The effect of early oral feeding after subtotal esophagectomy with immediate esophageal reconstruction on the patients’ nutritional status: randomized single-center study.

Background: The efficiency of early oral feeding (EOF) in the postoperative period is well known. Though in the esophagus surgery doctors still prefer another types of nutritional support after esophagectomy (EE) with immediate gastric tube reconstruction. Aims: to improve the results of patients treatment after EE with gastric tube reconstruction by choosing the method of nutritional support and to evaluate nutritional status of the patients with EOF. Materials and methods: weve conducted prospective single-center randomized study. Subtotal esophagectomy with immediate gastric tube reconstruction was performed to 60 patients. In the postoperative period we evaluated the results of treatment, the frequency and severity of complications, as well as anthropometric and laboratory indicators of the nutritional status before the operation, on 1, 3 and 6 postoperative day (POD). Results: Patients without high risk of malnutrition were randomly divided in 2 groups: main group (n=30) starting EOF on the 1 POD and control group (n=30) that remained nil by mouth and got parenteral feeding within 4 POD. The patients of EOF group had statistically significant earlier gas discharge (2[2;3] POD vs 4[3;6] POD, р = 0,000042) and stool appearance (3[2;4] POD vs 5[4;7] POD, р = 0,000004). There is a tendency of reduction of the duration of postoperative hospitalization in EOF group (8[7;9] POD vs 9[8;9] POD, р=0,13). EOF does not affect on frequency (46,6% vs 53,3%, р=0,66) and character of postoperative complications. After evaluation of the parameters of nutritional status we found statistically significant decrease of prealbumin level on 3 POD in EOF group (0,17 [0,13;0,21] vs 0,2 [0,16;0,34], р=0,03) of due to inability to compensate daily calorie needs in the first days after the operation. At 6 POD prealbumin became the same in both groups. There were no other significant differences between the groups. Conclusions: EOF after EE with immediate gastric tube reconstruction is safe and effective. EOF doesnt increase the frequency of anastomotic insufficiency and other complications.

157 SURGICAL PROCEDURE TO REDUCE ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY

Anastomotic leakage (AL) is one of the major complications of gastro-esophageal anastomosis after esophagectomy, which causes short-term morbidity and mortality, as well as poor long-term survival. The aim of this study was to investigate factors which were associated with AL after esophagectomy in order to determine the optimal surgical technique to reduce AL. Methods A total of 128 patients with thoracic esophageal cancer underwent subtotal esophagectomy followed by retrosternal reconstruction with gastric conduit with cervical anastomosis using circular staple in our institute from January 2008 and January 2020. The relationship between AL and surgical procedures as well as clinicopathological characteristics of the patients were retrospectively investigated. In addition, we divided the patients into 65 cases in former period (December 2015) and 63 cases in later period (January 2016-) to compare the incidence of AL. Results AL was observed in 12 cases (9.4%) of the 128 patients. The incidence of AL decreased from 16.9% (11/65) in former period to 1.6% (1/63) in later period (p = 0.004). In comparison between the cases with and without AL (12 cases vs 116cases), statistically significant difference was seen in BMI (average ± SD, 24.2 ± 4.7 vs 21.6 ± 3.1; p = 0.02), anastomotic site (posterior wall/greater curvature, 11/1 vs 54/62; p = 0.004), and level of anastomosis (above/below superior border of manubrium of sternum, 12/0 vs 33/83; p < 0.001). While multivariate analysis revealed that former or later period were the only independent factors relevant to AL (p = 0.01). Conclusion Surgical procedure which avoid excessive pressure on the gastric tube from the surrounding structures, such as sternum, may take an important role in reduction of AL after esophagectomy. However, multiple factors, such as nutritional status and obesity, also influence risk of anastomotic leakage.

CA19-9-producing esophageal adenocarcinoma originating from the esophageal cardia of the mid-thoracic esophagus: a case report

Background Although there are many studies on primary esophageal adenocarcinoma arising from Barrett's esophagus or ectopic gastric mucosa, reports on adenocarcinoma arising from esophageal cardiac glands are extremely rare. Herein, we report a case of mid-thoracic cancer antigen 19-9 (CA 19-9)-producing primary esophageal adenocarcinoma, which presumably originated from the cardiac glands. Case presentation A 74-year-old man was referred to our department with advanced esophageal cancer, which initially presented with dyspepsia. Serum levels of cancer antigen 19-9 (CA 19-9) were elevated (724.89 U/ml). Upper gastrointestinal endoscopy revealed a type 2 tumor on the posterior wall of the mid-thoracic esophagus approximately 29–32 cm from the incisor. Mucosal biopsy was consistent with a diagnosis of adenocarcinoma. Contrast-enhanced computed tomography showed a circumferential wall thickening in the mid-thoracic esophagus without enlarged lymph nodes or distant metastasis. Positron emission tomography–computed tomography showed accumulation in the primary tumor, but no evidence of lymph node or distant metastasis. According to these findings, the adenocarcinoma was staged as cT3N0M0, thereby, requiring subtotal esophagectomy with lymph node dissection. Postoperative course was uneventful. Histopathologic analysis revealed a 50 × 40 mm moderately differentiated adenocarcinoma with invasion to the thoracic duct and lymph node metastasis at #108(1/4), #109R(1/3), and #109L(1/3). After surgery, the stage was revised to moderately differentiated pT4apN2pM0 (pStage III). Immunostaining revealed expression of CA19-9 and suggested esophageal cardiac gland origin of the tumor. Three months after the surgery, the patient showed no recurrence and is undergoing outpatient observation. Conclusions We experienced a case of mid-thoracic CA19-9-producing primary esophageal adenocarcinoma, which was presumed to have originated in the esophageal cardiac glands. Due to the scarcity of studies regarding this condition, specific management needs to be further clarified.

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

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.