Size of the thoracic inlet predicts cervical anastomotic leak after retrosternal reconstruction after esophagectomy for esophageal cancer

SUMMARY Transthoracic esophagectomy with gastric tube formation is the surgical treatment of choice for esophageal cancer. The surgical reconstruction induces changes of gastric microcirculation, which are recognized as potential risk factors of anastomotic leak. This prospective observational study investigates the association of celiac trunk (TC) stenosis with postoperative anastomotic leak. One hundred fifty-four consecutive patients with esophageal cancer scheduled for Ivor–Lewis esophagectomy were included. Preoperative staging computed tomography (CT) was used to identify TC stenosis. Any narrowing of the lumen due to atherosclerotic changes was classified as stenosis. Percentage of stenotic changes was calculated using the North American Symptomatic Carotid Endarterectomy Trial formula. Multivariable analysis was used to identify possible risk factors for leak. The overall incidence of TC stenosis was 40.9%. Anastomotic leak was identified in 15 patients (9.7%). Incidence of anastomotic leak in patients with stenosis was 19.4% compared to 2.3% in patients without stenosis. Incidence of stenosis in patients with leak was 86.7% (13 of 15 patients) and significantly higher than 38.8% (54 of 139 patients) in patients without leak (P < 0.001). There was a significant difference in median degree of TC stenosis (50.0% vs 39.4%; P = 0.032) in patients with and without leak. In the multivariable model, TC stenosis was an independent risk factor for anastomotic leak (odds ratio: 5.98, 95% CI: 1.58–22.61). TC stenosis is associated with postoperative anastomotic leak after Ivor–Lewis esophagectomy. Routine assessment of TC for possible stenosis is recommended to identify patients at risk.

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The impact of cervical anastomotic leak after esophagectomy on long-term survival of patients with esophageal cancer

Surgery ◽

10.1016/j.surg.2021.10.011 ◽

2021 ◽

Author(s):

Vladimir Tverskov ◽

Ory Wiesel ◽

Daniel Solomon ◽

Ran Orgad ◽

Hanoch Kashtan

Keyword(s):

Esophageal Cancer ◽

Anastomotic Leak ◽

Term Survival ◽

Long Term Survival ◽

The Impact

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Anastomotic leakage after esophagectomy possibly caused by compression of the gastric conduit behind the sternoclavicular joint: a report of three cases

Surgical Case Reports ◽

10.1186/s40792-021-01250-3 ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Yasunori Kurahashi ◽

Yudai Hojo ◽

Tatsuro Nakamura ◽

Tsutomu Kumamoto ◽

Yoshinori Ishida ◽

...

Keyword(s):

Blood Flow ◽

Esophageal Cancer ◽

Anastomotic Leakage ◽

Gastric Wall ◽

Sternoclavicular Joint ◽

Gastric Conduit ◽

Thoracic Inlet ◽

Indocyanine Green Fluorescence ◽

Subtotal Esophagectomy ◽

First Case

Abstract Background The narrowness of the thoracic inlet is often a problem in retrosternal reconstruction after esophagectomy. We report here three cases in which compression of the gastric conduit behind the sternoclavicular joint possibly caused anastomotic leakage. Case presentations The first case was a 71-year-old man who underwent subtotal esophagectomy for upper esophageal cancer followed by retrosternal reconstruction. On postoperative day 2, he developed septic shock and underwent reoperation because of a necrotic gastric conduit. The tip of the conduit above the manubrium was necrotic due to strangulation as a result of compression by the sternoclavicular joint. The second and third cases were a 50-year-old woman and a 71-year-old man who underwent subtotal esophagectomy for middle and lower esophageal cancer, respectively, followed by retrosternal reconstruction. Despite indocyanine green fluorescence imaging indicating adequate blood flow in both cases, the tip of the conduit appeared pale and congested because of compression by the sternoclavicular joint after anastomosis. Postoperatively, these two patients developed anastomotic leakage that was confirmed endoscopically on the ventral side of the gastric wall that had been pale intraoperatively. Conclusions When performing reconstruction using the retrosternal route after esophagectomy, it is important to ensure that compression by the sternoclavicular joint does not have an adverse impact on blood flow at the tip of the gastric conduit.

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Prevalence of anastomotic leak and the impact of indocyanine green fluorescein imaging for evaluating blood flow in the gastric conduit following esophageal cancer surgery

Esophagus ◽

10.1007/s10388-017-0585-5 ◽

2017 ◽

Vol 14 (4) ◽

pp. 351-359 ◽

Cited By ~ 32

Author(s):

Masaki Ohi ◽

Yuji Toiyama ◽

Yasuhiko Mohri ◽

Susumu Saigusa ◽

Takashi Ichikawa ◽

...

Keyword(s):

Blood Flow ◽

Esophageal Cancer ◽

Indocyanine Green ◽

Anastomotic Leak ◽

Gastric Conduit ◽

Cancer Surgery ◽

Esophageal Cancer Surgery ◽

The Impact

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Intrathoracic hand-sewn esophagogastric anastomosis in prone position during totally minimally invasive two-stage esophagectomy for esophageal cancer

Diseases of the Esophagus ◽

10.1093/dote/doaa106 ◽

2020 ◽

Author(s):

Alexandros Charalabopoulos ◽

Spyridon Davakis ◽

Athanasios Syllaios ◽

Bruno Lorenzi

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Anastomotic Leak ◽

Prone Position ◽

Minimally Invasive Esophagectomy ◽

Esophagogastric Anastomosis ◽

Two Stage ◽

End Points ◽

Intrathoracic Anastomosis ◽

Invasive Esophagectomy

Summary Utilization of totally minimally invasive esophagectomy for cancer is on the rise. Esophagogastric anastomosis is mechanically or robotically performed routinely; little report exists of hand-sewn esophagogastric anastomosis. This is the largest so far study with thoracoscopic hand-sewn esophagogastric anastomosis during fully minimally invasive two-stage esophagectomy for esophageal cancer in prone position. Consecutive two-stage totally minimally invasive esophagectomies for cancer were performed by one surgical team, from September 2016 to March 2019. All operations were technically identical in terms of patient positioning, surgical approach, extend of lymphadenectomy and type of anastomosis formed. Primary end points were anastomotic leak and anastomotic stricture rate, while secondary end points were 30-day and 90-day mortality rates. From the overall n = 80 patients, n = 67 were males, while n = 13 were females. Mean age was 64.6 years. Mean length of stay was n = 14 days. There were no conversions to open. Mean operating time was 420 minutes with no blood loss over 200 mL noted. Pulmonary and cardiac complication rate was 23.75% and 2.5%, respectively. Anastomotic leak rate was 2.5%. Anastomotic strictures were seen in 12.5% of cases. 30-day and 90-day mortality rate was 2.5% and 5%, respectively, with none accounted for ischemic conduit complications. Intrathoracic anastomosis in totally minimally invasive esophagectomy is challenging and accountable for most of the mortality associated with the procedure. In thoracoscopic two-stage esophagectomy, a mechanical anastomosis is usually preferred; this is believed to be due to the complexity of manual anastomosis associated with the thoracoscopic approach. We aim to present our series of completely hand-sewn intrathoracic anastomosis utilizing a totally minimally invasive approach with favorable outcomes. With this study, reproducibility of the anastomosis is shown that can potentially favor a change in the practice of esophageal surgeons worldwide.

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Anastomotic Leak after Esophagectomy for Esophageal Cancer Treated with a Stent: A Case Report

Cureus ◽

10.7759/cureus.4055 ◽

2019 ◽

Author(s):

Mohamed Ahmed ◽

Saba Habis ◽

Ahmed Mahmoud ◽

Michael Chin ◽

Rasha Saeed

Keyword(s):

Esophageal Cancer ◽

Case Report ◽

Anastomotic Leak

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Does Circular Stapler Size in Surgical Management of Esophageal Cancer Affect Anastomotic Leak Rate? 4-Year Experience of a European High-Volume Center

Cancers ◽

10.3390/cancers12113474 ◽

2020 ◽

Vol 12 (11) ◽

pp. 3474

Author(s):

Dolores T. Müller ◽

Benjamin Babic ◽

Veronika Herbst ◽

Florian Gebauer ◽

Hans Schlößer ◽

...

Keyword(s):

Esophageal Cancer ◽

Minimally Invasive ◽

Anastomotic Leak ◽

Minimally Invasive Esophagectomy ◽

Circular Stapler ◽

High Volume ◽

Time Frame ◽

Invasive Esophagectomy ◽

Quality Of Surgery ◽

The Individual

Anastomotic leak is one of the most severe postoperative complications and is therefore considered a benchmark for the quality of surgery for esophageal cancer. There is substantial debate on which anastomotic technique is the best for patients undergoing Ivor Lewis esophagectomy. Our standardized technique is a circular stapled anastomosis with either a 25 or 28 mm anvil. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively (p = 0.0925). Stapler size should be chosen according to the individual anatomical situation of the patient. Stapler size may be of higher relevance in patients undergoing totally minimally invasive reconstruction.

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Intraoperative hypotension is not associated with adverse short-term postoperative outcomes after esophagectomy in esophageal cancer patients

10.21203/rs.3.rs-37807/v1 ◽

2020 ◽

Author(s):

Ephraim Teffera Yeheyis ◽

Seyoum Kassa ◽

Hiwot Yeshitila ◽

Abebe Bekele

Keyword(s):

Blood Pressure ◽

Esophageal Cancer ◽

Systolic Blood Pressure ◽

Hospital Stay ◽

Anastomotic Leak ◽

Postoperative Outcome ◽

Adverse Outcomes ◽

Prolonged Hospital Stay ◽

Intraoperative Hypotension ◽

Prolonged Hospital

Abstract Background The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied. Methods Prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastrostomy for esophageal cancer. Intraoperative Hypotension (IOH), defined as Systolic Blood Pressure (SBP) < 90 mm Hg lasting more than 5 minutes, was recorded. Patients’ 30 days post-operative composite outcome of mortality, anastomotic leak and prolonged hospital stay were analyzed as outcome variables Result A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. Mean duration of the surgery was 208 minutes. Intraoperative mean low SBP was 80mmHg while the lowest record was 55 mmHg. IOH occurred in 51 .2 % (n=29) of patients; of these, 7.4% (n=4) had anastomotic leak (OR 1.2, 95% CI 0.26-6.3; p=0.76) , mortality was 5.5% (n=3) (OR 1.44, 95% CI 0.22- 9.3; p =0.7) and 33 % (n=18) had prolonged hospital stay (OR 0.53, 95% CI 0.14- 1.9; p=0.34 ).Over all anastomotic leak rate was 13% (n=7). The 30 days operative mortality was 9.2% and 55 % (30) of patients had prolonged hospital stay. Multivariate analysis (logistic regression model) showed SBP < 90mmHg for more than 5 minutes was not significantly associated either with individual or composite out comes of mortality, anastomotic leak and prolonged hospital stay (AOR 1.06 ,95% CI 0.98-1.14; p=0.16) Conclusion In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association either with individual or composite adverse outcomes of mortality, anastomotic leak and prolonged hospital stay.

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