High Intrathoracic Anastomosis with Thoracoscopy Is Safe and Feasible for Treatment of Esophageal Squamous Cell Carcinoma

Successful Endoscopic Vacuum Therapy for Extensive Gastric Tubing Necrosis after Ivor-Lewis Esophagectomy: A Case Report

The stomach has become the most commonly used site for grafts to replace the esophagus in esophageal cancer surgery because of its good blood supply and ability to enable single-reconstruction anastomosis. However, anastomotic failure is a serious complication after esophageal cancer surgery. Unlike anastomotic leakage due to local ischemia, gastric tube necrosis is a life-threatening condition with a high mortality rate. Gastric tube necrosis involves extensive ischemia due to a decreased blood supply, and an urgent operation is mandatory in most cases. Endoscopic vacuum therapy (EVT) has been used for anastomotic leakage after esophageal surgery. In recent years, it has been successfully used for more extensive disease, including large esophageal perforation as an indication for reoperation. Hence, we report a case of extensive gastric tube necrosis treated by EVT after an Ivor Lewis operation.

Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy

Purpose

In minimally invasive esophagectomy (MIE), it is important to reduce the rate of anastomotic leakage to ensure its safety. At our institute, the double-ligation method (DLM) has been introduced to insert and fix the anvil of the circular stapler for intracorporeal circular esophagojejunostomy in gastric surgery. We adopted this method for intrathoracic anastomosis (IA) in MIE. The aim of this study was to investigate the safety of IA with DLM in MIE.

Methods

In this study, 48 patients diagnosed with primary middle or lower third segment thoracic esophageal carcinoma with clinical stage I, II, III or IV disease were retrospectively evaluated. Postoperative outcomes were assessed.

Results

Among the 48 patients, 42 patients underwent laparo-thoracoscopic esophagectomy and IA using a circular stapler with the DLM. The average total operation time and thoracoscopic operation time were 433 and 229 minutes, respectively. The average purse-string suturing time was 4.7 minutes. The rates of anastomotic leakage and stenosis were 2.4% and 14.3%, respectively. The overall incidence of postoperative complications (Clavien-Dindo grade of ≥III) was 16.7%. The average postoperative stay was 16 days.

Conclusion

The procedure of IA using a circular stapler with the DLM in MIE was safe and provided a low rate of anastomotic leakage.

Case report: Drainage tube penetrating anastomosis as a rare cause for long-term nonunion of esophagogastric anastomosis in neck

Anastomotic leakage is a life-threatening complication for esophageal cancer patients who received McKeown esophagectomy. Cervical drainage tube penetrating anastomosis is a rare but noteworthy cause of long-term nonunion of esophagogastric anastomosis. Here we reported two cases of esophageal cancer patients who received McKeown esophagectomy. The first case acquired the anastomotic leakage on postoperative day (POD) 7, and lasted for 56 days. The cervical drainage tube was removed at POD 38, and the leakage healed in 25 days. The second case acquired the anastomotic leakage on POD 8 and lasted for 95 days. The cervical drainage tube was removed at POD 57, and the leakage healed in 46 days. The two cases demonstrated the duration-prolonging effect of drainage tube penetrating anastomosis, which should not be overlooked in clinical practice. We suggested paying attention to the duration of leakage, the drainage fluids amounts and characteristics, and the imaging manifestations to help diagnose. If the cervical drainage tube penetrated the anastomosis, the tube should be eliminated as soon.

Implementation of the Esophagectomy Complication Consensus Group definitions: the benefits of speaking the same language

In 2015 the Esophagectomy Complication Consensus Group (ECCG) reported consensus definitions for complications after esophagectomy. This aimed to reduce variation in complication reporting, attributed to heterogeneous definitions. This systematic review aimed to describe the implementation of this definition set, including the effect on complication frequency and variation. A systematic literature review was performed, identifying all observational and randomized studies reporting complication frequencies after esophagectomy since the ECCG publication. Recruitment periods before and subsequent to the index ECCG publication date were included. Coefficients of variance were calculated to assess outcome heterogeneity. Of 144 studies which met inclusion criteria, 70 (48.6%) used ECCG definitions. The median number of separately reported complication types was five per study; only one study reported all ECCG complications. The coefficients of variance of the reported frequencies of eight of the 10 most common complications were reduced in studies which used the ECCG definitions compared with those that did not (P = 0.036). Among ECCG studies, the frequencies of postoperative pneumothorax, reintubation, and pulmonary emboli were significantly reduced in 2020-2021, compared with 2015-2019 (P = 0.006, 0.034, and 0.037 respectively). The ECCG definition set has reduced variation in esophagectomy morbidity reporting. This adds greater confidence to the observed gradual improvement in outcomes with time, and its ongoing use and wider dissemination should be encouraged. However, only a handful of outcomes are widely reported, and only rarely is it used in its entirety.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis

BACKGROUND

Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis.

MATERIALS AND METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes.

RESULTS

A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively.

CONCLUSION

HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis

BACKGROUND

Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis.

METHODS

A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes.

RESULTS

A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001).

CONCLUSION

Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

A new technology for reducing anastomotic fistula in the neck after esophageal cancer surgery

Background

To explore the risk factors and prevention methods of cervical mechanical anastomotic fistula and stenosis after the radical resection of esophageal cancer.

Methods

From March 2018 to November 2018, 128 patients undergoing mechanical anastomosis of esophageal cancer were selected from the Department of Thoracic Surgery of The First Affiliated Hospital of Zhengzhou University. All the enrolled patients were operated on using the Mckeown method, and a retrospective study was conducted. Data for preoperative and postoperative test indices, intraoperative embedding materials, postoperative complications, and preoperative and postoperative treatment were collected, and the relationship between various factors and the incidence of cervical anastomotic fistula and stenosis was analysed. Univariate analysis was conducted using t tests or Fisher's exact probability method, and multivariate analysis was conducted using logistic regression models.

Results

All 128 patients successfully underwent surgery without dying. The enrolled patients were evaluated using the Stooler classification, with 28 patients having grade 0, 41 patients having grade 1, 34 patients having grade 2, 21 patients having grade 3, and 4 patients having grade 4 stenosis. Patients with stenosis of grade 3 or above had obvious choking sensation, which could only be relieved by balloon dilation. Symptoms in all patients with stenosis were relieved by balloon dilation. There were no significant differences between the two groups regarding embedding materials, preoperative choking history, history of alcohol consumption, history of hypertension, history of coronary heart disease, history of diabetes, postoperative calcium concentration, average albumin concentration, average platelet concentration, body mass index, anastomotic fistula, preoperative chemotherapy, postoperative chemotherapy, or postoperative cough (P>0.05). There were significant differences in postoperative reflux (χ²=11.338, P<0.05) and scar constitution (χ²=12.497, P<0.05). The effects of embedding materials in patients with anastomotic fistula were significantly different (χ²=4.372, P<0.05).

Conclusions

Postoperative reflux and scar constitution may be risk factors for postoperative anastomotic stenosis after resection of esophageal cancer. There was almost no difference in the effects on esophageal anastomotic stenosis between embedding materials and the omentum majus, but Neoveil^® may have certain advantages in preventing cervical anastomotic fistula, and thus may have certain clinical application value.

Minimally invasive Ivor Lewis esophagectomy for esophageal cancer

Esophageal cancer is the malignant tumor arising from the esophagus and has a poor prognosis. Squamous cell carcinoma and adenocarcinoma are the main subtypes of esophageal cancer with different risk factors. In the early stage, surgical resection is the most curative treatment modality. However, the procedure is considered an advanced and technically demanding surgery because esophageal cancer surgery includes esophagectomy, lymph node dissection, and a creation of esophageal conduit. Stomach is the commonest organ for the esophageal substitute. In open procedures, pulmonary complications and anastomotic failure are the most severe problems. Minimally invasive esophagectomy (MIE) has been introduced to decrease the postoperative pulmonary complications, but anastomotic failure remains a serious issue because of the extra-anatomical anastomosis between the esophagus and the conduit in the thorax or the neck.