End to side circular stapled anastomosis during robotic-assisted Ivor Lewis minimally invasive esophagectomy (RAMIE)

Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224 minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.

There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy

Introduction Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. Patients and methods 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. Results 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. Conclusion Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

Pre-emptive active drainage of reflux (PARD) in Ivor-Lewis oesophagectomy with negative pressure and simultaneous enteral nutrition using a double-lumen open-pore film drain (dOFD)

Background Postoperative reflux can compromise anastomotic healing after Ivor-Lewis oesophagectomy (ILE). We report on Pre-emptive Active Reflux Drainage (PARD) using a new double-lumen open-pore film drain (dOFD) with negative pressure to protect the anastomosis. Methods To prepare a dOFD, the gastric channel of a triluminal tube (Freka®Trelumina, Fresenius) is coated with a double-layered open-pore film (Suprasorb®CNP drainage film, Lohmann & Rauscher) over 25 cm. The ventilation channel is blocked. The filmcoated segment is placed in the stomach and the intestinal feeding tube in the duodenum. Negative pressure is applied with an electronic vacuum pump (− 125 mmHg, continuous suction) to the gastric channel. Depending on the findings in the endoscopic control, PARD will either be continued or terminated. Results PARD was used in 24 patients with ILE and started intraoperatively. Healing was observed in all the anastomoses. The median duration of PARD was 8 days (range 4–21). In 10 of 24 patients (40%) there were issues with anastomotic healing which we defined as “at-risk anastomosis”. No additional endoscopic procedures or surgical revisions to the anastomoses were required. Conclusions PARD with dOFD contributes to the protection of anastomosis after ILE. Negative pressure applied to the dOFD (a nasogastric tube) enables enteral nutrition to be delivered simultaneously with permanent evacuation and decompression.

Comparison of Two Circular-Stapled Techniques for Esophageal Cancer: A Propensity-Matched Analysis

ObjectiveThe optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil™) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil™) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE).MethodsThe data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage.ResultsIn the propensity score-matched analysis, compared with the non-Orvil™ group, the Orvil™ group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p&lt;0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p&lt;0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p&lt;0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p&lt; 0.05).ConclusionsOrvil™ anastomosis exhibited better perioperative effects than non-Orvil™ anastomosis after the propensity score-matched analysis. Remarkably, the Orvil™ technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil™ technique.

P-OGC88 Is Routine Contrast Swallow after Ivor-Lewis Oesophagectomy Required or Justified?

Background Traditionally many Upper-GI cancer tertiary centres have carried out contrast swallow fluoroscopic studies as a routine after Ivor-Lewis “Two-Stage” Oesophagectomy. However, more recently studies have demonstrated the limited value of this test as a routine screening study. The primary outcome of our study was to assess the sensitivity of routine contrast swallow in identifying anastomotic leak post oesophagectomy and identify how the study changed management of these patients. Methods This was a single-centre retrospective study involving 2-observer data collection. Data was collected and analysed from clinical notes for all patients who underwent an Ivor-Lewis oesophagectomy for cancer between January 2011 to December 2020. Results A total of 220 patients were identified. Protocol at the centre was to obtain a routine contrast swallow in the Fluoroscopy department on the fifth post-operative day– which occurred in 211 patients (96%). A total of 19 (8.64%) patients were diagnosed with an anastomotic leak (clinically and/or radiologically), with contrast swallow imaging and/or computed tomography (CT). There was no correlation between incidence of leak and T stage (p = 0.38) and N staging (p = 0.22). Only 3 of 19 anastomotic leaks were positively identified on contrast swallow study. All patients with anastomotic leak identified by contrast swallow study were asymptomatic i.e. “subclinical”. 2 patients were managed conservatively; one underwent endoscopic stent insertion. CT scan with oral contrast was the mode of diagnosis for 16 anastomotic leaks; where 10 patients underwent a CT scan following a normal contrast swallow study due to suspicious symptoms and 6 patients underwent expedited CT scans prior to Day-5 contrast swallow study due to presence of symptoms and limitation of fluoroscopy resources. The sensitivity of the Day-5 contrast swallow study was calculated to be 15.8% (CI 3.4, 39.6) with a specificity of 98.0% (CI 95.0, 99.5). Conclusions Our data reflects that routine contrast swallow study on Day-5 post Ivor-Lewis esophagectomy has a poor sensitivity in detecting anastomotic leak and may be falsely reassuring. The vast majority of patients had no change in management as a result of contrast swallow. This adds to the growing body of evidence limiting the role of contrast swallow in this situation. We recommend that clinical judgement and use of CT and endoscopy be the surgeon’s prime tools in the diagnosis of anastomotic leak post oesophagectomy.

Comparative analysis of long-term oncologic outcomes for minimally invasive and open Ivor Lewis esophagectomy after neoadjuvant chemoradiation: a propensity score matched observational study

Background Locally advanced esophageal carcinoma is typically treated with neoadjuvant chemoradiation and esophagectomy (trimodality therapy). We compared the long-term oncologic outcomes of minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases after trimodality therapy. Methods This is a retrospective review of 223 patients diagnosed with esophageal carcinoma who underwent neoadjuvant chemoradiation followed by M-ILE or O-ILE from April 2009 to February 2019. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Kaplan–Meier survival curves were calculated for overall survival and recurrence-free survival comparing the two groups. Multivariate Cox proportional hazards regression models were used to determine predictive variables for overall and recurrence-free survival. Results The IPTW cohort included patients with esophageal carcinoma who underwent M-ILE (n = 142) or O-ILE (n = 68). The overall rate of postoperative adverse events was not significantly different after IPTW adjustment between the O-ILE and M-ILE trimodality groups (53.4% vs. 39.2%, p = 0.089). The 3-year overall survival (OS) for the M-ILE group was 59.4% (95% CI: 49.8–67.8) compared to 55.7% (95% CI: 39.2–69.4) for the O-ILE group (p = 0.670). The 3-year recurrence-free survival for the M-ILE group was 59.9% (95% CI: 50.2–68.2) compared to 61.6% (95% CI: 41.9–76.3) for the O-ILE group (p = 0.357). A complete response to neoadjuvant chemoradiation was significantly predictive of improved OS and RFS. Conclusion The overall and recurrence-free survival rates for M-ILE were not significantly different from O-ILE for esophageal carcinoma after trimodality therapy. Complete response to neoadjuvant chemoradiation was predictive of improved overall and recurrence- free survival.

The effect of age on short-term and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy: a propensity score-matched analysis

Background The number of elderly patients diagnosed with esophageal cancer rises. Current information about outcomes in elderly patients undergoing thoracoscopic Ivor Lewis esophagectomy is limited. The objective of this study was to evaluate the influence of age on short-and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy. Methods A retrospective review of 188 patients with esophageal cancer undergoing thoracoscopic Ivor Lewis esophagectomy between August 2014 and July 2019 was performed. Patients were divided into patients aged > 75 years (elderly group (EG), n = 37) and patients ≤ 75 years (younger group (YG), n = 151) and matched using propensity-score matching. Baseline characteristics, length of hospital stay, mortality and major postoperative complications (Clavien-Dindo ≥ grade III) were compared. Results After matching 74 patients remained (n = 37 in each group). Postoperatively, no significant differences in major and overall complications, intra-hospital and 30-day mortality, disease-free or overall survival up to 3 years after surgery were noted. The incidence of pulmonary complications (65% vs. 38%) and pneumonia (54% vs. 30%) was significantly higher and the median hospital length of stay (12 vs. 14 days) significantly longer in the EG versus YG. Conclusion Thoracoscopic Ivor Lewis esophagectomies resulted in acceptable postoperative major morbidity and mortality without compromising 3-years overall and disease-free survival in elderly compared to younger patients with esophageal cancer. However, the incidence of postoperative pulmonary complications was higher in patients aged over 75 years.

P-OGC37 Lymphatic embolisation for chylous abdomen following oesophagectomy

Background A 78 year old man underwent an Ivor Lewis oesophagectomy (laparoscopic converted to open abdominal phase, right thoracotomy) for a T2 N2 (3/81) R0 Type II GOJ adenocarcinoma post FLOT neoadjuvant chemotherapy. He developed a chylous abdomen requiring drainage radiologically. A percutaneous lymphatic embolisation was performed which showed a leak in the region of the cisterna chyli which was successfully treated. Methods A lymph node in each groin was cannulated under US guidance using spinal needles and an infusion of Lipiodol was started at a rate of 6ml/hr each side. Lymphatic opacification was monitored under fluoroscopy with contrast having reached the cisterna chyli within 30 minutes. Contrast was seen extravasating near cisterna chyli, confirming an injury at this site. A lumbar trunk lymphatic was cannulated with a Chiba needle and wire enabling positioning of a microcatheter as close to the point of injury as possible. Onyx liquid embolic was used to embolise the feeding lymphatic trunk. Results Post-procedural drain outputs demonstrated an immediate significant drop, with losses of only 300ml/24hr within 48 hours. Drain outputs continued to taper and the drains removed shortly after. The cisterna chyli is typically thought of as a retroperitoneal/para-aortic structure not prone to instrumentation during an ILGO. Despite reviewing the intra-operative footage, a definitive moment/point of injury remains unclear. Conclusions Conservative management of abdominal chyle leak including use of TPN and octreotide is often effective but in sustained large volume ascites(&gt;1000mls/24hr) this is unlikely to succeed. Percutaneous lymphatic embolization can be offered as a treatment option for these patients.