Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis

Full RAMIE vs Hybrid RAMIE: a retrospective study on outcomes evaluation and cost considerations

To compare the results of Minimally Invasive Esophagectomy performed with a Fully Robot-Assisted technique (F-RAMIE) and a Hybrid approach with laparoscopic abdominal phase (H-RAMIE). Multicentric retrospective analysis of patients who underwent F-RAMIE and H-RAMIE between 2018 and 2023. The primary endpoint was the rate of postoperative complications, secondary endpoints were clinical outcomes, oncological results and costs. Survival analyses were calculated according to the Kaplan-Meier method. The economic evaluation included costs related to operating room time, length of stay, surgical tools, and robotic system maintenance. A total of 100 patients from two experienced surgical centers were included: 64 H-RAMIE and 36 F-RAMIE. The two groups were comparable in baseline clinical conditions and staging. F-RAMIE was associated with longer operative time (434.7 ± 46.4 Vs. 477.3 ± 47.5 min, p < 0.001) and shorter length of Intensive Care Unit stay (1.1 ± 1.1 Vs. 2.3 ± 2.3 days, p = 0.002) than H-RAMIE. There were no significant differences in conversion rate, postoperative complications and length of stay. F-RAMIE demonstrated superior lymph node retrieval (43.8 ± 15.2 Vs. 22.4 ± 10.3, p < 0.001), but no differences in R0 resection rates. Overall survival and recurrences were comparable. Cost analysis revealed a slight economic advantage for F-RAMIE (20,556.3 ± 3,601.2 € Vs. 23,302.4 ± 5,894.5 € p = 0.012), mainly due to hospital stay-related cost (11,267.6 ± 5,912.8 € for H-RAMIE Vs. 8,360.3 ± 3,550.6 €, p = 0.007). F-RAMIE and H-RAMIE proved to be equally safe and effective in terms of postoperative complications and oncological outcomes.

Optimal oesophagogastric anastomosis techniques for oesophageal cancer surgery - A systematic review and network meta-analysis of randomised clinical trials

BACKGROUND

The optimal oesophagogastric anastomosis technique for oesophageal cancer surgery remains unclear. The aim of this study was to perform a network meta-analysis (NMA) of randomised clinical trials (RCTs) to compare oesophagogastric anastomosis techniques for oesophageal cancer surgery.

METHODS

A systematic review and NMA were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines-NMA extension. Statistical analyses were performed using R and Shiny.

RESULTS

Overall, 16 RCTs were included (14 provided data eligible for NMA). These included 2520 patients and 4 different anastomosis techniques: 1055 (41.9 %) patients underwent circular stapled (CS), 1232 (48.9 %) underwent handsewn (HS), 100 (3.9 %) underwent triangulated stapled (TS) and 133 (5.3 %) underwent linear stapled (LS). Fourteen studies reported on open surgery, while one reported on both open and minimally invasive techniques. At NMA, no significant difference was observed regarding anastomotic leak rates among all techniques, while HS significantly reduced anastomotic leaks following cervical technique (odds ratio (OR): 0.32, 95 % confidence interval (CI): 0.13-0.78). Moreover, HS (OR: 0.58, 95 % CI: 0.38-0.90) and LS (OR: 0.21, 95%CI: 0.06-0.71) significantly reduced anastomotic stricture rates, while LS significantly reduced anastomotic strictures following intrathoracic anastomotic technique (OR: 0.17, 95%CI: 0.06-0.90).

CONCLUSION

HS reduced anastomotic leaks following cervical anastomoses, while HS and LS reduced overall anastomotic strictures (with LS significantly reducing strictures following intrathoracic anastomoses). Importantly, institutional and surgeon expertise should be considered prior to adopting these results into contemporary practice for open oesphagectomy, with a call for the harmonisation of trials to align with contemporary, minimally invasive approaches.

Nanotechnology-based biomedical devices in the cancer diagnostics and therapy

Nanotechnology has significantly transformed the field of cancer diagnostics and therapeutics by introducing advanced biomedical devices. These nanotechnology-based devices exhibit remarkable capabilities in detecting and treating various cancers, addressing the limitations of traditional approaches, such as limited specificity and sensitivity. This review aims to explore the advancements in nanotechnology-driven biomedical devices, emphasizing their role in the diagnosis and treatment of cancer. Through a comprehensive analysis, we evaluate various nanotechnology-based devices across different cancer types, detailing their diagnostic and therapeutic effectiveness. The review also discusses FDA-approved nanotechnology products, patents, and regulatory trends, highlighting the innovation and clinical impact in oncology. Nanotechnology-based devices, including nanobots, smart pills, and multifunctional nanoparticles, enable precise targeting and treatment, reducing adverse effects on healthy tissues. Devices such as DNA-based nanorobots, quantum dots, and biodegradable stents offer noninvasive diagnostic and therapeutic options, showing high efficacy in preclinical and clinical settings. FDA-approved products underscore the acceptance of these technologies. Nanotechnology-based biomedical devices offer a promising future for oncology, with the potential to revolutionize cancer care through early detection, targeted treatment, and minimal side effects. Continued research and technological improvements are essential to fully realize their potential in personalized cancer therapy.

Predictive factors for refractory anastomotic stricture after cervical triangular anastomosis with gastric conduit reconstruction through the posterior mediastinum in minimally invasive esophagectomy

BACKGROUND

After esophagectomy, anastomotic strictures disturb food passage and increase the incidence of aspiration pneumonia. Multiple endoscopic balloon dilatations are required for stricture treatment. Therefore, long-term quality of life and nutritional status may be adversely affected. This study aimed to identify risk factors for strictures after cervical triangular anastomosis using a gastric conduit among patients who underwent minimally invasive esophagectomy (MIE).

METHODS

A total of 188 patients who underwent MIE for esophageal cancer between 2010 and 2020 at Kobe University Hospital were retrospectively examined. The incidence of strictures, number of dilatations for stricture, and time to stricture diagnosis were evaluated. Next, the potential independent risk factor for refractory strictures requiring more than 5 endoscopic balloon dilatations was clarified.

RESULTS

The study included 188 patients who satisfied the inclusion criteria. Anastomotic strictures were observed in 44 patients (23%). Neoadjuvant chemotherapy was significantly more common in patients with stricture than in patients without stricture (75% vs 58%, respectively; P = .041). The median number of endoscopic balloon dilatations was 5 (IQR, 1-31). Of note, 30 patients (68%) underwent their first dilatation within 3 months after MIE. In univariate and multivariate analyses, < 69 days from surgery to first endoscopic balloon dilatation was an independent risk factor for stricture requiring more than 5 endoscopic balloon dilatations after cervical triangular anastomosis in MIE (hazard ratio, 9.483; 95% CI, 2.220-54.274; P = .002).

CONCLUSION

Early postoperative anastomotic stricture might become refractory, and an appropriate treatment plan should be developed.

Risk factors for and treatment of anastomotic strictures after Ivor Lewis esophagectomy

INTRODUCTION

Anastomotic strictures following esophagectomy occur frequently and impact on nutrition and quality of life. Although strictures are often attributed to ischemia and anastomotic leaks, the role of anastomosis size and pyloroplasty is not well evaluated. Our study aims to assess the rate of and risk factors for anastomotic stricture following esophagectomy, and the impact of treatment with regular endoscopic balloon dilatations.

METHODS

Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, surgical outcomes and anastomotic strictures were recorded. Relationship of anastomotic strictures with circular stapler size, pyloroplasty and anastomotic leak was analyzed. Treatment of strictures with endoscopic balloon dilatation was reviewed and percentage weight loss at 1 year was evaluated.

RESULTS

Anastomotic strictures occurred in 17.4% of patients. Patient demographics between those with and without stricture were similar. Stricture rate was similar in patients with or without pyloroplasty (13.9% vs 21.7%, respectively, p = 0.14) and in those with or without an anastomotic leak (25.0% vs 16.6%, respectively, p = 0.345). Stricture risk increased with smaller sized stapler (25 mm = 33.3%, 28 mm = 15.3%, 31 mm = 4.8%; p = 0.027). The median number of dilatations required to fully treat strictures was 2 (IQR: 1-3). The median length of time from surgery to first dilatation was 2.9 months (IQR: 2.0-4.7) and to last dilatation was 6.1 months (IQR: 4.8-10.0). Median maximum dilatation diameter was 20 mm (IQR: 18.0-20.0). There were no complications from dilatations. Percentage weight loss at 1 year in patients with strictures was similar to those without strictures (8.7% vs 11.1%, respectively, p = 0.090).

CONCLUSIONS

Post-esophagectomy anastomotic strictures are common and not necessarily related to anastomotic leaks or absence of pyloroplasty. Smaller anastomosis size was strongly linked with stricture formation. A driven approach with regular endoscopic balloon dilation is safe and effective in treating these strictures with no excess weight loss at 1 year once treated.

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

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.

Safe Transition from Open to Total Minimally Invasive Esophagectomy for Cancer Utilizing Process Management Methodology

Background: The global shift from open esophagectomy (OE) to minimally invasive esophagectomy (MIE) for treating esophageal cancer is well-established. Recent data indicate that transitioning from hybrid minimally invasive esophagectomy (hMIE) to total minimally invasive esophagectomy (tMIE) can be challenging due to concerns about higher leakage rates and lower lymph node counts, especially at the beginning of the learning curve. This study aimed to demonstrate that a safe transition from OE to tMIE for cancer is possible using process management methodology. Methods: A step-change approach was adopted in process management planning, with hMIE serving as an intermediate step between OE and tMIE. This single-center, case-control study included 150 patients who underwent the Ivor Lewis procedure with curative intent for esophageal cancer. Among these patients, 50 underwent OE, 50 hMIE (laparoscopic procedure followed by conventional right thoracotomy), and 50 tMIE (laparoscopic and thoracoscopic approach). A preceptored training scheme was implemented during execution, and treatment results were monitored and controlled to ensure a safe transition. Results: During the transition, the tMIE group was not worse than the hMIE and OE groups regarding operation duration (p = 0.135), overall postoperative complications (p = 0.020), anastomotic leakage rates (p = 0.773), 30-day mortality (p = 1.0), and oncological outcomes (based on R status (p = 0.628) and 2-year survival (p = 0.967)). Additionally, the tMIE group showed superior results in terms of major postoperative pulmonary complications (p = 0.004) and ICU stay duration (p < 0.001). Conclusions: Utilizing managerial methodology and practice in surgery, as a bridge between interdisciplinary and transdisciplinary approaches, demonstrated that transitioning from OE to tMIE, with hMIE as an intermediate step, is safe and feasible without compromising outcomes.

Navigating complexities and considerations for suspected anastomotic leakage in the upper gastrointestinal tract: A state of the art review

This state-of-the-art review explores the intricacies of anastomotic leaks following oesophagectomy and gastrectomy, crucial surgeries for globally increasing esophageal and gastric cancers. Despite advancements, anastomotic leaks occur in up to 30 % and 10 % of oesophagectomy and gastrectomy cases, respectively, leading to prolonged hospital stays, substantial impact upon short- and long-term health-related quality of life and greater mortality. Recognising factors contributing to leaks, including patient characteristics and surgical techniques, are vital for preoperative risk stratification. Diagnosis is challenging, involving clinical signs, biochemical markers, and various imaging modalities. Management strategies range from non-invasive approaches, including antibiotic therapy and nutritional support, to endoscopic interventions such as stent placement and emerging vacuum-assisted closure devices, and surgical interventions, necessitating timely recognition and tailored interventions. A step-up approach, beginning non-invasively and progressing based on treatment success, is more commonly advocated. This comprehensive review highlights the absence of standardised treatment algorithms, emphasizing the importance of individualised patient-specific management.

Endoscopic ultrasound for structured surveillance after curative treatment of esophageal cancer

BACKGROUND

Structured surveillance after treatment of esophageal cancer is not established. Due to a paucity of data, no agreement exists on how surveillance should be performed. The main argument against intensive follow-up in esophageal cancer is that it may not lead to true survival advantage.

METHODS

Structured surveillance was performed in 42 patients after multimodal therapy with peri-operative chemotherapy (29) or definitive chemoradiotherapy (13) of esophageal cancer. The surveillance protocol included gastroscopy, endoscopic ultrasound, chest X-ray, abdominal ultrasound, and CEA measurement at regular intervals of up to five years. We analyzed relapse rate, time to relapse, localization of recurrence, diagnosis within or without structured surveillance, diagnostic method providing the first evidence of a relapse, treatment of recurrence, and outcome.

RESULTS

Median follow-up was 48 months; 18/42 patients suffered from tumor relapse, with 16 asymptomatic patients diagnosed within structured surveillance. Median time to recurrence was 9 months. Isolated local or locoregional recurrence occurred in 6, and isolated distant relapse in 9 patients. All patients with isolated locoregional recurrence were exclusively diagnosed with endoscopic ultrasound. Six patients received curatively intended therapy with surgery or chemoradiation, leading to long-lasting survival.

CONCLUSION

Structured surveillance offers the chance to identify limited and asymptomatic tumor relapse. Especially in cases of locoregional recurrence, long-lasting survival or even a cure can be achieved. Endoscopic ultrasound is the best method for the detection of locoregional tumor recurrence and should be an integral part of structured surveillance after curative treatment of esophageal cancer.

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.

Fully Robotic Side-to-Side Linear-Stapled Anastomosis During Robotic Ivor Lewis Esophagectomy

BACKGROUND

The adoption of robotic surgery for esophageal cancer has been expanding rapidly over the recent years. In the setting of two-field esophagectomy, different techniques exist for intrathoracic esophagogastric anastomosis, although the superiority of one over another has not been clearly demonstrated. Potential benefits in terms of anastomotic leakage and stenosis have been reported in association with a linear-stapled anastomosis as compared to the more widespread techniques of circular mechanical and hand-sewn reconstructions, however, there is still limited reported evidence on its application to robotic surgery. We here report our fully robotic technique of side-to-side, semi-mechanical anastomosis.

METHODS

All consecutive patients undergoing fully robotic esophagectomy featuring intrathoracic side-to-side stapled anastomosis by a single surgical team were included in this analysis. Operative technique is detailed, and perioperative data are assessed.

RESULTS

A total of 49 patients were included. There were no intraoperative complications and no conversion occurred. The rate of overall postoperative morbidity was 25, 14% being the relative rate of major complications. With anastomotic-related morbidity in particular, one patient developed minor anastomotic leakage.

CONCLUSIONS

Our experience demonstrates that a linear, side-to-side fully robotic stapled anastomosis can be created with a high technical success and minimal incidence of anastomosis-related morbidity.

Comparison of hand-sewn and circular stapled esophagogastric anastomoses in the neck after esophagectomy for thoracic esophageal cancer: a propensity score-matched analysis

Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage.

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.

Why pay more for robot in esophageal cancer surgery?

Esophagectomy is the gold standard for the treatment of resectable esophageal cancer. Traditionally, it is performed through a laparotomy and a thoracotomy, and is associated with high rates of postoperative complications and mortality. The advent of robotic surgery has represented a technological evolution in the field of esophageal cancer treatment. Robot-assisted Minimally Invasive Esophagectomy (RAMIE) has been progressively widely adopted following the first reports on the safety and feasibility of this procedure in 2004. The robotic approach has better short-term postoperative outcomes than open esophagectomy, without jeopardizing oncologic radicality. The results of the comparison between RAMIE and conventional minimally invasive esophagectomy are less conclusive. This article will focus on the role of RAMIE in the current clinical scenario with particular attention to its possible benefits and perspectives.

Efficacy of sternocleidomastoid muscle flap in reducing anastomotic mediastinal/pleural cavity leak

BACKGROUND

Anastomotic mediastinal/pleural cavity leak (AMPCL) is a life-threatening postoperative complication after esophagectomy. The objective of this study was to find a safe and effective surgical method to reduce the incidence of AMPCL.

METHODS

A total of 223 patients who underwent surgery in Fujian Medical University Union Hospital from May 2020 to October 2021 were enrolled in this study. Data for preoperative and postoperative test indices, postoperative complications, perioperative treatment were collected. After using 1:1 propensity score matching (PSM) to match two cohort (caliper = 0.1), the relationship between various factors and the incidence of AMPCL were analyzed.

RESULTS

209 patients were included for further analysis in the end. There were 95 patients in the sternocleidomastoid muscle flap embedding group (intervention group) and 114 in the routine operation group (control group). There was a significant difference in mean age between two groups. Gender, age, body mass index, diabetes, American society of anesthesiologists score, preoperative neoadjuvant therapy, pathological stage were included in performing 1:1 PSM, and there were no significant differences between two groups. Median operative time was significantly less in intervention group. Anastomotic leak (AL) did not present significant difference between two groups (8 [8.6] vs. 13 [14.0], p = 0.247), however, the AMPCL in intervention group was significantly lower than control group (0 [0] vs. 6 [6.5], p = 0.029).

CONCLUSIONS

The sternocleidomastoid muscle flap embedding could significantly reduce the incidence of AMPCL. This additional procedure is safe, and effective without increase in the occurrence of postoperative complications and hospital expenses.

Current Issues and Future Technologies in Esophageal Cancer Surgery

Gastrointestinal surgery has evolved rapidly in recent years, with laparoscopic techniques being implemented as the standard procedure and robotic surgery becoming increasingly important [...].

Robot-assisted esophagectomy with robot-sewn intrathoracic anastomosis (Ivor Lewis): surgical technique and early results

Esophagectomy is the selected treatment for nonmetastatic esophageal and esophagogastric junction cancer, although high perioperative morbidity and mortality incur. Robot-assisted minimally invasive esophagectomy (RAMIE) effectively reduces cardiopulmonary complications compared to open esophagectomy and offers a technical advantage, especially for lymph node dissection and intrathoracic anastomosis. This article aims at describing our initial experience of Ivor Lewis RAMIE, focusing on the technique's main steps and robotic-sewn esophagogastrostomy. Prospectively collected data from all consecutive patients who underwent Ivor Lewis RAMIE for cancer was reviewed. Reconstruction was performed with a gastric conduit pull-up and a robotic-sewn intrathoracic anastomosis. Intraoperative and postoperative complications were recorded as prescribed by the Esophagectomy Complications Consensus Group (ECCG). Thirty patients underwent Ivor Lewis RAMIE with complete mediastinal lymph node dissection and robot-sewn anastomosis. No intraoperative complications nor conversion occurred. Pulmonary complications totaled 26.7%. Anastomotic leakage (ECCG, type III) and conduit necrosis (ECCG, type III) both occurred in one patient (3.3%). Chylothorax appeared in 2 patients (6.7%) (ECCG, Type IIA). Anastomotic stricture, successfully treated with endoscopic dilatations, occurred in 8 cases (26.7%). Median overall postoperative stay was 11 days (range, 6-51 days). 30 day and 90 day mortality was 0%. R0 resection was performed in 96.7% of patients with a median number of 47 retrieved lymph nodes. RAMIE with robot-sewn intrathoracic anastomosis appears to be feasible, safe and effective, with favorable perioperative results. Nevertheless, further high-quality studies are needed to define the best anastomotic technique for Ivor Lewis RAMIE.

A 25 mm Circular Stapler Anastomosis Is Associated with Higher Anastomotic Leakage Rates Following Minimally Invasive Ivor Lewis Operation

(1) Background: Minimally invasive oesophagectomy (MIE) with intrathoracic anastomosis is increasingly used in treating patients with oesophageal cancer. Anastomotic leakage (AL) remains a critical perioperative complication, despite recent advances in surgical techniques. It remains unclear to what extent the size of the circular stapler (CS), a 25 mm CS or a bigger CS, may affect the incidence of AL. This study aimed to evaluate whether the CS size in oesophagogastrostomy affects the postoperative AL rates and related morbidity in MIE. (2) Methods: We conducted a retrospective review of consecutive patients who had undergone thoracic MIE between August 2014 and July 2019 using a CS oesophagogastric anastomosis at the level of the Vena azygos. The patients were grouped according to CS size (mm): small-sized (SS25) and large-sized (LS29). The patient demographics, data regarding morbidity, and clinical outcomes were compared. The primary outcome measure was the AL rate related to the stapler size. (3) Results: A total of 119 patients were included (SS25: n = 65; LS29: n = 54). Except for the distribution of squamous cell carcinoma, the demographics were similar in each group. The AL rate was 3.7% in the LS29 group and 18.5% in the SS25 group (p = 0.01). The major morbidity (CD ≥ 3a) was significantly more frequent in the SS25 group compared with the LS29 group (p = 0.02). CS size, pulmonary complications, and cardiovascular disease were independent risk factors for AL in the multivariate analysis. (4) Conclusions: A 29 mm CS is associated with significantly improved surgical outcomes following standard MIE at the level of the azygos vein and should be conducted whenever technically feasible.

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.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

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.

Linear Versus Circular Laparoscopic Gastrojejunal Anastomosis of Roux-en-Y Gastric Bypass: Systematic Review and Meta-Analysis of 22 Comparative Studies

PURPOSE

To compare the rate of complications of linear versus circular gastrojejunal anastomosis of laparoscopic Roux-en-Y gastric bypass.

METHODS

A systematic search of PubMed, Embase, and the Cochrane Library databases was carried out using the terms "laparoscopic," "circular," "linear," "anastomosis," "gastric bypass" in accordance to PRISMA guidelines. Only original articles in English language comparing linear versus circular anastomosis were included. No temporal interval was set. Outcome measures were wound infection, bleeding, marginal ulcer, leak, and stricture. Pooled odds ratio (OR) with a 95% confidence interval (CI) was calculated. Heterogeneity was assessed using the I2 statistic. Funnel plots were used to detect publication bias.

RESULTS

Twenty-two articles (7 prospective and 15 retrospective) out of 184 retrieved papers were included in this study. The pooled analysis showed a reduced odd of wound infection and bleeding after linear anastomosis. Likelihood of marginal ulcer, leak, and stricture was similar after the 2 techniques. Wound infection was reported in 15 studies (OR, 0.17; 95% CI, 0.06-0.45; P=0.0003; I2=91), bleeding in 9 (OR, 0.45; 95% CI, 0.34-0.59; P=0.00001; I2=6) marginal ulcer in 11 (OR, 0.61; 95% CI, 0.26-1.41; P=0.25; I2=65), leaks in 15 (OR, 0.61; 95% CI, 0.21-1.67; P=0.34; I2=83) and stricture in 18 (OR, 0.48; 95% CI, 0.23-1.00; P=0.05; I2=68).

CONCLUSION

Laparoscopic RYGB can be safely performed both with circular and linear staplers. Rates of wound infection and bleeding were significantly lower after linear gastrojejunal anastomosis.

End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes

PURPOSE

The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups.

METHODS

We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications.

RESULTS

Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups.

CONCLUSIONS

The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy (MT), with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of MT anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which MT anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

14 patients were included, with a mean age of 63 years. The mean operative time was 436 min (360-581), being diagnosed of anastomotic leak (AL) 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis (AS). The median stay was 20 days, without any death in the series.

DISCUSSION

Multiple publications suggest the superiority in terms of AL and AS of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

Circular Stapler Method for Avoiding Stricture of Cervical Esophagogastric Anastomosis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Analysis of outcomes of a transoral circular stapled anastomosis following major upper gastrointestinal cancer resection

BACKGROUND

Esophageal anastomoses performed following esophagectomy and total gastrectomy are technically challenging with a significant risk of anastomotic leak. A safe, reliable, and easy anastomotic technique is required to improve patient outcomes and reduce morbidity.

METHOD

This paper analyses 328 consecutive patients who underwent transoral circular stapled esophageal anastomosis (ORVIL™) from a prospectively collected single-center database between December 2011 and February 2019.

RESULTS

Two hundred and twenty-seven esophagectomies and 101 gastrectomies were performed using OrVil™ anastomoses. The mean patient age was 63.7 years. Of 328 consecutive OrVil™-based anastomoses, there were 10 clinically significant anastomotic leaks requiring radiological or operative intervention (3.05%). Twenty-eight (8.54%) patients developed anastomotic stricture, all of which were successfully treated with endoscopic balloon dilatation (a median of 1 dilatation was required per patient).

CONCLUSION

The OrVil™ anastomotic technique is reliable and safe to perform. This is the largest reported series of the OrVil™ anastomotic technique to date. Leak rates and anastomotic dilations were similar to other reported series. Based on our experience, we consider the use of the OrVil™ device for reconstruction after major upper GI resection to be safe and reliable.

Anastomotic stricture after Ivor Lewis esophagectomy: An evaluation of incidence, risk factors, and treatment

BACKGROUND

Anastomotic stricture is a recognized complication after esophagectomy. It can impact the patient's quality of life and may require recurrent dilatations. Thus, the aim of this study was to evaluate the frequency of strictures, contributing factors, and long-term outcomes of management in patients undergoing esophagectomy with thoracic anastomosis using a standardized circular stapled technique.

METHODS

All patients who underwent a 2-stage transthoracic esophagectomy with curative intent between January 2010 and December 2019 at NOGU, Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded.

RESULTS

Overall, 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, 2, and 3 dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients, respectively. Multivariable analysis identified the occurrence of an anastomotic leak (odds ratio 1.906, 95% confidence interval 1.088-3.341, P = .024) and circular staple size <28 mm (odds ratio 1.462, 95% confidence interval 1.033-2.070, P = .032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs 4.7%, odds ratio 3.089, 95% confidence interval 1.349-7.077, P = .008).

CONCLUSION

This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy, with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of triangular esophagogastrostomy anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which triangular esophagogastrostomy anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

A total of 14 patients were included, with a mean age of 63 years. The mean operative time was 436minutes (360-581), being diagnosed of anastomotic leak 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis. The median stay was 20 days, without any death in the series.

CONCLUSIONS

Multiple publications suggest the superiority in terms of anastomotic leak and anastomotic stenosis of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.