Impact of anastomotic leak on outcomes after transhiatal esophagectomy

Anatomical and anastomotic viability indexes for stratifying the risk of anastomotic leakage in esophagectomy with retrosternal reconstruction

Background

Risk prediction of anastomotic leakage using anatomical and vascular factors has not been well established. This study aimed to assess the anatomical and vascular factors affecting the hemodynamics of the gastric conduit and develop a novel risk stratification system in patients undergoing esophagectomy with retrosternal reconstruction.

Methods

This retrospective cohort study analyzed 202 patients with esophageal cancer who underwent subtotal esophagectomy with gastric tube retrosternal reconstruction between January 2008 and December 2020. Risk factors for anastomotic leakage (AL), including the anatomical index (AI) and anastomotic viability index (AVI), were evaluated using a logistic regression model.

Results

According to the logistic regression model, the independent risk factors for AL were preoperative body mass index ≥23.6 kg/m2 (odds ratio [OR], 7.97; 95% confidence interval [CI], 2.44-26.00; P < 0.01), AI <1.4 (OR, 23.90; 95% CI, 5.02-114.00; P < 0.01), and AVI <0.62 (OR, 8.02; 95% CI, 2.57-25.00; P < 0.01). The patients were stratified into four AL risk groups using AI and AVI as follows: low-risk group (AI ≥1.4, AVI ≥0.62 [2/99, 2.0%]), intermediate low-risk group (AI ≥1.4, AVI <0.62 [2/29, 6.9%]), intermediate high-risk group (AI <1.4, AVI ≥0.62 [8/53, 15.1%]), and high-risk group (AI <1.4, AVI <0.62 [11/21, 52.4%]).

Conclusion

The combination of AI and AVI strongly predicted AL. Additionally, the use of AI and AVI enabled the stratification of the risk of AL in patients who underwent esophagectomy with retrosternal reconstruction.

Anastomotic Stricture After Minimally Invasive Esophagectomy

BACKGROUND

Despite improved outcomes, minimally invasive esophagectomy (MIE) continues to be associated with anastomotic strictures. Most resolve after a single dilation; however, some become refractory. Little is known about strictures after MIE in North America.

METHODS

We performed a single-institution retrospective review of MIEs from 2015 to 2019. Primary outcomes were the proportion of patients requiring anastomotic dilation and the dilation rate per year. Univariate analyses of patients undergoing dilation by various risk factors were performed with nonparametric tests, and multivariate analyses of the dilation rate were conducted using generalized linear models.

RESULTS

Of 391 included patients, 431 dilations were performed on 135 patients (34.5%, 3.2 dilations per patient who required at least 1 per patient). One complication occurred after dilation. Comorbidities, tumor histology, and tumor stage were not significantly associated with stricture. Three-field MIE was associated with a higher percentage of patients undergoing dilation (48.9% vs 27.1%, P < .001) and a higher rate of dilations (0.944 vs 0.441 dilations per year, P = .007) than 2-field MIE, and this association remained significant after controlling for covariates. When accounting for surgeon variability, this difference was no longer significant. Among patients with 1 or more dilations, those receiving dilation within 100 days of surgery needed more subsequent dilations (2.0 vs 0.6 dilations per year, P < .001).

CONCLUSIONS

After controlling for multiple variables, a 3-field MIE approach was associated with a higher rate of repeat dilations in patients undergoing MIE. A shorter interval between esophagectomy and initial dilation is strongly associated with the need for repeated dilations.

Comparison of robotic-assisted minimally invasive esophagectomy versus minimally invasive esophagectomy: A propensity-matched study from a single high-volume institution

OBJECTIVE

Robotic-assisted minimally invasive esophagectomy accounts for a growing proportion of esophagectomies, potentially due to improved technical capabilities simplifying the challenging aspects of standard minimally invasive esophagectomy. However, there is limited evidence directly comparing both operations. The objective is to evaluate the short-term and long-term outcomes of robotic-assisted minimally invasive esophagectomy in comparison with the minimally invasive esophagectomy approach for patients with esophageal cancer over a 7-year period at a high-volume center. The primary end points of this study were overall survival and disease-free survival. Secondary end points included operation-specific morbidity, lymph node yield, readmission status, and in-hospital, 30-day, and 90-day mortality.

METHODS

Patients who underwent robotic-assisted minimally invasive esophagectomy or standard minimally invasive esophagectomy over a 7-year period were identified from a prospectively maintained database. Inclusion criteria were patients with stage I to III disease, operations performed past the learning curve, and no evidence of scleroderma or cirrhosis. A 1:3 propensity match (robotic-assisted minimally invasive esophagectomy:minimally invasive esophagectomy) for multiple clinical covariates was performed to identify the final study cohort. Perioperative outcomes were compared between the 2 operations.

RESULTS

A total of 734 patients undergoing minimally invasive esophagectomy (n = 630) or robotic-assisted minimally invasive esophagectomy (n = 104) for esophageal cancer were identified. After exclusions and matching, a total cohort of 246 patients undergoing robotic-assisted minimally invasive esophagectomy (n = 65) or minimally invasive esophagectomy (n = 181) were identified. There was no difference in overall survival (P = .69) or disease-free survival (P = .70). There were no significant differences in rates of major morbidity: pneumonia (17% vs 17%, P = .34), chylothorax (8% vs 9%, P = .95), recurrent laryngeal nerve injury (0% vs 1.5%, P = 1), anastomotic leak (5% vs 4%, P = .49), intraoperative complications (9% vs 8%, P = .73), or complete resection rates (99% vs 96%, P = .68). There was no difference in in-hospital (P = .89), 30-day (P = .66) or 90-day mortality (P = .73) between both cohorts. The robotic-assisted minimally invasive esophagectomy cohort yielded a higher median lymph node harvest in comparison with the minimally invasive esophagectomy cohort (32 vs 29, P = .02).

CONCLUSIONS

Robotic-assisted minimally invasive esophagectomy may improve lymphadenectomy in patients undergoing esophagectomy for cancer. Minimally invasive esophagectomy and robotic-assisted minimally invasive esophagectomy are otherwise associated with similar mortality, morbidity, and perioperative outcomes. Further prospective study is required to investigate whether improved lymph node resection may translate to improved oncologic outcomes.

Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis

INTRODUCTION

A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level.

METHODS

This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data.

RESULTS

Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level.

CONCLUSION

The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.

Risk stratification of anastomotic stricture using early postoperative endoscopic and computed tomography findings in patients undergoing esophagectomy with cervical esophagogastric anastomosis for esophageal cancer

Anastomotic stricture (AS) is one of the major complications after esophagectomy for esophageal cancer. We have previously reported that severe mucosal degeneration (MD) of the anastomotic site was associated with the incidence of AS. Meanwhile, there are few reports to correlate anastomotic internal circumference (AIC) with computed tomography (CT) with the incidence of AS. Therefore, this study was conducted to clarify the correlation of early postoperative endoscopic and CT findings with the incidence of AS. We assessed 205 patients who underwent esophagectomy. We then divided them into the non-AS group (n = 164) and the AS group (n = 41) and compared their background data and intraoperative and postoperative outcomes. We also evaluated the risk factors for AS using logistic regression model. Multivariate analysis revealed small AIC (P = 0.003; OR = 4.400; 95% CI = 1.650-11.700) and severe MD (P < 0.001; OR = 7.200; 95% CI = 2.650-19.600) as the independent risk factors for AS development. We also stratified the patients into the following four groups according to the incidence of AS: low-risk (normal AIC and intact or mild MD, 6.2%), intermediate-risk (small AIC and intact or mild MD, 29.4%), high-risk (normal AIC and severe MD, 42.9%), and very high-risk (small AIC and severe MD, 61.1%). Early postoperative endoscopic and CT findings were useful in predicting the development of AS after esophagectomy.

Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak

Introduction

Morbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy.

Aim

To quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD).

Material and methods

We identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days.

Results

Eleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation.

Conclusions

Laparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.

Anastomotic Leaks following Esophagectomy for Esophageal and Gastroesophageal Junction Cancer: The Key Is the Multidisciplinary Management

Introduction

Anastomotic leakage after esophagectomy is associated with high mortality and impaired quality of life.

Aim

The objective of this work was to determine the effectiveness of management of esophageal anastomotic leakage (EAL) after esophagectomy for esophageal and gastroesophageal junction (GEJ) cancer.

Methods

Patients submitted to esophagectomy for esophageal and GEJ cancer at a tertiary oncology hospital between 2014 and 2019 (n = 119) were retrospectively reviewed and EAL risk factors and its management outcomes determined.

Results

Older age and nodal disease were identified as independent risk factors for anastomotic leak (adjusted OR 1.06, 95% CI 1.00-1.13, and adjusted OR 4.89, 95% CI 1.09-21.8). Patients with EAL spent more days in the intensive care unit (ICU; median 14 vs. 4 days) and had higher 30-day mortality (15 vs. 2%) and higher in-hospital mortality (35 vs. 4%). The first treatment option was surgical in 13 patients, endoscopic in 10, and conservative in 3. No significant differences were noticeable between these patients, but sepsis and large leakages were tendentially managed by surgery. At follow-up, 3 patients in the surgery group (23%) and 9 in the endoscopic group (90%) were discharged under an oral diet (p = 0.001). The in-hospital mortality rate was 38% in the surgical group, 33% in the conservative group, and 10% in endoscopic group (p = 0.132). In patients with EAL, the presence of septic shock at leak diagnosis was the only predictor of mortality (p = 0.004). ICU length-of-stay was non-significantly lower in the endoscopic therapy group (median 4 days, vs. 16 days in the surgical group, p = 0.212).

Conclusion

Risk factors for EAL may help change pre-procedural optimization. The results of this study suggest including an endoscopic approach for EAL.

Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series

BACKGROUND

One cause of anastomotic leakage after radical esophagectomy is blood flow insufficiency at the cervical anastomosis site. .

METHODS

Eighteen patients, who underwent radical esophagectomy with gastric tube reconstruction, were studied. The regional tissue oxygen saturation (rSO2) was measured at the tip (point pre 0) and 2, 4, and 6 cm on the distal side of the tip (point pre 1, pre 2, and pre 3, respectively) before the gastric tube was raised to the cervical site through the retrosternal route. After that, rSO2 was measured at the tip, 2 and 4 cm on the distal side of the tip (points post 0, post 1, and post 2), the actual anastomotic site (point AN), and the chest skin as an indicator of whole-body oxygenation. The relationship between rSO2 scores and the rate of anastomotic leakage was determined.

RESULTS

The mean rSO2 at pre 0, pre 1, pre 2, and pre 3 were 48.9%, 52.3%, 54.8%, and 56.9%, respectively (p < 0.05). The mean rSO2 at post 0, post 1, and post 2 were 47.8%, 50.5%, and 52.3%, respectively, and the rSO2 at point AN was 52.1%.Anastomotic leakage was found in 6 patients. The rSO2 at points pre 0, pre 1, and pre 2, post 0 and point AN were significantly lower in patients with anastomosis leakage than those without (p < 0.05).

CONCLUSION

Tissue oxygen saturation monitoring was a useful indicator of blood flow insufficiency in the gastric tube during radical esophagectomy.

Risk stratification of anastomotic leakage using eGFR and FIB-4 index in patients undergoing esophageal cancer surgery

PURPOSE

Renal insufficiency and liver cirrhosis are identified as independent risk factors for anastomotic leakage (AL) after esophagectomy. However, research evaluating the incidence of AL using quantitative data to measure renal function and liver fibrosis remain to be limited. Therefore, this study was conducted to evaluate postoperative AL after esophagectomy using estimated glomerular filtration rate (eGFR) and fibrosis-4 (FIB-4) index.

METHODS

In total, 184 patients who underwent esophagectomy were included in this study; then, they were divided into the non-AL group (n = 161) and AL group (n = 23), after which their background data and intraoperative and postoperative outcomes were compared. In addition, risk factors for AL were evaluated using a logistic regression model.

RESULTS

Preoperative body mass index of ≥21.5 kg/m², hemoglobin A1c level of ≥7.3%, FIB-4 index of ≥1.44, and eGFR of <59 ml/min/1.73 m² were found to be significantly frequent in the AL group compared with the non-AL group. Multivariate analysis revealed FIB-4 index of ≥1.44 (p = 0.013; OR, 3.780; 95% CI, 1.320-10.800) and eGFR of <59 ml/min/1.73 m² (p = 0.018; OR, 3.110; 95% CI, 1.220-8.020) as the independent risk factors for AL. In addition, we stratified the patients into three groups based on the incidence of AL as follows: low risk (5.5%, low FIB-4 index), intermediate risk (13.0%, high FIB-4 index and eGFR), and high risk (37.5%, high FIB-4 index and low eGFR).

CONCLUSION

Preoperative eGFR and FIB-4 index were found to be useful markers to predict AL after esophagectomy.

Predictors of Anastomotic Leak After Esophagectomy for Cancer: Not All Leaks Increase Mortality

BACKGROUND

The impact of preoperative chemotherapy/radiation on esophageal anastomotic leaks (ALs) and the correlation between AL severity and mortality risk have not been fully elucidated. We hypothesized that lower severity ALs have a similar risk of mortality compared to those without ALs, and preoperative chemotherapy/radiation increases AL risk.

METHODS

The 2016-2017 American College of Surgeons National Surgical Quality Improvement Program's procedure-targeted esophagectomy database was queried for patients undergoing any esophagectomy for cancer. A multivariable logistic regression analysis was performed for risk of ALs.

RESULTS

From 2042 patients, 280 (13.7%) had ALs. AL patients requiring intervention had increased mortality risk including those requiring reoperation, interventional procedure, and medical therapy (P < .05). AL patients requiring no intervention had similar mortality risk compared to patients without ALs (P > .05). Preoperative chemotherapy/radiation was not predictive of ALs (P > .05).

CONCLUSION

Preoperative chemotherapy/radiation does not contribute to risk for ALs after esophagectomy. There is a stepwise increased risk of 30-day mortality for ALs requiring increased invasiveness of treatment.

A nomogram illustrating the probability of anastomotic leakage following cervical esophagogastrostomy

BACKGROUND

Early diagnosis of anastomotic dehiscence following cervical esophagogastrostomy may become difficult. Estimation of an individual probability could help to establish preventive and diagnostic measures. The predictive impact of epidemiological, surgery-related data and laboratory parameters on the development of anastomotic dehiscence was investigated in the immediate perioperative period.

METHODS

Retrospective study in 412 patients with cervical esophagogastrostomy following esophagectomy. Epidemiological data, risk factors, underlying disease, pre-treatment- and surgery-related data, C-reactive protein and albumin levels pre-and post-operatively were evaluated. We applied univariable and multivariable logistic regression analysis and developed a nomogram for individual risk assessment.

RESULTS

There were 345 male, 67 female patients, mean aged 61.5 years; 284 had orthotopic, 128 retrosternal gastric pull-up; 331 patients had carcinoma, 81 non-malignant disease. Mean duration of operation was 184 min; 235 patients had manual, 113 mechanical and 64 semi-mechanical suturing; 76 patients (18.5%) developed anastomotic dehiscence clinically evident at mean 11.4 days after surgery. In univariable testing young age, retrosternal conduit transposition, manual suturing, high body mass index, high ASA and high postoperative levels of C-reactive protein were predictors for anastomotic leakage. These six parameters which had yielded a p < 0.1 in the univariable analysis, were entered into a multivariable analysis and a nomogram allowing the determination of the patient's individual risk was created.

CONCLUSION

By using the nomogram as a supportive measure in the perioperative management, the patient's individual probability of developing an anastomotic leak could be quantified which may help to take preventive measures improving the outcome.

A novel nomogram to predict the risk of anastomotic leakage in patients after oesophagectomy

Background

Anastomotic leakage is a dangerous postoperative complication of oesophageal surgery. The present study aimed to develop a simple and practical scoring system to predict the risk of anastomotic leakage after oesophageal resection.

Methods

A consecutive series of 330 patients who underwent oesophageal cancer surgery from January 2016 to January 2018 at the Shanghai Chest Hospital were included to develop a prediction model. Anastomotic leakage was evaluated using oesophagography, computed tomography, or flexible endoscopy. Least absolute shrinkage and selection operator regression based on a generalized linear model was used to select variables for the anastomotic leakage risk model while avoiding overfitting. Multivariable logistic regression analysis was applied to build forest plots and a prediction model. The concordance index or the area under the curve was used to judge the discrimination, and calibration plots verified the consistency. Internal validation of the model was conducted, and the clinical usefulness and threshold screening of the model were evaluated by decision curve analysis.

Results

The factors included in the predictive nomogram included Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia. The model displayed a discrimination performance with a concordance index of 0.690 (95% confidence interval: 0.620–0.760) and good calibration. A concordance index value of 0.664 was maintained during the internal validation. The calibration curve showed good agreement between the actual observations and the predicted results.

Conclusion

The present prediction model, which requires only seven variables and includes Sex, diabetes history, anastomotic type, reconstruction route, smoking history, CRP level and presence of cardiac arrhythmia, may be useful for predicting anastomotic leakage in patients after oesophagectomy.

Intraoperative near infrared fluorescence imaging for the assessment of the gastric conduit

Esophagectomy remains a mainstay of multi-modality therapy in the treatment of malignant disease, as well as selected benign conditions. Anastomotic and conduit complications remain the Achilles' heel of these operations, contributing to major morbidity and mortality. Adequate vascular perfusion of the gastric conduit is vital to avoid these complications, with surgeon observational assessment the mainstay of determining the vascular health of the gastric conduit. Rates of morbidity remain significant, and technologies aimed at better assessing relative tissue perfusion and ischemia are increasingly under investigation and utilized. One such technique is the use of intraoperative near-infrared fluorescence imaging to directly assess these parameters. The application of this technique has shown promise in perfusion assessment during esophagectomy, and potential reduction in anastomotic complications.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

International Survey on the Management of Anastomotic Leakage After Esophageal Resection

BACKGROUND

Anastomotic leakage is one of the most severe complications following esophageal surgery, leading to significant morbidity, prolonged hospital stay, considerable costs, decreased quality of life, and increased mortality. Management of anastomotic leakage is complicated and has currently not been standardized. The objective of this research is to gain insight into the different opinions on anastomotic leakage management among upper gastrointestinal surgeons and verify the need for diagnostic and treatment guidelines.

METHODS

Surgeons with interest in esophageal surgery were invited to participate in an international online questionnaire. The survey consisted of questions pertaining to the surgeons' experience, operation techniques, management routine, and opinion on future international guidelines on the treatment of anastomotic leakage.

RESULTS

Of the 331 invited surgeons, 40% participated in the survey. Among the 129 responders, 90.7% use laboratory diagnostics and 62.8% use imaging or endoscopy postoperatively on a routine basis to detect anastomotic leakage. In case of suspected anastomotic leakage, the most chosen diagnostic imaging modalities were computed tomography scan (35.7%) or dynamic swallow investigation (33.3%). Independent from the clinical manifestations, participants of this survey treat patients very differently. More than 70% of the responders agreed that there is a need for diagnostic and therapeutic international guidelines on anastomotic leakage management.

CONCLUSIONS

This survey shows that there is no standardized guideline for diagnostic workup or management of anastomotic leakage and that there is a need for an international guideline regarding the optimal management of anastomotic leakage.

Generalized cardiovascular disease on a preoperative CT scan is predictive for anastomotic leakage after esophagectomy

BACKGROUND

Recent studies demonstrated that calcification of arteries supplying the gastric tube is associated with anastomotic leakage after esophagectomy. However, it remains unclear whether this association only derives from local flow limitations, or generalized vascular disease as well. The purpose of this study was to determine whether calcification throughout the entire cardiovascular system is associated with anastomotic leakage.

METHODS

Consecutive patients who underwent an esophagectomy with gastric tube reconstruction and cervical anastomosis for esophageal cancer were analyzed. Diagnostic CT images were scored for the presence of arterial calcification on 10 locations based on a visual grading system. The association with anastomotic leakage was studied using logistic regression analysis.

RESULTS

A total of 406 patients were included for analysis of whom 104 developed anastomotic leakage (25.6%). Presence of calcification in the coronary arteries (minor calcification: 36.5% leakage; no calcification: 18.1%, p = .001), supra-aortic arteries (minor calcification: 30.9% leakage; major calcification: 35.3%; no calcification: 16.1%, p = .007 and p < .001, respectively) and thoracic aorta (major calcification: 33.3% leakage; no calcification: 19.4%, p = .011) was associated with leakage. In multivariable analysis, minor calcification of the coronary arteries (OR 2.29, 95% CI: 1.28-4.12, p = .005) and calcification of the supra-aortic arteries (OR 2.48, 95% CI: 1.30-4.74, p = .006 for minor calcification and OR 2.72, 95% CI: 1.49-4.99, p = .001 for major calcification) remained independently associated with leakage.

CONCLUSIONS

Calcification of the coronary and supra-aortic arteries on routine CT are predictive of cervical anastomotic leakage after esophagectomy. These results suggest that generalized cardiovascular disease is a strong indicator for the risk of leakage.

Near infrared perfusion assessment of gastric conduit during minimally invasive Ivor Lewis esophagectomy

INTRODUCTION

Anastomotic leak and conduit necrosis are devastating complications following Ivor Lewis esophagectomy. Near infrared imaging (NIR) using IndoCyanine Green allows for real time tissue perfusion assessment which may reduce anastomotic leak during minimally invasive Ivor Lewis esophagectomy (MIE).

METHODS

Forty consecutive MIE were performed by a single surgeon at a tertiary referral center. The first 20 were assessed for gastric conduit perfusion by clinical criteria (Group 1). The second 20 were also assessed using NIR laparoscopic system (Group 2).

RESULTS

Comparing Group 1 to Group 2, no significant differences were found in overall complication rate, readmission or reoperation rate. NIR resulted in resection of the non perfused proximal portion of the conduit in 30% (6/20). Two patients in group 2 group developed anastomotic leak (2/20) compared to 0 in Group 1 (p = 0.49). Graft necrosis led to one mortality in Group 1, while there were 0 mortalities in Group 2. (p = 1.0).

CONCLUSION

Although NIR plays a role in assessment of tissue perfusion, in our study its use did not result in reduction of anastomotic leak rate.

Experiences in the management of anastomotic leakages and analysis of the factors affecting leakage healing in patients with esophagogastric junction cancer

BACKGROUND

It was reported in the literatures that the incidence of anastomotic leakage in patients with esophagogastric junction cancer decreased due to application of staplers and closure devices as well as gastric conduit technique in recent years, however, it increased slightly at our center since widely using the above devices and gastric conduit techniques from 2009. The objective of this study was to summarize our experiences in the management of anastomotic leakages and analyze the factors affecting leakage healing in the patients with esophagogastric junction cancer after surgical resection in recent 6 years.

METHODS

All patients who received surgical resections for esophagogastric junction cancer and diagnosed anastomotic leak at our center between January 2009 and December 2014 were retrospectively analyzed, we also enrolled the patients who had a longer hospital stay (>30 days) as they may develop anastomotic leak. The binary logistic regression in SPSS 16.0 was applied to analyze the factors that may affect leakage healing.

RESULTS

Of the 1,815 surgically treated esophagogastric junction cancer patients, 91 cases were diagnosed anastomotic leakage postoperatively. The patients were divided into two groups based on the median leakage healing time (40 days) in this series: fast healing group (37 cases) and slowly healing group (54 cases). All factors that may affect the leakage healing were put into analysis by using binary logistic regression. The results of the analysis showed that leakage size (OR =1.073, P=0.004), thoracic drainage (OR =12.937, P=0.037) and smoking index ≤400 (OR =1.001, P=0.04) significantly affected the healing time, while drinking history (P=0.177), duration of fever after anastomotic leak developed (P=0.084), and hypoproteinemia after leak (P=0.169) also apparently but not significantly affect the healing time.

CONCLUSIONS

Though many factors may affect leakage healing in the esophagogastric junction carcinoma patients, leakage size, thoracic drainage and smoking index (≤400) are the most important factors affecting the leakage healing. Placement of a chest tube beside the anastomosis area during operation for early identification and control of an anastomotic leak to minimize contamination of the mediastinum is the most important way to promote leakage healing. A chest tube placing into the purulent cavities after the patients experienced leaks is also important for the cure of leakage. More attention should be paid perioperatively to the patients who had a smoking index (≥400) and the patients who suffered fever or hypoproteinemia.

Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment

BACKGROUND

Esophagojejunal anastomosis leakage after total gastrectomy (TG) for esophagogastric junction (EGJ) adenocarcinoma (ADC) constitutes one of the most serious and sometimes life-threatening complications. Management remains controversial and still challenging.

METHODS

A total of 198 patients operated for type I and II EGJ ADC were reviewed. Diagnosis of leakage was based on a combination of clinical and radiological findings. It was classified including objective endoscopic and clinical parameters requiring different type of treatment.

RESULTS

Anastomotic leakage was diagnosed in 14 patients (7%). Two cases recovered with conservative therapy. Six cases underwent endoscopy with clips placement in 2 and partially covered self-expandable metal stent placement in 4. Other two cases underwent reoperation with reconstruction of anastomosis and primary repair respectively. In the last four cases emergency surgery with total esophagectomy and diversion was required. Mortality occurred only in 3 of these patients and overall treatment was successful in 11 patients (78.5%).

CONCLUSIONS

No consensus has been reached on the best method of esophagojejunal anastomosis leakage management and the rate of failure remains significant. Different options of treatment are available but early detection and multidisciplinary approaches are the keys to obtain successful results irrespective of the employed strategy.

Cancer Recurrence After Esophagectomy: Impact of Postoperative Infection in Propensity-Matched Cohorts

BACKGROUND

Postoperative infection increases cancer recurrence and worsens survival in colorectal cancer, but the relationship for esophagogastric adenocarcinoma after esophagectomy is not well defined. We aimed to determine whether recurrence and survival after minimally invasive esophagectomy for esophagogastric adenocarcinoma were influenced by postoperative infection using propensity-matched analysis.

METHODS

We abstracted data for 810 patients (1997-2010) and defined exposure as at least 1 in-hospital or 30-day infectious complication (n = 206 [25%]). Using 29 pretreatment/intraoperative variables, patients were propensity-score matched (caliper = 0.05). Time to cancer recurrence and survival (Kaplan-Meier curves and the Breslow test), and associated factors (Cox regression with shared frailty) were assessed.

RESULTS

After propensity matching (n = 167 pairs), median bias across propensity-score variables was reduced from 12.9% (p < 0.001) to 4.4% (p = 1.000). Postoperative infection was not associated with rate (n = 60 versus 63; McNemar p = 0.736) or time to recurrence in those in whom disease recurred (median, 10.7 versus 11.1 months; Wilcoxon signed-rank p = 0.455) but was associated with shorter overall survival (n = 124 versus 102 deaths; median, 26 versus 41 months; Breslow p = 0.002). After adjusting for age, body mass index, neoadjuvant therapy, sex, comorbidity score, positive resection margins, pathologic stage, R0 resection, and recurrence, postoperative infection was associated with a 44% greater hazard for death (hazard ratio, 1.44; 95% confidence interval, 1.10-1.89).

CONCLUSIONS

In patients with esophagogastric adenocarcinoma, infections after esophagectomy were not associated with an increased rate or earlier time to recurrence when baseline characteristics associated with infection risk were balanced using propensity-score matching. Despite this, overall survival was shorter in patients with infectious complications. After adjusting for other important survival predictors, infections after esophagectomy continued to be independently associated with worse survival.

Ischemic Conditioning of the Stomach in the Prevention of Esophagogastric Anastomotic Leakage After Esophagectomy

Esophagectomy with esophagogastric anastomosis is a major procedure, and its most feared complication is anastomotic leakage. Ischemic conditioning of the stomach is a method used with the aim of reducing the risk of leakage. It consists of partial gastric devascularization through embolization or laparoscopy followed by esophagectomy and anastomosis at a second stage, thus providing the time for the gastric conduit to adapt to the acute ischemia at the time of its formation. This review analyzes the information from all currently available experimental and clinical studies with the purpose of assessing the current role of the technique and to provide future recommendations.

Partial esophagogastrostomy with esophagogastric anastomosis below the aortic arch in cardiac carcinoma: characteristics and treatment of postoperative anastomotic leakage

BACKGROUND

Anastomotic leakage is a severe and common complication for surgeries of cardiac cancer. Here we explore the clinical features, diagnosis, and treatment strategies of anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis.

METHODS

From January 2009 to December 2013, 1,196 patients with cardiac carcinoma underwent esophagectomy and esophagogastric anastomosis in Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences. Of them, 25 patients developed symptomatic anastomotic leakage. Their clinical data were retrospectively reviewed.

RESULTS

Among these 25 patients with anastomotic leakage, three died after active treatment and fifteen healed with thoracic drainage time 18-115 days. The left seven patients who did not heal until discharge developed chronic infection sinus of anastomotic leakage. Without infection symptoms, they were discharged 30-100 days after surgery with nasoenteral tube and thoracic drainage.

CONCLUSIONS

Anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis can be classified into five subtypes: occult type, left thoracic type, right thoracic type, mediastinal type, and mixd type. Subtyping of anastomotic leakage is useful and convenient for diagnosis and treatment.

Surgical treatments for esophageal cancers

The following, from the 12th OESO World Conference: Cancers of the Esophagus, includes commentaries on the role of the nurse in preparation of esophageal resection (ER); the management of patients who develop high-grade dysplasia after having undergone Nissen fundoplication; the trajectory of care for the patient with esophageal cancer; the influence of the site of tumor in the choice of treatment; the best location for esophagogastrostomy; management of chylous leak after esophagectomy; the optimal approach to manage thoracic esophageal leak after esophagectomy; the choice for operational approach in surgery of cardioesophageal crossing; the advantages of robot esophagectomy; the place of open esophagectomy; the advantages of esophagectomy compared to definitive chemoradiotherapy; the pathologist report in the resected specimen; the best way to manage patients with unsuspected positive microscopic margin after ER; enhanced recovery after surgery for ER: expedited care protocols; and long-term quality of life in patients following esophagectomy.

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.

Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review

BACKGROUND

Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak.

DATA SOURCES

We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy.

CONCLUSIONS

Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.

Managing complications II: conduit failure and conduit airway fistulas

Conduit failure and conduit airway fistula are rare complications after esophagectomy, however they can be catastrophic resulting in high mortality. Survivors can expect a prolonged hospital course with multiple interventions and an extended period of time prior to being able to resume oral nutrition. High index of suspicion can aid in early diagnosis. Conduit failure usually requires a period of proximal esophageal diversion and staged reconstruction. Conduit airway fistulas may be amenable to endoscopic repair but this has a high failure rate and many patients will require surgical repair with closure of the fistula and interposition of vascularized tissue to minimize recurrence.

Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database

BACKGROUND

Anastomotic leak is an important cause of morbidity and mortality after esophagectomy. Few studies have targeted risk factors for the development of leak after esophagectomy. The purpose of this study is to use The Society of Thoracic Surgeons Database to identify variables associated with leak after esophagectomy.

METHODS

The Society of Thoracic Surgeons Database was queried for patients treated with esophagectomy for esophageal cancer between 2001 and 2011. Univariate and multivariate analysis of variables associated with an increased risk anastomotic leak was performed.

RESULTS

There were 7,595 esophagectomies, with 804 (10.6%) leaks. Thirty-day mortality and length of stay were higher for patients with anastomotic leak. Mortality in patients requiring surgical management was 11.6% (38 of 327) compared with 4.4% (20 of 458) in medically managed leaks (p < 0.001). The leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomoses, 12.3% versus 9.3%, respectively (p = 0.006). There was no difference in leak-associated mortality between the two approaches. Factors associated with leak on univariate analysis include obesity, heart failure, coronary disease, vascular disease, hypertension, steroids, diabetes, renal insufficiency, tobacco use, procedure duration greater than 5 hours, and type of procedure (p < 0.05). Multivariable regression analysis associated heart failure, hypertension, renal insufficiency, and type of procedure as risk factors for the development of leak (p < 0.05).

CONCLUSIONS

Anastomotic leak after esophagectomy is an important cause of postoperative mortality and increased length of stay. We have identified important risk factors for the development of esophageal anastomotic leak after esophagectomy. Further studies aimed at risk reduction are warranted.

Comparison of clinical outcomes after conservative and surgical treatment of isolated anastomotic leaks after esophagectomy for esophageal cancer

The clinical course and outcome of isolated anastomotic leaks (IALs) after esophagectomy are significantly different from those of necrotic leaks. The purpose of this study was to investigate the clinical features, diagnosis, treatment, and long-term outcome in patients with IALs after esophagectomy with reconstruction for esophageal cancer. A total of 663 patients underwent esophagectomy with esophageal reconstruction because of esophageal cancer between 2000 and 2010 at the Seoul Asan Medical Center. IALs occurred in 23 patients (3.5%). All patients with IAL were male, with a median age of 61 years. Patients with IAL were divided into three groups based on their clinical course. group A comprised patients who had definite clinical symptoms and/or signs indicating mediastinal contamination or leak before routine contrast esophagography was performed. Groups B and C comprised patients who had no definite clinical symptoms and/or signs of leaks before the routine contrast examination. Furthermore, group B contained those patients who resumed oral intake because no leak was found in the routine contrast examination and was diagnosed some days after resuming oral intake. Group C contained those patients who kept fasting because the leak was found in the routine contrast examination. The median follow-up period was 30 months. The mean time to closure of the IAL was 70.1 ± 96.0 days (range 4-364). There was a 72.7% overall closure rate within 60 days. By univariate analysis, the mean time to closure of the IAL was found to be significantly longer for group A patients or in cases where the patients had an uncontained leak, leukocytosis, or empyema. However, there was no statistically significant differences in age, neoadjuvant treatment, site of anastomosis (cervical vs. thoracic), fever, or treatment of the leak. By multivariate analysis, group A was found to be an independent predictive factor for the time to closure of the IAL. Repeat contrast studies revealed no anastomotic leaks in 18 patients and the formation of contained fistula in four cases (excluding one patient who died in hospital). The four patients with a contained fistula showed no clinical symptoms or signs, and tolerated resumed oral intake. IALs were resolved in most cases with low leak-related mortality, and resolution of the leaks occurred within 2 months in the majority of patients.

The Role of Esophagogastric Anastomotic Technique in DecreasingBenign Stricture Formation in the Surgery of Esophageal Carcinoma

INTRODUCTION

Postoperative stenosis and dysphagia after esophageal carcinoma resection is the major problem. The aim of this study is to compare two types cervical esophagogastric anastomosis in reduction of stricture formation in esophageal cancer surgery.

METHODS

The subjects of this study were 223 patients undergoing esophageal carcinoma resection during 1998 to 2007. Twenty two patients were excluded from the study because of recurrent malignancy of anastomosis, mortality and losing in follow up period. Two hundred and one patients remained by the end of study were classified into two groups: 98 patients were treated by routinely transverse hand-sewn cervical esophagogastric anastomosis (group 1); and 103 patients were treated by the proposed oblique hand-sewn esophagogastric anastomotic technique (group 2). All the operations were with high abdominal and left cervical incisions (Transhiatal esophagectomy). All patients of both groups were followed up at least 6-month for detection of anastomotic strictures.

RESULTS

Postoperative dysphagia occurred in 20 patients of group 1 versus 5 patients of group 2. In working up by rigid esophagoscopy, two patients of group 2 and four patients of group 1 had not true strictures. Anastomotic strictures occurred in 16 cases of group 1, versus 3 cases of group 2. Statistical comparative analysis results of two groups about stricture formation were significant (3% versus 16% P= 0.003).

CONCLUSION

The oblique hand-sewn esophagogastric anastomostic techniques reduce markedly the rate of stricture formation after esophagectomy.

[Cervical anastomotic leak after esophagectomy: diagnosis and management]

INTRODUCTION

Cervical anastomotic leaks after esophagectomy are still a frequent and severe complication that needs an early diagnosis and an appropriate treatment. The aim of this study was to describe our experience with the management of this complication.

PATIENTS AND METHODS

Retrospective study (2003-2011) of a consecutive series of 77 patients with a cervical esophagogastric anastomosis, 18 of them (23.3%) presenting a leak. Fistulae were classified into 4 groups depending on clinical presentation, radiology (esophagogram or CT), surgical findings (in case of re-operation) and, since 2010, endoscopic examination. Type I leaks were an asymptomatic or radiographic leak, type II had local signs limited to the neck, type III was associated with respiratory symptoms due to a pleural or mediastinal collection, and type IV with a systemic disorder secondary to gastric necrosis.

RESULTS

Four patients (22.2%) were classified as type I, 8 (44.4%) as type II, 3 (16.6%) as type III, and 3 (16.6%) as type IV. Eight patients were managed conservatively; in 9 a self-expanding stent was used, 5 required a thoracotomy, and one of them (type IV) died. Leaks were related to a higher associated morbidity (61 versus 30%; P=.019) and a longer hospital stay (median of 28.5 vs 14 days; P=.009).

CONCLUSIONS

Almost one quarter of cervical esophagogastric anastomoses present some kind of anastomotic leak. Although most of them can be treated conservatively or by endoscopy, they are associated with an increase in morbidity and mortality.

Tracheal compression by the gastric tube in esophageal cancer with ankylosing spondylitis and an analysis of the mediastinal condition in 84 cases of esophagectomy: report a case

Pneumonia, recurrent nerve injury and anastomotic leakage are common complications occurring after esophagectomy. However, there have so far been few reports on tracheal compression by the gastric tube. The patient was a 66-year-old female with a history of ankylosing spondylitis and esophageal superficial squamous carcinoma treated with endoscopic mucosal resection. The new lesion was located just next to the last treated lesion. Therefore, it was difficult to treat this lesion endoscopically because of severe stenosis and scarring due to the previous treatment. Transhiatal esophagectomy was therefore performed. However, severe tracheal obstruction occurred following extubation after the surgery due to compression caused by the gastric tube. This case was successfully treated with a mediastinal pleural incision through a right thoracotomy. The distance between the sternum and the vertebra in this case was narrower than normal, thereby inducing this rare condition.

Management of esophageal perforation and anastomotic leak by transluminal drainage

INTRODUCTION

The management of esophageal perforations and leaks remains a challenge. Although there are broad management principles, each situation may require a different surgical approach. The aim of this report was to describe the management of these esophageal crises by transluminal drainage via a transabdominal approach.

METHODS

Between 2005 and 2009, patients with anastomotic or gastric staple line leak (n = 4) or esophageal perforation (n = 2) underwent transabdominal surgery and transluminal drainage. This simple technique has, to the best of our knowledge, not been previously reported.

RESULTS

All six patients survived. The median intensive care unit and hospital stays were 12 days (range 0-32) and 63 days (range 32-99), respectively. At a median follow-up time of 25 months (range 15-60), five of the six patients remain alive and well. One patient with node positive esophageal carcinoma has died from relapsed disease.

CONCLUSIONS

Transabdominal transluminal drainage should be added to the list of potential techniques that can be employed in management of esophageal leaks and perforations. It is a valuable adjunct to the armamentarium of the esophageal surgeon for dealing with these challenging situations.

Esophageal preservation in five male patients after endoscopic inner-layer circumferential resection in the setting of superficial cancer: a regenerative medicine approach with a biologic scaffold

As a result of injury caused by chronic gastroesophageal reflux, Barrett's esophagus with high-grade dysplasia and esophageal adenocarcinoma are rapidly increasing problems in the United States. The current standard of care involves esophagectomy, a procedure associated with a high morbidity, a negative impact on long term quality of life, and a mortality rate of 1-6 percent. An entirely endoscopic technique for circumferential, long segment en bloc removal of the mucosa and submucosa with subsequent placement of a biologic scaffold material that promotes a constructive remodeling response and minimizes stricture is described herein. The results of this approach are reported for five patients with 4-24-month follow-up. Restoration of normal mature, K4+/K14+, squamous epithelium, and return to a normal diet without significant dysphagia is reported for all patients. Two of five patients show a small focus of recurrent Barrett's esophagus at the gastroesophageal junction, but the entire length and circumference of the reconstituted esophageal mucosa remains free of disease. This experience provides evidence that a regenerative medicine approach may, for the first time, enable aggressive endoscopic resection of early stage neoplasia without the need for esophagectomy and its associated complications.