, 12 (23%) were grade 1, 21 (40%) were grade 2 and 19 (37%) were grade 3. In our cohort, only body mass index, and not intraoperative vasopressor use and fluid administration, was significantly associated with increased odds of postoperative anastomotic leak following open Ivor Lewis esophagectomy.

Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis

BACKGROUND

Leakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery.

METHOD

Embase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A "random-effects model" was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I²-test.

RESULTS

From the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7-24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42-3.34)), celiac axis (OR 1.62(CI 1.15-2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27-5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I² = 71% and 59%, respectively) but not for the right branches of the celiac axis (I² = 0%).

CONCLUSION

This meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.

Modified Collard versus end-to-side hand-sewn anastomosis for cervical anastomosis after McKeown esophagectomy

Background

According to previously published studies, esophagectomy with modified Collard anastomosis has been reported to have low incidences of anastomotic leak and stricture. However, the optional anastomotic method after esophagectomy is still controversial. We conducted this study to compare the incidence of postoperative anastomotic stricture formation and dysphagia over three years after an esophagectomy with modified Collard anastomosis (MC) or end‐to‐side (ETS) hand‐sewn anastomosis. Meanwhile, the early postoperative anastomotic leakage and other complications, hospital stay and 30‐ and 90‐day mortality were also evaluated.

Methods

The clinical data of 905 patients undergoing McKeown esophagectomy were retrospectively reviewed. The rate of postoperative stricture formation after three years was demonstrated by stricture‐free survival which is the primary end‐point of this study. The incidence of dysphagia, first time of onset of stricture and number of dilatations were also recorded during follow‐up.

Results

The incidence of anastomotic leak tended to be higher in the MC group compared with that in the ETS group (13.0% vs. 8.7%, P = 0.064). The rates of anastomotic stricture in the MC group were significantly less than in the ETS group (P = 0.004). The number of dilatations in the MC group were significantly greater than those in the ETS group (2.34 vs. 2.46, P = 0.011).

Conclusions

A modified Collard cervical esophagogastric anastomosis was associated with lower rates of anastomotic stricture and dysphagia, compared with ETS hand‐sewn anastomosis. However, the modified Collard anastomosis is accompanied by an increased anastomotic leakage rate.

Semimechanical anastomosis during oesophagectomy reduces leaks and stenosis: a propensity score matched analysis

OBJECTIVES

Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique.

METHODS

Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998-September 2015), when both TM and SM techniques were used, and a validation period (October 2015-April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding.

RESULTS

The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P < 0.001) and stricture rate (0% vs 7%; P = 0.005). After propensity score matching, the difference in leak (0% vs 14%; P = 0.013) and stricture rate (0% vs 10%; P = 0.022) was confirmed. During the validation period, which included 100 oesophagectomies performed with SM anastomosis, 1 leak (1%) and 1 stricture (1%) were observed.

CONCLUSIONS

SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

Background

Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research.

Purpose

The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery.

Conclusions

There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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.

Study protocol for a multicenter prospective cohort study on esophagogastric anastomoses and anastomotic leak (the Oesophago-Gastric Anastomosis Audit/OGAA)

Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2-3% as compared to 17-35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien-Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings.

Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique?

BACKGROUND

Robot-assisted surgery for esophageal cancer is increasingly applied. Despite this upsurge, the preferential technique to create a robot-assisted intrathoracic anastomosis has not been established.

DATA SOURCES

Bibliographic databases were searched to identify studies that performed a robot-assisted Ivor Lewis esophagectomy and described the technical details of the anastomotic technique. Out of 1701 articles, 16 studies were included for systematic review.

CONCLUSIONS

This review shows that all technique used to create a thoracoscopic anastomosis can be adopted to robotic surgery. Techniques can be divided into three categories: robotic hand-sewn, circular stapling or linear stapling and robotic hand-sewn closure of the stapler defect. With limited robotic experience, circular stapling might be the preferred technique, however requires a well-trained bedside assistant. The linear stapling technique or hand-sewn technique are more challenging but enable experienced robotic surgeons to perform a controlled anastomosis without bedside support.

Evaluation of preoperative risk factors and postoperative indicators for anastomotic leak of minimally invasive McKeown esophagectomy: a single-center retrospective analysis

BACKGROUND

Minimally invasive McKeown esophagectomy is an important surgical approach for esophageal cancer. Anastomotic leak is one of its common and serious complications. We assumed that the preoperative risk factors and postoperative indicators would predict or detect anastomotic leak.

METHODS

Between December 2016 and July 2017, patients underwent minimally invasive McKeown esophagectomy were identified and their preoperative variables and postoperative test indicators were recorded. Fisher's exact test, 2-tailed unpaired t test, nonparametric test and logistic regression were used to compare these datum between patients with or without anastomotic leak (AL). Receiver Operator Characteristic (ROC) curve was used to identify the best cut-off value of drainage amylase concentration for distinguishing anastomotic leak.

RESULTS

In all the 96 patients included, 12 patients were diagnosed as anastomotic leak by the esophagram. No differences in preoperative variables were observed between patients with and without AL. Patients in AL group appeared to have a lower prealbumin concentration in AL group on POD (postoperative day) 4(P = 0.05), POD 5(P = 0.04), POD 6 (P = 0.06). Prealbumin concentration cutoff value of 128 g/L on postoperative day 5 is 100.00% sensitive and 50.00% specific for predicting esophageal leaks. Drain amylases levels were higher in patients with anastomotic leak than those without anastomotic leak on POD 3(P = 0.03), POD 4(P = 0.01), POD 5(P < 0.001), POD 6(P < 0.001). The drain amylase cutoff value of 85 IU/L on postoperative day 4 was 75.00% sensitive and 84.00% specific for detecting esophageal leaks; the cutoff value of 65 IU/L on postoperative day 5 was 91.67% sensitive and 80.77% specific. The cutoff of 55/L on POD 6 is 100% sensitive and 86.96% specific.

CONCLUSION

Drainage amylase concentration on postoperative days may help to discover anastomotic leak in early stage after minimally invasive McKeown esophagectomy. Prealbumin concentration below 128 g/L on POD 5 might be potential risk factor for anastomotic leak.

Comparison of the modified Collard and hand-sewn anastomosis for cervical esophagogastric anastomosis after esophagectomy in esophageal cancer patients: A propensity score-matched analysis

BACKGROUND

Several studies have reported that modified Collard anastomosis is useful for cervical anastomosis after esophagectomy for thoracic esophageal cancer. However, no large-scale study has confirmed the efficacy of the modified Collard anastomosis.

METHODS

Between 2008 and 2016, 398 consecutive esophageal cancer patients who underwent esophagectomy and cervical anastomosis were enrolled in this study. Patients with a short remnant cervical esophagus were excluded. We investigated the utility of the modified Collard anastomosis by comparing the results of postoperative complications using a propensity score-matched analysis between the hand-sewn method (HS) and the modified Collard anastomosis (MC) for esophagogastric anastomosis of the neck after esophagectomy in thoracic esophageal cancer patients.

RESULTS

Of the 398 patients, 127 were included in the MC group and 127 were included in the HS group after propensity score matching. Clinical characteristics did not differ between the two groups. Frequency of anastomotic leakage tended to be lower in the MC group than in the HS group (3% vs. 7%, P = 0.127). Frequency of anastomotic stenosis was significantly lower in the MC group than in the HS group (13% vs. 59%, P < 0.001). Multivariate logic analysis showed that anastomotic technique (HS) and performance status were independent factors associated with anastomotic stenosis (odds ratio, 12.24 and 2.52; P-value <0.001 and 0.047, respectively).

CONCLUSION

In cervical esophagogastric anastomosis after esophagectomy, the modified Collard anastomosis is more suitable than hand-sewn anastomosis in terms of reducing the frequency of anastomotic stenosis.

Impact of the Kocher maneuver on anastomotic leak after esophagogastrostomy in combined thoracoscopic-laparoscopic esophagectomy

OBJECTIVES

Anastomotic leak is a common complication after esophagectomy for esophageal cancer. This study evaluated the impact of the Kocher maneuver on the incidence of anastomotic leak following esophagogastrostomy using a 3-cm-wide gastric conduit.

METHODS

This single-institution, retrospective, cohort study included 43 patients who underwent thoraco-laparoscopic esophagectomy. The Kocher maneuver was not performed in the first half of the study period between April 2014 and May 2015 (first half group, n=14), but was performed in the second half between May 2015 and January 2017 (second half group, n=29). Primary endpoint was the incidence of anastomotic leak. Metrological values of the gastric conduit were postoperatively assessed on computed tomography. Blood perfusion of the gastric conduit was prospectively examined using the indocyanine green fluorescence method.

RESULTS

The incidence of anastomotic leak was 14%; the incidence was significantly lower in the second half group than in the first half group (3.4% vs. 35.7%, p=0.01). The Kocher maneuver was the only significant independent risk factor associated with anastomotic leak (OR 0.064, 95% CI 0.007-0.625, p=0.018). The postoperative length of the entire gastric conduit was significantly shorter in the second half group than in the first half group. A more anal location of the 3-cm-wide gastric conduit was associated with better blood perfusion.

CONCLUSIONS

The Kocher maneuver may enable shortening of the gastric conduit, leading to better blood perfusion of the tip of the gastric conduit, and a significant reduction in the occurrence of anastomotic leak.

Anastomotic leakage after intrathoracic versus cervical oesophagogastric anastomosis for oesophageal carcinoma in Chinese population: a retrospective cohort study

OBJECTIVE

To investigate the characteristics and predictors for anastomotic leakage after oesophagectomy for oesophageal carcinoma from the perspective of anastomotic level.

DESIGN

Retrospective cohort study.

SETTINGS

A single tertiary medical centre in China.

PARTICIPANTS

From January 2010 to December 2016, all patients with oesophageal cancer of the distal oesophagus or gastro-oesophageal junction undergoing elective oesophagectomy with a curative intent for oesophageal carcinoma with intrathoracic oesophagogastric anastomosis (IOA) versus cervical oesophagogastric anastomosis (COA) were included. We investigated anastomotic level and perioperative confounding factors as potential risk factors for postoperative leakage by univariate and multivariate logistic regression.

PRIMARY OUTCOME MEASURES

The primary outcome was the odds of anastomotic leakage by different confounding factors. Secondary outcome was the association of IOA versus COA with other postoperative outcomes.

RESULTS

Of 458 patients included, 126 underwent cervical anastomosis and 332 underwent intrathoracic anastomosis. Anastomotic leakage developed in 55 patients (12.0%), with no statistical differences between COA and IOA (16.6% vs 10.2%; p=0.058). Multivariable analysis identified active diabetes mellitus (OR 2.001, p=0.047), surgical procedure (open: reference; minimally invasive: OR 1.770, p=0.049) and anastomotic method (semimechanical: reference; stapled: OR 1.821; handsewn: OR 2.271, p=0.048) rather than anastomotic level (IOA: reference; COA: OR 1.622, p=0.110) were independent predictors of leakage.

CONCLUSIONS

Surgical and anastomotic techniques rather than the level of anastomotic site were independent predictors of postoperative anastomotic leakage in patients undergoing oesophageal cancer surgery.

Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae

Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.