Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Incidence and treatment of anastomotic leakage after esophagectomy in German acute care hospitals: a retrospective cohort study

BACKGROUND

Anastomotic leakage (AL) is a major concern following esophagectomy due to the associated morbidity and mortality. The impact of hospital volume on postoperative outcomes after esophagectomy has previously been reported. The aim of this study was to analyze the current trends in postoperative anastomotic leakage and associated failure-to-rescue after esophagectomy in relation to hospital volume in German acute care hospitals using real-world data from the German Diagnosis-Related Groups (G-DRG) database.

MATERIALS AND METHODS

A retrospective secondary data analysis of the G-DRG database was performed for all in-hospital cases of patients undergoing esophagectomy from 2013 to 2021. AL and in-house mortality rates were assessed in relation to hospital case volume and endoscopic treatment modalities.

RESULTS

The study included 32 335 cases. The mean reported AL rate was 17.1% with a mean failure-to-rescue rate of 18.9%. AL rates did not differ between hospitals with an annual case-volume ≤ 25 procedures/year vs. >25 procedures/year (16.8% vs. 17.6%, OR 1.06, P = 0.07). However, in high-volume centers (> 25 procedures/year), in-hospital mortality for cases with AL (failure-to-rescue) was lower compared to medium-volume (10-25 cases/year) and low-volume (1-9 cases/year) centers (14.2% vs. 21.5% vs. 25.1%). The use of endoscopic vacuum therapy (EVT) increased over time, reaching 58.1% of AL cases in 2021 compared to 14.2% in 2013, while the use of self-expanding metal stents (SEMS) decreased from 37.0% in 2013 to 9.3% in 2021.

CONCLUSIONS

AL rates after esophagectomy remain high. In-house mortality is significantly lower in high-volume hospitals highlighting the importance to consider improvements in centralization of procedures. Further efforts are needed to reduce AL rates and improve outcomes after esophagectomy.

Impact and Measurement of Mechanical Tension in Bowel Anastomosis: A Scoping Review of the Current Literature

INTRODUCTION

Creating a "tension-free anastomosis" is a fundamental principle in safe bowel surgery. This review aims to summarize the current literature regarding the measurement and impact of tension on bowel anastomoses.

METHODS

This scoping review was conducted using a systematic literature search in the PubMed, SCOPUS, and EMBASE databases. Data were synthesized in tables and summarized paragraphically, with studies assessed using the Newcastle-Ottawa scale.

RESULTS

Out of the 350 studies identified in the initial literature review, 25 were included in this study. Several studies indicated that anastomotic leak and tension are strongly associated, with the presence of tension making leaks up to 10 times more likely. However, no objective and clinically available methods exist to measure tension on bowel anastomosis in humans. Freedom from tension has traditionally been measured via surrogate measures of adequate bowel mobilization and subjective assessment by operating surgeons. Animal and cadaveric studies have been the frontier for objective measurement of wall tension. These studies use tensiometers to measure tension and automated machines or pulley and ratcheting systems to increase tension at specified intervals. However, these methods are universally destructive due to their design of measuring maximal tensile load and are not readily adaptable to the operating room.

CONCLUSIONS

The current literature does not address the objective measurement of bowel tension in live human subjects. Given the importance of tension, developing an objective, safe, intraoperative method to measure bowel wall tension would be a valuable surgical tool.

Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis

One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.

Configuration of anastomotic doughnuts of stapled anastomoses in upper gastrointestinal surgery is associated with anastomotic leakage

OBJECTIVE

The aim of this study was to evaluate whether the configuration of anastomotic doughnuts from upper gastrointestinal surgeries was associated with anastomotic leakage (AL).

BACKGROUND

AL is a severe postoperative complication after upper gastrointestinal cancer surgeries. AL is associated with an increase in overall and cancer-related morbidity and mortality in patients with esophageal and gastric cancer. New intraoperative biomarkers are needed to predict the risk of AL to implement early preventive measures.

MATERIALS AND METHODS

Anastomotic doughnuts from 102 patients undergoing surgery for esophageal or gastric cancer using circular staplers were examined. The minimal and maximal height and width of the anastomotic doughnuts were measured and correlated with the postoperative AL rate.

RESULTS

The AL rate in our study collective was 15,7 %. The minimal width (Wmin) of the oral and aboral anastomotic doughnuts was significantly lower in patients with AL compared to patients without AL (p = 0.002 and p = 0.041 respectively). The Wmin of the esophageal anastomotic doughnut was an independent risk factor for AL in the multivariable analysis (p = 0.034). Negative predictive values for the measurements of anastomotic doughnuts (Wmin) with regard to the risk of AL were higher than for the commonly used postoperative biomarker C-reactive protein.

CONCLUSION

Minimal anastomotic doughnut width was statistically significantly associated with AL. Thus, not only the evaluation of the completeness of the anastomotic doughnuts but also intraoperative measurements could be used to predict the risk of AL to initiate early preventive measures to prevent the development of AL and/or reduce AL-associated morbidity.

Risk Factors for Anastomotic Leakage Following Stoma Closure: A Retrospective Study in Tertiary Hospitals in Yemen

Introduction Anastomotic leakage (AL) following stoma closure is a significant complication that can lead to increased morbidity and mortality. Identifying risk factors associated with AL is essential for improving surgical outcomes, especially in resource-limited settings like Yemen. Methods We conducted this retrospective study at Al-Thawra Modern General Hospital and the Republican Teaching Hospital Authority in Sana'a, Yemen, between August 2020 and April 2024. The analysis included 50 patients aged 18-65 years who underwent stoma closure. We analyzed patient data, including demographics, comorbidities, surgical technique, and outcomes, to identify risk factors for AL. Results The incidence of AL was six (12%) out of 50 cases. Significant risk factors included smoking, with AL present in four (67%) smokers and two (33%) non-smokers (p = 0.045). Patients with diverticulitis were more likely to require a stoma in two (33%) cases, and perforated small bowel with peritonitis in one (17%) case, compared to trauma cases in two (7%) and colorectal cancer cases at one (11%) (p = 0.038). AL was most common in colorectal anastomosis, observed in four (67%) cases, compared to other sites in two (5%) cases (p = 0.001). The surgical technique impacted the incidence of AL, with hand-sewn anastomosis showing a higher rate in four (67%) cases compared to stapled anastomosis in two (33%) cases (p = 0.036). No significant associations were found for age, sex, American Society of Anesthesiologists (ASA) classification, or surgeon experience. Conclusion This study identifies key risk factors for AL following stoma closure in the context of hospitals in Yemen, emphasizing the need for targeted preoperative and intraoperative strategies, such as smoking cessation and careful surgical technique selection, to reduce the risk of AL. Future studies should focus on larger cohorts and the impact of enhanced perioperative care protocols in low-resource settings.

Early Postoperative Serum Lactate Levels Predict Anastomotic Leakage After Minimally Invasive Esophagectomy

BACKGROUND

Anastomotic leakage (AL) is a major complication after esophagectomy for esophageal cancer, and the significance of elevated postoperative lactate levels in the occurrence of AL is unclear.

PATIENTS AND METHODS

We evaluated 583 patients who underwent minimally invasive esophagectomy for esophageal cancer. Serum lactate levels were measured immediately after esophagectomy and in the morning on postoperative days (POD) 1, 2, 3, and 4. We also evaluated the factors associated with AL using multivariable logistic regression analysis.

RESULTS

AL occurred in 8.9% (n = 52) of patients, and the median onset of AL was POD10 (interquartile range: 7-13). The lactate levels immediately after esophagectomy through POD3 were significantly higher in patients with AL than in those without AL. A further multivariable logistic regression analysis showed that elevated lactate level on POD2 was an independent predictor of the occurrence of AL (odds ratio 11.9; 95% confidence interval: 4.04-17.3; P < 0.001). Severe AL was significantly more frequent in the higher lactate patients (P < 0.001). Furthermore, in patients with AL with higher lactate, the onset tended to be earlier (P = 0.054), and the treatment duration of AL was significantly longer compared with those with lower lactate (P = 0.037).

CONCLUSIONS

AL was significantly associated with elevated postoperative lactate levels. Elevated lactate levels on POD2 could be significant predictor of AL development after esophagectomy.

Enhancing Preoperative Outcome Prediction: A Comparative Retrospective Case-Control Study on Machine Learning versus the International Esodata Study Group Risk Model for Predicting 90-Day Mortality in Oncologic Esophagectomy

Risk prediction prior to oncologic esophagectomy is crucial for assisting surgeons and patients in their joint informed decision making. Recently, a new risk prediction model for 90-day mortality after esophagectomy using the International Esodata Study Group (IESG) database was proposed, allowing for the preoperative assignment of patients into different risk categories. However, given the non-linear dependencies between patient- and tumor-related risk factors contributing to cumulative surgical risk, machine learning (ML) may evolve as a novel and more integrated approach for mortality prediction. We evaluated the IESG risk model and compared its performance to ML models. Multiple classifiers were trained and validated on 552 patients from two independent centers undergoing oncologic esophagectomies. The discrimination performance of each model was assessed utilizing the area under the receiver operating characteristics curve (AUROC), the area under the precision-recall curve (AUPRC), and the Matthews correlation coefficient (MCC). The 90-day mortality rate was 5.8%. We found that IESG categorization allowed for adequate group-based risk prediction. However, ML models provided better discrimination performance, reaching superior AUROCs (0.64 [0.63-0.65] vs. 0.44 [0.32-0.56]), AUPRCs (0.25 [0.24-0.27] vs. 0.11 [0.05-0.21]), and MCCs (0.27 ([0.25-0.28] vs. 0.15 [0.03-0.27]). Conclusively, ML shows promising potential to identify patients at risk prior to surgery, surpassing conventional statistics. Still, larger datasets are needed to achieve higher discrimination performances for large-scale clinical implementation in the future.

Oesophageal fluoroscopy in adults-when and why?

Oesophageal fluoroscopy is a radiological procedure that uses dynamic recording of the swallowing process to evaluate morphology and function simultaneously, a characteristic not found in other clinical tests. It enables a comprehensive evaluation of the entire upper gastrointestinal tract, from the oropharynx to oesophagogastric bolus transport. The number of fluoroscopies of the oesophagus and the oropharynx has increased in recent decades, while the overall use of gastrointestinal fluoroscopic examinations has declined. Radiologists performing fluoroscopies need a good understanding of the appropriate clinical questions and the methodological advantages and limitations to adjust the examination to the patient's symptoms and clinical situation. This review provides an overview of the indications for oesophageal fluoroscopy and the various pathologies it can identify, ranging from motility disorders to structural abnormalities and assessment in the pre- and postoperative care. The strengths and weaknesses of this modality and its future role within different clinical scenarios in the adult population are discussed. We conclude that oesophageal fluoroscopy remains a valuable tool in diagnostic radiology for the evaluation of oesophageal disorders.

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.

Oblique conformal anastomosis decreased the risks of cervical anastomotic leakage after totally minimally invasive esophagectomy

OBJECTIVE

To investigate the effectiveness of the original oblique conformal anastomosis presented in this research in reducing the incidence of cervical anastomotic leak after performing totally minimally invasive esophagectomy (TMIE).

METHODS

The esophagus and stomach of 27 fresh pigs, termed the esophagogastric model, were used to simulate human esophagogastric organs for this study's in vitro experimental objectives. Nine esophagogastric models of similar weight were divided into three groups. Esophagogastrostomy with circular-stapled end-to-side anastomosis was performed. A tension gauge was used to pull the anastomosis, and the tension at which anastomotic leakage occurred was recorded. Furthermore, a retrospective assessment of 539 patients who underwent TMIE was conducted to analyze the influencing factors of cervical anastomotic leakage.

RESULTS

Experiments on the esophagogastric models showed a higher fracture strength of oblique conformal anastomosis than that of conventional anastomosis (F2,18 = 40.86, P < 0.05), which was associated with a lower incidence of cervical anastomotic leakage (X2 = 9.0260, P = 0.0027). Retrospective analysis of 539 esophageal cancer patients who underwent TMIE showed that in contrast to conventional anastomosis, oblique conformal anastomosis was an independent protective factor against cervical anastomotic leakage (P = 0.0462, OR = 0.5872, 95% CI = 0.3497-0.9993).

CONCLUSION

Oblique conformation anastomosis was stronger and involved a more prominent reduced risk of cervical anastomotic leakage than conventional anastomosis after TMIE.

Role of indocyanine green fluorescence imaging for evaluating blood supply in the gastric conduit via the substernal route after McKeown minimally invasive esophagectomy

BACKGROUND

Anastomotic leakage (AL) is a determining factor of morbidity and mortality after esophagectomy. Adequate perfusion of the gastric conduit is crucial for AL prevention. This study aimed to determine whether intraoperative angiography using indocyanine green (ICG) fluorescence improves the incidence of AL after McKeown minimally invasive esophagectomy (MIE) with gastric conduit via the substernal route (SR).

METHODS

This retrospective cohort study included 120 patients who underwent MIE with gastric conduit via SR for esophageal cancer between February 2019 and April 2023. Of 120 patients, 88 experienced intraoperative angiography using ICG (ICG group), and 32 patients experienced intraoperative angiography without ICG (no-ICG group). Baseline characteristics and operative outcomes, including AL as the main concern, were compared between the 2 groups. In addition, the outcomes among patients in the ICG group with different levels of fluorescence intensity were compared.

RESULTS

The ICG and no-ICG groups were comparable in baseline characteristics and operative outcomes. There was no significant difference between the 2 groups regarding the rate of AL (31.0% vs 37.5%; P = .505), median dates of AL (9 vs 9 days; P = .810), and severity of AL (88.9%, 11.11%, and 0.0% vs 66.7%, 16.7%, and 16.7% for grades I, II, and III, respectively; P = .074). Patients in the ICG group with lower intensity of ICG had higher rates of leakage (24.6%, 39.3%, and 100% in levels I, II, and III of ICG intensity, respectively; P = .04).

CONCLUSION

The use of ICG did not seem to reduce the rate of AL. However, abnormal intensity of ICG fluorescence was associated with a higher rate of AL, which implies a predictive potential.

Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis

BACKGROUND

Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported.

PURPOSE

Compare short-term outcomes among different GIC techniques.

MATERIALS AND METHODS

Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference.

RESULTS

Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments.

CONCLUSIONS

Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy

BACKGROUND

After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy.

MATERIAL AND METHODS

A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22).

RESULTS

Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg.

CONCLUSIONS

EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.

Effect of gastric ischemic conditioning prior to esophagectomy: systematic review and meta-analysis

Ischemia at the anastomotic site is thought to be a protagonist in the development of anastomosis-related complications while different strategies to overcome this problem have been reported. Gastric ischemic conditioning (GIC) prior to esophagectomy has been described with this intent. Evaluate the effect of GIC on anastomotic complications after esophagectomy. Scopus, Web of Science, MEDLINE, and PubMed were investigated up to March 31st, 2023. We considered articles that appraised short-term outcomes after GIC vs. no GIC in patients undergoing esophagectomy. Anastomotic leak (AL), anastomotic stricture (AS), and gastric conduit necrosis (GCN) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Fourteen studies (1760 patients) were included. Of those, 732 (41.6%) underwent GIC, while 1028 (58.4%) underwent one-step esophagectomy. Compared with no GIC, GIC was related to a reduced RR for AL (R RR = 0.63; 95% CI 0.47-0.86; p < 0.01) and AS (RR = 0.51; 95% CI 0.29-0.91; p = 0.02), whereas no differences were found for GCN (RR = 0.56; 95% CI 0.19-1.61; p = 0.28). Postoperative pneumonia (RR = 1.09; p = 0.99), overall complications (RR = 0.87; p = 0.19), operative time (SMD - 0.58; p = 0.07), hospital stay (SMD 0.66; p = 0.09), and 30-day mortality (RR = 0.69; p = 0.22) were comparable. GIC prior to esophagectomy seems associated with a reduced risk for AL and AS. Further studies are necessary to identify the subset of patients who can benefit from this procedure, the optimal technique, and the timing of GIC prior to esophagectomy.

Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy

BACKGROUND

Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC).

METHODS

Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA).

RESULTS

One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01).

CONCLUSION

Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.

Comparison of long-term quality of life outcomes between endoscopic vacuum therapy and other treatments for upper gastrointestinal leaks

BACKGROUND

While endoscopic vacuum assisted closure (EVAC) therapy is a validated treatment for gastrointestinal leaks, its impact on long-term quality of life (QoL) is uncertain. The purpose of this study was to evaluate the impact of successful EVAC management on long-term QoL outcomes.

METHODS

An institutional review board approved prospectively maintained database was retrospectively reviewed to identify patients undergoing treatment for gastrointestinal leaks between June 2012 and July 2022. The Short-Form 36 (SF-36) survey was used to assess QoL. Patients were contacted by telephone and sent the survey electronically. QoL outcomes between patients who underwent successful EVAC therapy and those who required conventional treatment (CT) were analyzed and compared.

RESULTS

A total of 44 patients (17 EVAC; 27 CT) completed the survey and were included in our analysis. All included patients had foregut leaks with sleeve gastrectomy being the most common sentinel operation (n = 20). The mean time from the sentinel operation was 3.8 years and 4.8 years for the EVAC and CT groups, respectively. When evaluating long-term QoL, the EVAC group scored higher in all QoL domains when compared to the CT group with physical functioning (87.3 vs 69.3, p = 0.04), role limitations due to physical health (84.1 vs 45.7, p = 0.02), energy/fatigue (60.0 vs 40.9, p = 0.04), and social functioning (86.2 vs 64.1, p = 0.04) reaching statistical significance. Overall, patients who achieved organ preservation via successful EVAC therapy scored higher in all domains with role limitations due to physical health (p = 0.04) being statistically significant. In a multivariable regression analysis, increased age and a history of prior abdominal surgery at the time of the sentinel operation were patient characteristics that negatively impacted QoL outcomes.

CONCLUSION

Patients with gastrointestinal leaks successfully managed by EVAC therapy have better long-term QoL outcomes when compared to patients undergoing other treatments.

Anastomotic Leakages after Surgery for Gastroesophageal Cancer: A Systematic Review and Meta-Analysis on Endoscopic versus Surgical Management

INTRODUCTION

With the increase of esophageal and gastric cancer, surgery will be more often performed. Anastomotic leakage (AL) is one of the most feared postoperative complications of gastroesophageal surgery. It can be managed by conservative, endoscopic (such as endoscopic vacuum therapy and stenting), or surgical methods, but optimal treatment remains controversial. The aim of our meta-analysis was to compare (a) endoscopic and surgical interventions and (b) different endoscopic treatments for AL following gastroesophageal cancer surgery.

METHODS

Systematic review and meta-analysis, with search in three online databases for studies evaluating surgical and endoscopic treatments for AL following gastroesophageal cancer surgery.

RESULTS

A total of 32 studies comprising 1,080 patients were included. Compared with surgical intervention, endoscopic treatment presented similar clinical success, hospital length of stay, and intensive care unit length of stay, but lower in-hospital mortality (6.4% [95% CI: 3.8-9.6%] vs. 35.8% [95% CI: 23.9-48.5%]. Endoscopic vacuum therapy was associated with a lower rate of complications (OR 0.348 [95% CI: 0.127-0.954]), shorter ICU length of stay (mean difference -14.77 days [95% CI: -26.57 to -2.98]), and time until AL resolution (17.6 days [95% CI: 14.1-21.2] vs. 39.4 days [95% CI: 27.0-51.8]) when compared with stenting, but there were no significant differences in terms of clinical success, mortality, reinterventions, or hospital length of stay.

CONCLUSIONS

Endoscopic treatment, in particular endoscopic vacuum therapy, seems safer and more effective when compared with surgery. However, more robust comparative studies are needed, especially for clarifying which is the best treatment in specific situations (according to patient and leak characteristics).

Implementation of minimally invasive Ivor Lewis esophagectomy: learning curve of a single high-volume center

Open esophagectomy is considered to be the main surgical procedure in the world for esophageal cancer treatment. Implementing a new surgical technique is associated with learning curve morbidity. The objective of this study is to determine the learning curve based on anastomotic leakage (AL) after implementing minimally invasive Ivor Lewis esophagectomy (MI-ILE) in January 2015. All 257 patients who underwent MI-ILE in a single high-volume center between January 2015 and December 2020 were retrospectively included in this study. The learning curve was evaluated using the standard CUSUM analysis with an expected AL rate of 11%. Secondary outcome parameters were postoperative complications, textbook outcome, and lymph node yield divided by the year of operation. Hierarchical binary logistic regression analysis was used to check for potential confounding variables. The CUSUM analysis showed a learning curve of 179 cases. The mean AL rate decreased from 33.3% in 2015 to 9.5% in 2020 (P = 0.007). There was an increase in the mean lymph node yield from 21 in 2018 to 28 in 2019 (P < 0.001) and textbook outcome from 37.3% in 2015 to 66.7% in 2020 (P = 0.005). A newly implemented MI-ILE has a learning curve of 179 patients based on a reference AL rate of 11% using the CUSUM method. Whether future generation surgeons will show similar learning curve numbers, implicating continuous development of different introduction programs of new techniques, will have to be the focus of future research.

The Impact of Acute Systemic Inflammation Secondary to Oesophagectomy and Anastomotic Leak on Computed Tomography Body Composition Analyses

This study aimed to longitudinally assess CT body composition analyses in patients who experienced anastomotic leak post-oesophagectomy. Consecutive patients, between 1 January 2012 and 1 January 2022 were identified from a prospectively maintained database. Changes in computed tomography (CT) body composition at the third lumbar vertebral level (remote from the site of complication) were assessed across four time points where available: staging, pre-operative/post-neoadjuvant treatment, post-leak, and late follow-up. A total of 20 patients (median 65 years, 90% male) were included, with a total of 66 computed tomography (CT) scans analysed. Of these, 16 underwent neoadjuvant chemo(radio)therapy prior to oesophagectomy. Skeletal muscle index (SMI) was significantly reduced following neoadjuvant treatment (p < 0.001). Following the inflammatory response associated with surgery and anastomotic leak, a decrease in SMI (mean difference: -4.23 cm²/m², p < 0.001) was noted. Estimates of intramuscular and subcutaneous adipose tissue quantity conversely increased (both p < 0.001). Skeletal muscle density fell (mean difference: -5.42 HU, p = 0.049) while visceral and subcutaneous fat density were higher following anastomotic leak. Thus, all tissues trended towards the radiodensity of water. Although tissue radiodensity and subcutaneous fat area normalised on late follow-up scans, skeletal muscle index remained below pre-treatment levels.

Routine decompression by nasogastric tube after oesophagectomy for oesophageal cancer

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To evaluate the effects of routine nasogastric decompression as compared to no nasogastric decompression after oesophagectomy. In the case of routine decompression, we will also aim to assess the effects of early versus late removal of the nasogastric tube.

Dry or wet? Fluid therapy in upper gastrointestinal surgery patients

A correct perioperative fluid administration represents one of the most important items proposed by the Enhanced Recovery After Surgery Society. Upper gastrointestinal (UGI) surgery patients undergoing major oncological procedures are often elderly and frail. Should we prefer a wet or a dry patient? Both conditions should probably be avoided in this surgical setting. We present a narrative review on perioperative fluid administration in UGI patients undergoing major surgery, also analyzing the role of Goal Directed therapy.

Risk factors and consequences of post-esophagectomy delirium: a systematic review and meta-analysis

Post-operative delirium (POD) is a state of mental and neurocognitive impairment characterized by disorientation and fluctuating levels of consciousness. POD in the context of esophageal surgery may herald serious and potentially life-threatening post-operative complications, or conversely be a symptom of severe underlying pathophysiologic disturbances. The aim of the present systematic review and meta-analysis is to explore risk factors associated with the development of POD and assess its impact on post-operative outcomes. A systematic literature search of the MedLine, Web of Science, Embase and Cochrane CENTRAL databases and the clinicaltrials.gov registry was undertaken. A random-effects model was used for data synthesis with pooled outcomes expressed as Odds Ratios (OR), or standardized mean differences (WMD) with corresponding 95% Confidence Intervals. Seven studies incorporating 2449 patients (556 with POD and 1893 without POD) were identified. Patients experiencing POD were older (WMD 0.29 ± 0.13 years, P < 0.001), with higher Charlson's Comorbidity Index (CCI; WMD 0.31 ± 0.23, P = 0.007) and were significantly more likely to be smokers (OR 1.38, 95% CI 1.07-1.77, P = 0.01). Additionally, POD was associated with blood transfusions (OR 2.08, 95% CI 1.56-2.77, P < 0.001), and a significantly increased likelihood to develop anastomotic leak (OR 2.03, 95% CI 1.25-3.29, P = 0.004). Finally, POD was associated with increased mortality (OR 2.71, 95% CI 1.24-5.93, P = 0.01) and longer hospital stay (WMD 0.4 ± 0.24, P = 0.001). These findings highlight the clinical relevance and possible economic impact of POD after esophagectomy for malignant disease and emphasize the need of developing effective preventive strategies.

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.

C-reactive protein and drain amylase: their utility in ruling out anastomotic leakage after minimally invasive Ivor-Lewis esophagectomy

INTRODUCTION

Anastomotic leakage (AL) is one of the most feared complications after esophagectomy for esophageal cancer. We investigated the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL.

METHODS

This is a retrospective study of 193 patients who underwent a minimally invasive Ivor-Lewis procedure between January 2017 and October 2021. Mean CRP and median drain amylase levels between patients with and without AL were compared during the first five postoperative days (POD). ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP.

RESULTS

In 30 of the 193 patients (16%), AL was diagnosed with a median time to diagnosis of 9 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 59, 110 and 106 mg/L had a high sensitivity of 93%, 90% and 90% on POD 3, 4 and 5. No difference in median drain amylase levels was observed.

CONCLUSIONS

CRP levels with a cut-off point of 110 mg/L on POD 4 do not improve earlier detection of AL, but have a high sensitivity for excluding AL. The value of drain amylase in the first 5 days after surgery is limited.

The Application of Two-Stage Operation for High-Risk Patients with Oesophageal Cancer Following Gastrectomy

BACKGROUND

Oesophageal replacement by colonic interposition remains a major challenge due to its complexity and high incidence of complications; here we applied the two-stage operation strategy to oesophageal replacement by colonic interposition in high-risk oesophageal cancer patients following gastrectomy.

METHODS

We performed a retrospective analysis on the data of patients with a history of distal gastrectomy who underwent one-stage and two-stage oesophageal replacement by colonic interposition from February 2012 to February 2020, and explored the relationship between the staging strategy and postoperative outcomes.

RESULTS

The clinical data of 93 patients were collected and analysed. There were no significant differences in the patients' characteristics between the two groups (all p > 0.05), except for comorbidities and Charlson Comorbidity Index (all p < 0.05). The Clavien-Dindo score between the two groups was also not significantly different (p > 0.05). The logistic regression models revealed that patients who had received preoperative therapy had a higher Clavien-Dindo score (p < 0.05), but the stage strategy did not (p > 0.05).

CONCLUSIONS

The two-stage operation is feasible in high-risk patients who need to undergo colonic interposition for oesophageal replacement. At the same time, it lowers the technical threshold of colonic interposition for oesophageal replacement, increasing this surgical technique's acceptability.

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.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference − 11.57 days; 95% CI [− 17.45 to − 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

Predictability of Endoscopic Success for Foregut and Bariatric Leak in an Experienced Quaternary Center

BACKGROUND

Leaks of the esophagus and stomach are difficult to manage and associated with significant morbidity and mortality. Endoscopic therapy can manage these leaks without surgical intervention. Our goal is to create a scoring tool to aid in predicting the success of endoscopic therapy in these patients.

STUDY DESIGN

An IRB-approved prospectively maintained database was retrospectively reviewed for all patients treated for gastrointestinal leaks from July 2013 to January 2021, including patients treated for esophageal and stomach leaks. Endpoints include success of leak closure for patients treated solely by endoscopic therapy (ET) compared with surgical therapy as failed endoscopic therapy (FET). A multivariable logistic regression model was fitted to identify independent risk factors for predicting success of endoscopic therapy, and a scoring calculator was developed.

RESULTS

There were 80 patients (60 females) with a mean age of 50 years. The ET group included 59 patients (74%), whereas the FET group included 21 patients (26%). Patient demographics, comorbidities, surgical history, and timing of leak diagnosis were used. Multivariable analysis resulted in 4 variables associated with higher probability of successful endoscopic leak management without need for additional surgery. These included increased age, lower BMI, lack of previous bariatric surgery, and quicker identification of the leak. Consequently, a scoring nomogram was developed with values from 0 to 22.

CONCLUSION

Our data show the development of a scoring calculator capable of quantifying the likelihood of success treating foregut and bariatric leaks with endoscopic therapies. This can be used clinically to guide treatment decisions.

Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer

Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.

Serum albumin at resection predicts in-hospital death, while serum lactate and aPTT on the first postoperative day anticipate anastomotic leakage after Ivor-Lewis-esophagectomy

Background

Anastomotic leakage (AL) is a major complication after esophagectomy, potentiating morbidity and mortality. There are several patient risk factors associated with AL, but high-fidelity postoperative predictors are still under debate. The aim was to identify novel reliable predictors for AL after esophagectomy.

Methods

A high-volume single-center database study, including 138 patients receiving Ivor-Lewis-esophagectomy between 2017 and 2019, was performed. Serum levels of albumin, aPTT, and lactate before and after surgery were extracted to assess their impact on AL and in-hospital mortality.

Results

High serum lactate on postoperative day 1 (POD1) could be shown to predict AL after esophagectomy [AL vs. no AL: 1.2 (0.38) vs. 1.0 (0.37); p < 0.001]. Accordingly, also differences of serum lactate level between end (POD0-2) and start of surgery (POD0-1) (p < 0.001) as well as between POD1 and POD0-1 (p < 0.001) were associated with AL. Accordingly, logistic regression identified serum lactate on POD 1 as an independent predictor of AL [HR: 4.37 (95% CI: 1.28–14.86); p = 0.018]. Further, low serum albumin on POD0 [2.6 (0.53) vs. 3.1 (0.56); p = 0.001] and high serum lactate on POD 0–1 [1.1 (0.29) vs. 0.9 (0.30); p = 0.043] were associated with in-hospital death. Strikingly, logistic-regression (HR: 0.111; p = 0.008) and cox-regression analysis (HR: 0.118; p = 0.003) showed low serum albumin as an independently predictor for in-hospital death after esophagectomy.

Conclusions

This study identified high serum lactate as an independent predictor of AL and low serum albumin as a high-fidelity predictor of in-hospital death after esophagectomy. These parameters can facilitate improved postoperative treatment leading to better short-term as well as long-term outcomes.

Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database

OBJECTIVE

This study aims to verify the utility of international online datasets to benchmark and monitor treatment and outcomes in major oncologic procedures.

BACKGROUND

The Esophageal Complication Consensus Group (ECCG) has standardized the reporting of complications after esophagectomy within the web-based Esodata.org database. This study will utilize the Esodata dataset to update contemporary outcomes and to monitor trends in practice in an era of rapid technical change.

METHODS

This observational study, based on a prospectively developed specific database, updates esophagectomy outcomes collected between 2015 and 2018. Evolution in patient and operative demographics, treatment, complications, and quality outcome measures were compared between patients undergoing surgery in 2015 to 2016 and 2017 to 2018.

RESULTS

Between 2015 and 2018, 6022 esophagectomies from 39 centers were entered into Esodata. Most patients were male (78.3%) with median age 63. Patients having minimally invasive esophagectomy constituted 3177 (52.8%), a chest anastomosis 3838 (63.7%), neoadjuvant chemoradiotherapy 2834 (48.7%), and R0 resections 5441 (93.5%). For quality measures, 30- and 90-day mortality was 2.0% and 4.5%, readmissions 9.7%, transfusions 12%, escalation in care 22.1%, and discharge home 89.4%. Trends in quality measures between 2015 and 2016 (2407 patients) and 2017 and 2018 (3318 patients) demonstrated significant (P < 0.05) improvements in readmissions 11.1% to 8.5%, blood transfusions 14.3% to 10.2%, and escalation in care from 24.5% to 20% A significantly (P < 0.05) reduced incidence in pneumonia (15.3%-12.8%) and renal failure (1.0%-0.4%) was observed. Anastomotic leak rates increased from 11.7% to 13.1%, whereas leaks requiring surgery decreased 3.3% and 3.0%, respectively.

CONCLUSIONS

The Esodata database provides a valuable resource for assessing contemporary international outcomes. This study highlights an increased application of minimally invasive approaches, a high percentage of complications, improvements in pneumonia and key quality metrics, but with anastomotic leak rates still >10%.

Stem cell therapy applied for digestive anastomosis: Current state and future perspectives

BACKGROUND

Digestive tract resections are usually followed by an anastomosis. Anastomotic leakage, normally due to failed healing, is the most feared complication in digestive surgery because it is associated with high morbidity and mortality. Despite technical and technological advances and focused research, its rates have remained almost unchanged the last decades. In the last two decades, stem cells (SCs) have been shown to enhance healing in animal and human studies; hence, SCs have emerged since 2008 as an alternative to improve anastomoses outcomes.

AIM

To summarise the published knowledge of SC utilisation as a preventative tool for hollow digestive viscera anastomotic or suture leaks.

METHODS

PubMed, Science Direct, Scopus and Cochrane searches were performed using the key words "anastomosis", "colorectal/colonic anastomoses", "anastomotic leak", "stem cells", "progenitor cells", "cellular therapy" and "cell therapy" in order to identify relevant articles published in English and Spanish during the years of 2000 to 2021. Studies employing SCs, performing digestive anastomoses in hollow viscera or digestive perforation sutures and monitoring healing were finally included. Reference lists from the selected articles were reviewed to identify additional pertinent articles.Given the great variability in the study designs, anastomotic models, interventions (SCs, doses and vehicles) and outcome measures, performing a reliable meta-analysis was considered impossible, so we present the studies, their results and limitations.

RESULTS

Eighteen preclinical studies and three review papers were identified; no clinical studies have been published and there are no registered clinical trials. Experimental studies, mainly in rat and porcine models and occasionally in very adverse conditions such as ischaemia or colitis, have been demonstrated SCs as safe and have shown some encouraging morphological, functional and even clinical results. Mesenchymal SCs are mostly employed, and delivery routes are mainly local injections and cell sheets followed by biosutures (sutures coated by SCs) or purely topical. As potential weaknesses, animal models need to be improved to make them more comparable and equivalent to clinical practice, and the SC isolation processes need to be standardised. There is notable heterogeneity in the studies, making them difficult to compare. Further investigations are needed to establish the indications, the administration system, potential adjuvants, the final efficacy and to confirm safety and exclude definitively oncological concerns.

CONCLUSION

The future role of SC therapy to induce healing processes in digestive anastomoses/sutures still needs to be determined and seems to be currently far from clinical use.

The use of mesenchymal stem cells in animal models for gastrointestinal anastomotic leak: A systematic review

AIM

Anastomotic leak is the most feared complication of gastrointestinal surgery. Mesenchymal stem cell technology is used clinically to promote wound healing; however, the safety and efficacy of this technology on anastomotic healing has yet to be defined. The aim of this study was to investigate whether mesenchymal stem cells confer any benefit when applied to animal models for gastrointestinal anastomotic leak, identify the methodology and how efficacy is assessed.

METHODS

The MEDLINE, EMBASE, WebofScience and Cochrane Library databases were interrogated between 1 January1947 to 1 May 2020. All studies where mesenchymal stem cells were applied to laboratory animal leak models to demonstrate a healing effect were considered. All experimental and histological outcomes were examined. Compliance to ARRIVE and current International Consensus was assessed.

RESULTS

A total of 1205 studies were screened. Twelve studies reported on 438 gastrointestinal anastomoses in four species using 11 models; seven in the colon. No studies utilised a model with a known leak rate. Significant variance was observed in histological outcomes with efficacy demonstrated in five out of 12 studies. One study demonstrated a benefit in leak rate. Colorectal studies had a greater median ARRIVE compliance, 60.8% (IQR 63.2-64.5) compared to noncolorectal 45.4% (IQR 43.8-49.0).

CONCLUSIONS

Mesenchymal stem cell delivery to an animal anastomosis is safe and feasible. Use may confer benefit but findings are currently limited to surrogate histological outcomes. There is consistency in outcome measures reported but variance in how this is assessed. Poor compliance to ARRIVE but good compliance to current international consensus in leak models of the colon was observed.

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.

Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy

Recently, it has been shown that directly starting oral feeding (DOF) from postoperative day one (POD1) after a totally minimally invasive Ivor-Lewis esophagectomy (MIE-IL) can further improve postoperative outcomes. However, in some patients, tube feeding by a preemptively placed jejunostomy is necessary. This single-center cohort study investigated risk factors associated with failure of DOF in patients that underwent a MIE-IL between October 2015 and April 2021. A total of 165 patients underwent a MIE-IL, in which DOF was implemented in the enhanced recovery after surgery program. Of these, 70.3% (n = 116) successfully followed the nutritional protocol. In patients in which tube feeding was needed (29.7%; n = 49), female sex (compared to male) (OR 3.5 (95% CI 1.5-8.1)) and higher ASA scores (III + IV versus II) (OR 2.2 (95% CI 1.0-4.8)) were independently associated with failure of DOF for any cause. In case of failure, this was either due to a postoperative complication (n = 31, 18.8%) or insufficient caloric intake on POD5 (n = 18, 10.9%). In the subgroup of patients with complications, higher ASA scores (OR 2.8 (95% CI 1.2-6.8)) and histological subtypes (squamous-cell carcinoma versus adenocarcinoma and undifferentiated) (OR 5.2 (95% CI 1.8-15.1)) were identified as independent risk factors. In the subgroup of patients with insufficient caloric intake, female sex was identified as a risk factor (OR 5.8 (95% CI 2.0-16.8)). Jejunostomy-related complications occurred in 17 patients (10.3%). In patients with preoperative risk factors, preemptively placing a jejunostomy may be considered to ensure that nutritional goals are met.

Risk prediction nomogram for major morbidity related to primary resection for esophageal squamous cancer

BACKGROUND AND OBJECTIVES

Postoperative major complications after esophageal cancer resection vary and may significantly impact long-term outcomes. This study aimed to build an individualized nomogram to predict post-esophagectomy major morbidity.

METHODS

This retrospective study included 599 consecutive patients treated at a single center between January 2017 and April 2019. Of them, 420 and 179 were assigned to the model development and validation cohorts, respectively. Major morbidity predictors were identified using multiple logistic regression. Model discrimination and calibration were evaluated by validation. Regarding clinical usefulness, we examined the net benefit using decision curve analysis.

RESULTS

The mean age was 64 years; 79% of the patients were male. The most common comorbidities were hypertension, diabetes mellitus, and stroke history. The 30-day postoperative major morbidity rate was 24%. Multivariate logistic regression analysis showed that age, smoking history, coronary heart disease, dysphagia, body mass index, operation time, and tumor size were independent risk factors for surgery-associated major morbidity. Areas under the receiver-operating characteristic curves of the development and validation groups were 0.775 (95% confidence interval, 0.721-0.829) and 0.792 (95% confidence interval, 0.709-0.874), respectively. In the validation cohort, the nomogram showed good calibration. Decision curve analysis demonstrated that the prediction nomogram was clinically useful.

CONCLUSION

Morbidity models and nomograms incorporating clinical and surgical data can be used to predict operative risk for esophagectomy and provide appropriate resources for the postoperative management of high-risk patients.

Prediction Model of Anastomotic Leakage Among Esophageal Cancer Patients After Receiving an Esophagectomy: Machine Learning Approach

Background

Anastomotic leakage (AL) is one of the severe postoperative adverse events (5%-30%), and it is related to increased medical costs in cancer patients who undergo esophagectomies. Machine learning (ML) methods show good performance at predicting risk for AL. However, AL risk prediction based on ML models among the Chinese population is unavailable.

Objective

This study uses ML techniques to develop and validate a risk prediction model to screen patients with emerging AL risk factors.

Methods

Analyses were performed using medical records from 710 patients who underwent esophagectomies at the National Clinical Research Center for Cancer between January 2010 and May 2015. We randomly split (9:1) the data set into a training data set of 639 patients and a testing data set of 71 patients using a computer algorithm. We assessed multiple classification tools to create a multivariate risk prediction model. Our ML algorithms contained decision tree, random forest, naive Bayes, and logistic regression with least absolute shrinkage and selection operator. The optimal AL prediction model was selected based on model evaluation metrics.

Results

The final risk panel included 36 independent risk features. Of those, 10 features were significantly identified by the logistic model, including aortic calcification (OR 2.77, 95% CI 1.32-5.81), celiac trunk calcification (OR 2.79, 95% CI 1.20-6.48), forced expiratory volume 1% (OR 0.51, 95% CI 0.30-0.89); TLco (OR 0.56, 95% CI 0.27-1.18), peripheral vascular disease (OR 4.97, 95% CI 1.44-17.07), laparoscope (OR 3.92, 95% CI 1.23-12.51), postoperative length of hospital stay (OR 1.17, 95% CI 1.13-1.21), vascular permeability activity (OR 0.46, 95% CI 0.14-1.48), and fat liquefaction of incisions (OR 4.36, 95% CI 1.86-10.21). Logistic regression with least absolute shrinkage and selection operator offered the highest prediction quality with an area under the receiver operator characteristic of 72% in the training data set. The testing model also achieved similar high performance.

Conclusions

Our model offered a prediction of AL with high accuracy, assisting in AL prevention and treatment. A personalized ML prediction model with a purely data-driven selection of features is feasible and effective in predicting AL in patients who underwent esophagectomy.

Esophagectomy for Esophageal Cancer Performed During the Early Phase of the COVID-19 Pandemic

Delay in time to esophagectomy for esophageal cancer has been shown to have worse peri-operative and long-term outcomes. We hypothesized that COVID-19 would cause a delay to surgery, with worse perioperative outcomes, compared to standard operations. All esophagectomies for esophageal cancer at a single institution from March-June 2020, COVID-19 group, and from 2019 were reviewed and peri-operative details were compared between groups. Ninety-six esophagectomies were performed in 2019 vs 37 during March-June 2020 (COVID-19 group). No differences between groups were found for preoperative comorbidities. Wait-time to surgery from final neoadjuvant treatment was similar, median 50 days in 2019 vs 53 days during COVID-19 p = 0.601. There was no increased upstaging, from clinical stage to pathologic stage, 9.4% in 2019 vs 7.5% in COVID-19 p = 0.841. Fewer overall complications occurred during COVID-19 vs 2019, 43.2% vs 64.6% p = 0.031, but complications were similar by specific grades. Readmission rates were not statistically different during COVID-19 than 2019, 16.2% vs 10.4% p = 0.38. No peri-operative mortalities or COVID-19 infections were seen in the COVID-19 group. Esophagectomy for esophageal cancer was not associated with worse outcomes during the COVID-19 pandemic with minimal risk of infection when careful COVID-19 guidelines are followed. Prioritization is recommended to ensure no delays to surgery.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Impact of Smoking Status on Perioperative Morbidity, Mortality, and Long-Term Survival Following Transthoracic Esophagectomy for Esophageal Cancer

Introduction

Esophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy.

Objective

This study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer.

Methods

Consecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]).

Results

During the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses.

Conclusion

Although smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-09720-6.

Economic Burden of Endoscopic Vacuum Therapy Compared to Alternative Therapy Methods in Patients with Anastomotic Leakage After Esophagectomy

BACKGROUND

Endoscopic vacuum therapy (EVT) has become a promising option in the management of anastomotic leakage (AL) after esophagectomy. However, EVT is an effortful approach associated with multiple interventions. In this study, we conduct a comparative cost analysis for methods of management of AL.

METHODS

All patients who experienced AL treated by EVT, stent, or reoperation following Ivor Lewis esophagectomy for esophageal cancer were included. Cases that were managed by more than one modality were excluded. For the remaining cases, in-patient treatment cost was collected for material, personnel, (par)enteral nutrition, intensive care, operating room, and imaging.

RESULTS

42 patients were treated as follows: EVT n = 25, stent n = 13, and reoperation n = 4. The mean duration of therapy as well as length of overall hospital stay was significantly shorter in the stent than the EVT group (30 vs. 44d, p = 0.046; 34 vs. 53d, p = 0.02). The total mean cost for stent was €33.685, and the total cost for EVT was €46.136, resulting in a delta increase of 37% for EVT vs. stent cost. 75% (€34.320, EVT), respectively, 80% (€26.900, stent) of total costs were caused by ICU stay. Mean pure costs for endoscopic management were relatively low and comparable between both groups (EVT: €1.900, stent: €1.100, p = 0.28).

CONCLUSION

Management of AL represents an effortful approach that results in high overall costs. The expenses directly related to EVT and stent therapy were however comparatively low with more than 75% of costs being attributable to the ICU stay. Reduction of ICU care should be a central part of cost reduction strategies.

Meta-analysis of prognostic factors of overall survival in patients undergoing oesophagectomy for oesophageal cancer

INTRODUCTION

Currently, the American Joint Commission on Cancer (AJCC) staging system is used for prognostication for oesophageal cancer. However, several prognostically important factors have been reported but not incorporated. This meta-analysis aimed to characterize the impact of preoperative, operative, and oncological factors on the prognosis of patients undergoing curative resection for oesophageal cancer.

METHODS

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling to determine pooled univariable hazard ratios (HRs). The study was prospectively registered with the PROSPERO database (Registration: CRD42018157966).

RESULTS

One-hundred and seventy-one articles including 73,629 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these. the strongly associated prognostic factors were 'pathological' T stage (HR: 2.07, CI95%: 1.77-2.43, P < 0.001), 'pathological' N stage (HR: 2.24, CI95%: 1.95-2.59, P < 0.001), perineural invasion (HR: 1.54, CI95%: 1.36-1.74, P < 0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82-2.59, P < 0.001), poor tumor grade (HR: 1.53, CI95%: 1.34-1.74, P < 0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30-1.66, P < 0.001).

CONCLUSION

Several tumor biological variables not included in the AJCC 8th edition classification can impact on overall survival. Incorporation and validation of these factors into prognostic models and next edition of the AJCC system will enable personalized approach to prognostication and treatment.

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.