Impact on outcome of the route of conduit transposition after transhiatal oesophagectomy: A randomized controlled trial

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.

Anterior versus posterior mediastinal reconstruction after esophagectomy in esophageal cancer patients: a systematic review and meta-analysis

PURPOSE

Esophagectomy is the primary surgical treatment for esophageal cancer, although other treatment approaches are often incorporated, including preoperative chemotherapy and chemoradiotherapy. The two major routes of esophageal reconstruction after esophagectomy are the anterior mediastinal (retrosternal, heterotopic) and posterior mediastinal (prevertebral, orthotopic) routes. However, which of these two routes of reconstruction is the most appropriate remains controversial. This systematic review aimed to compare the efficacy and safety of anterior mediastinal reconstruction with those of posterior mediastinal reconstruction after esophagectomy in esophageal cancer.

METHODS

In January 2022, a literature search of the CENTRAL, MEDLINE, and EMBASE databases was conducted to identify all published and unpublished randomized controlled trials, regardless of language. Eight studies were included for quantitative synthesis.

RESULTS

Postoperative death (9/129 and 4/125, risk ratio [RR]: 2.07, 95% confidence interval [CI]: 0.65-6.64) and incidence of anastomotic leak (24/208 and 26/208, RR: 0.95, 95% CI: 0.56-1.62) were not significantly different between the two mediastinal reconstructions. We could not perform a meta-analysis for quality of life, loss of body weight, or postoperative hospital stay due to data limitations.

CONCLUSION

Overall, there was low-quality evidence to suggest that the outcomes of the anterior and posterior mediastinal routes of reconstruction are not significantly different in patients with esophageal cancer.

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

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

Surgical outcomes of two different reconstruction routes for esophagectomy in esophageal cancer patients: a meta-analysis

To evaluate the effects of two different reconstruction routes (the posterior mediastinal route (PR) and the retrosternal route (RR)) on the surgical outcomes of patients after esophagectomy for esophageal carcinoma. PubMed, Embase, Web of Science and Scopus were searched from database inception to March 2021. Randomized controlled trials (RCTs) and case-control trials on the surgical outcomes of patients undergoing esophagectomy via one of the two routes were included. RevMan 5.3 software was used for the meta-analysis. In total, 19 studies were included, 8 were RCTs and 11 were case-control studies. The meta-analysis showed that among the case-control trials, the PR had reduced rates of anastomotic leakage [odds ratio (OR) = 0.56, 95% confidence interval (CI) (0.43, 0.74), P < 0.01]. In addition, it had reduced rates of anastomotic stenosis [OR = 0.42, 95% CI (0.30, 0.59), P < 0.01] and pulmonary complications [OR = 0.63, 95% CI (0.47, 0.84), P < 0.01]. However, there was no significant difference in cardiac complications [RCTs, relative risk (RR) = 0.57, 95% CI (0.29, 1.11), P = 0.10; case-control trials, OR = 1.06, 95% CI (0.70, 1.62), P = 0.78] or postoperative mortality [RCTs, RR = 0.47, 95% CI (0.19, 1.16), P = 0.10; case-control trials, OR = 0.68, 95% CI (0.32, 1.44), P = 0.31]. Compared with the RR, the PR had reduced rates of anastomotic leakage, anastomotic stenosis and pulmonary complications.

Comparison of QoL Between Substernal and Posterior Mediastinal Routes in Esophagogastrostomy

BACKGROUND

After esophagectomy, various reconstruction routes can be considered for technical and oncologic objectives. The substernal route is believed to cause more dysphagia or delayed gastric emptying symptoms than the posterior mediastinal route. We evaluated and compared the quality of life (QoL) after reconstruction by either the substernal or posterior mediastinal routes in the McKeown procedure.

METHODS

Between 2011 and 2018, 378 patients who received an esophagectomy and cervical esophagogastrostomy for esophageal cancer were followed up. Among these patients, 278 received reconstruction via the substernal route and 100 via the posterior mediastinal route. Patients completed the validated questionnaires, EORTC QLQ-C30 and QLQ-OES18, before surgery and at 1, 2, 3, 6, 12, and 24 months after surgery. Linear mixed-effects models were used to examine changes in questionnaire scores over time.

RESULTS

One month after surgery, patients QoL deteriorated and more symptoms were observed than at baseline. Global health status, nausea and vomiting, and esophageal pain gradually recovered from 2 months and recovered to initial levels at 2 years. However, the other functional and symptom scales of the QLQ-C30 and OES18 were not normalized at 2 years after the operation. When comparing the substernal and posterior mediastinal routes, QLQ-OES18 symptom scales, such as eating, dysphagia, trouble with swallowing saliva trouble with taste and reflux, were no different between the two groups, even after adjusting confounding factors at 2 years after the operation.

CONCLUSION

The cervical esophagogastrostomy with a substernal route showed comparable QoL to reconstruction with a posterior mediastinal route.

Indocyanine green fluorescence imaging for subtotal esophagectomy due to esophageal stenosis after acute esophageal necrosis: a report of two cases

Although esophageal stricture after acute esophageal necrosis (AEN) is often refractory to dilation therapy, there have been few reports of surgical intervention. We report two rare cases of successful subtotal esophagectomy and esophagogastrostomy for esophageal strictures after AEN using indocyanine green (ICG) fluorescence imaging. In case 1, emergent esophagogastroduodenoscopy (EGD) in a 56-year-old man with coffee-ground emesis revealed black esophageal mucosa in the middle to lower esophagus, indicating AEN. Despite conservative therapy, an esophageal stricture developed after 2 weeks. Repeated endoscopic balloon dilation (EBD) did not resolve the stenosis; esophagectomy was thus performed approximately 6 months after AEN onset. We evaluated the blood flow to the esophagus using ICG fluorescence imaging to determine the proximal surgical resection line. The postoperative course was uneventful. In case 2, an 81-year-old woman with upper gastrointestinal bleeding with hematemesis and chest pain was diagnosed with AEN by EGD and was treated with conservative therapy. An esophageal stricture developed after 3 weeks, and repeated EBD was ineffective. Approximately 2 months after AEN onset, she underwent esophagectomy using ICG fluorescence imaging. The postoperative course was uneventful. Considering that AEN is a blood flow disorder, ICG fluorescence imaging is a useful technology to prevent surgical morbidity.

Size of the thoracic inlet predicts cervical anastomotic leak after retrosternal reconstruction after esophagectomy for esophageal cancer

BACKGROUND

Although an anastomotic leak after esophagectomy is one of the most common postoperative complications, it is not well understood whether specific anatomic factors of the different route of reconstruction can predispose to the development of anastomotic leak after esophagectomy. This study aimed to clarify whether various factors related to the size of the thoracic inlet are independent predictors of anastomotic leak after esophagectomy.

METHODS

We reviewed 248 patients who underwent esophagectomy with retrosternal reconstruction of the gastric conduit between January 2013 and March 2019. Various factors related to the size of the thoracic inlet were measured using computed tomography. Multivariate logistic regression was used to analyze the association between various measurements and anastomotic leak.

RESULTS

Anastomotic leak occurred in 38 patients (15.3%). On univariate analysis, the thickness of the sternum, the thickness of the clavicle, the sternum-trachea distance, the ratio of the sternum-trachea distance/sternum-vertebral body distance, sex, body mass index, and method of anastomosis were statistically significantly associated with anastomotic leak. On multivariate analysis, the ratio of the sternum-trachea distance/sternum-vertebral body distance and the method of anastomosis were the independent risk factors for anastomotic leak.

CONCLUSION

The ratio of the sternum-trachea distance/sternum-vertebral body distance is associated with cervical anastomotic leak after retrosternal gastric conduit reconstruction after esophagectomy. Measurement of the thoracic inlet space may contribute to preoperative planning, such as for the route of the conduit for reconstruction and anastomotic site.

Association of level of anastomosis and anastomotic leak after esophagectomy in anterior mediastinal reconstruction

AIM

The purpose of this study was to investigate modifiable predisposing factors associated with anastomotic leak in the anterior mediastinal (AM) reconstruction route.

METHODS

We reviewed the data on 154 patients who underwent esophagectomy and gastric tube reconstruction using the AM route between 2008 and 2016. The data included computed tomography (CT) scans with sagittal reconstruction of the thoracic section. The level of the esophagogastric anastomosis (LEA) and pretracheal distance (PTD) was measured from sagittal reconstructed CT images. Vascularization of the gastric tube was evaluated by postoperative endoscopy. Variables associated with anastomotic leak were determined using univariate and multivariate analyses.

RESULTS

Anastomotic leak developed in 13 patients (8%). The cut-off level at which the anastomosis was less likely to develop a leak, as determined by Chi-square tests, was 1.5 cm for LEA and 1.3 cm for PTD. On univariate analysis, the factors that were significantly associated with the risk of anastomotic leak included diabetes, hand-sewn anastomosis, the LEA ≥ 1.5 cm, and severe mucosal degeneration. On multivariate analysis, diabetes (OR 4.7, 95% CI 1.29-17.2), LEA ≥ 1.5 cm (OR 20.1, 95% CI 3.15-128), and severe mucosal degeneration (OR 7.2, 95% CI 1.42-36.8) were found to be statistically significant independent risk factors.

CONCLUSION

Use of the AM route to place the cervical anastomosis within 1.5 cm above the suprasternal notch might avoid excessive pressure on the gastric tube from the surrounding structures, resulting in a reduction in the risk of an anastomotic leak.

Risk Factors for Weight Loss 1 Year After Esophagectomy and Gastric Pull-up for Esophageal Cancer

BACKGROUND

Loss of body weight is regarded as a marker of malnutrition after esophagectomy. This study investigated changes in body weight and risk factors for weight loss after esophagectomy for esophageal cancer.

METHODS

We retrospectively reviewed records of 181 patients who underwent esophagectomy and gastric pull-up from 2012 to June 2016. Patients with operative mortality and recurrences were excluded. Percent change in body weight was defined as change in body weight (%) = (1-year body weight - preoperative body weight) × 100/preoperative body weight.

RESULTS

Mean age of patients was 62.98 ± 8.23 years with 164 men (90.6%). Mean preoperative body weight was 63.12 ± 9.42 kg, and body weight at 1 year was 56.04 ± 8.59 kg. Mean change in body weight was - 10.95 ± 7.50%, and 98 (54.1%) patients showed weight loss more than 10% compared to initial body weight. Univariable analysis showed that initial body weight, narrow gastric tube, thoracotomy, laparotomy, and postoperative vocal cord palsy (VCP) were related to more than 10% weight loss. Multivariable analysis showed that initial body weight (odds ratio [OR] = 1.041, p = 0.031) and postoperative VCP (OR = 2.772, p = 0.025) were adverse risk factors for weight loss 1 year after esophagectomy, whereas conduit type, route of reconstruction, postoperative complications, anastomotic complications, minimally invasive esophagectomy, and adjuvant therapy were not.

CONCLUSIONS

Initial body weight and postoperative VCP were related to weight loss. Patients with VCP need additional nutritional monitoring and support.

Pyloroplasty may reduce weight loss 1 year after esophagectomy

Weight loss after esophagectomy is common and is associated with unfavorable prognosis. However, the clinical features and surgical methods that influence postesophagectomy weight loss are not well characterized. This study aims to determine those features (especially the surgical methods) that may affect postoperative weight loss. We reviewed 221 esophageal cancer patients who had undergone esophagectomy at Kumamoto University Hospital (Kumamoto, Japan) between November 2012 and June 2015. Among these, we recruited 106 patients who had undergone transthoracic esophagectomy with gastric conduit reconstruction, had no cancer recurrence within 1 year, and no missing follow-up data. We tabulated the body weight changes and risk factors associated with weight loss exceeding 10% at 1-year postesophagectomy. The mean body weights at baseline and 1-year postsurgery were 60.3 kg (standard error (SE): 0.91) and 52.6 (SE: 0.91), respectively. One year postsurgery, the body weights had changed as follows: mean: -12.2%; median: -12.9%; standard deviation: 9.06; range: -36.1-18.56%; interquartile range: -10.5 to -14.0%. In the multivariate logistic regression analysis, the absence of pyloroplasty was the sole risk factor for more than 10% weight loss (OR: 3.22; 95% CI: 1.08-11.9; P = 0.036). Our data suggest that pyloroplasty with esophagectomy can overcome the post-surgical weight loss.

[Management of delayed complications after esophagectomy]

Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.

Impact of the route of reconstruction on post-operative morbidity and malnutrition after esophagectomy: a multicenter cohort study

BACKGROUND

Reconstruction after esophagectomy is mainly performed through the retrosternum (RS) or posterior mediastinum (PM). However, the best approach is not clear. This study aimed to assess the impact of the route of gastric conduit reconstruction, after esophagectomy for esophageal squamous cell carcinoma (ESCC), on post-operative outcomes.

METHODS

We analyzed 298 patients who underwent radical esophagectomy for ESCC at three high volume centers between 2008 and 2009. Among them, the RS was selected in 166 patients and PM in 118; while, the antethoracic route was used in 14 patients. Post-operative morbidity, mortality, and long-term outcome were compared.

RESULTS

There were no differences between patients of the two routes with respect to operative blood loss (RS: 753 ± 519, PM: 748 ± 414 g) and post-operative complications, including pulmonary problems (RS: 15 %, PM: 10.2 %) and anastomotic leakage (RS: 9.0 %, PM: 5.1 %); although, the operating time (RS: 566 ± 97, PM: 472 ± 79 min; p < 0.0001) was shorter in the PM group than the RS group. The percentage weight loss after surgery was significantly less in the PM group than the RS group at 1 year (8.6 vs. 11.1 %; p = 0.025); although, the percentage at discharge was not different between the groups (PM: 4.9 %, RS: 6.3 %; p = 0.072). Multivariate analysis identified pre-operative body weight and the reconstruction route as significant and independent factors associated with 1-year weight loss.

CONCLUSIONS

The results indicate gastric tube reconstruction through the posterior mediastinal route after esophagectomy may relieve post-operative 1-year malnutrition without increasing post-operative complications.

Surgical techniques to prevent delayed gastric emptying after esophagectomy with gastric interposition: a systematic review

Delayed gastric emptying is observed in 10% to 50% of patients after esophagectomy with gastric interposition. The effects of gastric interposition diameter, pyloric drainage, reconstructive route, and anastomotic site on postoperative gastric emptying were systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Most studies showed superior passage of the gastric tube compared with the whole stomach. Pyloric drainage is not significantly associated with the risk of developing delayed gastric emptying after esophagectomy. For reconstructive route and anastomotic site, available evidence on delayed gastric emptying is limited. Prospectively randomized studies with standardized outcome measurements are recommended.

Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis

BACKGROUND

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.

METHODS

Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.

RESULTS

No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61-13.9; P = 0.005).

CONCLUSIONS

A tailored surgical approach to the patient's physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.