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Zhang C, Wang K, Zhang Z, Zhao X, Yao B, Zhang W. Safety and short‑term outcomes of a modified tubular esophagogastrostomy versus double tract reconstruction after proximal gastrectomy: a propensity score matching analysis. BMC Cancer 2025; 25:908. [PMID: 40399830 PMCID: PMC12096559 DOI: 10.1186/s12885-025-14284-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2025] [Accepted: 05/07/2025] [Indexed: 05/23/2025] Open
Abstract
OBJECTIVE To comparatively evaluate the short-term clinical efficacy and quality of life (QoL) between modified tubular esophagogastrostomy (mTEG) and double tract reconstruction (DTR) following proximal gastrectomy (PG), aiming to establish evidence-based recommendations for reconstruction method selection. METHODS The mTEG technique involved three essential steps: 1) tubular reconstruction of gastric remnant, 2) 3-cm artificial gastric fornix creation, and 3) His angle sharpening with posterior mediastinal fixation. This retrospective study included 288 PG patients (2021-2024). Propensity score matching (1:1, caliper = 0.03) balanced baseline characteristics, and thirty-three matched pairs were analyzed. Outcomes encompassed operative metrics, postoperative complications (Clavien-Dindo ≥ II), nutritional status (prealbumin, albumin, hemoglobin, BMI at 1/3/6 months), and QoL (EORTC QLQ-STO22 at 6 months). RESULTS The mTEG group demonstrated shorter median operative time (163.7 vs 247.9 min, p < 0.001) and postoperative hospitalization (8.3 vs 9.9 days, p = 0.001). Intraoperative outcomes including blood loss and lymph node yield were comparable. Early complications (≤ 30 days) occurred exclusively in the DTR group (4 cases: 2 anastomotic leakage, 1chylous leakage and 1 pulmonary related). complication rates showed no statistical difference (p > 0.05). Endoscopic findings demonstrated comparable incidence of reflux esophagitis in Los Angeles Grade B or higher (11.1% vs 4.5%, p = 0.457). Nutritional parameters and QoL scores remained equivalent between groups at all timepoints (p > 0.05). CONCLUSION mTEG represents a technically optimized reconstruction method that achieves equivalent nutritional preservation and reflux prevention compared to DTR, while offering distinct advantages in surgical efficiency and postoperative recovery. These findings support mTEG as a viable reconstruction option for PG patients.
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Affiliation(s)
- Chaoyang Zhang
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China
| | - Kaixing Wang
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China
| | - Zhidong Zhang
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China.
| | - Xuefeng Zhao
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China
| | - Bin Yao
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China
| | - Weishuai Zhang
- The Third Department of Surgery, The Fourth Hospital of Hebei Medical University, No. 12 Jiankang Rd. Changan District, Shijiazhuang, 050011, China
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Mylonakis A, Chrysikos D, Dellaportas D, Schizas D. Kocher maneuver in modern esophagectomy: Time for re-evaluation? Surgery 2025; 180:109033. [PMID: 39732551 DOI: 10.1016/j.surg.2024.109033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2024] [Accepted: 11/18/2024] [Indexed: 12/30/2024]
Affiliation(s)
- Adam Mylonakis
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimosthenis Chrysikos
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dionysios Dellaportas
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Schizas
- First Department of Surgery, Laikon General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Osterkamp JTF, Nerup N, Svendsen MBS, Strandby RB, Svendsen LB, Aasvang EK, Vad H, Plamboeck A, Achiam MP. Central ligation or partial preservation of the right gastric artery does not seem to affect conduit or anastomotic perfusion during robot-assisted resection of gastroesophageal junction cancer: a randomized clinical trial. Dis Esophagus 2025; 38:doae102. [PMID: 39558692 DOI: 10.1093/dote/doae102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 09/03/2024] [Accepted: 11/04/2024] [Indexed: 11/20/2024]
Abstract
The gastric conduit can be created with partial preservation or a central ligation of the right gastric artery. Central ligation may facilitate complete removal of lymph node (LN) station 3; however, whether this influences conduit and anastomotic perfusion is unknown. Hence this study investigated whether a central ligation of the right gastric artery would affect conduit or anastomotic perfusion compared with partial preservation (local standard) during robot-assisted resection of gastroesophageal junction cancer. Patients scheduled for robot-assisted resection of gastroesophageal junction cancer were randomized to either central ligation or partial preservation of the right gastric artery. Perfusion was assessed using quantified indocyanine green angiography: before gastric mobilization, after conduit formation, and after anastomosis. Hemodynamic variables during surgery and surgical outcomes were recorded. We included 70 patients between June 2020 and October 2021, of whom 5 were excluded from the final analysis. The two patient groups did not differ in conduit (0.07 [interquartile range (IQR), 0.05-0.08] vs. 0.07 u [IQR, 0.05-0.08], P = 0.86) or anastomotic perfusion (0.08 [standard deviation (SD), ±0.02] vs. 0.08 u [SD, ±0.02], P = 0.21), nor did they differ in intraoperative blood loss, anastomotic leaks, postoperative complications, or 1-year survival. However, more LNs were resected in the central ligation group (36 [IQR, 30-44] vs. 28 [IQR, 23-43], P = 0.02). Introducing a central ligation of the right gastric artery did not seem to affect conduit or anastomotic perfusion, compared with partial preservation. However, significantly more LNs were resected.
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Affiliation(s)
- Jens Thomas Fredrik Osterkamp
- Department of Transplantation and Digestive Diseases, Centre for Cancer and Organ Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Transplantation and Digestive Diseases, Centre for Cancer and Organ Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Morten Bo S Svendsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Rune B Strandby
- Department of Transplantation and Digestive Diseases, Centre for Cancer and Organ Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Department of Transplantation and Digestive Diseases, Centre for Cancer and Organ Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Vad
- Department of Cardiothoracic Surgery, Centre for Cancer and Organ Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Astrid Plamboeck
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael P Achiam
- Department of Transplantation and Digestive Diseases, Centre for Cancer and Organ Diseases, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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4
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Zhao H, Koyanagi K, Ninomiya Y, Kazuno A, Yamamoto M, Shoji Y, Yatabe K, Kanamori K, Tajima K, Mori M. Modification of the lesser curvature incision line enhanced gastric conduit perfusion as determined by indocyanine green fluorescence imaging and decreased the incidence of anastomotic leakage following esophagectomy. Esophagus 2025; 22:68-76. [PMID: 39304552 PMCID: PMC11717851 DOI: 10.1007/s10388-024-01089-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024]
Abstract
AIM This study aimed to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of gastric conduit as determined by indocyanine green fluorescence imaging and reducing the incidence of anastomotic leakage. METHODS A total of 272 patients who underwent esophagectomy at our institute between 2014 and 2022 were enrolled in this study. These patients were divided based on two different types of cutlines on the lesser curvature: conventional group (n = 141) following the traditional cutline and modified group (n = 131) adopting a modified cutline. Gastric conduit perfusion was assessed by ICG fluorescence imaging, and clinical outcomes after esophagectomy were evaluated. RESULTS The distance from the pylorus to the cutline was significantly longer in the modified group compared with the conventional group (median: 9.0 cm vs. 5.0 cm, p < 0.001). The blood flow speed in the gastric conduit wall was significantly higher in the modified group than that in the conventional group (median: 2.81 cm/s vs. 2.54 cm/s, p = 0.001). Furthermore, anastomotic leakage was significantly lower (p = 0.024) and hospital stay was significantly shorter (p < 0.001) in the modified group compared with the conventional group. Multivariate analysis identified blood flow speed in the gastric conduit wall as the only variable significantly associated with anastomotic leakage. CONCLUSIONS ICG fluorescence imaging is a feasible, reliable method for the assessment of gastric conduit perfusion. Modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomotic site, and reduce the risk of anastomotic leakage after esophagectomy.
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Affiliation(s)
- Hongbo Zhao
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yoshiaki Shoji
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Kanamori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kohei Tajima
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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Nickel F, Studier-Fischer A, Özdemir B, Odenthal J, Müller LR, Knoedler S, Kowalewski KF, Camplisson I, Allers MM, Dietrich M, Schmidt K, Salg GA, Kenngott HG, Billeter AT, Gockel I, Sagiv C, Hadar OE, Gildenblat J, Ayala L, Seidlitz S, Maier-Hein L, Müller-Stich BP. Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging and machine learning in an experimental model for minimally invasive esophagectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2025; 51:106908. [PMID: 37105869 DOI: 10.1016/j.ejso.2023.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 03/26/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Esophagectomy is the mainstay of esophageal cancer treatment, but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome. Therefore, the objective of this work was to optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis. MATERIAL AND METHODS A live porcine model (n = 58) for MIE was used with gastric conduit formation and simulation of linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and simulation of anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic simulation site was evaluated using HSI and was validated with histopathology. RESULTS The tissue oxygenation (ΔStO2) after the anastomotic simulation remained constant only for the short stapler in caudal position (-0.4 ± 4.4%, n.s.) while it was impaired markedly in the other groups (short-cranial: -15.6 ± 11.5%, p = 0.0002; long-cranial: -20.4 ± 7.6%, p = 0.0126; long-caudal: -16.1 ± 9.4%, p < 0.0001). Tissue samples from avascular stomach as measured by HSI showed correspondent eosinophilic pre-necrotic changes in 35.7 ± 9.7% of the surface area. CONCLUSION Tissue oxygenation at the site of anastomotic simulation of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the simulated anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. The experimental model with HSI and ML allow for systematic optimization of gastric conduit perfusion and anastomotic technique while clinical translation will have to be proven.
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Affiliation(s)
- F Nickel
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany; HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany
| | - A Studier-Fischer
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany; School of Medicine, Heidelberg University, Heidelberg, Germany
| | - B Özdemir
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - J Odenthal
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - L R Müller
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany; Division of Computer Assisted Medical Interventions, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany
| | - S Knoedler
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - K F Kowalewski
- Department of Urology, Medical Faculty of Mannheim at the University of Heidelberg, Mannheim, Germany
| | - I Camplisson
- Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, USA
| | - M M Allers
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M Dietrich
- Department of Anaesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - K Schmidt
- Department of Anaesthesiology and Intensive Care Medicine, Essen University Hospital, Essen, Germany
| | - G A Salg
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - H G Kenngott
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A T Billeter
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - I Gockel
- Department of Visceral, Transplantation, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Germany
| | - C Sagiv
- DeePathology Ltd., Ra'anana, Israel
| | | | | | - L Ayala
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany; Division of Computer Assisted Medical Interventions, German Cancer Research Center (DKFZ), Heidelberg, Germany; Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - S Seidlitz
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany; Division of Computer Assisted Medical Interventions, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - L Maier-Hein
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany; Division of Computer Assisted Medical Interventions, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany; Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - B P Müller-Stich
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany; HIDSS4Health - Helmholtz Information and Data Science School for Health, Heidelberg and Karlsruhe, Germany.
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Klontzas ME, Ri M, Koltsakis E, Stenqvist E, Kalarakis G, Boström E, Kechagias A, Schizas D, Rouvelas I, Tzortzakakis A. Prediction of Anastomotic Leakage in Esophageal Cancer Surgery: A Multimodal Machine Learning Model Integrating Imaging and Clinical Data. Acad Radiol 2024; 31:4878-4885. [PMID: 38955594 DOI: 10.1016/j.acra.2024.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/18/2024] [Accepted: 06/18/2024] [Indexed: 07/04/2024]
Abstract
RATIONALE AND OBJECTIVES Surgery in combination with chemo/radiotherapy is the standard treatment for locally advanced esophageal cancer. Even after the introduction of minimally invasive techniques, esophagectomy carries significant morbidity and mortality. One of the most common and feared complications of esophagectomy is anastomotic leakage (AL). Our work aimed to develop a multimodal machine-learning model combining CT-derived and clinical data for predicting AL following esophagectomy for esophageal cancer. MATERIAL AND METHODS A total of 471 patients were prospectively included (Jan 2010-Dec 2022). Preoperative computed tomography (CT) was used to evaluate celia trunk stenosis and vessel calcification. Clinical variables, including demographics, disease stage, operation details, postoperative CRP, and stage, were combined with CT data to build a model for AL prediction. Data was split into 80%:20% for training and testing, and an XGBoost model was developed with 10-fold cross-validation and early stopping. ROC curves and respective areas under the curve (AUC), sensitivity, specificity, PPV, NPV, and F1-scores were calculated. RESULTS A total of 117 patients (24.8%) exhibited post-operative AL. The XGboost model achieved an AUC of 79.2% (95%CI 69%-89.4%) with a specificity of 77.46%, a sensitivity of 65.22%, PPV of 48.39%, NPV of 87.3%, and F1-score of 56%. Shapley Additive exPlanation analysis showed the effect of individual variables on the result of the model. Decision curve analysis showed that the model was particularly beneficial for threshold probabilities between 15% and 48%. CONCLUSION A clinically relevant multimodal model can predict AL, which is especially valuable in cases with low clinical probability of AL.
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Affiliation(s)
- Michail E Klontzas
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Medical Imaging, University Hospital of Heraklion, Crete, Greece; Computational BioMedicine Laboratory, Institute of Computer Science, Foundation for Research and Technology (FORTH), Heraklion, Crete, Greece; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece
| | - Motonari Ri
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Solna, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Emmanouil Koltsakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Stenqvist
- Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Georgios Kalarakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Department of Radiology, School of Medicine, University of Crete, Voutes Campus, Heraklion, Greece; Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Boström
- Department of Diagnostic Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Aristotelis Kechagias
- Department of Digestive Surgery, Kanta-Häme Central Hospital, Hämeenlinna 13530, Finland
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens 115-27, Greece
| | - Ioannis Rouvelas
- Department of Clinical Science, Intervention and Technology (CLINTEC), Division of Surgery and Oncology, Karolinska Institutet, Solna, Sweden; Department of Upper Abdominal Diseases, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Antonios Tzortzakakis
- Department for Clinical Science, Intervention and Technology (CLINTEC), Division of Radiology, Karolinska Institutet, Stockholm, Sweden; Medical Radiation Physics and Nuclear Medicine, Section for Nuclear Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
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7
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Merritt RE. Conduit Selection for Reconstruction After Esophagectomy for Esophageal Cancer. Surg Oncol Clin N Am 2024; 33:549-556. [PMID: 38789197 DOI: 10.1016/j.soc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
The reconstruction of the esophagus after esophagectomy presents many technical and management challenges to surgeons. An effective gastrointestinal conduit that replaces the resected esophagus must have adequate length to reach the upper thoracic space or the neck, have robust vascular perfusion, and provide sufficient function for an adequate swallowing mechanism. The stomach is currently the preferred conduit for esophageal reconstruction after esophagectomy. However, there are circumstances, where the stomach cannot be utilized as a conduit. In these cases, an alternative conduit must be considered. The current alternative conduits include colon, jejunum, and tubed skin flaps.
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Affiliation(s)
- Robert E Merritt
- Division of Thoracic Surgery, The James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, N847 Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Ishikawa Y. Expanding Our Horizons: Editorial Comment on "The Effect of Laparoscopic Gastric Ischemic Preconditioning Prior to Esophagectomy on Anastomotic Stricture Rate with Comparison to Esophagectomy-Alone Controls". Ann Surg Oncol 2024; 31:4165-4166. [PMID: 38568376 DOI: 10.1245/s10434-024-15238-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Yoshitaka Ishikawa
- Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan.
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Li KK, Wang YJ, Zhang TM, Zhang L, Zhao SL, Chen L, Bao T, Zhao XL, Xie XF, Guo W. Right gastroepiploic artery length determined anastomotic leakage after minimally invasive esophagectomy for esophageal cancer: a prospective cohort study. Int J Surg 2024; 110:2757-2764. [PMID: 38349216 DOI: 10.1097/js9.0000000000001181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND This prospective cohort study, conducted at a high-volume esophageal cancer center from July 2019 to July 2022, aimed to investigate the link between the right gastroepiploic artery (RGEA) length and anastomotic leakage (AL) rates following minimally invasive esophagectomy (MIE). Real-world data on stomach blood supply in the Chinese population were examined. MATERIALS AND METHODS A total of 516 cases were enrolled, categorized into two groups based on the Youden index-determined optimal cut-off value for the relative length of RGEA (length of RGEA/length of gastric conduit, 64.69%) through ROC analysis: Group SR (short RGEA) and Group LR (long RGEA). The primary observation parameter was the relationship between AL incidence and the ratio of direct blood supply from RGEA. Secondary parameters included the mean length of the right gastroepiploic artery, greater curvature, and the connection type between right and left gastroepiploic vessels. Patient data were prospectively recorded in electronic case report forms. RESULTS The study revealed median lengths of 43.60 cm for greater curvature, 43.16 cm for the gastric conduit, and 26.75 cm for RGEA. AL, the most common postoperative complication, showed a significant difference between groups (16.88 vs. 8.84%, P =0.01). Multivariable binary logistic regression identified Group SR and LR (odds ratio: 2.651, 95% CI: 1.124-6.250, P =0.03) and Neoadjuvant therapy (odds ratio: 2.479, 95% CI: 1.374-4.473, P =0.00) as independent predictors of AL. CONCLUSIONS The study emphasizes the crucial role of RGEA length in determining AL incidence in MIE for esophageal cancer. Preserving RGEA and fostering capillary arches between RGEA and LGEA are recommended strategies to mitigate AL risk.
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Affiliation(s)
- Kun-Kun Li
- Department of Thoracic Surgery, Daping Hospital, Army Medical University, People's Republic of China
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10
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Ishida H, Fukutomi T, Taniyama Y, Sato C, Okamoto H, Ozawa Y, Onodera Y, Koseki K, Unno M, Kamei T. Blood flow ratio in the gastric conduit measured by laser Doppler flowmetry: A predictor of anastomotic leakage after esophagectomy. Ann Gastroenterol Surg 2024; 8:234-242. [PMID: 38455484 PMCID: PMC10914705 DOI: 10.1002/ags3.12754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/10/2023] [Accepted: 10/30/2023] [Indexed: 03/09/2024] Open
Abstract
Background Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. Methods A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Results Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Conclusion Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.
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Affiliation(s)
- Hirotaka Ishida
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Toshiaki Fukutomi
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yusuke Taniyama
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Chiaki Sato
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Hiroshi Okamoto
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yohei Ozawa
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Yu Onodera
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Ken Koseki
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Michiaki Unno
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
| | - Takashi Kamei
- Department of SurgeryTohoku University Graduate School of MedicineSendai‐shiMiyagiJapan
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Chen C, Ding C, He Y, Guo X. High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy. Eur J Cardiothorac Surg 2024; 65:ezae050. [PMID: 38341665 DOI: 10.1093/ejcts/ezae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy. METHODS A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching. RESULTS After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002). CONCLUSIONS For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.
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Affiliation(s)
- Chunji Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital Affiliated with Fudan University, Shanghai, China
| | - Chengzhi Ding
- Department of Thoracic Surgery, Henan Provincial People's Hospital; Zhengzhou University People's Hospital, Zhengzhou, China
| | - Yi He
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xufeng Guo
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Chen YW, Chuang CY, Yang SS, Shai SE, Lee MC, Chen HY, Lin CH. Comparison of wide and narrow gastric conduit in esophageal cancer surgery. J Chin Med Assoc 2023; 86:1074-1082. [PMID: 37773051 DOI: 10.1097/jcma.0000000000001004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Gastric conduit is most widely used method for esophageal reconstruction. Despite its popularity, certain complications, such as anastomotic leakage and strictures, remain to be resolved. In the present study, we reviewed the outcomes of narrow gastric conduit compared to wide gastric conduit reconstruction. METHODS We retrospectively reviewed 493 patients with esophageal cancer who received esophagectomy with reconstruction in Taichung Veteran General Hospital, Taiwan between January 2010 and December 2019. We performed gastric conduit reconstruction with two different methods, narrow gastric conduit made of multistaples (more than four staples) and wide gastric conduit made of two or three staples. Among the 493 patients, 170 patients underwent wide gastric conduit formation and 323 patients underwent narrow gastric conduit. After propensity score matching, 140 patients from each group were matched by 1:1. RESULTS The average anastomotic leakage rate is 80 of 493 (16.23%). The leakage rate, length of hospital stay, intensive care unit (ICU) admission, and ICU stay were significantly lower in the narrow gastric conduit group than in the wide gastric conduit group. The need for postoperation dilatation was significantly higher in wide gastric conduit group (19.41% vs 11.76%, p = 0.0217), and the time to first dilatation was similar in both groups ( p = 0.9808). Similar results were observed even after propensity score matching. In univariate analysis, the narrow gastric conduit, circular stapler, video-assisted thoracic surgery, and laparoscopic surgery were associated with a reduced risk of anastomotic leakage. However, these factors are not statistically significant in a multivariate logistic regression analysis. CONCLUSION The narrow gastric conduit is not inferior to the wide gastric conduit and can be considered an alternative option for gastric conduit preparation.
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Affiliation(s)
- Yi-Wen Chen
- Division of Thoracic Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
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Sun S, Wang Z, Huang C, Li K, Liu X, Fan W, Zhang G, Li X. Different gastric tubes in esophageal reconstruction during esophagectomy. Esophagus 2023; 20:595-604. [PMID: 37490217 PMCID: PMC10495279 DOI: 10.1007/s10388-023-01021-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 07/06/2023] [Indexed: 07/26/2023]
Abstract
Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.
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Affiliation(s)
- Shaowu Sun
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Zhulin Wang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Chunyao Huang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Kaiyuan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Xu Liu
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Wenbo Fan
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China
| | - Guoqing Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
| | - Xiangnan Li
- Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, No. 1 Jian She Road, Zhengzhou, 450052, Henan Province, China.
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Agarwal L, Dash NR, Pal S, Agarwal A, Madhusudhan KS. Pattern of Aorto-coeliac Calcification Correlating Cervical Esophago-gastric Anastomotic Leak After Esophagectomy for Cancer: a Retrospective Study. J Gastrointest Cancer 2023; 54:759-767. [PMID: 35965285 DOI: 10.1007/s12029-022-00856-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Cervical esophagogastric anastomotic leak (CEGAL) is a troublesome complication after esophagectomy and gastric pull-up. The aim of the study was to identify the preoperative clinical and radiological factors associated with increased risk of CEGAL. METHODS Consecutive patients whose clinical and imaging data were available and who underwent cervical esophago-gastric anastomosis following esophagectomy and gastric pull-up for esophageal cancer, between January 2013 and January 2021, were included. The patient details were collected from a prospectively maintained database. The demographic, clinical, and laboratory data including preoperative hemoglobin and serum albumin levels were recorded. Preoperative computed tomographic (CT) images were reviewed by two independent radiologists to assign vascular calcification scores for proximal aorta, distal aorta, aortic bifurcation, celiac trunk, and celiac artery branches. The primary outcome evaluated was clinically evident neck leak. Univariate and multivariate analysis of the clinical and radiological factors was performed to identify significant predictors. RESULTS A total of 100 patients (mean age: 54.7 years; 60 males, 40 females) were included in the study and of them, 27 developed CEGAL. Compared to the group without CEGAL, the patient group with CEGAL had significantly higher mean age (60.3 vs. 52.7 years, p < 0.01), and higher incidences of diabetes mellitus (25.9% vs 10.9%, p = 0.03), major proximal aortic calcification (29.6% vs. 6.3%, p < 0.01), and major celiac trunk calcification (22.2% vs. 6.3%, p = 0.02). Multivariate regression analysis identified age and presence of major proximal aortic calcification as independent risk factors for the development of CEGAL. CONCLUSION Major calcification of the proximal aorta and advanced age are independent risk factors for CEGAL after esophagectomy.
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Affiliation(s)
- Lokesh Agarwal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Nihar Ranjan Dash
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India.
| | - Sujoy Pal
- Department of Gastrointestinal Surgery and Liver Transplant, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110025, India
| | - Ayushi Agarwal
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
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15
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Seleim HM, Eskander AE. Thoracoscopic-Assisted Esophageal Replacement with a Detached Reversed Gastric Tube Pedicled Graft: Technical Report and Preliminary Outcomes. J Pediatr Surg 2023; 58:1640-1645. [PMID: 36894444 DOI: 10.1016/j.jpedsurg.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/02/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Reflux is one of the most common late complications after gastric tube esophageal replacement in children. Herein, we report a novel approach for safely and selectively replacing the caustic strictured thoracic esophagus with a detached reversed gastric tube (d-RGT) pedicled graft with preservation of the cardia and implementation of thoracoscopy for optimizing the mediastinal pull-through process, and its outcomes. METHODS All children who presented to our facility with an intractable postcorrosive thoracic esophageal stricture through 2020 and 2021 were enrolled in this study. The primary operational steps were thoracoscopic esophagectomy, laparotomy for d-RGT fashioning, and cervicotomy for anastomosis after the thoracoscopically monitored mediastinal pull-through process. RESULTS Eleven children met the enrollment criteria, and their perioperative characteristics were assessed. The mean operative time was 201 min. The average duration of hospitalization was 5 days. There was no perioperative mortality. A transient cervical fistula was reported for one patient and a cervical side anastomotic stricture in another patient. A third patient developed kinking of the lower end of the d-RGT at the diaphragmatic crura level and this was treated satisfactorily by redoing the abdominal side surgery. After a mean follow-up of 8.5 months, none of the patients experienced reflux, dumping syndrome, or neoconduit redundancy. CONCLUSIONS The pattern of vascular supply of the d-RGT allowed for its total irrigation. Thoracoscopy assisted in preparing the mediastinal path for a safe and precise pull-through process. The lack of reflux seen on imaging and endoscopy in these children suggests that retaining the cardia may be beneficial. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Hamed M Seleim
- Pediatric Surgery, Tanta University Hospital, Tanta, Egypt.
| | - Ayman E Eskander
- Pediatric Gastroenterology, Cairo University Specialized Pediatric Hospital, Cairo, Egypt
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16
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Charalampous C, Kofopoulos-Lymperis E, Pikouli A, Lykoudis P, Pararas N, Papaconstantinou D, Nastos C, Myoteri D, Dellaportas D. Gastric conduit reconstruction after esophagectomy with right gastroepiploic artery absence: a case report. J Surg Case Rep 2023; 2023:rjad474. [PMID: 37593193 PMCID: PMC10431203 DOI: 10.1093/jscr/rjad474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023] Open
Abstract
Gastric conduit reconstruction is the standard choice after esophagectomy. Conduit's vascular supply is of primary importance mainly based on right gastroepiploic vessels. A 57-year-old male with absent right gastroepiploic artery, due to a duodenal bleeding ulcer treated with gastroduodenal artery ligation 10 years ago, was treated for gastroesophageal cancer and required esophagectomy. Surgical merits of this troublesome scenario are highlighted. Previous surgical history is highly important for patients requiring complex surgery as esophagectomy. The use of the stomach as conduit after esophagectomy is always the primary option; however vascular supply of it should not be compromised. Variations are rare and careful planning may overcome obstacles as in this case.
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Affiliation(s)
- C Charalampous
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - E Kofopoulos-Lymperis
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - A Pikouli
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - P Lykoudis
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - N Pararas
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - D Papaconstantinou
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - C Nastos
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - D Myoteri
- Pathology Department, National and Kapodistrian University of Athens, Aretaieion University Hospital, Athens, Greece
| | - D Dellaportas
- 3 Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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Hirahara N, Matsubara T, Hayashi H, Yamamoto T, Hyakudomi R, Takai K, Zotani H, Taniura T, Ishitobi K, Tajima Y. Rational Gastric Conduit Stump Closure Method Using Endo GIA Radial Reload in End-to-Side Anastomosis of the Esophagogastric Conduit. J Laparoendosc Adv Surg Tech A 2023; 33:801-806. [PMID: 37057971 DOI: 10.1089/lap.2022.0593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
Background: The lack of tension at the anastomosis site and the blood flow of the gastric conduit are important to prevent anastomotic leakage in the anastomosis of the esophagogastric conduit. This study reports a gastric conduit stump closure method using Endo GIA™ Radial Reload in end-to-side anastomosis of the esophagogastric conduit, especially focusing on blood flow. Methods: A 4-cm conduit was created to ensure an intramural vascular network. The gastric conduit was elevated to the neck through the posterior mediastinal route, and end-to-side anastomosis of the esophagus and gastric conduit was performed using a circular stapler. Closure of the gastric stump with an Endo GIA Radial Reload was performed 2 cm proximal to the anastomosis on the end side of the esophagogastric conduit. The lesser curvature of the stump of the gastric conduit is the most frequent site of anastomotic leakage as it has the least blood flow, and the pressure is highest when the pressure inside the gastric conduit increases. Therefore, the gastric conduit stump was closed using the Endo GIA Radial Reload to resect the intersection of the gastric stump and lesser curvature from which the gastric conduit was created. The gastric conduit stump is gently curved; therefore, the pressure applied to the gastric conduit stump could be dispersed when the intragastric pressure increases. Results: No anastomotic leakage was observed among the 21 patients who underwent this method. Conclusion: This method is a novel anastomosis method to prevent anastomotic leakage in an end-to-side anastomosis of the esophagogastric conduit.
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Affiliation(s)
- Noriyuki Hirahara
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Takeshi Matsubara
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Hikota Hayashi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Tetsu Yamamoto
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Ryoji Hyakudomi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Kiyoe Takai
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Hitomi Zotani
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Takahito Taniura
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Kazunari Ishitobi
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoshitsugu Tajima
- Department of Digestive and General Surgery, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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Kita R, Kobayashi H, Kondo M, Kaihara S. Impact of intravenous injection of glucagon on anastomotic leakage in esophagectomy. Heliyon 2023; 9:e16442. [PMID: 37292332 PMCID: PMC10245153 DOI: 10.1016/j.heliyon.2023.e16442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 02/04/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023] Open
Abstract
Background Anastomotic leakage after esophagectomy affects the early postoperative state and prognosis. However, effective measures to prevent anastomotic leakage in esophagogastric anastomosis have not been established. Methods This single-center, retrospective, observational study included 147 patients who underwent esophagectomy for esophageal cancer between 2010 and 2020. Glucagon was administered to extend the gastric tube in patients who underwent esophagectomy from January 2016. The patients were divided into two groups: a glucagon-treated group (2016-2020) and a control group (2010-2015). The incidence of anastomotic leakage was compared between the two groups for evaluation of the preventive effects of glucagon administration on anastomotic leakage. Results The length of the gastric tube from the pyloric ring to the final branch of the right gastroepiploic artery was extended by 2.8 cm after glucagon injection. The incidence of anastomotic leakage was significantly lower in the glucagon-treated group (19% vs. 38%; p = 0.014). Multivariate analysis showed that glucagon injection was the only independent factor associated with a reduction in anastomotic leakage (odds ratio, 0.26; 95% confidence interval, 0.07-0.87). Esophagogastric anastomosis was performed proximal to the final branch of the right gastroepiploic artery in 37% patients in the glucagon-treated group, and these cases showed a lower incidence of anastomotic leakage than did those with anastomosis distal to the final branch of the right gastroepiploic artery (10% vs. 25%, p = 0.087). Conclusions Extension of the gastric tube by intravenous glucagon administration during gastric mobilization in esophagectomy for esophageal cancer may be effective in preventing anastomotic leakage.
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Affiliation(s)
- Ryosuke Kita
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
- Department of Gastrointestinal Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroyuki Kobayashi
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Masato Kondo
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Satoshi Kaihara
- Department of Surgery, Kobe City Medical Center General Hospital, Hyogo, Japan
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Ishikawa Y, Chang AC, Lin J, Orringer MB, Lynch WR, Lagisetty KH, Wakeam E, Reddy RM. Wider Gastric Conduit Morphology Is Associated with Improved Blood Flow During Esophagectomy. J Gastrointest Surg 2023; 27:845-854. [PMID: 36526829 DOI: 10.1007/s11605-022-05530-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 11/04/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND It remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy. METHODS Patients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively. RESULTS Three hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups. CONCLUSIONS Conduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks.
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Affiliation(s)
- Yoshitaka Ishikawa
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Jules Lin
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Mark B Orringer
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - William R Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Kiran H Lagisetty
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Elliot Wakeam
- Division of Thoracic Surgery, University of Toronto, 149 College Street, ON, M5T 1P5, Toronto, Canada
| | - Rishindra M Reddy
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
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20
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Walsh TN. The Esophagogastric Anastomosis: The Importance of Anchoring Sutures in Reducing Anastomotic Leak Rates. ANNALS OF SURGERY OPEN 2023; 4:e231. [PMID: 37600864 PMCID: PMC10431275 DOI: 10.1097/as9.0000000000000231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/29/2022] [Indexed: 02/04/2023] Open
Abstract
Background The incidence of anastomotic leakage in gastrointestinal surgery is highest after esophagogastric anastomosis, with leakage rates of 10% to 38% still being reported, but little consensus as to cause or corrective. The role of anastomotic tension from a series of physiological forces acting on the anastomosis from the moment of recovery from anesthesia may be underestimated. It was hypothesized that anchoring the conduit in the mediastinum would provide the greatest protection during the vulnerable healing phase. Patients and Methods A prospectively maintained database was interrogated for anastomotic leakage following the introduction of an anastomotic technique employing anchoring sutures where the gastric conduit was secured to the mediastinal pleura with 3 obliquely inserted load-bearing sutures. A contrast study was performed between days 5 and 7 and all intrahospital mortalities underwent autopsy. Clinical, radiological, and autopsy leaks were recorded. Results Of 146 intrathoracic esophagogastric anastomoses in 144 patients, 81 (55%) of which were stapled, there was 1 clinical leak and 1 patient with an aortoenteric fistula, considered at autopsy to be possibly due to an anastomotic leak, to give an anastomotic leak rate of 2 in 146 (1.37%). Conclusion The low anastomotic leak rate in this series is potentially due to the protective effect of anchoring sutures, the chief difference from an otherwise standard anastomotic technique. These sutures protect the anastomosis from a series of distracting forces during the most vulnerable phase of healing. It is intuitive that the absence of tension would also reduce any risk posed by a minor impairment of blood supply or any imperfection of the technique.
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Affiliation(s)
- Thomas N. Walsh
- From the Royal College of Surgeons in Ireland Department of Surgery, Connolly Hospital Blanchardstown, Dublin, Ireland
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Motegi D, Ichikawa H, Bamba T, Muneoka Y, Kano Y, Usui K, Hanyu T, Ishikawa T, Hirose Y, Miura K, Tajima Y, Shimada Y, Sakata J, Nakagawa S, Kosugi SI, Wakai T. Ulcer Scarring in the Gastric Conduit Is a Risk Factor for Anastomotic Leakage After Esophagectomy for Esophageal Cancer. J Gastrointest Surg 2023; 27:250-261. [PMID: 36509899 DOI: 10.1007/s11605-022-05545-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/19/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a serious complication after esophagectomy for esophageal cancer. The objective of this study was to identify the risk factors for AL. METHODS Patients with esophageal cancer who underwent curative esophagectomy and cervical esophagogastric anastomosis between 2009 and 2019 (N = 346) and those between 2020 and 2022 (N = 17) were enrolled in the study to identify the risk factors for AL and the study to assess the association between the risk factors and blood flow in the gastric conduit evaluated by indocyanine green (ICG) fluorescence imaging, respectively. RESULTS AL occurred in 17 out of 346 patients (4.9%). Peptic or endoscopic submucosal dissection (ESD) ulcer scars were independently associated with AL (OR 6.872, 95% CI 2.112-22.365) in addition to diabetes mellitus. The ulcer scars in the anterior/posterior gastric wall were more frequently observed in patients with AL than in those without AL (75.0% vs. 17.4%, P = 0.042). The median flow velocity of ICG fluorescence in the gastric conduits with the scars was significantly lower than in those without the scars (1.17 cm/s vs. 2.23 cm/s, P = 0.004). CONCLUSIONS Peptic or ESD ulcer scarring is a risk factor for AL after esophagectomy in addition to diabetes mellitus. The scars in the anterior/posterior gastric wall are significantly associated with AL, impairing blood flow of the gastric conduit. Preventive interventions and careful postoperative management should be provided to minimize the risk and severity of AL in patients with these risk factors.
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Affiliation(s)
- Daisuke Motegi
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Hiroshi Ichikawa
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan.
| | - Takeo Bamba
- Department of Gastroenterological Surgery, Niigata Cancer Center Hospital, 2-15-3 Kawagishi-Cho, Chuo-Ku, Niigata City, Niigata, 951-8566, Japan
| | - Yusuke Muneoka
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Yosuke Kano
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Kenji Usui
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Takaaki Hanyu
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
- Department of Surgery, Shibata Prefectural Hospital, 1-2-8 Hon-Cho, Shibata City, Niigata, 957-8588, Japan
| | - Takashi Ishikawa
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Yuki Hirose
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Kohei Miura
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Yosuke Tajima
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Yoshifumi Shimada
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Jun Sakata
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
| | - Satoru Nakagawa
- Department of Gastroenterological Surgery, Niigata Cancer Center Hospital, 2-15-3 Kawagishi-Cho, Chuo-Ku, Niigata City, Niigata, 951-8566, Japan
| | - Shin-Ichi Kosugi
- Department of Digestive and General Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, 4132 Urasa, Minami-Uonuma City, Niigata, 949-7302, Japan
| | - Toshifumi Wakai
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-Dori, Chuo-Ku, Niigata City, Niigata, 951-8510, Japan
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Takahashi K, Nishikawa K, Tanishima Y, Ishikawa Y, Kobayashi T, Masuda T, Kurogochi T, Yuda M, Tanaka Y, Matsumoto A, Yano F, Eto K. Risk stratification of anastomotic stricture using early postoperative endoscopic and computed tomography findings in patients undergoing esophagectomy with cervical esophagogastric anastomosis for esophageal cancer. Dis Esophagus 2022; 35:6530218. [PMID: 35178563 DOI: 10.1093/dote/doac004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 12/13/2021] [Indexed: 12/11/2022]
Abstract
Anastomotic stricture (AS) is one of the major complications after esophagectomy for esophageal cancer. We have previously reported that severe mucosal degeneration (MD) of the anastomotic site was associated with the incidence of AS. Meanwhile, there are few reports to correlate anastomotic internal circumference (AIC) with computed tomography (CT) with the incidence of AS. Therefore, this study was conducted to clarify the correlation of early postoperative endoscopic and CT findings with the incidence of AS. We assessed 205 patients who underwent esophagectomy. We then divided them into the non-AS group (n = 164) and the AS group (n = 41) and compared their background data and intraoperative and postoperative outcomes. We also evaluated the risk factors for AS using logistic regression model. Multivariate analysis revealed small AIC (P = 0.003; OR = 4.400; 95% CI = 1.650-11.700) and severe MD (P < 0.001; OR = 7.200; 95% CI = 2.650-19.600) as the independent risk factors for AS development. We also stratified the patients into the following four groups according to the incidence of AS: low-risk (normal AIC and intact or mild MD, 6.2%), intermediate-risk (small AIC and intact or mild MD, 29.4%), high-risk (normal AIC and severe MD, 42.9%), and very high-risk (small AIC and severe MD, 61.1%). Early postoperative endoscopic and CT findings were useful in predicting the development of AS after esophagectomy.
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Affiliation(s)
- Keita Takahashi
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Katsunori Nishikawa
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichiro Tanishima
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yoshitaka Ishikawa
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takehiro Kobayashi
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takahiro Masuda
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Takanori Kurogochi
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Masami Yuda
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Yujiro Tanaka
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Akira Matsumoto
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Fumiaki Yano
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
| | - Ken Eto
- Department of Gastrointestinal Surgery, Jikei University School of Medicine, Tokyo, Japan
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Voron T, Julio C, Pardo E. Cancers œsophagiens : nouveautés et défis des prises en charge chirurgicales. Bull Cancer 2022; 110:533-539. [PMID: 36336479 DOI: 10.1016/j.bulcan.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/06/2022]
Abstract
Surgical resection of esophageal carcinoma is one of the mainstays of curative treatment for these cancers. During the last decade, numerous improvements in surgical approaches and perioperative management of these patients have resulted in a decrease in postoperative morbidity and mortality. Thus, centralization of patients with esophagogastric adenocarcinoma in high volume center, development of minimally invasive surgery and improvements in surgical imaging have led to reduce mortality rate, major pulmonary complication rate and postoperative chylothorax rate. Optimization of postoperative management with enhanced recovery programs has meanwhile reduced the rate of major postoperative complication and the hospital length of stay. The objective of this review is to give an overview of novelties and challenges regarding surgical management of patients with esophageal carcinoma.
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Affiliation(s)
- Thibault Voron
- AP-HP, hôpital Saint-Antoine, Sorbonne université, service de chirurgie générale et digestive, Paris, France.
| | - Camille Julio
- AP-HP, hôpital Saint-Antoine, Sorbonne université, service de chirurgie générale et digestive, Paris, France
| | - Emmanuel Pardo
- AP-HP, hôpital Saint-Antoine, Sorbonne University, Department of Anesthesiology and Intensive Care, GRC 29, DMU DREAM, Paris, France
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24
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A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial. Int J Surg 2022; 106:106921. [PMID: 36116675 DOI: 10.1016/j.ijsu.2022.106921] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/18/2022] [Accepted: 09/12/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.
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25
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Wu Y, XuWu, Zhang J, Li X, Liu N, Li J, Chen X, Wei L. Effect of modified esophagectomy perioperative technique resection for patients with locally advanced esophageal cancer (tumor length > 8 cm): initial experience in 45 cases. J Cardiothorac Surg 2022; 17:226. [PMID: 36056357 PMCID: PMC9438225 DOI: 10.1186/s13019-022-01942-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 08/15/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patients with locally advanced esophageal cancer with a lesion length greater than 8 cm (LCWEC) are prone to high mortality in a short time due to esophagotracheal fistula (ETF) and esophagoaortic fistula (EAF). We tried to explore a safe salvage surgical method during the perioperative period to maximize the resection of the tumor on the premise of safety and reconstruction of the alimentary tract to avoid early death due to ETF and EAF. Methods From December 2007 to November 2018, forty-five LCWEC patients were treated using the modified Wu’s esophagectomy. Patient features, surgical techniques, postoperative complications, and pathology outcomes were analyzed. Results The average length of the tumors was 12.5 cm (range 8.1–22.5 cm), and the average transverse tumor diameter was 5.8 cm (range 4.5–7.8 cm). No complications like anastomotic leakage, anastomotic stenosis, chylothorax, delayed gastric emptying, vocal cord paralysis, dumping syndrome, and reflux were detected. The 30-day and in-hospital mortality rates were 0%. Complete (R0) resection was achieved in 38 (84.4%) cases. The resection margin rate of positive anastomosis was 0%. Until the death of the patients, no feeding failure due to gastrointestinal obstruction and early death due to ETF or EAF occurrence. During follow-up, the median time to death was 17.2 months for patients treated with surgery alone and 32 months for patients treated with postoperative multimodal treatment. Conclusion The modified Wu’s esophagectomy is a safe and feasible salvage surgical method for LCWEC resection.
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Affiliation(s)
- Yunfei Wu
- Department of Thoracic Surgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - XuWu
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China.
| | - Junhua Zhang
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Xiang Li
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Nanbo Liu
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Jun Li
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Xuyuan Chen
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
| | - Lichun Wei
- Department of Thoracic Surgery, Huiqiao Medical Center, Nanfang Hospital, Southern Medical University, No. 1838, North Guangzhou Road, Guangzhou, Guangdong, China
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26
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Zhang H, Zuo Z, Yan X, Wang F, Yang L, Qiu G, Chen LQ, Wang Y. Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy. Front Surg 2022; 9:957093. [PMID: 35965865 PMCID: PMC9365067 DOI: 10.3389/fsurg.2022.957093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/04/2022] [Indexed: 11/25/2022] Open
Abstract
Background With the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis. Methods After stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired. Results The clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period. Conclusion Two purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.
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Affiliation(s)
- Hanlu Zhang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Zeping Zuo
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Xiuji Yan
- Department of Plastic and Burns Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Fuqiang Wang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Lin Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Guanghao Qiu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
- Correspondence: Long-Qi Chen Yun Wang
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
- Correspondence: Long-Qi Chen Yun Wang
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27
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Yang Y, Ma L. Oesophageal reconstruction with a reversed gastric conduit for a complex oesophageal cancer patient: a case report. BMC Surg 2022; 22:225. [PMID: 35690775 PMCID: PMC9188175 DOI: 10.1186/s12893-022-01630-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/04/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The gastric conduit is the best replacement organ for oesophageal reconstruction, but a reversed gastric conduit (RGC) is rare. Oesophageal reconstruction for oesophageal cancer patients with a previous history of complicated gastrointestinal surgery is rather difficult. Here, we report a case in which oesophageal reconstruction was successfully managed using RGC based solely on the left gastroepiploic artery supply. CASE PRESENTATION A 69-year-old man with oesophageal cancer had a history of endoscopic intestinal polypectomy and pylorus-preserving pancreaticoduodenectomy (PPPD). The right gastroepiploic artery and right gastric artery had been completely severed. The only supply artery that could be used for the gastric conduit was just the left gastroepiploic artery. Because of the complex history of abdominal surgery, we had no choice but to use the RGC to complete the oesophageal reconstruction, in which the gastric conduit was passed reversely through the hiatus to the oesophageal bed and layered end-to-side manual intrathoracic anastomosis with the esophagus. The patient had transient feeding problems with postoperative delayed thoracic stomach emptying but no anastomotic stenosis or thoracic stomach fistula. He was satisfied with his life and had no long-term complications. There was no significant effect on gut physiological function, and RGC could work normally. CONCLUSIONS Oesophageal reconstruction with RGC is a feasible procedure for complex oesophageal carcinoma that can simplify complicated surgical procedures, has less influence on gut function, is less invasive, and is safe.
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Affiliation(s)
- Yanbo Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Sichuan, 610041, Chengdu, People's Republic of China.,Chest Oncology Institute, West China Hospital, Sichuan University, Chengdu, China.,Western China Collaborative Innovation Centre for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China
| | - Lin Ma
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Sichuan, 610041, Chengdu, People's Republic of China. .,Chest Oncology Institute, West China Hospital, Sichuan University, Chengdu, China. .,Western China Collaborative Innovation Centre for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, Chengdu, China.
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28
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Tzortzakakis A, Kalarakis G, Huang B, Terezaki E, Koltsakis E, Kechagias A, Tsekrekos A, Rouvelas I. Role of Radiology in the Preoperative Detection of Arterial Calcification and Celiac Trunk Stenosis and Its Association with Anastomotic Leakage Post Esophagectomy, an Up-to-Date Review of the Literature. Cancers (Basel) 2022; 14:cancers14041016. [PMID: 35205764 PMCID: PMC8870074 DOI: 10.3390/cancers14041016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Esophageal cancer is the sixth deadliest among all cancers worldwide. Multimodal treatment, including surgical resection of the esophagus, offers the potential for cure even in advanced cases, but esophagectomy is still associated with serious complications. Among these, anastomotic leakage has the most significant clinical impact, both in terms of prognosis and health-related quality of life. Identifying patients at a high risk for leakage is of great importance in order to modify their treatment and, if possible, avoid this complication. This review aims to study the current literature regarding the role of radiology in detecting potential risk factors associated with anastomotic leakage. The measurement of calcium plaques on the aorta, as well as the detection of narrowing of the celiac trunk and its branches, can be easily assessed by preoperative computed tomography, and can be used to individualize perioperative patient management to effectively reduce the rate of leakage. Abstract Surgical resection of the esophagus remains a critical component of the multimodal treatment of esophageal cancer. Anastomotic leakage (AL) is the most significant complication following esophagectomy, in terms of clinical implications. Identifying risk factors for AL is important for modifying patient management and improving surgical outcomes. This review aims to examine the role of radiological risk factors for AL after esophagectomy, and in particular, arterial calcification and celiac trunk stenosis. Eligible publications prior to 25 August 2021 were retrieved from Medline and Google Scholar using a predefined search algorithm. A total of 68 publications were identified, of which 9 original studies remained for in-depth analysis. The majority of these studies found correlations between calcifications in the aorta, celiac trunk, and right post-celiac arteries and AL following esophagectomy. Some studies suggest celiac trunk stenosis as a more appropriate surrogate. Our up-to-date review highlights the need for automated quantification of aortic calcifications, as well as the degree of celiac trunk stenosis in preoperative computed tomography in patients undergoing esophagectomy, to obtain robust and reproducible measurements that can be used for a definite correlation.
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Affiliation(s)
- Antonios Tzortzakakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Medical Radiation Physics and Nuclear Medicine, Functional Unit of Nuclear Medicine, Karolinska University Hospital, 141 86 Huddinge, Sweden
| | - Georgios Kalarakis
- Department of Clinical Science, Division of Radiology, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden; (A.T.); (G.K.)
- Department of Radiology, Karolinska University Hospital, Huddinge, 141 86 Stockholm, Sweden
| | - Biying Huang
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of General Surgery, Södertälje Hospital, 152 86 Södertälje, Sweden
| | - Eleni Terezaki
- Department of Emergency Medicine, Karolinska University Hospital, 171 64 Stockholm, Sweden;
| | - Emmanouil Koltsakis
- Department of Radiology, Karolinska University Hospital, Solna, 171 64 Stockholm, Sweden;
| | - Aristotelis Kechagias
- Department of Digestive Surgery, Kanta-Häme Central Hospital, 13530 Hämeenlinna, Finland;
| | - Andrianos Tsekrekos
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
| | - Ioannis Rouvelas
- Department of Upper Abdominal Surgery, Karolinska University Hospital Huddinge, 141 86 Stockholm, Sweden; (B.H.); (A.T.)
- Department of Clinical Science, Division of Surgery, Intervention and Technology (CLINTEC), Karolinska Institutet, 141 86 Stockholm, Sweden
- Correspondence: ; Tel.: +46-70-797-68-14
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29
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Lai Y, Li H, Tian L, Ye X, Hu Y. Baseball bat-like gastric tube for end-to-side oesophageal-gastric anastomosis decreased risks of anastomotic leakage after oesophagectomy for oesophageal cancer: A retrospective propensity score matched comparative study with 613 patients. Int J Surg 2022; 98:106227. [PMID: 35041978 DOI: 10.1016/j.ijsu.2022.106227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the relationship between baseball bat-like gastric tubes for end-to-side oesophageal-gastric anastomosis and occurrence of anastomotic leakage after oesophagectomy for oesophageal cancer. METHODS From July 2019 to June 2021, 613 patients with bat-like or narrow gastric tubes for end-to-side oesophageal-gastric anastomosis in oesophagectomy were retrospectively enrolled, in which 120 patients had narrow gastric tubes and 493 had bat-like gastric tubes. Clinical data including baseline characteristics, in-hospital variables and follow-up outcomes were collected. RESULTS Higher occurrence of anastomotic leak was observed in the narrow group in the unmatched cohort (14.2%, 17/120 vs. 7.3%, 36/493; P = 0.016) or the matched cohort after Propensity Score Matching (PSM) analysis (14.2%, 17/120 vs. 7.5%, 27/360, P = 0.028) when compared to the bat-like group; Multivariable analysis for risk factors of postoperative anastomotic leak in the unmatched cohort showed that the use of bat-like gastric tube was an independent protective factor (OR: 0.502, 95% CI: 0.270-0.935, P = 0.030). CONCLUSIONS Bat-like gastric tube can be used for end-to-side oesophageal-gastric anastomosis in oesophagectomy. This technique by improving blood supply to the area distal to the anastomosis decreased the incidence of anastomotic leak.
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Affiliation(s)
- Yutian Lai
- Department of Lung Cancer, West China Hospital, Sichuan University, Chengdu, 610041, PR China West China Hospital of Medicine, Sichuan University, Chengdu, 610041, PR China Department of Endoscopy Center, West China Hospital, Sichuan University, Chengdu, 610041, PR China Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, PR China
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Hanada K, Tsunoda S, Ogiso S, Nishigori T, Hisamori S, Obama K. McKeown esophagectomy with concomitant median arcuate ligament release in a case of esophageal cancer with celiac artery stenosis. Surg Case Rep 2022; 8:5. [PMID: 34993694 PMCID: PMC8738834 DOI: 10.1186/s40792-022-01359-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The celiac artery stenosis due to compression by median arcuate ligament (MAL) has been reported in many cases of pancreaticoduodenectomy, but not in cases of esophagectomy. Recently, the celiac artery stenosis due to MAL or arteriosclerosis has been reported to be associated with the gastric tube necrosis or anastomotic leakage following Ivor-Lewis esophagectomy. Herein, we present the first reported case of esophageal cancer with celiac artery stenosis due to compression by the MAL successfully treated by McKeown esophagectomy and gastric tube reconstruction following prophylactic MAL release. CASE PRESENTATION A 72-year-old female patient was referred to our department for esophagectomy. The patient had received two courses of neoadjuvant chemotherapy with 5-FU and cisplatin for T2N0M0 squamous cell carcinoma of the middle esophagus. Preoperative contrast-enhanced computed tomography (CECT) showed celiac artery stenosis due to compression by the MAL. The development of collateral arteries around the pancreatic head was observed without evidence of aneurysm formation. The patient reported no abdominal symptoms. After robot-assisted esophagectomy with mediastinal lymphadenectomy, gastric mobilization, supra-pancreatic lymphadenectomy, and preparation of the gastric tube were performed under laparotomy. Subsequently, the MAL was cut, and released to expose the celiac artery. Improved celiac artery blood flow was confirmed by decreased pulsatility index on intraoperative Doppler sonography. The operation was completed with the cervical esophagogastric anastomosis following cervical lymphadenectomy. Postoperative CECT on postoperative day 7 demonstrated increased celiac artery patency. The patient had an uncomplicated postoperative course thereafter. CONCLUSIONS Prophylactic MAL release may be considered in patients with celiac artery stenosis due to compression by the MAL on preoperative CECT for esophagectomy.
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Affiliation(s)
- Keita Hanada
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeru Tsunoda
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Satoshi Ogiso
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Tatsuto Nishigori
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kazutaka Obama
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Nakajima M, Muroi H, Kikuchi M, Fujita J, Ihara K, Nakagawa M, Morita S, Nakamura T, Yamaguchi S, Kojima K. Dislocation of the gastric conduit reconstructed via the posterior mediastinal route is a significant risk factor for anastomotic disorder after McKeown esophagectomy. Ann Gastroenterol Surg 2022; 6:75-82. [PMID: 35106417 PMCID: PMC8786694 DOI: 10.1002/ags3.12496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/07/2021] [Accepted: 07/27/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Anastomotic disorder of the reconstructed gastric conduit is a life-threating morbidity after thoracic esophagectomy. Although there are various reasons for anastomotic disorder, the present study focused on dislocation of the gastric conduit (DGC). METHODS The study cohort comprised 149 patients who underwent transthoracic esophagectomy. The relationships between DGC and peri- and postoperative morbidities were analyzed retrospectively. Data were analyzed to determine whether body mass index (BMI) and extension of the gastric conduit were related to DGC. Uni- and multivariate Cox regression analyses were performed to identify the factors associated with anastomotic disorder. RESULTS DGC was significantly related to anastomotic leakage (P < .001), anastomotic stricture (P = .018), and mediastinal abscess/empyema (P = .031). Compared with the DGC-negative group, the DGC-positive group had a significantly larger mean preoperative BMI (23.01 ± 3.26 kg/m2 vs. 21.22 ± 3.13 kg/m2, P = .001) and mean maximum cross-sectional area of the gastric conduit (1024.75 ± 550.43 mm2 vs. 619.46 ± 263.70 mm2, P < .001). Multivariate analysis revealed that DGC was an independent risk factor for anastomotic leakage (odds ratio: 4.840, 95% confidence interval: 1.770-13.30, P < .001). Body weight recovery tended to be better in the DGC-negative group than in the DGC-positive group, although this intergroup difference was not significant. CONCLUSION DGC reconstructed via the posterior mediastinal route is a significant cause of critical morbidities related to anastomosis. In particular, care is required when performing gastric conduit reconstruction via the posterior mediastinal route in patients with a high BMI.
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Affiliation(s)
- Masanobu Nakajima
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | - Hiroto Muroi
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | - Maiko Kikuchi
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | - Junki Fujita
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | - Keisuke Ihara
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | | | - Shinji Morita
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
| | | | - Satoru Yamaguchi
- Department of SurgeryDokkyo Medical University Nikko Medical CenterNikkoJapan
| | - Kazuyuki Kojima
- First Department of SurgeryDokkyo Medical UniversityShimotsugagunJapan
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Laparoscopic ischaemic conditioning of the gastric conduit prior to a hybrid mckeown oesophagectomy may not decrease the risk of anastomotic leak. Wideochir Inne Tech Maloinwazyjne 2021; 16:669-677. [PMID: 34950261 PMCID: PMC8669984 DOI: 10.5114/wiitm.2021.105529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 02/03/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Morbidity associated with anastomotic leak after oesophagectomy is significant. Techniques to reduce this risk include ischaemic conditioning of the gastric conduit prior to oesophagectomy. Aim To quantify the rate of anastomotic leak after a hybrid minimally invasive McKeown oesophagectomy preceded by laparoscopic gastric devascularization (LGD). Material and methods We identified patients who had undergone neoadjuvant chemoradiotherapy followed by LGD and McKeown oesophagectomy and conducted a retrospective case series. The primary outcome was anastomotic leak, and secondary outcomes included common post-operative complications within 30 days. Results Eleven patients were identified. Seventy-three per cent were male, and 7 of 11 patients were age 70+ years. 91% of tumours were located in the lower oesophagus or gastroesophageal junction (GEJ), and 72% of the series had clinical stage of II–III. The median ischaemic conditioning time was 15 days. Eighteen per cent of patients developed an anastomotic leak, and all were managed non-operatively. One patient developed an anastomotic stricture. Three patients developed pneumonia. Three patients suffered wound infection at the site of the neck incision. One had respiratory failure requiring ventilator support. None required reoperation or readmission. There were no mortalities following either operation. Conclusions Laparoscopic ischaemic conditioning via LGD prior to a hybrid McKeown oesophagectomy for malignancy was associated with a leak rate similar to previously published data for a McKeown oesophagectomy without prior LGD.
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Hagiwara K, Yamashita H. Anomalous vascular anatomy of the left gastric artery in oesophagectomy. ANZ J Surg 2021; 92:1213-1214. [PMID: 34591361 DOI: 10.1111/ans.17219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ken Hagiwara
- Department of Digestive Surgery, Nihon University School of Medicine, Chiyoda-ku, Japan
| | - Hiroharu Yamashita
- Department of Digestive Surgery, Nihon University School of Medicine, Chiyoda-ku, Japan
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Ishii K, Tsubosa Y, Mayanagi S, Inoue M, Haneda R. Tissue Oxygen Saturation during Gastric Tube Reconstruction with Cervical Anastomosis for Esophagectomy: A Case Series. J INVEST SURG 2021; 35:809-813. [PMID: 34542377 DOI: 10.1080/08941939.2021.1968080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND One cause of anastomotic leakage after radical esophagectomy is blood flow insufficiency at the cervical anastomosis site. . METHODS Eighteen patients, who underwent radical esophagectomy with gastric tube reconstruction, were studied. The regional tissue oxygen saturation (rSO2) was measured at the tip (point pre 0) and 2, 4, and 6 cm on the distal side of the tip (point pre 1, pre 2, and pre 3, respectively) before the gastric tube was raised to the cervical site through the retrosternal route. After that, rSO2 was measured at the tip, 2 and 4 cm on the distal side of the tip (points post 0, post 1, and post 2), the actual anastomotic site (point AN), and the chest skin as an indicator of whole-body oxygenation. The relationship between rSO2 scores and the rate of anastomotic leakage was determined. RESULTS The mean rSO2 at pre 0, pre 1, pre 2, and pre 3 were 48.9%, 52.3%, 54.8%, and 56.9%, respectively (p < 0.05). The mean rSO2 at post 0, post 1, and post 2 were 47.8%, 50.5%, and 52.3%, respectively, and the rSO2 at point AN was 52.1%.Anastomotic leakage was found in 6 patients. The rSO2 at points pre 0, pre 1, and pre 2, post 0 and point AN were significantly lower in patients with anastomosis leakage than those without (p < 0.05). CONCLUSION Tissue oxygen saturation monitoring was a useful indicator of blood flow insufficiency in the gastric tube during radical esophagectomy.
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Affiliation(s)
- Kenjiro Ishii
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yasuhiro Tsubosa
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Shuhei Mayanagi
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Masazumi Inoue
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
| | - Ryoma Haneda
- Division of Esophageal Surgery, Shizuoka Cancer Center, Shizuoka, Japan
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Lazzaro RS, Inra ML. Commentary: Hand-sewn or stapled esophageal anastomosis: Ask not what your anastomosis can do for you, but what you can do for your esophageal anastomosis. JTCVS OPEN 2021; 7:355-356. [PMID: 36003703 PMCID: PMC9390669 DOI: 10.1016/j.xjon.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Richard S. Lazzaro
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY
| | - Matthew L. Inra
- Department of Cardiovascular and Thoracic Surgery, Northwell Health Lenox Hill Hospital, New York, NY
- Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Hempstead, NY
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Urbán D, Cserni T, Boros M, Juhász Á, Érces D, Varga G. Bladder augmentation from an insider's perspective: a review of the literature on microcirculatory studies. Int Urol Nephrol 2021; 53:2221-2230. [PMID: 34435307 DOI: 10.1007/s11255-021-02971-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023]
Abstract
Augmentation cystoplasty is an exemplary multiorgan intervention in urology which is particularly associated with microvascular damage. Our aim was to review the available intravital imaging techniques and data obtained from clinical and experimental microcirculatory studies involving the most important donor organs applied in bladder augmentation. Although numerous direct or indirect methods are available to assess the condition of microvessels the implementation of microcirculatory diagnostic methods in humans is still challenging and the assessment of organ microcirculation in the operating theatre has limitations. Nevertheless, preclinical studies generally report good internal validity and although prospective human protocols with reduced variability are needed, a possible positive impact of microcirculatory diagnostics on the clinical outcomes of urologic surgery can be anticipated.
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Affiliation(s)
- Dániel Urbán
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Tamás Cserni
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.,Department of Paediatric Urology, The Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - Mihály Boros
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Árpád Juhász
- Department of General and Thoracic Surgery, Hetényi Géza County Hospital, Tószegi u. 21., Szolnok, 5000, Hungary
| | - Dániel Érces
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary
| | - Gabriella Varga
- Institute of Surgical Research, University of Szeged, Pulz u. 1., Szeged, 6724, Hungary.
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Itou C, Arai Y, Sone M, Sugawara S, Onishi Y, Kimura S. Transgastric Feeding Tube Insertion into the Jejunum after Esophagectomy: Direct Puncture of the Gastric Conduit. J Vasc Interv Radiol 2021; 32:1464-1469. [PMID: 34363940 DOI: 10.1016/j.jvir.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous ultrasound (US)-guided direct puncture of a reconstructed gastric conduit after esophagectomy for performing a percutaneous radiologic gastrojejunostomy. MATERIALS AND METHODS Between 2014 and 2020, 26 consecutive patients with esophageal cancer (mean age, 70 years ± 8.3) with a total of 27 attempts of percutaneous radiologic gastrojejunostomy for postsurgical enteral feeding at the National Cancer Center Hospital were included in this study. One patient required a repeat procedure because of persistent anorexia after the removal of the first tube. All patients except 1 had a gastric conduit reconstructed via a retrosternal route. All procedures were performed under local anesthesia with moderate sedation and analgesia. A gastric conduit was directly punctured with an 18-gauge needle under ultrasonographic guidance, followed by feeding tube insertion into the proximal jejunum. Technical details of the procedures, technical success (defined as adequate tube placement), procedure-related complications, and clinical outcomes were reviewed. RESULTS The mean procedure time was 25 minutes ± 15, and technical success was obtained in every attempt. Minor complications included mild local pain (n = 7), unintentional tube removal (n = 2), local abdominal wall hematoma (n = 1), and superficial cellulitis (n = 1); no major complications were observed. During a mean follow-up period of 118.3 days ± 85.8, 13 patients resumed oral intake, and the feeding tube could be removed in 4 patients. No procedure-related deaths occurred. CONCLUSIONS The US-guided direct puncture technique is feasible for percutaneous gastrojejunal tube insertion in postsurgical patients with esophageal cancer with gastric conduit reconstruction.
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Affiliation(s)
- Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan.
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuyuki Onishi
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
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Housman B, Lee DS, Wolf A, Nicastri D, Kaufman A, Rizk N, Housman A, Song K, Hakami A, Flores RM. Major modifications to minimize thoracic esophago-gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy. J Surg Oncol 2021; 124:529-539. [PMID: 34081346 DOI: 10.1002/jso.26550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/20/2021] [Accepted: 05/19/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND The Ivor Lewis esophagectomy (ILE) remains the procedure of choice for localized middle or lower esophageal carcinoma. Nevertheless, anastomotic leak remains a common complication with rates from 3% to 25% and a stricture rate as high as 40%. The frequency of these complications suggests that the procedure itself may have inherent limitations including the use of potentially ischemic tissue for the esophagogastric anastomosis. We introduce a modified technique that reduces operative steps, preserves blood supply, and uses a modified esophagogastric anastomosis. METHODS All consecutive patients undergoing ILE with the described modified technique were identified. An esophagram was performed on postoperative day six or seven. To ensure that all cases were identified, anastomotic leaks were defined as any radiographic evidence of contrast extravasation. RESULTS A total of 110 patients underwent the modified esophagectomy with 2 anastomotic leaks (1.82%) and zero strictures. There was 1 late death but no early deaths (<30 or 90 days) or early re-admissions (<30 days). The average number of risk factors was 2.12, and 98 patients (90%) had at least 1 risk factor in their medical history. CONCLUSIONS The modifications proposed simplify procedural steps, limit unnecessary dissection and introduce a technique that ends the practice of connecting ischemic tissue. We believe this technique contributes to surgical durability and reduces the rate of postoperative leak and eliminates stricture.
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Affiliation(s)
- Brian Housman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Dong-Seok Lee
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Andrea Wolf
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Daniel Nicastri
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Andrew Kaufman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nabil Rizk
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Arno Housman
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Kimberly Song
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Ardeshir Hakami
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Raja M Flores
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
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Zheng L, Lee IJ, Shin JH, Chu HH, Li HL. Endovascular Management of Gastric Conduit Hemorrhage following Transthoracic Esophagectomy. J Vasc Interv Radiol 2021; 32:1144-1149. [PMID: 34022402 DOI: 10.1016/j.jvir.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 10/21/2022] Open
Abstract
Seven patients underwent angiography and attempted embolization for massive hemorrhage of the gastric conduit after transthoracic esophagectomy. Endoscopy revealed ulcers in 5 patients, tumor recurrence in 1 patient, and unknown etiology in 1 patient. Arteriography revealed extravasation, pseudoaneurysm, or tumor blush arising from the intercostal artery (n = 4) or right gastric artery (n = 2), which were successfully embolized. The bleeding source was not identified in 1 patient, who died from persistent hemorrhage.
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Affiliation(s)
- Lin Zheng
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - In Joon Lee
- Department of Radiology, National Cancer Center, Goyang-si, Gyeonggi-do, Korea
| | - Ji Hoon Shin
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China; Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea.
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
| | - Hai-Liang Li
- Department of Radiology, The Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
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Maruyama S, Okamura A, Watanabe M. ASO Author Reflections: Does Damaged Stomach Increase the Risk of Anastomotic Leakage After Esophagectomy? Ann Surg Oncol 2021; 28:7247-7248. [PMID: 34018085 DOI: 10.1245/s10434-021-10168-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Suguru Maruyama
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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Maruyama S, Okamura A, Kanie Y, Sakamoto K, Fujiwara D, Kanamori J, Imamura Y, Watanabe M. Influence of Damaged Stomach on Anastomotic Leakage following Cervical Esophagogastrostomy in Patients with Esophageal Cancer. Ann Surg Oncol 2021; 28:7240-7246. [PMID: 33999347 DOI: 10.1245/s10434-021-10145-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/25/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is one of the most common complications after esophagectomy. Although some patients have a history of peptic ulcers or other prior stomach diseases, the influence of a damaged stomach (DS) on AL incidence remains unclear. Therefore, we investigated the association between DS and incidence of AL in patients who underwent esophagectomy. PATIENTS AND METHODS Between 2015 and 2019, a total of 447 consecutive patients who underwent cervical esophagogastrostomy using gastric tube following esophagectomy were enrolled. DS was defined on the basis of endoscopic findings of ulcers or scars due to medical history or prior treatment. We compared the incidence of AL between patients with DS and those with a healthy stomach (HS). Univariate and multivariate logistic regression analyses were used to identify factors that could predict AL incidence. RESULTS Fifty-one patients (11.4%) had DS. Causes of DS included peptic ulcer (n = 36), endoscopic resection for early gastric cancer (n = 9), percutaneous endoscopic gastrostomies (n = 5), and post-chemotherapy scar for gastric malignant lymphoma (n = 1). Overall, AL occurred in 35 patients (7.8%). The incidence of AL in the DS group was significantly higher than in the HS group (15.7 vs. 6.8%, p = 0.03). DS was one of the independent predictive factors for AL (odds ratio, 2.75; 95% confidence interval, 1.10-6.92; p = 0.03) on multivariate analysis. Further, the diseases in the lower third of the conduit were associated with AL. CONCLUSIONS Presence of DS can predict AL in patients who underwent cervical esophagogastrostomy after esophagectomy.
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Affiliation(s)
- Suguru Maruyama
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akihiko Okamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan.
| | - Yasukazu Kanie
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kei Sakamoto
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Daisuke Fujiwara
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Jun Kanamori
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
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Dixit J, Subash A, Gowda N, Deepak H, Amanulla. Hand Rule of 5 for a Robust Gastric Conduit in Minimal Access Onco-Surgery. Indian J Surg Oncol 2021; 12:432-436. [PMID: 34295091 DOI: 10.1007/s13193-021-01323-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 04/14/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Jaganath Dixit
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India.,Department of Surgical Oncology, HCG Cancer Hospital, Bengaluru, Karnataka India
| | - Anand Subash
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - Naveen Gowda
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - H Deepak
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
| | - Amanulla
- Department of Surgical Oncology, HCG Cancer Centre, Bangalore, India
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Sasaki K, Omoto I, Uchikado Y, Okumura H, Noda M, Tsuruda Y, Kita Y, Arigami T, Mori S, Kurahara H, Nakajyo A, Koriyama C, Natsugoe S, Ohtsuka T. Comparison of greater curvature and lesser curvature circular-stapled esophagogastrostomy after esophagectomy in patients with esophageal cancer: a prospective randomized controlled trial. Surg Today 2021; 51:575-581. [PMID: 32974752 DOI: 10.1007/s00595-020-02147-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Using a circular stapler to create an anastomosis for esophagogastrostomy after esophagectomy is well accepted; however, it remains uncertain if the greater curvature (GC) or lesser curvature (LC) of the gastric conduit is better for the anastomosis. We conducted this prospective study to compare the integrity of esophagogastrostomy between the esophagus and the GC or LC side of the gastric conduit. METHODS The subjects of this study were 70 patients who underwent esophagectomy and were randomized to a "GC" group and an "LC" group (n = 35 each). The primary and secondary end points were anastomotic leakage (AL) and anastomotic stricture (AS), respectively. RESULTS The overall AL rate was 22.1%, without a significant difference between the groups. Stump leakage developed in eight of nine patients in the GC group, whereas leakage developed at the esophagogastric anastomosis in five of six patients in the LC group. The rate of stump leakage was significantly higher than that of esophagogastric AL in the GC group. The overall AS rate was 4.4%, with a significant difference between the groups (0% in the GC group vs. 9.1% in the LC group). CONCLUSIONS AL rates were comparable in the two groups, but the sites of leakage were significantly different.
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Affiliation(s)
- Ken Sasaki
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan.
| | - Itaru Omoto
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yasuto Uchikado
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Hiroshi Okumura
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Masahiro Noda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yusuke Tsuruda
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Yoshiaki Kita
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takaaki Arigami
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shinichiro Mori
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Hiroshi Kurahara
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Akihiro Nakajyo
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Chihaya Koriyama
- Department of Epidemiology and Preventive Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Shoji Natsugoe
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
| | - Takao Ohtsuka
- Department of Digestive Surgery, Breast and Thyroid Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima-shi, Kagoshima, 890-8520, Japan
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Koyanagi K, Ozawa S, Ninomiya Y, Oguma J, Kazuno A, Yatabe K, Higuchi T, Yamamoto M. Association between indocyanine green fluorescence blood flow speed in the gastric conduit wall and superior mesenteric artery calcification: predictive significance for anastomotic leakage after esophagectomy. Esophagus 2021; 18:248-257. [PMID: 33165752 DOI: 10.1007/s10388-020-00797-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/30/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Near-infrared fluorescence using indocyanine green (ICG) has been applied as a real-time navigation tool to observe blood flow in gastric conduit wall after esophagectomy. Atherosclerosis might impair the blood flow of the systemic organs. The aim of the study was to investigate the significances of ICG blood flow speed in the gastric conduit wall and atherosclerotic calcification for the prediction of anastomotic leakage after esophagectomy. METHODS The 109 esophageal cancer patients were prospectively enrolled. ICG fluorescence blood flow speed in the gastric conduit wall and abdominal aortic calcification index (ACI), celiac artery (CA) calcification, and superior mesenteric artery (SMA) calcification were determined. Then, the correlation between ICG fluorescence blood flow speed and anastomotic leakage as well as ACI, CA, and SMA calcification were evaluated. RESULTS Anastomotic leakage occurred in 15 patients. ACI ranged from 0 to 65. CA calcification and SMA calcification were present in 25 and 12 patients. Multivariate analysis demonstrated that ICG fluorescence blood flow speed in the gastric conduit wall of 2.07 cm/s or less (P < 0.001) and SMA calcification (P = 0.026) were the significant independent predictors of anastomotic leakage. Only SMA calcification was significantly associated with ICG fluorescence blood flow speed in the gastric conduit wall (P = 0.026). CONCLUSIONS This study demonstrated that ICG fluorescence blood flow speed in the gastric conduit wall can predict anastomotic leakage after esophagectomy and microvascular perfusion of capillary vessels of the gastric conduit might be impaired by systemic atherosclerosis.
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Affiliation(s)
- Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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45
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Maglangit SACA, Macalindong SS, Dofitas RB, Cabaluna ND. Indocyanine Green (ICG) fluorescence angiography of gastric conduit after transhiatal thoracic esophagectomy with proximal gastrectomy for esophagogastric junction adenocarcinoma: A case report and initial experience at a tertiary government hospital in the Philippines. Int J Surg Case Rep 2021; 80:105653. [PMID: 33611079 PMCID: PMC7905447 DOI: 10.1016/j.ijscr.2021.105653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE We documented the initial experience in our institution where we used indocyanine green (ICG) fluorescence angiography as adjunct in the evaluation of the vascular supply of a reconstructed gastric conduit for esophageal replacement for esophagogastric junction (EGJ) cancer surgery. CASE PRESENTATION A 62-year-old patient consulted with a two-month history of melena and weight loss and unremarkable chest and abdominal physical examinations. CLINICAL FINDINGS AND INVESTIGATIONS Upper endoscopy and contrast-enhanced computed tomography scans of the chest and abdomen demonstrated an EGJ tumor with no nodal and distant metastases, which revealed adenocarcinoma on biopsy. INTERVENTION AND OUTCOME The patient underwent combined thoracoscopic-assisted and transhiatal thoracic esophagectomy with proximal gastrectomy. Esophageal reconstruction was done via a retrosternal gastric pull-up. The perfusion and viability of the gastric conduit were confirmed as per usual methods of inspection and palpation. ICG fluorescence angiography further demonstrated and confirmed the vascular perfusion of the gastric conduit and the optimal site of anastomosis. The patient had an unremarkable postoperative course with no reported anastomotic leakage and stricture formation at 12 months follow-up. RELEVANCE AND IMPACT ICG fluorescence angiography represents a feasible and promising tool in assessing viability of esophageal replacement and choosing the optimal site for anastomosis with the proximal esophagus. It can aid in choosing the most appropriate site of anastomosis to prevent ischemia-related complications such as leakage or stricture. This particular case can serve as an initial learning experience to guide surgeons in our institution in the use of ICG fluorescence angiography for esophageal replacements after esophagectomy.
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Affiliation(s)
- Sittie Aneza Camille A Maglangit
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines.
| | - Shiela S Macalindong
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
| | - Rodney B Dofitas
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
| | - Nelson D Cabaluna
- Division of Surgical Oncology, Head & Neck, Breast, Skin & Soft Tissue, and Esophagogastric Surgery, Department of Surgery, Philippine General Hospital, University of the Philippines Manila, Philippines
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Zhang CC, Liesenfeld L, Klotz R, Koschny R, Rupp C, Schmidt T, Diener MK, Müller-Stich BP, Hackert T, Sauer P, Büchler MW, Schaible A. Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection. BMC Gastroenterol 2021; 21:72. [PMID: 33593301 PMCID: PMC7885467 DOI: 10.1186/s12876-021-01651-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/28/2020] [Indexed: 12/12/2022] Open
Abstract
Background Anastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection. Methods From March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included. Results Fifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest. Conclusions EVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities. Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).
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Affiliation(s)
- Chengcheng Christine Zhang
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Lukas Liesenfeld
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Ronald Koschny
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Christian Rupp
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, University of Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Dorothea Liebermann-Meffert (*1930: †2020)-A Life Dedicated to Surgery. World J Surg 2021; 45:653-654. [PMID: 33386455 DOI: 10.1007/s00268-020-05891-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
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Liddle S, Mirakhur A, Debru E. Challenging delayed bleeding after an Ivor Lewis oesophagectomy. J Surg Case Rep 2020; 2020:rjaa471. [PMID: 33365117 PMCID: PMC7745143 DOI: 10.1093/jscr/rjaa471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/04/2020] [Accepted: 10/21/2020] [Indexed: 01/15/2023] Open
Abstract
A 66-year-old man underwent a minimally invasive oesophagectomy for oesophageal adenocarcinoma. Surgery and recovery were routine; however, he represented 8 days later with a massive upper gastrointestinal bleed. He was stabilized, but over a 2-week period experienced several bleeds requiring transfusion and multiple endoscopies, all showing a prominent luminal vessel at the oesophago-gastric (OG) anastomosis. Haemostatic clipping was attempted resulting in pulsatile bleeding and transfer to the radiology suite where angiography showed extravasation of contrast at the OG anastomosis from the terminal portion of the gastro-epiploic arcade. Coil embolization was successful and did not result in ischaemia. It was our standard to construct the OG anastomosis with the end-to-end anastomosis circular stapler (DST™ Series EEA™), 4.8-mm staple height. However, we now use the 3.5-mm staple height for improved haemostasis and ensure that the area for anastomosis is cleared of omental tissue so as not to incorporate a visible vessel.
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Affiliation(s)
- Sean Liddle
- Division of General Surgery, Peter Lougheed Hospital, Calgary, Alberta T1Y 6J4, Canada
| | - Anirudh Mirakhur
- Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 1N4, Canada
| | - Estifanos Debru
- Division of General Surgery, Peter Lougheed Hospital, Calgary, Alberta T1Y 6J4, Canada
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49
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Safi N, Johannessen HO, Medhus AW, Mala T, Kazmi SSH. Laser Doppler Flowmetry and Visible Light Spectroscopy of the Gastric Tube During Minimally Invasive Esophagectomy. Vasc Health Risk Manag 2020; 16:497-505. [PMID: 33273819 PMCID: PMC7708681 DOI: 10.2147/vhrm.s269138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/30/2020] [Indexed: 02/01/2023] Open
Abstract
Introduction Ischemia is considered as the main reason for thoracic gastroesophageal anastomotic leaks after esophagectomy. Microcirculatory monitoring with laser Doppler flowmetry and visible light spectroscopy may provide valuable intraoperative real-time information about the gastric tube’s tissue perfusion and circulation. Patients and Methods Ten patients with esophageal cancer operated with minimally invasive esophagectomy participated in this single-center, prospective, observational pilot study. A single probe with laser Doppler flowmetry and visible light spectroscopy was used to perform transserosal microcirculation assessment of the gastric tube at predefined anatomical sites during different operation phases. Group comparison and changes were evaluated using the paired sample t-test. Results A reduction in StO2 was found at all measuring sites after the gastric tube formation compared with the baseline measurements. The mean StO2 reduction from baseline to gastric tube formation and after anastomosis was 16% (range 4%–28%) and 42% (range, 35%–52%), respectively. A statistically significant increase in the rHb concentration, representing venous congestion, was detected at the most cranial part of the gastric tube (P = 0.04). Three patients developed anastomotic leaks. Conclusion Intraoperative real-time laser Doppler flowmetry and visible light spectroscopy are feasible and may provide insight to microcirculatory changes in the gastric tube and at the anastomotic site. Patients with anastomotic leaks seem to have critical local tissue StO2 reduction and venous congestion that should be further evaluated in studies with larger sample sizes.
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Affiliation(s)
- Nathkai Safi
- Department of Vascular Surgery, Heart, Lung and Vascular Clinic, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Oslo University, Oslo, Norway
| | | | | | - Tom Mala
- Faculty of Medicine, Oslo University, Oslo, Norway.,Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Syed S H Kazmi
- Department of Vascular Surgery, Heart, Lung and Vascular Clinic, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, Oslo University, Oslo, Norway
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50
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Antonowicz S, Reddy S, Sgromo B. Gastrointestinal side effects of upper gastrointestinal cancer surgery. Best Pract Res Clin Gastroenterol 2020; 48-49:101706. [PMID: 33317793 DOI: 10.1016/j.bpg.2020.101706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/21/2020] [Accepted: 11/05/2020] [Indexed: 02/07/2023]
Abstract
In this chapter, we describe the gastrointestinal side effects of oesophagectomy, gastrectomy and pancreaticoduodenectomy for cancer, with a focus on long-term functional impairments and their management. Improvements in upper gastrointestinal cancer surgery have led to a growing group of long-term survivors. The invasive nature of these surgeries profoundly alters the upper gastrointestinal anatomy, with lasting implications for long-term function, and how these impairments may be treated. Successfully maintaining a high quality of survivorship requires multidisciplinary approach, with survivorship care plans focused on function as much as the detection of recurrence.
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Affiliation(s)
- S Antonowicz
- Oxford Oesophago Gastric Centre, Oxford University Hospitals NHS Trust, UK
| | - S Reddy
- Hepatobiliary and Pancreatic Unit, Oxford University Hospitals NHS Trust, UK
| | - B Sgromo
- Oxford Oesophago Gastric Centre, Oxford University Hospitals NHS Trust, UK.
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