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<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<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< 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.

The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis

Background Protective ileostomy is always applied to avoid clinically significant anastomotic leakage and other postoperative complications for patients receiving laparoscopic rectal cancer surgery. However, whether it is necessary to perform the ileostomy is still controversial. This meta-analysis aims to analyze the efficacy of ileostomy on laparoscopic rectal cancer surgery. Methods Cochrane Library, EMBASE, Web of Science, and PubMed were applied for systematic search of all relevant literature, updated to May 07, 2021. Studies compared patients with and without ileostomy for laparoscopic rectal cancer surgery. We applied Review Manager software to perform this meta-analysis. The quality of the non-randomized controlled trials was assessed using the Newcastle-Ottawa scale (NOS), and the randomized studies were assessed using the Jadad scale. Results We collected a total of 1203 references, and seven studies were included using the research methods. The clinically significant anastomotic leakage rate was significantly lower in ileostomy group (27/567, 4.76%) than that in non-ileostomy group (54/525, 10.29%) (RR = 0.47, 95% CI 0.30–0.73, P for overall effect = 0.0009, P for heterogeneity = 0.18, I2 = 32%). However, the postoperative hospital stay, reoperation, wound infection, and operation time showed no significant difference between the ileostomy and non-ileostomy groups. Conclusion The results demonstrated that protective ileostomy could decrease the clinically significant anastomotic leakage rate for patients undergoing laparoscopic rectal cancer surgery. However, ileostomy has no effect on postoperative hospital stay, reoperation, wound infection, and operation time. The efficacy of ileostomy after laparoscopic rectal cancer surgery: a meta-analysis.

Microscopic inflammation in ileocecal specimen does not correspond to a higher anastomotic leakage rate after ileocecal resection in Crohn’s disease

Background Patients with Crohn’s disease suffer from a higher rate of anastomotic leakages after ileocecal resection than patients without Crohn’s disease. Our hypothesis was that microscopic inflammation at the resection margins of ileocecal resections in Crohn’s disease increases the rate of anastomotic leakages. Patients and methods In a retrospective cohort study, 130 patients with Crohn’s disease that underwent ileocecal resection between 2015 and 2019, were analyzed. Anastomotic leakage was the primary outcome parameter. Inflammation at the resection margin was characterized as “inflammation at proximal resection margin”, “inflammation at distal resection margin” or “inflammation at both ends”. Results 46 patients (35.4%) showed microscopic inflammation at the resection margins. 17 patients (13.1%) developed anastomotic leakage. No difference in the rate of anastomotic leakages was found for proximally affected resection margins (no anastomotic leakage vs. anastomotic leakage: 20.3 vs. 35.3%, p = 0.17), distally affected resection margins (2.7 vs. 5.9%, p = 0.47) or inflammation at both ends (9.7 vs. 11.8%, p = 0.80). No effect on the anastomotic leakage rate was found for preoperative hemoglobin concentration (no anastomotic leakage vs. anastomotic leakage: 12.3 vs. 13.5 g/dl, p = 0.26), perioperative immunosuppressive medication (62.8 vs. 52.9%, p = 0.30), BMI (21.8 vs. 22.4 m2/kg, p = 0.82), emergency operation (21.2 vs. 11.8%, p = 0.29), laparoscopic vs. open procedure (p = 0.58), diverting ileostomy (31.9 vs. 57.1%, p = 0.35) or the level of surgical training (staff surgeon: 80.5 vs. 76.5%, p = 0.45). Conclusion Microscopic inflammation at the resection margins after ileocecal resection in Crohn’s disease is common. Histologically inflamed resection margins do not appear to affect the rate of anastomotic leakages. Our data suggest that there is no need for extensive resections or frozen section to achieve microscopically inflammation-free resection margins.

Non-placement versus placement of a drainage tube around the cervical anastomosis in McKeown esophagectomy: study protocol for a randomized controlled trial

Background Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal cancer. Currently, transthoracic and abdominal esophagectomy with cervical anastomosis (McKeown esophagectomy) is a frequently used technique in Japan. However, cervical anastomosis is still an invasive procedure with a high incidence of anastomotic leakage. The use of a drainage tube to treat anastomotic leakage is effective, but the routine placement of a closed suction drain around the anastomosis at the end of the operation remains controversial. The objective of this study is to evaluate the postoperative anastomotic leakage rate, duration to oral intake, hospital stay, and analgesic use with nonplacement of a cervical drainage tube as an alternative to placement of a cervical drainage tube. Methods This is an investigator-initiated, investigator-driven, open-label, randomized controlled parallel-group, noninferiority trial. All adult patients (aged ≥20 and ≤85 years) with histologically proven, surgically resectable (cT1–3 N0–3 M0) squamous cell carcinoma, adenosquamous cell carcinoma, or basaloid squamous cell carcinoma of the intrathoracic esophagus, and European Clinical Oncology Group performance status 0, 1, or 2 are assessed for eligibility. Patients (n = 110) with resectable esophageal cancer who provide informed consent in the outpatient clinic are randomized to either nonplacement of a cervical drainage tube (n = 55) or placement of a cervical drainage tube (n = 55). The primary outcome is the percentage of Clavien–Dindo grade 2 or higher anastomotic leakage. Discussion This is the first randomized controlled trial comparing nonplacement versus placement of a cervical drainage tube during McKeown esophagectomy with regards to the usefulness of a drain for anastomotic leakage. If our hypothesis is correct, nonplacement of a cervical drainage tube will be recommended because it is associated with a similar anastomotic leakage rate but less pain than placement of a cervical drainage tube. Trial registration UMIN-CTR, 000031244. Registered on 1 May 2018.

P103 A HAND-SEWN INTRATHORACIC ANASTOMOSIS IN ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): A DETAILED DESCRIPTION OF TECHNIQUE AND OUTCOMES

Aim The aim of this study was to describe a technique that was developed and refined to construct a hand-sewn intrathoracic anastomosis during robot-assisted minimally invasive esophagectomy (RAMIE). Background & Methods Whilst some case series have reported promising results of a hand-sewn intrathoracic anastomosis during RAMIE, the exact techniques were often not described in detail. Therefore, the current single-center retrospective study was designed to provide a detailed and reproducible technical description of a hand-sewn, intrathoracic anastomosis that was developed and refined for patients who underwent RAMIE in a high volume center for esophageal cancer surgery (2016-2018). Video recordings were reviewed to evaluate technical details regarding the anastomosis, including number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Technical details and distances were extracted and measured by using video analysis software. Moving average analyses were performed to evaluate whether the anastomotic leakage rate changed over the consecutive cases. Results A total of 68 patients were included in the study. For creation of the anastomosis, the gastric conduit was opened on a median distance of 19 millimeters (range 0-66) from the gastric conduit tip. After initially performing end-to-end anastomoses, a switch was made to an end-to-side anastomosis for the majority of 55 patients (81%). A median total of 27 sews (range 20-38) were required to close the anastomosis. In the last 22 patients of the cohort (32%), 4 tension release stitches were placed after circular suturing of the anastomosis. A re-inforcing omental wrap was positioned around the anastomosis in 64 patients (94%). The moving average curve for anastomotic leakage started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68). Conclusion This is the first study to report technical features and outcomes of a hand-sewn intrathoracic anastomosis during RAMIE in detail. Although an acceptable anastomotic leakage rate was observed in the final inclusion phase, a hand-sewn intrathoracic anastomosis during RAMIE may carry a substantial learning curve.