Angleplasty in gastric tube reconstruction after esophagectomy

Anastomosis oversewing technique to prevent leakage after oesophagectomy: a propensity score-matched analysis

OBJECTIVES

Oesophagogastric anastomosis is a core part of oesophagectomy, and anastomotic leakage is among its main concerns. We used the oversewing technique to reinforce the anastomosis created with a circular stapler. This study investigated the use of oversewing to reduce the incidence of anastomotic leakage without increasing morbidity.

METHODS

This study enrolled 1734 patients who underwent oesophagectomy for oesophageal cancer between April 2012 and December 2019. Using propensity score-matched analysis, the clinical results of postoperative complications were compared between anastomotic-oversewn and -unsewn oesophagectomies.

RESULTS

Of the 1734 patients, 661 were included in the anastomotic-unsewn group and 661 in the anastomotic-oversewn group after propensity score matching. The clinical characteristics did not differ between the 2 groups, but the frequency of anastomotic leakage was significantly higher in the anastomotic-unsewn group than in the anastomotic-oversewn group (10.3% vs 4.7%, P < 0.001). Multivariable logistic analysis showed oversewn anastomosis and smoking history as the independent factors associated with anastomotic leakage (odds ratios, 0.399 and 2.383; P < 0.001 and P = 0.012, respectively). On the sub-group analysis, the relative risk for anastomotic leakage was significantly higher with unsewn than with oversewn anastomosis in patients <65 years old, those with American Association of Anesthesiologists score II, those who had middle segment oesophageal cancer and those who have undergone the McKeown approach and cervical anastomosis.

CONCLUSIONS

Anastomosis oversewing technique may be a practical method to reduce anastomotic leakage, especially in younger patients and those who have undergone the McKeown approach and cervical anastomosis.

Esophageal Biomechanics Revisited: A Tale of Tenacity, Anastomoses, and Suture Bite Lengths in Swine

BACKGROUND

Anastomotic tension has repeatedly been associated with anastomotic leakages after esophagectomy for cancer or esophageal atresia repair. We therefore aimed to determine which anastomotic technique would come as close as possible to the native esophagus in sustaining traction forces. Constant traction for several minutes at esophageal remnants and large suture bites are also considered relevant in long-gap esophageal atresia repair.

METHODS

Porcine esophagi were subjected to linear traction using a motorized horizontal test stand. We compared breaking strengths of native esophagi to simple continuous, simple interrupted, stapled, and barbed suture anastomoses. We also investigated the effects of suture bite length and phases of constant traction on breaking strengths and powered all experiments to at least 80% using exploratory investigations (n = 5 per group).

RESULTS

Continuous suture anastomoses had a breaking strength comparable to native esophagi (Δ = -5.25 Newton, 95% confidence interval: -10.69 to 0.19 Newton, p = 0.058) and outperformed all other investigated anastomoses (Δ ≥14.01 Newton, p ≤ 0.02). Breaking strength correlated with suture bite length (R = 0.905) and predicted breaking strength for the simple stitch (adjusted R² = 0.812, p < 0.0001), but not for anastomoses. Phases of incrementally increasing constant traction resulted in higher breaking strengths (Δ = 13.36 Newton, 95% confidence interval: 9.93 to 16.79 Newton, p < 0.0001) and higher length gain (Δ = 1.06 cm, 95% confidence interval: 0.65 to 1.48 cm, p < 0.0001) compared with controls.

CONCLUSIONS

Only simple continuous anastomoses achieved the linear breaking strength of native tissue. Our study provides important insights in tolerance to traction forces, but its results have to be corroborated in living animals as anastomotic leakages are multifactorial processes.

The effect of narrowed gastric conduits on anastomotic leakage following minimally invasive oesophagectomy

OBJECTIVES

Anastomotic leakage remains a major complication following minimally invasive oesophagectomy (MIO). In this study, our objective was to determine whether a narrower gastric conduit would lead to lower incidence of anastomotic leakage following MIO.

METHODS

In this retrospective study, patients with oesophageal cancer undergoing MIO were assigned to receive 5-cm-wide gastric conduits (from May 2011 to February 2012, Group W) and then 3-cm-wide gastric conduits (from March 2012 to December 2012, Group N) for gastro-oesophageal anastomosis. The length of the gastric conduit and the anastomotic details were recorded during surgery. Perfusion status of the conduit was analysed before and after anastomosis using a laser Doppler perfusion monitor. Following surgery, the incidence of anastomotic leakage in the two groups was statistically compared to identify differences between the two methods of gastric formation.

RESULTS

There were 126 patients in Group N and 133 patients in Group W. Patient demographics and surgical observations were comparable between the two groups. In Group N, the length of gastric conduit was significantly greater than in Group W (39.1 ± 2.7 vs 35.6 ± 4.4 cm, P = 0.0021). Lower reduction of perfusion units was recorded in Group N after gastro-oesophageal anastomosis (45.7 vs 28.1%, P = 0.004). Postoperatively, a total of 34 cases (13.13%) of anastomotic leakage was observed, and the incidence of anastomotic leakage was significantly lower in Group N than in Group W (8.7 vs 17.3%, P = 0.041).

CONCLUSIONS

Narrow gastric tubes were longer and less interfered in perfusion, which contributed to lower incidence of anastomotic leakage following minimally invasive oesophagectomy. Further study of the long-term effects of such treatment is required to confirm the advantages of this technique.