End-to-end versus end-to-side esophagogastrostomy after esophageal cancer resection: a prospective randomized study. Ann Surg. 2011;254:226-233. [PMID: 21725230 DOI: 10.1097/SLA.0b013e31822676a9]

Minimally Invasive Ivor-Lewis Esophagectomy (MIILE): A Single-Center Experience

With the development of minimally invasive procedures, minimally invasive Ivor-Lewis esophagectomy (MIILE) has been proposed as a safe and feasible surgical choice for the treatment of esophageal cancer. This retrospective study evaluated MIILE results from a single medical center. A total of 619 patients were selected as candidates for Ivor-Lewis esophagectomy from December 2011 to May 2015, in which 334 patients accepted MIILE and 285 patients accepted open Ivor-Lewis esophagectomy (OILE). General characteristics, surgical data, complication rates, and survival were analyzed. Differences in general characteristics between groups were not significant. Intraoperative blood loss (P < 0.01), postoperative volume of drainage for the first day (P < 0.01), time to drain removal (P ≤ 0.01), wound infection rate (P = 0.04), and length of hospital stay (P < 0.01) were significantly reduced in the MIILE group. There were no statistically significant differences in general morbidity (P = 0.56), the total swept lymph nodes (P = 0.47), mortality (P = 0.34), and survival rate at 3 years (P = 0.63). MIILE is a safe and feasible method for the treatment of esophageal cancer, in which good outcomes were reported and some advantages were found over the open procedure.

Blood flow speed of the gastric conduit assessed by indocyanine green fluorescence: New predictive evaluation of anastomotic leakage after esophagectomy

Anastomotic leakage is considered as an independent risk factor for postoperative mortality after esophagectomy, and an insufficient blood flow in the reconstructed conduit may be a risk factor of anastomotic leakage. We investigated the clinical significance of blood flow visualization by indocyanine green (ICG) fluorescence in the gastric conduit as a means of predicting the leakage of esophagogastric anastomosis after esophagectomy.Forty patients who underwent an esophagectomy with gastric conduit reconstruction were prospectively investigated. ICG fluorescence imaging of the gastric conduit was detected by a near-infrared camera system during esophagectomy and correlated with clinical parameters or surgical outcomes.In 25 patients, the flow speed of ICG fluorescence in the gastric conduit wall was simultaneous with that of the greater curvature vessels (simultaneous group), whereas in 15 patients this was slower than that of the greater curvature vessels (delayed group). The reduced speed of ICG fluorescence stream in the gastric conduit wall was associated with intraoperative blood loss (P = 0.008). Although anastomotic leakage was not found in the simultaneous group, it occurred in 7 patients of the delayed group (P < 0.001). A flow speed of ICG fluorescence in the gastric conduit wall of 1.76 cm/s or less was determined by a receiver operating characteristic (ROC) curve, identified as a significant independent predictor of anastomotic leakage after esophagectomy (P = 0.004).This preliminary study demonstrates that intraoperative evaluation of blood flow speed by ICG fluorescence in the gastric conduit wall is a useful means to predict the risk of anastomotic leakage after esophagectomy.

Recent improvements in the management of esophageal anastomotic leak after surgery for cancer

Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.

Total mechanical stapled oesophagogastric anastomosis on the neck in oesophageal cancer - prevention of postoperative mediastinal complications

Oesophagogastric anastomosis after oesophagus resection is commonly performed on the neck. Even though a few different techniques of oesophagogastric anastomosis have been previously detailed, both manual and mechanical procedures have been burdened with leakages and strictures. Our simple technique of oesophagogastric anastomosis is a modification of mechanical anastomosis with the use of a circular stapler in order to prevent postoperative leak and concomitant mediastinal complications. Since 2008, we have performed nine oesophagogastric anastomoses following oesophagus resection. The mean age of the operated patients was 54 years. There was no mortality among the operated patients in the early post-operative period. The mean follow-up period for the patients operated on in our department was 17 months until the time of the analysis. None of the patients showed any leakage or stricture, and no mediastinal complications were reported in the group. Following our own experience, mechanical anastomosis with the use of a circular stapler seems to decrease the time of the operation as well as significantly reducing the incidence of leakages from the anastomosis. This type of anastomosis may decrease the number of postoperative strictures and the most dangerous mediastinal infections.

Quality of Life and Late Complications After Minimally Invasive Compared to Open Esophagectomy: Results of a Randomized Trial

Background

The minimally invasive esophagectomy (MIE) is widely being implemented for esophageal cancer in order to reduce morbidity and improve quality of life. Non-randomized studies investigating the mid-term quality of life after MIE show conflicting results at 1-year follow-up. Therefore, the aim of this study is to determine whether MIE has a continuing better mid-term 1-year quality of life than open esophagectomy (OE) indicating both a faster recovery and less procedure-related symptoms.

Methods

A one-year follow-up analysis of the quality of life was conducted for patients participating in the randomized trial in which MIE was compared with OE. Late complications as symptomatic stenosis of anastomosis are also reported.

Results

Quality of life at 1 year was better in the MIE group than in the OE group for the physical component summary SF36 [50 (6; 48–53) versus 45 (9; 42–48) p .003]; global health C30 [79 (10; 76–83) versus 67 (21; 60–75) p .004]; and pain OES18 module [6 (9; 2–8) versus 16 (16; 10–22) p .001], respectively. Twenty six patients (44 %) in the MIE and 22 patients (39 %) in the OE group were diagnosed and treated for symptomatic stenosis of the anastomosis.

Conclusions

This first randomized trial shows that MIE is associated with a better mid-term one-year quality of life compared to OE.

Albert-Lembert versus hybrid-layered suture in hand sewn end-to-end cervical esophagogastric anastomosis after esophageal squamous cell carcinoma resection

BACKGROUND

Hand sewn cervical esophagogastric anastomosis (CEGA) is regarded as preferred technique by surgeons after esophagectomy. However, considering the anastomotic leakage and stricture, the optimal technique for performing this anastomosis is still under debate.

METHODS

Between November 2010 and September 2012, 230 patients who underwent esophagectomy with hand sewn end-to-end (ETE) CEGA for esophageal squamous cell carcinoma (ESCC) were analyzed retrospectively, including 111 patients underwent Albert-Lembert suture anastomosis and 119 patients underwent hybrid-layered suture anastomosis. Anastomosis construction time was recorded during operation. Anastomotic leakage was recorded through upper gastrointestinal water-soluble contrast examination. Anastomotic stricture was recorded during follow up.

RESULTS

The hybrid-layered suture was faster than Albert-Lembert suture (29.40±1.24 min vs. 33.83±1.41 min, P=0.02). The overall anastomotic leak rate was 7.82%, the leak rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (3.36% vs. 12.61%, P=0.01). The overall anastomotic stricture rate was 9.13%, the stricture rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (5.04% vs. 13.51%, P=0.04).

CONCLUSIONS

Hand sewn ETE CEGA with hybrid-layered suture is associated with lower anastomotic leakage and stricture rate compared to hand sewn ETE CEGA with Albert-Lembert suture.

Multistage resection of esophageal squamous cell cancer of the cardia - successful despite complications

Surgery is the treatment of choice for squamous cell esophageal cancer. Complete resection of the esophagus with reconstruction of the digestive tract is performed for tumors located in the chest or cardia. The aim of the report is to present the case of a complete esophageal and gastric resection complicated by colon graft necrosis. The patient was a 45-year-old woman diagnosed with cancer of the cardia infiltrating the distal section of the esophagus and the body and fundus of the stomach. The initial surgical procedure included the opening of three body cavities followed by resection of the thoracic esophagus, stomach, and a portion of the left hepatic lobe. Right colon interposition was performed to restore digestive tract continuity. On the 8th day, a leak was observed in the esophagointestinal anastomosis. Management consisted in two surgical procedures, one of which ended in the removal of the colon patch. The fourth and final procedure was conducted after 10 months.

Esophageal reconstruction by colon interposition after esophagectomy for cancer analysis of current indications, operative outcomes, and long-term survival

INTRODUCTION

Colon interposition is an alternative solution for esophageal reconstruction if the stomach cannot be used. The study reviews current indications and results of coloplasty for cancer.

METHODS

Patients who underwent colon interposition for gastro-esophageal malignancy were included. Primary coloplasty was defined as upfront colon interposition. Salvage coloplasty was defined as colon interposition after primary reconstruction failure. Mortality, morbidity, function, and survival were evaluated.

RESULTS

We included 28 patients (24 men, median age 61 years). Ten (36%) patients underwent primary coloplasty due to previous gastrectomy (n = 5), conduit gastric cancer (n = 2), extensive gastroesophageal involvement (n = 2), and gastric cancer recurrence (n = 1). Salvage coloplasty was performed in 18 (64%) patients for postoperative graft necrosis (n = 5) and intractable strictures (n = 3). Operative mortality, morbidity, and graft necrosis rates were 14% (4/28), 86% (24/28), and 14% (4/28), respectively; there were no significant differences between primary and salvage coloplasty. Survival rates at 1-, 3-, and 5 years were 81%, 51%, and 38%, respectively. Survival was decreased after primary coloplasty when compared to salvage coloplasty (P = 0.03). Nine patients experienced tumor recurrence (primary: n = 6, salvage: n = 3) after coloplasty and eight of them died.

CONCLUSION

Colon interposition after esophagectomy is a useful but morbid endeavor. Colon interposition as salvage therapy is associated with improved survival compared to its use as primary esophageal replacement, and colon interposition in the latter cohort should be used with caution due to poor cancer-specific survival in this patient population.

Embedded Three-Layer Esophagogastric Anastomosis Reduces Morbidity and Improves Short-Term Outcomes After Esophagectomy for Cancer

BACKGROUND

There exists great controversy regarding the use of esophagogastric anastomotic techniques in the treatment of esophageal cancer. The aim of this study was to compare two types of cervical esophagogastric anastomoses with respect to the reduction of postoperative anastomotic leaks, stenosis, and gastroesophageal reflux.

METHODS

From June 2010 to September 2013, 339 patients who underwent two different cervical esophagogastric anastomotic procedures after thoracolaparoscopic esophagectomy for esophageal cancer were identified.

RESULTS

A total of 166 patients with esophageal cancer were treated using an embedded three-layer anastomosis (embedded group), and 173 were treated using a conventional two-layer anastomosis (conventional group). The rates of anastomotic leak (2.4% [4 of 166] versus 7.5% [13 of 173], p = 0.031) and benign anastomotic stricture (4.8% [8 of 166] versus 12.7% [22 of 173], p = 0.010) were significantly lower in the embedded group compared with the conventional group. The mean reflux scores were significantly higher among the patients in the conventional group compared with the patients in the embedded group at 1 month (25.2 versus 19.0, p = 0.001), 3 months (27.8 versus 21.4, p = 0.001), and 6 months (23.4 versus 17.8, p < 0.001) of follow-up. The mean scores for dysphagia were significantly lower among the patients in the embedded group compared with the patients in the conventional group at both 3 months (22.7 versus 29.8, p = 0.012) and 6 months (16.0 versus 21.3, p = 0.008) of follow-up.

CONCLUSIONS

The new embedded three-layer esophagogastric anastomosis offers several advantages and reduces the incidence of postoperative complications such as anastomotic leak, stricture, and gastroesophageal reflux.

Outcomes of cervical end-to-side triangulating esophagogastric anastomosis with minimally invasive esophagectomy

BACKGROUND

Esophagogastric anastomosis after esophagectomy has been performed with a variety of techniques during the past decade. However, anastomotic leakage and stricture are still important clinical problems after esophagogastric anastomosis, causing burdensome symptoms and poor quality of life. Herein, we describe a novel cervical end-to-side triangulating esophagogastric anastomoasis using linear stapler.

METHODS

A total of 90 patients (85 % male; mean age 63 years) with thoracic esophageal cancer who underwent cervical end-to-side esophagogastric triangular anastomosis using a linear stapler after minimally invasive esophagectomy between November 2006 and April 2013 were retrospectively reviewed.

RESULTS

The median operation time was 602 min (range 424-936 min). The volume of blood loss during the entire operative procedure was 127 ml (range 0-700 ml). There were no cases of anastomotic leakage in this study, although four patients (4.4 %) developed dysphagia associated with benign anastomotic stricture formation. All patients with a benign anastomotic stricture underwent balloon dilation, which resulted in improvement in their symptoms.

CONCLUSIONS

Considering the absence of anastomotic leakage and low rate of anastomotic stricture formation in this study, our modified triangular esophagogastric anastomosis technique appears promising and may contribute to reduced morbidity and mortality rates following esophagectomy.

Intraoperative Assessment of Perfusion of the Gastric Graft and Correlation With Anastomotic Leaks After Esophagectomy

Anastomotic complications are a major source of morbidity after esophagectomy with gastric pull-up and are often related to poor graft perfusion. The aim of this study was to evaluate the use of laser-assisted fluorescent-dye angiography to assess perfusion in gastric grafts and determine the relationship between perfusion and anastomotic leaks.

Objective:

The aim of the study was to evaluate laser-assisted fluorescent-dye angiography (LAA) to assess perfusion in the gastric graft and to correlate perfusion with subsequent anastomotic leak.

Background:

Anastomotic leaks are a major source of morbidity after esophagectomy with gastric pull-up (GPU). In large part, they occur as a consequence of poor perfusion in the gastric graft.

Methods:

Real-time intraoperative perfusion was assessed using LAA before bringing the graft up through the mediastinum. When there was a transition from rapid and bright to slow and less robust perfusion, this site was marked with a suture. The location of the anastomosis relative to the suture was noted and the outcome of the anastomosis ascertained by retrospective record review.

Results:

Intraoperative LAA was used to assess graft perfusion in 150 consecutive patients undergoing esophagectomy with planned GPU reconstruction. An esophagogastric anastomosis was performed in 144 patients. A leak was found in 24 patients (16.7%) and were significantly less likely when the anastomosis was placed in an area of good perfusion compared with when the anastomosis was placed in an area of less robust perfusion by LAA (2% vs 45%, P < 0.0001). By multivariate analysis perfusion at the site of the anastomosis was the only significant factor associated with a leak.

Conclusions:

Intraoperative real-time assessment of perfusion with LAA correlated with the likelihood of an anastomotic leak and confirmed the critical relationship between good perfusion and anastomotic healing. The use of LAA may contribute to reduced anastomotic morbidity.

Development and Validation of a Disease-Specific Instrument to Measure Diet-Targeted Quality of Life for Postoperative Patients with Esophagogastric Cancer

BACKGROUND

Patients who have undergone esophagectomy or gastrectomy have certain dietary limitations because of changes to the alimentary tract. This study attempted to develop a psychometric scale, named "Esophago-Gastric surgery and Quality of Dietary life (EGQ-D)," for assessment of impact of upper gastrointestinal surgery on diet-targeted quality of life.

METHODS

Using qualitative methods, the study team interviewed both patients and surgeons involved in esophagogastric cancer surgery, and we prepared an item pool and a draft scale. To evaluate the scale's psychometric reliability and validity, a survey involving a large number of patients was conducted. Items for the final scale were selected by factor analysis and item response theory. Cronbach's alpha was used for assessment of reliability, and correlations with the short form (SF)-12, esophagus and stomach surgery symptom scale (ES(4)), and nutritional indicators were analyzed to assess the criterion-related validity.

RESULTS

Through multifaceted discussion and the pilot study, a draft questionnaire comprising 14 items was prepared, and a total of 316 patients were enrolled. On the basis of factor analysis and item response theory, six items were excluded, and the remaining eight items demonstrated strong unidimensionality for the final scale. Cronbach's alpha was 0.895. There were significant associations with all the subscale scores for SF-12, ES(4), and nutritional indicators.

CONCLUSIONS

The EGQ-D scale has good contents and psychometric validity and can be used to evaluate disease-specific instrument to measure diet-targeted quality of life for postoperative patients with esophagogastric cancer.

Systematic review of intervention design and delivery in pragmatic and explanatory surgical randomized clinical trials

BACKGROUND

Surgical interventions are complex, with multiple components that require consideration in trial reporting. This review examines the reporting of details of surgical interventions in randomized clinical trials (RCTs) within the context of explanatory and pragmatic study designs.

METHODS

Systematic searches identified RCTs of surgical interventions published in 2010 and 2011. Included studies were categorized as predominantly explanatory or pragmatic. The extent of intervention details in the reports were compared with the CONSORT statement for reporting trials of non-pharmacological treatments (CONSORT-NPT). CONSORT-NPT recommends reporting the descriptions of surgical interventions, whether they were standardized and adhered to (items 4a, 4b and 4c). Reporting of the context of intervention delivery (items 3 and 15) and operator expertise (item 15) were assessed.

RESULTS

Of 4541 abstracts and 131 full-text articles, 80 were included (of which 39 were classified as predominantly pragmatic), reporting 160 interventions. Descriptions of 129 interventions (80.6 per cent) were provided. Standardization was mentioned for 47 (29.4 per cent) of the 160 interventions, and 22 articles (28 per cent) reported measurement of adherence to at least one aspect of the intervention. Seventy-one papers (89 per cent) provided some information about context. For one-third of interventions (55, 34.4 per cent), some data were provided regarding the expertise of personnel involved. Reporting standards were similar in trials classified as pragmatic or explanatory.

CONCLUSION

The lack of detail in trial reports about surgical interventions creates difficulties in understanding which operations were actually evaluated. Methods for designing and reporting surgical interventions in RCTs, contributing to the quality of the overall study design, are required. This should allow better implementation of trial results into practice.

Hand-Sewn Versus Stapled Esophagogastric Anastomosis in the Neck: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The application of cervical esophagogastric anastomoses was of great concern. However, between circular stapler (CS) and hand-sewn (HS) methods with anastomosis in the neck, which one has better postoperative effects still puzzles surgeons. This study aims to systematically evaluate the effectiveness, security, practicality, and applicability of CS compared with the HS method for the esophagogastric anastomosis after esophageal resection. A systematic literature search, as well as other additional resources, was performed which was completed in January 2013. The relevant randomized controlled trials (RCTs) about the surgical technique for esophageal resection were included. Trial data was reviewed and extracted independently by two reviewers. The quality of the included studies was assessed by the recommended standards basing on Cochrane handbook 5.1.0, and the data was analyzed via RevMan 5 software (version 5.2.0). Nine studies with 870 patients were included. The results showed that in comparing HS to CS methods with cervical anastomosis, no significant differences were found in the risk of developing anastomotic leakages (relative risk (RR) = 1.30, 95 % confidence intervals (CI) 0.87-1.92, p = 0.20), as well as the anastomosis stricture (RR = 0.97, 95 % CI 0.47-1.99, p = 0.93), postoperative mortality (RR = 0.83, 95 % CI 0.43-1.58, p = 0.57), blood loss (mean difference (MD) = 39.68; 95 % CI -6.97, 86.33; p = 0.10) and operative time (MD = 18.05; 95 % CI -3.22, 39.33; p = 0.10). However, the results also illustrated that the CS methods with cervical anastomosis might be less time-consuming and have shorter hospital stay and higher costs. Based upon this meta-analysis, there were no differences in the postoperative outcomes between HS and CS techniques. And the ideal technique of cervical esophagogastric anastomosis following esophagectomy remains under controversy.

The comprehensive complication index: a novel and more sensitive endpoint for assessing outcome and reducing sample size in randomized controlled trials

OBJECTIVE

To test whether the newly developed comprehensive complication index (CCI) is more sensitive than traditional endpoints for detecting between-group differences in randomized controlled trials (RCTs).

BACKGROUND

A major challenge in RCTs is the choice of optimal endpoints to detect treatment effects. Mortality is no longer a sufficient marker in studies, and morbidity is often poorly defined. The CCI, integrating all complications including their severity in a linear scale ranging from 0 (no complication) to 100 (death), is a new tool, which may be more sensitive than other traditional endpoints to detect treatment effects on postoperative morbidity.

METHODS

The CCI was tested in 3 published RCTs from European centers evaluating pancreas, esophageal and colon resections. To compare the sensitivity of the CCI with traditional morbidity endpoints, for example, presence of any (yes/no) or only the most severe complications, all postoperative events were assessed, and the CCI calculated. Treatment effects and sample size calculations were compared using the CCI and traditional endpoints.

RESULTS

Although RCTs failed to show between-group differences using any or most severe complications, the CCI revealed significant differences between treatment groups in 2 RCTs-after pancreas (P=0.009) and esophageal surgery (P=0.014). The CCI in the RCT on colon resections confirmed the absence of between-group differences (P=0.39). The required sample sizes in trials are up to 9 times lower for the CCI than for traditional morbidity endpoints.

CONCLUSIONS

This study demonstrates superiority of the CCI to traditional endpoints. The CCI may serve as an appealing endpoint for future RCTs and may reduce the sample size.

Radiation dose does not influence anastomotic complications in patients with esophageal cancer treated with neoadjuvant chemoradiation and transhiatal esophagectomy

BACKGROUND

Neoadjuvant chemoradiation might increase anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation and esophagectomy. The aim of this study was to determine the influence of radiation dose on the incidence of leakage and stenosis.

METHODS

Fifty-three patients with esophageal cancer received neoadjuvant chemoradiation (23 × 1.8 Gy) (combined with Paclitaxel and Carboplatin) followed by a transhiatal esophagectomy between 2009 and 2011. On planning CT, the future anastomotic region was determined and the mean radiation dose, V20, V25, V30, V35 and V40 were calculated. Logistic regression analysis was conducted to examine determinants of anastomotic leakage and stenosis.

RESULTS

Anastomotic leaks occurred in 13 of 53 patients (25.5%) and anastomotic stenosis occurred in 24 of 53 patients (45.3%). Median follow-up was 20 months. Logistic regression analysis showed that mean dose, V20-V40, age, co-morbidity, method of anastomosis, operating time and interval between last radiotherapy treatment and surgery were not predictors of anastomotic leakage and stenosis.

CONCLUSIONS

A radiation dose of 23 × 1.8 Gy on the future anastomotic region has no influence on the occurrence of anastomotic leakage and stenosis in patients with esophageal cancer treated with neoadjuvant chemoradiation followed by transhiatal esophagectomy.

Rising C-reactive protein and procalcitonin levels precede early complications after esophagectomy

BACKGROUND

Elective esophagectomy with gastric tube reconstruction carries a high risk for complications. Early and accurate diagnosis could improve patient management. Increased C-reactive protein (CRP) levels may be associated with any, surgical or infectious, complication and procalcitonin (PCT) specifically with infectious complications.

METHODS

We measured CRP and PCT on post-operative days 0, 1, 2, and 3 in 45 consecutive patients. Complications were recorded up to 10 days post-esophagectomy.

RESULTS

Twenty-eight patients developed a post-operative complication (5 surgical, 14 infectious, 9 combined surgical/infectious, including anastomotic leakage), presenting on day 3 or later. Elevated days 2 and 3 and a rise in CRP preceded the diagnosis of general or combined surgical/infectious complications (minimum area under the receiver operating characteristics curve (AUROC) 0.75, P = 0.006). Elevated day 3 PCT preceded combined complications (AUROC 0.86, P < 0.001). High day 1 and 3 PCT levels preceded anastomotic leakage (minimum AUROC 0.76, P = 0.005), as did the day 3 CRP levels and their increases (minimum AUROC 0.78, P = 0.002).

CONCLUSIONS

This small study suggests that high or increasing CRP levels may precede the clinical diagnosis of general or surgical/infectious complications after esophagectomy. Elevated PCT levels may more specifically and timely precede combined surgical/infectious complications mainly associated with anastomotic leakage.

Cancer of the oesophagus and gastroesophageal junction - a difficult clinical problem

INTRODUCTION

Cancer located in the oesophagus and gastroesophageal junction is a complex clinical problem and the results of its treatment still remain unsatisfactory. The objective of the study was the clinical analysis of a group of patients with cancer of the oesophagus or gastroesophageal junction, who received combined medical and surgical treatment.

MATERIAL AND METHODS

The analysis was performed on a group of 128 patients with the diagnosis of oesophageal cancer or cancer of the gastroesophageal junction. Analysis of medical records and follow-up examinations were used in the research procedure.

RESULTS

From among 128 patients with a diagnosis of oesophageal or gastroesophageal junction cancer, 50 (38.5%) received surgical resections. The surgery most frequently performed (n = 15) was sub-total oesophageal resection according to Akiyama procedure by right-sided thoracotomy (oesophageal anastomosis in the neck). The largest group were patients (n = 26) with stage T3N1M0 of advancement of the disease. In all cases of cancer located in the lower third of the oesophagus, an adenocarcinoma pattern was diagnosed in the histopathological examination, whereas in the case of cancers located in the middle third and upper third of the thoracic oesophagus a carcinoma planoepitheliale pattern was seen. Anastomotic leaks occurred in seven patients (14%). Six patients died during the post-operative period (12%). The mean survival time in the group of analysed patients was two years.

CONCLUSIONS

Cancer of the oesophagus or gastroesophageal junction is associated with low resectability, high risk of complications after surgery, and poor oncologic outcome. It is necessary to seek new methods of treatment.

Omentoplasty in the prevention of anastomotic leakage after oesophagectomy: a meta-analysis

OBJECTIVE

To evaluate the efficacy of omentoplasty for the prevention of anastomotic leakage after oesophagectomy.

METHODS

A systemic review of the Cochrane Library database CENTRAL, MEDLINE and EMBASE from inception to March 2014 was performed. Randomized controlled trials comparing omentoplasty with non-omentoplasty after oesophageal resection for a primary oncological indication were included. Meta-analysis was performed for anastomotic leakage, specific complication rates, in hospital mortality, local recurrence and duration of hospitalization. Data was reported as a Peto odds ratio (Peto OR), odds ratio (OR), weighted mean difference (WMD) or relative risk (RR) with 95% confidence intervals (CI).

RESULTS

Three randomized controlled trials with a total of 633 anastamoses were included. The omentoplasty group demonstrated a significantly lower incidence of postoperative anastomotic leakage (Peto OR: 0.26; 95% CI 0.14 to 0.52), and reduced duration of hospitalization (WMD -2.13; 95% CI -3.57 to -0.69). There was no significant difference between the omentoplasty and non-omentoplasty groups in the incidence of anastomotic strictures (RR: 0.91, 95% CI: 0.33 to 2.57), hospital mortality (RR: 0.86, 95% CI: 0.29 to 2.51), pulmonary complications (RR: 0.90, 95% CI: 0.59 to 1.35) and recurrence after surgery (RR: 1.17, 95% CI: 0.95 to 1.43).

CONCLUSIONS

Omentoplasty may reduce the incidence of anastomotic leakage following oesophagectomy for oesophageal cancer.

Calcification of arteries supplying the gastric tube: a new risk factor for anastomotic leakage after esophageal surgery

PURPOSE

To evaluate the association between the amount and location of calcifications of the supplying arteries of the gastric tube, as determined with a vascular calcification scoring system, and the occurrence of anastomotic leakage after esophagectomy with gastric tube reconstruction in patients with esophageal cancer.

MATERIALS AND METHODS

Institutional review board approval was obtained, and the informed consent requirement was waived for this retrospective study. Consecutive patients who underwent elective esophagectomy for cancer with gastric tube reconstruction and cervical anastomosis between 2003 and 2012 were identified from a prospective database. Vascular calcification scores were retrospectively assigned by reviewing the routine preoperative computed tomographic (CT) images. In patients with anastomotic leakage, presence and severity of calcifications of the aorta (score of 0-2), celiac axis (score of 0-2), right postceliac arteries (common hepatic, gastroduodenal, and right gastroepiploic arteries; score of 0-1), and left postceliac arteries (splenic and left gastroepiploic arteries, score of 0-1) along with patient- and procedure-related characteristics were compared with those of patients without leakage by using multivariate logistic regression analysis.

RESULTS

Of 246 patients, 58 (24%) experienced anastomotic leakage. No significant differences in patient-related factors were found between patients with leakage and those without leakage, with the exception of more chronic use of steroids in the leakage group (7% [four of 58] vs 0% [0 of 188], P = .003). At univariate analysis, leakage was more common in patients with calcification of the aorta (27% [28 of 102] and 35% [13 of 37] vs 16% [17 of 107], P = .029) and the right postceliac arteries (55% [six of 11] vs 22% [52 of 235], P = .013). At multivariate analysis, both minor (odds ratio, 2.00; 95% confidence interval: 1.02, 3.94) and major (odds ratio, 2.87; 95% confidence interval: 1.22, 6.72) aortic calcifications were associated with leakage. Also, an independent association with leakage was found for calcifications of the right postceliac arteries (odds ratio, 4.22; 95% confidence interval: 1.24, 14.4).

CONCLUSION

Atherosclerotic calcification of the aorta and right postceliac arteries that supply the gastric tube is an independent risk factor for anastomotic leakage after esophagectomy.

A new clinical scoring system to define pneumonia following esophagectomy for cancer

BACKGROUND

Pneumonia is a frequently observed complication following esophagectomy. The lack of a uniform definition of pneumonia leads to large variations of pneumonia rates in literature. This study was designed to develop a scoring system for diagnosing pneumonia following esophagectomy at the hospital ward.

METHODS

In a prospective cohort study of esophagectomy patients, known risk factors for pneumonia, temperature, leukocyte count, pulmonary radiography and sputum culture added were evaluated. Primary outcome was defined as the decision to treat suspected pneumonia. Multivariate Cox regression analysis with backward selection was used to identify predictors of pneumonia treatment.

RESULTS

The majority of postoperative pneumonia treatments (88.2%) occurred at the hospital ward, where treatment was observed in 67 (36.2%) of 185 patients. Independent diagnostic determinants for pneumonia treatment were temperature (hazard ratio (HR) = 1.283, p = 0.073), leukocyte count (HR = 1.040, p = 0.078) and pulmonary radiography (HR >11.0, p = 0.000). Sputum culture did not influence the decision to treat pneumonia. These findings were used to develop a scoring system which includes temperature, leukocyte count and pulmonary radiography.

CONCLUSION

The decision to treat pneumonia is based on temperature, leukocyte count and pulmonary radiography findings. The proposed clinical scoring system for pneumonia following esophagectomy at the hospital ward has the potential to aid clinical practice and improve comparability of future research in esophageal cancer surgery.

Clinical analysis of embedding treatment for gastroesophageal anastomotic stoma during resection of esophageal and esophagogastric junction cancer

AIM: To evaluate the necessity of the embedding treatment for anastomotic stoma during resection of esophageal and cardiac carcinoma.

METHODS: From March 2012 to August 2013, 244 patients underwent the resection of esophageal and cardiac carcinoma at the Department of Thoracic Surgery, the First Affiliated Hospital of Xinjiang Medical University. These patients were divided into two groups: a control group and an experimental group. The control group (n = 166) underwent surgery with embedding treatment for anastomotic stoma, while the experimental group (n = 78) underwent simple anastomosis. Postoperative parameters were compared between the two groups.

RESULTS: The rate of anastomotic leakage was 1.28% (1/78) in the experimental group and 5.42% (9/166) in the control group (P = 0.24). The anastomotic diameter was 13.23 ± 2.93 mm in the experimental group and 10.91 ± 2.80 mm in the control group (P = 0.00). The rate of anastomotic stricture was 5.26% (4/76) in the experimental group and 17.42% (27/155) in the control group (P = 0.01). The dysphagia score in the experimental group was significantly lower than that in the control group (P = 0.02), while the reflux score between the two groups showed no statistically significant difference (P = 0.50).

CONCLUSION: The embedding treatment for gastroesophageal anastomotic stoma can not effectively prevent the formation of the anastomotic leakage and the occurrence of reflux esophagitis but increases the incidence of anastomotic stricture.

Planned delay of oral intake after esophagectomy reduces the cervical anastomotic leak rate and hospital length of stay

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.

Esophageal anastomosis

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.

Clinical application of mucosal valve technique for anastomosis during esophagogastrostomy

BACKGROUND

The study aims to compare the efficacy in prevention of anastomotic complications using layer-to-layer mucosal valve technique versus circular stapled technique for esophagogastric intrathoracic anastomosis after resection for esophageal and gastric cardiac carcinoma.

METHODS

From January 2005 to December 2010, 136 patients received layer-to-layer mucosal valve technique (LM group), 219 received circular stapled anastomosis (CS group) after curative intent resection for esophageal and gastric cardiac carcinoma. The technique details were reported and the clinical results were analyzed.

RESULTS

The two groups were comparable on clinical baseline characteristics. The average duration of operation was longer with LM technique by 16 min, but without statistical significance (P = 0.073). There was no anastomotic leakage in the LM group, while in the CS group, leakage occurred in seven patients (3.2 %, P = 0.047). Both the incidence and grade of postoperative dysphagia were significantly lower in the LM group (P < 0.05). Significantly fewer patients experienced stricture after LM technique (3.8 %) compared with CS anastomosis (18.2 %, P < 0.001). CS anastomosis was associated with a significantly higher incidence of persistent stricture requiring more dilatation (P < 0.001). Symptoms of reflux were better controlled by LM technique; 82.7 % of patients were asymptomatic with respect to reflux compared to 58.9 % in the CS group, P < 0.001. And there was a significant reduction in the incidence of esophagitis in remnant esophagus in the LM group (P = 0.001).

CONCLUSIONS

The layered mucosal valve anastomosis could significantly diminish the incidence of anastomotic complications and could be used as an alternative for esophagogastric anastomosis after resection of esophageal and gastric cardiac carcinoma.

Complex anastomotic leaks following esophageal resections: the new stent over sponge (SOS) approach

A new approach for the treatment of complicated anastomotic leaks following esophageal resections by combining vacuum-assisted therapy with covered self-expanding stents is reported. This is not an approach for a simple leak but a rescue maneuver for complex uncontained leaks. It is known that anastomotic leakages particularly situated in the chest can be successfully treated with endoscopically placed self-expanding stents with/without additional drainage. If this approach fails, reoperation with substantial morbidity is frequently necessary. Two complicated anastomotic leakages refractory to stenting alone were successfully treated with the combination of an endo-sponge-assisted device covered by a self-expanding metallic stent. If stent therapy fails or the perianastomotic abscess cavity is large and complex to drain from outside, the endoscopic two-modality approach can be considered.

Triangulating stapling technique for esophagogastrostomy after minimally invasive esophagectomy

BACKGROUND

The triangulating stapling technique is one of the reconstruction methods used that provides favorable surgical outcomes in several areas of the digestive tract. However, the results in the cervical esophagogastric anastomosis are not well documented.

METHODS

Using a prospectively maintained comprehensive database, we reviewed the surgical results of 160 consecutive patients who underwent minimally invasive esophagectomy followed by cervical triangulating stapling esophagogastrostomy during 2 periods from May 2002 to May 2012 so as to determine the efficacy of the triangulating stapling technique using 2 different types of stapling devices.

RESULTS

The rates of anastomotic leakage and stricture in this series were low (1% and 15%, respectively). The rate of anastomotic stricture was significantly reduced when a linear stapler with a cutting knife was used (9%). A logistic regression analysis showed a reduction of anastomotic stricture to be significantly associated with the use of only a linear stapler with a cutting knife.

CONCLUSION

Cervical esophagogastric anastomosis by the triangulating stapling technique is safe and feasible. We consider a linear stapling device equipped with a cutting knife to be more suitable for performing the triangulating stapling technique.

End-to-end cervical esophagogastric anastomoses are associated with a higher number of strictures compared with end-to-side anastomoses

BACKGROUND

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

METHODS

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

RESULTS

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p = 0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p = 0.04). Moreover, a median of 11 (7-17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2-8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p < 0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p = 0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p = 0.03 and p = 0.01, respectively).

CONCLUSION

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.

Early severe mediastinal bleeding after esophagectomy: a potentially lethal complication

BACKGROUND

Anastomotic leakage after cervical oesophagogastrostomy is a common and difficult problem. Mediastinal manifestation of anastomotic leakage may lead to mediastinitis with dramatic and potentially lethal outcome. Contamination of the mediastinum can be controlled by endoscopic placement of an expandable metal stent. We present two cases of severe haemorrhage after mediastinal manifestation of anastomotic leakage in patients with and without expandable metal stent (EMS).

CASES

This case report describes two cases of severe haemorrhage after thoracolaparoscopic esophagectomy with cervical oesophagogastrostomy. The recovery of both patients was complicated by anastomotic leakage with mediastinal manifestation. In one case, 11 days after placement of an EMS for anastomotic leakage a bleeding occurred in the cervical wound. Angiography during surgery showed contrast leakage in the aortic arch. Despite sternotomy and endovascular catheterization, there were no surgical options to treat this condition and the patient died of exsanguination. In the other case the patient presented with severe hematemesis 11 days after surgery. Shortly after this hematemesis the patient became hemodynamic instable. The patient was taken to the operation theatre, but before any intervention could take place resuscitation was needed and the patient died of exsanguination.

CONCLUSIONS

Severe haemorrhage is a rare and potentially lethal complication after esophagectomy. This condition is related to anastomotic leakage with mediastinal manifestation. Awareness of this potentially lethal complication is important for early recognition and treatment of this condition. The role of endoscopic stenting of the cervical anastomosis is controversial and potentially dangerous.

Surgical quality of care in esophageal malignancies

Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high. Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: ‘esophagectomy’, ‘esophagus’, ‘neoplasm’ and ‘cancer’ to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care. Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients. Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons’ practice.

Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis

OBJECTIVE

To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection.

BACKGROUND DATA

Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined.

METHODS

A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration.

RESULTS

Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66-1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95-2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16-2.42), and (3) reduced the length of the operation time (mean: -15.3 minutes, range: -28.1 to -2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration.

CONCLUSION

The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.

Surgery of esophageal cancer

BACKGROUND

Surgery is the only option for curative treatment in patients with esophageal carcinoma. Despite the debates related to the peri-operative therapy regime, a generally accepted consensus on surgical approach is not reached yet. The debate focuses mainly on pros and cons between radical transthoracic resection and the (limited) transhiatal resection in the last decade.

METHODS

The PubMed database was searched for randomized trials, meta-analyses, and retrospective single-center studies. The search terms were "esophageal carcinoma," "esophageal junction carcinomas," "transhiatal," "transthoracic," "morbidity," "mortality," and "surgery."

RESULTS

The radical transthoracic approach should be the standard of care for esophageal carcinoma since it does not go along with an increased risk of postoperative morbidity or mortality but reveals an improved survival. Patient-related co-morbidities are the most influencing factors for the postoperative outcome. For type II esophageal junction carcinoma, treatment options from transhiatal extended gastrectomy to esophagectomy with hemigastrectomy or esophagogastrectomy with colonic interposition are existing. In type III esophagogastric junction carcinomas, the transhiatal extended gastrectomy is the standard of care, and the minimally invasive approach should be performed in specialized centers.

CONCLUSION

Based on current available study results, this expert review provides a decision support for the best surgical strategy depending on tumor localization and patients' characteristics.

Endoscopic vacuum therapy of anastomotic leakage and iatrogenic perforation in the esophagus

BACKGROUND

The management of anastomotic leakage and iatrogenic esophageal perforation has shifted over recent decades from aggressive surgery to conservative and, recently, endoscopic therapy alternatives. The authors present their results for endoscopic vacuum therapy used to treat both entities.

METHODS

In the authors' institution, 17 cases of anastomotic leakage and 7 cases of iatrogenic perforation due to interventional endoscopy or rigid panendoscopy with either intraluminal or intracavitary endoscopic vacuum therapy were treated.

RESULTS

In 23 of 24 cases, the endoscopic treatment was successful. The median duration of therapy was 11 days (range, 4-46 days). All 7 cases of iatrogenic perforation and 16 of 17 anastomotic leakage cases were cured after a median therapy duration of 5 and 12 days, respectively.

CONCLUSIONS

Endoscopic vacuum therapy is applicable for a wide range of esophageal defects. In the authors' experience, it has seemed to be the best choice for iatrogenic perforations and has been a potent supplement in the management of anastomotic leakages.