AbstractBackgroundAnastomotic Leakage Research Articles

312. H ANASTOMOSIS IN MECKOWN ESOPHAGECTOMY FOR THE REDUCED ANASTOMOTIC LEAKAGE, OBSTRUCTION, AND GASTROESOPHAGEAL REFLUX

Abstract Background Anastomotic Leakage, obstruction, and gastroesophageal reflux are the major conditions to be taken into account during restoration of alimentary transit in Meckown esophagectomy. There are numerous types of anastomosis techniques to achieve different emphases while the optimal one has not been established. The outcomes of the novel H anastomosis and the conventional end to end layered anastomosis were explored in a prospective cohort study. Methods Patients with resectable esophageal cancer underwent Meckown esophagectomy applying end to end layered anastomosis (Conventional group) or H anastomosis (H group) were included. Besides demographic information, the incidence of anastomotic leakage and other major complications were also recorded. The incidence and severity of postoperative digestive symptoms were assessed by a standard questionnaire including Mellow-Pinkas score for dysphagia and reflux frequency at 6 months after surgery. 24 h-PH and impedance surveillance was also performed on patients receiving H anastomosis. Results Of the 122 eligible patients, 88 received end to end layered anastomosis and 34 underwent H anastomosis respectively. 3(3.4%) patients underwent anastomotic leakage in Conventional group and 1(2.9%) in H group (P = 0.897) The incidences of other perioperative complications were comparable between two groups. The H anastomosis was associated with lower incidence of gastroesophageal reflux (17.2% vs 35.8%, P = 0.117) and higher proportion of patients without food solidity limitation (Mellow-Pinkas score = 0) (79.4% versus 69.1% P = 0.305). The DeMeester score extracted from 24 h-PH and impedance surveillance showed the H anastomosis achieved 70% objective reflux free rate. Conclusion H anastomosis is a refinement of intussusception anastomosis and layered anastomosis to preserve the anti-reflux function of one-direction valve formed by intussuscepted tissues, leakage free from the different locations of layers of anastomosis and obstruction prevention from the removal of intussuscepted muscular layer of esophagus and seromuscular layer of stomach. A multicenter randomized trial comparing the outcomes of the H anastomosis and end to end anastomosis is in process to validate these conclusions.

319. A SUCCESSFUL CASE OF VACUUM-STENT TREATMENT FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH COMPLICATED POST-SURGICAL COURSE

Abstract Background Anastomotic leakage after esophagectomy is associated with severe morbidity. Endoscopic vacuum therapy (EVT) has gained a greater role in endoscopic treatment of these defects and is most often applied using endoscopically placed vacuum-sponges. Recently, the vacuum-stent was introduced as a new device to apply EVT, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet. Methods This video describes a patient with anastomotic leakage after esophagectomy with complicated post-surgical course, successfully treated with a vacuum-stent, including the technical aspects of the technique. First, a guidewire was placed and the vacuum-stent was advanced over the guidewire and introduced into the esophagus. The vacuum-stent was placed over the defect and deployed using the distal release system. Lastly, the vacuum-stent was connected to a vacuum pump, which was set to a pressure of -125 mmHg on the day of placement and -75 mmHg from the second day on. Generally, the vacuum-stent was removed after 7 days. If the defect persisted, another vacuum-stent was placed. Case/Results: A 65-year-old female had undergone a minimally invasive esophagectomy with gastric conduit reconstruction and intrathoracic anastomosis. Post-surgically, the patient had dysphagia due to an elongated gastric conduit, only improving after stent placement. However, this caused a stent-induced broncho-esophageal fistula and was no definite treatment. Therefore, she underwent surgery to close the fistula with a bovine patch and gastric conduit re-construction. A prophylactic vacuum-sponge was placed, but 8 days post-surgery, endoscopy showed a dislocated sponge and dehiscence of the complete anastomosis. A vacuum-stent was placed. After 3 vacuum-stents in 20 days, the defect had closed endoscopically, which was confirmed by CT-scan with oral contrast. Conclusions The vacuum-stent seems to be a safe and possibly organ-saving treatment option for anastomotic leakage after esophagectomy. Link to video: https://we.tl/t-eOVEhUiwge

154. EVALUATION OF BLOOD FLOW IN RECONSTRUCTED GASTRIC TUBE AND IDENTIFICATION OF OPTIMAL ANASTOMOSES IN ESOPHAGECTOMY

Abstract Background Anastomotic leakage in esophageal cancer surgery may be reduced by the evaluated blood flow to the reconstructed organ, but it is difficult to evaluate quantitatively arterial and venous blood flow. This study aimed to evaluate quantitatively blood flow that has not been possible before, and to determine the relationship between the blood flow in the gastric tube with anastomosis leakage using near-infrared spectroscopy. Methods This single-center, observational study included 50 patients aged 51 to 82 who underwent radical esophagectomy with gastric tube reconstruction for esophageal cancer from June 2022 and January 2023. Regional tissue oxygen saturation was measured at the antrum (point X), the anastomotic point (point Z), and the midpoint between points X and Z (point Y) before and after gastric tube formation. These, alongside the decreasing rate of oxygen saturation at the three points, were investigated in relation to anastomosis leakage. Results Regional tissue oxygen saturation at points X and Z after gastric tube formation was significantly lower in the presence of leakage than in its absence. The decreasing rate of regional tissue oxygen saturation at point Z was significantly higher in the presence of leakage than in its absence. There was no significant difference in the decreasing rate of regional tissue oxygen saturation at point X and Y between the presence and absence of leakage. The cut-off decreasing rate of the rSO2 was 29.4%. Conclusion Regional tissue oxygen saturation levels may be useful for measuring blood flow and may be a predictor of anastomosis leakage.

333. HIGH CERVICAL ANASTOMOSIS USING NARROW GASTRIC TUBE CAN REDUCE LEAKAGE AFTER MCKEOWN ESOPHAGECTOMY

Abstract Background Anastomotic leakage is one of the most serious complications after esophagectomy. High cervical anastomosis with narrow gastric tube has the potential to reduce the leakage after McKeown esophagectomy. Methods A total of 533 patients who received McKeown radical resection for esophageal cancer in Shanghai Chest Hospital from March 2018 to March 2023 were included in this study, including 281 patients in the normal anastomosis (NA) group and 252 patients in the high anastomosis (HA) group. Potential confounding factors in baseline characteristics were balanced by 1:1 propensity score matching (PSM). We compared the pathological and perioperative results before and after matching between the HA group and NA group, and finally used univariate and multivariate logistic analysis to analyze the independent risk factors of anastomotic leakage. Results After matching, 190 patients remained in both groups. In the comparison of pathological and surgical results, we found that the HA group had an advantage in lymph node harvest (Before matching: 21.3 ± 9.7 vs. 15.8 ± 7.5, p < 0.001; After matching: 21.1 ± 10.0 vs. 15.8 ± 7.7, p < 0.001). There were no significant differences in operation time, blood loss and R0 resection rate between the two groups after matching. The grade of tumor differentiation in HA group was better than that in NA group (p < 0.001), and the pathological staging was earlier than that in NA group (p < 0.001). Overall postoperative complications, including pulmonary infection (p < 0.001), anastomotic leakage (p < 0.001), recurrent laryngeal nerve paralysis (p = 0.031), and pleural effusion (p < 0.001), were significantly lower in the HA group than those in the NA group. Multivariate analysis indicated that age > 65 [odds ratio (OR) = 1.433, 95% confidence interval (CI) 1.248–1.753; p = 0.003], T4a (OR = 1.19, 95% CI 1.023–1.629; p = 0.016), Neoadjuvant treatment (OR = 0.075, 95% CI 0.038–0.150; p < 0.001) and HA (OR = 0.631, 95% CI 0.213–0.707; p = 0.014) were independent predictors for anastomotic leakage. Conclusions For patients undergoing McKeown esophagectomy, high anastomosis can effectively reduce the incidence of anastomotic leakage and reduce overall perioperative complications. It is a recommended optimized surgical procedure.

Risk Factors and Outcomes of Occurrence of Anastomotic Leakage and Reoperations for its Management after Colorectal Surgery

Abstract Background Anastomotic leakage (AL) is still the most annoying postsurgery complication after colorectal resection due to its serious complications up to death. Limited data were available regarding differences in AL incidence, management, and consequences for different types of colorectal resection.The aim of the present work was to evaluate differences in incidence of AL, incidence of postoperative complications, and length of hospital stay in a large number of patients who underwent elective colorectal resection for management of colorectal lesions. In addition to detect when and what type of reoperation for management of AL occur after colorectal resection. Patients All 250 included patients underwent elective surgeries for colorectal resection with performance of primary anastomosis for management of colorectal neoplastic and non-neoplastic diseases in the period between May 2016 and July 31, 2021.We followed the patients for 90 days; we registered the follow-up findings. Results the rates of AL occurrence were variable after the different procedures. The lowest rate of AL occurrence was found in patients who underwent right hemicolectomy, then in patients who underwent sigmoidectomy, left hemicolectomy, transversectomy and anterior resection (p = 0.004). A stoma was frequently performed during reoperation (79.5%) which was significantly different between different procedures: 65.5% in right hemicolectomy, 75.0% in transversectomy, 85.7% in left hemicolectomy, and 93.0% in sigmoid resection (p < 0.001). Conclusion Rates, types, time of occurrence and severity of AL vary according to the type of colectomy performed and selective construction of stoma during AL reoperation is currently safely applied with comparable mortality rates for patients who did and who did not have a stoma after reoperation.

Eso-Sponge® for anastomotic leakage after oesophageal resection or perforation: outcomes from a national, prospective multicentre registry

BackgroundAnastomotic leakage (AL) after oesophagectomy and oesophageal perforations are associated with significant morbidity and mortality. Minimally invasive endoscopy is often used as first-line treatment, particularly endoluminal vacuum therapy (EVT). The aim was to assess the performance of the first commercially available endoluminal vacuum device (Eso-Sponge®) in the management of AL and perforation of the upper gastrointestinal tract (GIT).MethodsThe Eso-Sponge® registry was designed in 2014 as a prospective, observational, national, multicentre registry. Patients were recruited with either AL or perforation within the upper GIT. Data were collected with a standardized form and transferred into a web-based platform. Twenty hospitals were enrolled at the beginning of the study (registration number NCT02662777; http://www.clinicaltrials.gov). The primary endpoint was successful closure of the oesophageal defect.ResultsEleven out of 20 centres recruited patients. A total of 102 patients were included in this interim analysis; 69 patients with AL and 33 with a perforation were treated by EVT. In the AL group, a closure of 91 per cent was observed and 76 per cent was observed in the perforation group. The occurrence of mediastinitis (P = 0.002) and the location of the defect (P = 0.008) were identified as significant predictors of defect closure.ConclusionsThe Eso-Sponge® registry offers the opportunity to collate data on EVT with a uniform, commercially available product to improve standardization. Our data show that EVT with the Eso-Sponge® is an option for the management of AL and perforation within the upper GIT.

In-hospital economic burden of anastomotic leakage after colorectal anastomosis surgery: a real-world cost analysis in Italy

Background Anastomotic leakage (AL) is a severe complication of colorectal surgery. We aimed to quantify inpatient costs and key cost contributors associated with AL in a single Italian center. Research design and methods Electronic records for adults who had undergone colorectal surgery with anastomosis (January 2015 – December 2016), were retrospectively reviewed. Patients with AL were identified using clinical signs and/or imaging findings and/or intraoperative findings. Available data included patient, clinical, and procedural characteristics, healthcare resource utilization and inpatient costs. Multivariate models were used to adjust for potential confounders. Results AL occurred in 12.3% of patients (N=317). Mean adjusted inpatient cost was 108% higher (p<0.001) for patients with AL versus no AL (€14,711; 95% CI: 12,113; 17,866 versus €7,089; 95% CI: 6,623; 7,587). Key cost contributors were ward stay, disposables, operating room and hospital consultations. Mean losses (reimbursement minus costs) were €2,041/patient with AL. AL extended mean length of stay by 9 days and increased odds of reoperation and ICU stay (all p<0.001). Conclusions Patients with AL place considerable economic and resource burden on healthcare systems and hospital reimbursement rates do not cover treatment costs. This study highlights an unmet need for novel techniques to reduce the burden of AL.

Evaluation of abdominal aortic calcification by plain CT predicts anastomotic leakage in laparoscopic surgery for colorectal cancer.

Anastomotic leakage is one of the most severe and critical complications of laparoscopic surgery for colorectal cancer. However, definitive preoperative predictors of anastomotic leakage remain elusive. With the ageing of society, the number of colorectal cancer patients with arteriosclerotic disease in Japan is increasing. This study was performed to evaluate the correlation between preoperative arteriosclerosis and anastomotic leakage. In total, 98 patients undergoing laparoscopic surgery for colorectal cancer with reconstruction using the double-stapling technique without diversion of the stoma were enrolled in the study. Preoperative assessment of arteriosclerotic disease was performed by abdominal computed tomography. The calcification volume percentage of the aorta between the level of the celiac artery root and aortic bifurcation was calculated using ZIOstation2 software, and the relationship between arteriosclerosis and anastomotic leakage was analysed. Among 98 cases, anastomotic leakage was observed in 16 (16.3%). The median calcification volume percentage (range) was 2.35% (0-40.3%). Age, male sex, hypertension, dissection number, estimated glomerular filtration rate and tumour location were correlated with anastomotic leakage on statistical analysis. Statistical analysis showed that calcification volume percentage was one of the robust risk factors for anastomotic leakage (odds ratio: 1.09, 95% confidence interval: 1.03-1.17, P<0.01). Calcification of the abdominal aorta may be a promising predictor of AL after laparoscopic surgery for colorectal cancer reconstruction using the double-stapling technique.

Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection

BackgroundAnastomotic 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.MethodsFrom 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.ResultsFifty-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.ConclusionsEVT 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).

Colorectal anastomotic leak: transcriptomic profile analysis.

Anastomotic leakage in patients undergoing colorectal surgery is associated with morbidity and mortality. Although multiple risk factors have been identified, the underlying mechanisms are mainly unknown. The aim of this study was to perform a transcriptome analysis of genes underlying the development of anastomotic leakage. A set of human samples from the anastomotic site collected during stapled colorectal anastomosis were used in the study. Transcriptomic profiles were generated for patients who developing anastomotic leakage and case-matched controls with normal anastomotic healing to identify genes and biological processes associated with the development of anastomotic leakage. The analysis included 22 patients with and 69 without anastomotic leakage. Differential expression analysis showed that 44 genes had adjusted P < 0.050, consisting of two upregulated and 42 downregulated genes. Co-functionality analysis of the 150 most upregulated and 150 most downregulated genes using the GenetICA framework showed formation of clusters of genes with different enrichment for biological pathways. The enriched pathways for the downregulated genes are involved in immune response, angiogenesis, protein metabolism, and collagen cross-linking. The enriched pathways for upregulated genes are involved in cell division. These data indicate that patients who develop anastomotic leakage start the healing process with an error at the level of gene regulation at the time of surgery. Despite normal macroscopic appearance during surgery, the transcriptome data identified several differences in gene expression between patients who developed anastomotic leakage and those who did not. The expressed genes and enriched processes are involved in the different stages of wound healing. These provide therapeutic and diagnostic targets for patients at risk of anastomotic leakage.

Three-tube method and covered metallic stent for the treatment of anastomotic leakage after esophagectomy

BackgroundAnastomotic leakage is common and life-threatening complication after esophagectomy. The management of esophageal anastomotic leakage remains challenging. We aimed to determine the safety, feasibility and efficacy of three-tube method and covered metallic stent placement for the management of anastomotic leakage.MethodsTwenty-six consecutive patients with anastomotic leakage were treated using three-tube method and covered metallic stent and the medical records were retrospectively assessed. All patients received placement of abscess drainage tube, jejunal feeding tube and gastrointestinal decompression tube as well as esophageal covered stent, followed by continue abscess drainage, nutritional support and anti-inflammatory treatment. Tubes and esophageal stents will be removed once anastomotic leakage heals.ResultsThe procedure was technically successful in 23 patients (95.8%). A total of 31 covered stents were used. Esophageal stents and abscess drainage tubes were successfully removed from 14 patients. The median retention duration was 2.3 months and 2.6 months for stent and abscess drainage tubes, respectively. No perioperative death, esophageal rupture, massive hemorrhage, or other severe complications were observed during procedures. The abscess cavity had markedly decreased in 8 patients or disappeared in 16 cases. During follow-up, 8 patients died of cancer recurrence and 2 patients died of severe pulmonary infection. The 1-, 3-, 5-year survival rates were 60.1, 51.5 and 51.5%, respectively.ConclusionThree-tube method and covered metallic stent placement is safe, feasible and efficacious for treatment of anastomotic leakage after esophagectomy.

62 THE STERNO-TRACHEAL DISTANCE IS AN IMPORTANT FACTOR OF ANASTOMOTIC LEAKAGE OF RETROSTERNAL GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY

Abstract Background Anastomotic leakage (AL) is a serious complication after esophagectomy. The retrosternal (RS) route has been selected majorly to reduce reflux and related pneumonia and considering mediastinal recurrences. AL has been developed more in RS than posterior mediastinal (PM) route reconstruction. Therefore, we suspected the sterno-tracheal distance (STD) might be related to AL and started the selection according to the STD from 2009. Methods A total of 221 patients who underwent a subtotal esophagectomy with gastric tube reconstruction during January 2004—April 2017 were investigated. The patients were classified into the 'after STD selection' (A; n = 144) group and the 'before STD selection' (B, n = 77) group. The incidences of and the risk factors for AL between the two groups were compared. Results The incidence of AL was high in the B group (18.2%), and 78.6% of the patients who developed AL were treated with RS route. The median STDs of the patients with AL and no AL were 10.3 mm and 14.5 mm, respectively (p = 0.001). These results demonstrated that the STD was a risk factor for AL in the RS route. Based on these results, 13 mm was set as the cutoff value. After STD selection, the median STD increased from 14.0 mm to 17.3 mm (p = 0.001), and the incidence of AL decreased significantly from 26.2% to 11.1% in the RS route (p = 0.037). Conclusion The STD was the independent risk factor for AL in the RS route. RS route reconstruction should be avoided for the patients with STD &amp;lt;13 mm.

Predictive risk factors for anastomotic leakage after anterior resection of rectal cancer in elderly patients over 80\u2009years old: an analysis of 288 consecutive patients

BackgroundAnastomotic leakage (AL) is a common complication after anterior resection of rectal cancer. Few studies have been conducted to determine whether the traditional predictors of AL can be applied to elderly patients (age ≥ 80) undergoing anterior resection (AR) or low anterior resection (LAR) of rectal cancer. This study was designed to explore the predictive factors for AL after anterior resection of rectal cancer in patients over 80 years old.MethodsFrom January 2007 to May 2019, consecutive elderly (age ≥ 80) rectal cancer patients undergoing AR or LAR at our institution were systematically reviewed. The general information, perioperative outcomes, and comorbidities were collected.ResultsA total of 288 consecutive patients were included in this study. The average age was 82.8 ± 2.4 years, and 30 (10.4%) patients developed AL. The univariate analyses showed that neoadjuvant therapy (50.0% vs. 27.9%, P = 0.013), the number of stapler firings ≥ 3 (60.0% vs. 36.0%, P = 0.011), and coronary heart disease (CHD) (46.7% vs. 17.8%, P < 0.001) were associated with an increased incidence of AL. The multivariate analysis showed that the number of stapler firings ≥ 3 (OR = 4.77, 95% CI = 1.33–15.21, P = 0.035) and CHD (OR = 8.33, 95% CI = 1.94–13.05, P = 0.003) were independent risk factors for AL.ConclusionThe number of stapler firings ≥ 3 and CHD were independent risk factors for AL in elderly patients (age ≥ 80) with rectal cancer. A temporary ileostomy or the Hartmann procedure is recommended for patients with CHD, male patients, patients considered to be obese, and patients with a lower tumor location, which may increase the number of stapler firings. Certainly, we recommend that the number of stapler firings should be minimized to alleviate the economic and physical burden of patients.

PS01.160: PERIOPERATIVE PERFUSION ASSESSMENT WITH QUANTITATIVE FLUORESCENCE ANGIOGRAPHY

Abstract Background Anastomotic leakage (AL) occurs relatively frequent in oncologic esophageal surgery and is associated with increased morbidity and mortality, and risk of local recurrence of cancer. Poor anastomotic perfusion is probably an important factor of AL. Traditionally; perfusion has been assessed visually and manually by palpation, methods proven to be irreproducible and not possible in a minimal-invasive environment. Few studies on ICG-FA used in esophageal resection exists and some have shown promising results. However, most studies only use a visual interpretation of the angiography, leading to observer bias. In addition, this subjective visual assessment only allows a binary outcome; perfusion or no perfusion. A quantitative (q-ICG) approach enables a scaled, objective assessment, useful in lowering the risk of AL, however, also in exploring interventions and risk factors leading to improved or attenuated perfusion. The aim of this study was to establish a valid, reproducible perioperative q-ICG method. Methods Design and validation: A Q-ICG method for assessment of ICG-FA was developed in a porcine model, using seven pigs. To establish which metric of Q-ICG to use, neutron labeled microspheres were injected intraarterially as microspheral flow is considered the gold standard in microvascular flow assessment. Tissue samples from the stomach were excised and the regional flow was calculated, this was compared with Q-ICG metrics by correlation analysis. Attenuated perfusion: In seven pigs, the stomach and segments of small bowel were partly devascularized and local lactates were correlated to Q-ICG. Improved perfusion: As glucagon-like peptide-2(GLP-2) enhances fore- and midgut perfusion, 20 pigs underwent small bowel resection and anastomosis and randomized to GLP-2 or placebo, to test if Q-ICG could determine a difference in perfusion. Results We found excellent correlation of the q-ICG metric ‘normalized slope’ to regional microspheral flow (r = 0.92–0.96, P = 0.001). In addition, local lactate measurements of the devascularized stomach and small bowel correlated to the normalized slope of q-ICG (Spearman rho = 0.8). Q-ICG found significant improved anastomotic perfusion of pigs treated with GLP-2 (P &lt; 0.05). Conclusion We established and validated a method of Q-ICG in normal, attenuated and improved perfusion, that may be useful in esophageal surgery, where construction of an anastomosis requires an optimal perfusion. Disclosure All authors have declared no conflicts of interest.

PS01.173: MANAGEMENT OF INTRATHORACIC AND CERVICAL ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW

Abstract Background Anastomotic leakage affects up to 30% of patients after esophagectomy each year and leads to considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy has the best clinical outcome, based on currently available literature. Methods A systematic literature search was performed in Medline, Embase and Web of Science until April 2017. All studies reporting on the treatment of anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Results Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Regarding intrathoracic anastomotic leakages, mortality rates in the conservative, endoscopic stent, endoscopic drainage, endoscopic vacuum assisted closure system and surgery treatment group were 14%, 8%, 8%, 0%, and 50%, respectively. Regarding cervical anastomotic leakages, mortality rates in the conservative, endoscopic stent and endoscopic dilatation group were 8%, 29%, and 0%, respectively. Conclusion Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting one treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. A prospective registration study could provide answers to issues as which leakage characteristics determine its severity and which treatment options have the best outcomes for a given anastomotic leakage severity. Disclosure All authors have declared no conflicts of interest.

RA04.07: A NOVEL TECHNIQUE FOR CERVICAL GASTROESOPHAGEAL ANASTOMOSIS DURING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Anastomotic leakage, fibrous stricture and gastroesophageal reflux are three major complications of gastroesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to the traditional side-to-side anastomosis (SS), and the end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux. Methods A total of 390 patients with thoracic esophageal cancer underwent a minimally invasive esophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. The new anastomotic technique was improved from a type of side-to-side anastomosis technique which was reported by Collard et al. The difference of our new technique is that the part of the anastomotic stump was pushed into the tubular stomach. It let the end part of esophagus was embedded in the gastric tube while the end portion of the stomach was also reversed into the gastric tube (figure 1, 2, 3). The major postoperative complications including postoperative leakage, stricture and reflux were compared using three armed controlled study. Results With regard to the incidence of anastomotic leakage and reflux, the patients who underwent Jiang's anastomosis had a significantly lower rate than those in the SS group and CS group (Leaks: 1.0% vs. 8.8% and 8.5%, P = 0.025, 0.001; Reflux: 5.7% vs. 23.5% and 18.3%, P = 0.003, 0.001). The incidence of dysphagia was 10.4% with an occurrence rate of 1.5% for anastomotic strictures in the NA group. It was significant lower than that in the CS group (41.5% vs. 18.9%, P &lt; 0.05) but not significantly different from that in SS group (11.8% vs. 2.9%). Conclusion The novel anastomotic technique remarkably reduced the incidence of gastroesophageal-anastomotic leakage, stricture and reflux and was a safe and effective technique for minimally invasive esophagectomy. Disclosure All authors have declared no conflicts of interest.

PS01.132: RISK FACTORS OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH GASTRIC TUBE RECONSTRUCTION FOR THORACIC ESOPHAGEAL CANCER

Abstract Background Anastomotic leakage is a major complication after esophagectomy. Recent studies reported that anastomotic leakage is associated with poor prognosis. We aimed to identify the risk factors of anastomotic leakage after esophagectomy for thoracic esophageal cancer. Methods We analyzed retrospectively consecutive patients who underwent esophagectomy with reconstruction using gastric tube by cervical anastomosis for thoracic esophageal cancer between January 2009 and December 2017. In the reconstruction, end-to side mechanical anastomosis with circular stapler through the posterior mediastinal route was preferred until 2014, and end-to end hand-sewn anastomosis through the retrosternal route was preferred from 2015. As inflammation-based and/or nutritional markers, prognostic nutritional index (PNI), modified Glasgow Prognostic Score (mGPS), Controlling Nutritional Status (CONUT) score, and neutrophil lymphocyte ratio (NLR) were investigated. Receiver operator characteristic curve analyses were performed to set the cut-off value of continuous variables. Risk factors predicting anastomotic leakage were analyzed using logistic regression model. Results A total of 170 patients (144 males and 26 females) were evaluated. Median age was 65 years (59 − 70). Anastomotic leakage was observed in 21 patients (12.3%). A mechanical anastomosis with circular stapler (P = 0.047) and longer operative time (≧560 minutes) (P = 0.015) were identified as risk factors of anastomotic leakage in univariate analysis. Multivariate analysis including variables with P &lt; 0.1 on univariate analyses identified lower PNI (&lt; 45) (P = 0.044, OR 2.78, 95% CI: 1.02 − 7.56) and mechanical anastomosis with a circular stapler (P = 0.036, OR 3.30, 95% CI: 1.07 − 10.09) as independent risk factors. Conclusion Our findings suggested that preoperative lower PNI and mechanical anastomosis were independent risk factors of anastomotic leakage after esophagectomy. Further studies aimed at preoperative nutritional intervention and anastomotic technique are warranted. Disclosure All authors have declared no conflicts of interest.

PS02.213: PREDICTING ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY: THE VALUE OF C-REACTIVE PROTEIN. A NATIONWIDE REGISTER STUDY

Abstract Background Anastomotic leakage (AL) after oesophageal surgery is a serious complication, leading to increased postoperative mortality. Early detection and treatment is essential. The aim of this study was to investigate if inflammatory serum parameters in the early postoperative course after oesophageal cancer surgery, could predict development of an AL. Methods All patients in Sweden with AL after thoraco-abdominal surgery for oesophageal or gastroesophageal junction cancer from 2006–01-01 to 2017–01-31 were collected from the Swedish National Registry for esophageal and gastric cancer (NREV). Two matched controls for each AL-patient were also selected from the registry. Pre-, per- and postoperative variables were collected from NREV. The following parameters were collected from patient charts: number of days from surgery to AL, diagnostic modality, method of treatment, serum levels of C-reactive protein (CRP), White blood cell count (WBC) and serum-Albumin taken on postoperative day 1 to 7 (POD1–7). Thoracic- and cervical anastomosis were analysed separately. Perioperative data and inflammatory markers were compared between controls and AL-patients. Receiver Operating Characteristic (ROC) curves was constructed to identify optimal cut-off values and a multivariate analysis was performed to identify independent risk factors. Results A total of 155 patients with AL and 307 controls (n = 462) were analysed. In patients with thoracic anastomosis median levels of CRP and WBC were significantly different on POD 2–7 and on POD 4–7 comparing AL-patients to controls. In patients with cervical anastomosis there was a significant difference in WBC levels on POD 1–7. ROC-curve analysis identified CRP on POD3 (cut-off 221) and POD4 (cut-off 203) as the best candidates for predicting AL in patients with a thoracic anastomosis, displaying an area under curve of 0.754 (Sensitivity 59%, Specificity 83%) and 0.731 (Sensitivity: 57%, Specificity 82%). Conclusion In this nation-wide register study we found that a model combining S-CRP levels on POD 3 and POD 4 after a thoraco-abdominal esophagectomy, could identify patients with increased risk of anastomotic leakage several days before it was diagnosed. However, since the sensitivity of this test is relatively low for predicting AL, it must be assessed in a larger clinical context. Disclosure All authors have declared no conflicts of interest.

PS01.131: POSTOPERATIVE ANASTOMOTIC LEAKAGE AND PNEUMONIA FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE SINGLE-CENTER ANALYSIS

Abstract Background Anastomotic leakage and pneumonia following esophagectomy remain a significant clinical challenge and contribute to the postoperative outcome. Aim of this study was to investigate the relation between risk factors for the occurrence of leakage or pneumonia and the postoperative outcome and to identify further risk factors. Methods We analyzed 53 consecutive patients who underwent a surgical resection of the esophagus (distal esophagectomy and abdominothoracical esophagectomy) from January 2015 until August 2017. Patients demographics, perioperative parameters, and postoperative events were analyzed. Patient data were expressed as mean ± SD (range). P &lt; 0.05 was considered statistically significant. Results Postoperative pneumonia and anastomotic leakage occurred in 15 (28%) and 8 (15%) patients, respectively. Median operative time was 330.7 (± 69.6) minutes, and median length of stay was 24.8 (± 10.6) days. 2 (3.8%) of the patients required blood transfusion due to intraoperative bleeding. BMI, ASA-score, and an intraoperative performed lymphadenectomy did not affect the occurrence of pneumonia or anastomotic leakage. Patients with anastomotic leakage stayed longer at the ICU. However, the overall hospitalization rate did not differ significantly. As an independent risk factor, we identified that hypoproteinaemia with a protein level ≤ 5 g/dl (p-value 0.036) leads to a significant higher occurrence of anastomotic leakage. We could not identify any risk factors with regards to postoperative pneumonia. Conclusion The prevalence of hypoproteinaemia in patients after esophagectomy was associated with a higher occurrence of postoperative anastomotic leakage. These results indicate the importance of the perioperative nutrition aiming for a balanced protein level irrespective of comorbidity and surgical procedure. Disclosure All authors have declared no conflicts of interest.

PS01.190: FLEXIBLE GASTRIC TUBE: A NOBLE METHOD OF GASTRIC TUBE RECONSTRUCTION WITHOUT ANASTOMOTIC LEAKAGE

Abstract Background Anastomotic leakage is one of the most frequent and severe morbidities after esophagectomy. For preventing anastomotic leakage, it is important to design a gastric tube with sufficient blood supply and to perform precise anastomosis at a well-conditioned site. We herein show our method of gastric tube reconstruction and evaluate the outcome. Methods Seven hundred and forty-six esophageal carcinoma patients who received subtotal esophagectomy with gastric tube reconstruction via the retrosternal route between 1994 and 2017 were enrolled in the present study. Although we previously used a greater curvature gastric tube with a 4 cm in diameter (narrow group), since 2000, a ‘flexible gastric tube,’ which was designed on an individual basis with the aim of preserving the vascular plexus in the center of the anterior and posterior stomach wall to the maximum possible extent in order to supply a sufficient amount of blood to the tip of the gastric tube was used (flexible group). Cervical esophagogastric end-to-side anastomosis using the circular stapler was performed during the whole period. The clinical outcomes were compared between the two groups. Results Anastomotic leakage was observed in 36 (4.8%) patients. While 24 of 155 (15.5%) patients showed anastomotic leakage in the narrow group, 12 of 591 (2.0%) patients showed anastomotic leakage in the flexible group and the clinical outcomes were significantly improved. Conclusion Our method of gastric tube reconstruction helped to improve the rate of anastomotic leakage after esophagectomy. At present, we are investigating the status of the blood flow using an ICG fluorescence method and by measuring the degree of oxygen saturation and hemoglobin using a new non-invasive monitoring tool during the operation. Postoperative assessments of the anastomotic site are performed using endoscopic examinations. We herein report the results of these assessments. Disclosure All authors have declared no conflicts of interest.