Severity Of Anastomotic Leakage Research Articles

Quality of Reporting on Anastomotic Leaks in Colorectal Cancer Trials: A Systematic Review.

Although attempts have been made in the past to establish consensus regarding the definitions and grading of the severity of colorectal anastomotic leakage, widespread adoption has remained limited. A systematic review of the literature was conducted with the objective of examining the various elements used to report and define anastomotic leakage in colorectal cancer resections. A systematic review, using the PubMed, Embase, and Cochrane Library Database, of all published randomized controlled trials, systematic reviews, and meta-analyses containing data related to adult patients undergoing colorectal cancer surgery and reporting anastomotic leakage as a primary or secondary outcome, with a definition of anastomotic leakage included. Definitions of anatomotic leakage, clinical symptoms, radiological modalities and findings, findings at reoperation, as well as grading terminology or classifications for anastomotic leakage. Of the 471 articles reporting anastomotic leakage as a primary or secondary outcome, a definition was reported in 95 studies (45 randomized controlled trials, 13 systematic reviews, and 37 meta-analyses), involving a total of 346,140 patients. Of these 95 articles, 68% reported clinical signs and symptoms of anastomotic leakage, 26% biochemical criteria, 63% radiological modalities, 62% radiological findings, and 13% findings at reintervention. Only 45% (n = 43) of included studies reported grading of anastomotic leakage severity or leak classification, and 41% (n = 39) included a timeframe for reporting. There was a high heterogeneity between the included studies. This evidence synthesis confirmed incomplete and inconsistent reporting of anastomotic leakage across the published colorectal cancer literature. There is a great need for the development and implementation of a consensus framework for defining, grading, and reporting anastomotic leakage. Prospectively registered at PROSPERO ID 454660.

Open left diaphragm method enables safe surgery with a good visual field in a laparoscopic transhiatal approach for esophagogastric junction adenocarcinoma laparoscopic transhiatal reconstruction via an open left diaphragm method.

Despite being oncologically acceptable for esophagogastric junction adenocarcinoma with an esophageal invasion length of 3-4cm, the transhiatal approach has not yet become a standard method given the difficulty of reconstruction in a narrow space and the risk of severe anastomotic leakage. This study aimed to clarify the safety and feasibility of the open left diaphragm method during the transhiatal approach for esophagogastric junction adenocarcinoma. This retrospective study compared the clinical outcomes of patients who underwent proximal or total gastrectomy with lower esophagectomy for Siewert type II/III adenocarcinomas with esophageal invasion via the laparoscopic transhiatal approach with or without the open left diaphragm method from April 2013 to December 2021. Overall, 42 and 13 patients did and did not undergo surgery with the open left diaphragm method, respectively. The median operative time was only slightly shorter in the open left diaphragm group than in the non-open left diaphragm group (369 vs. 482min; P = 0.07). Grade ≥ II postoperative respiratory complications were significantly less common in the open left diaphragm group than in the non-open left diaphragm group (17% vs. 46%, P = 0.03). Neither group had grade ≥ IV anastomotic leakage, and two cases of anastomotic leakage requiring reoperation were drained using the left diaphragmatic release technique. Transhiatal lower esophagectomy with gastrectomy using the open left diaphragm method is safe, highlighting its advantages for Siewert type II/III esophagogastric junction adenocarcinoma with an esophageal invasion length of ≤ 4cm.

Preoperative risk factors and cumulative incidence of temporary ileostomy non-closure after sphincter-preserving surgery for rectal cancer: a meta-analysis

BackgroundTemporary ileostomy (TI) has proven effective in reducing the severity of anastomotic leakage after rectal cancer surgery; however, some ileostomies fail to reverse over time, leading to conversion into a permanent stoma (PS). In this study, we aimed to investigate the preoperative risk factors and cumulative incidence of TI non-closure after sphincter-preserving surgery for rectal cancer.Materials and methodsWe conducted a meta-analysis after searching the Embase, Web of Science, PubMed, and MEDLINE databases from their inception until November 2023. We collected all published studies on the risk factors related to TI non-closure after sphincter-preserving surgery for rectal cancer.ResultsA total of 1610 studies were retrieved, and 13 studies were included for meta-analysis, comprising 3026 patients. The results of the meta-analysis showed that the identified risk factors included older age (p = 0.03), especially > 65 years of age (p = 0.03), male sex (p = 0.009), American Society of Anesthesiologists score ≥ 3 (p = 0.004), comorbidity (p = 0.001), and distant metastasis (p < 0.001). Body mass index, preoperative hemoglobin, preoperative albumin, preoperative carcinoma embryonic antigen, tumor location, neoadjuvant chemoradiotherapy, smoking, history of abdominal surgery, and open surgery did not significantly change the risk of TI non-closure.ConclusionWe identified five preoperative risk factors for TI non-closure after sphincter-preserving surgery for rectal cancer. This information enables surgeons to identify high-risk groups before surgery, inform patients about the possibility of PS in advance, and consider performing protective colostomy or Hartmann surgery.

Clinical Outcomes of Ileostomy Closure during versus after Adjuvant Chemotherapy in Patients with Rectal Cancer.

Protective ileostomy can effectively prevent severe anastomotic leakage after rectal cancer surgery; however, the optimal timing for ileostomy closure during adjuvant chemotherapy remains unclear. This study aimed to explore the safety and long-term outcomes of early ileostomy closure during adjuvant chemotherapy. Patients who underwent laparoscopic rectal cancer surgery combined with protective ileostomy and adjuvant chemotherapy between April 2017 and April 2021 were retrospectively evaluated. Patients were divided into an early closure group during chemotherapy (group A) and a late closure group after chemotherapy (group B). A total of 215 patients were included in this study, with 115 in group A and 100 in group B. There were no significant differences in demographic and clinical characteristics between the two groups. In group A, durations of stoma status (p < 0.001) and low anterior resection syndrome (LARS) (p < 0.001) were shorter, and rectal stenosis (p=0.036) and stoma-related complications (p=0.007), especially stoma stenosis (p=0.041), were less common. However, compliance with chemotherapy was worse (p=0.009). There were no significant differences in operative time, postoperative hospital stay, postoperative complications, incidence and severity of LARS, disease-free survival, or overall survival between groups. Early ileostomy closure can effectively reduce the duration of stoma status, duration of LARS, rectal stenosis, and stoma-related complications while not affecting surgical complications and oncological outcomes. Ileostomy closure should not be delayed because of adjuvant chemotherapy. However, follow-up should be strengthened to increase compliance and integrity with chemotherapy.

Comparison of substernal and posterior mediastinal route of reconstruction after minimally invasive esophagectomy for esophageal cancer

BackgroundSubsternal (ST) and posterior mediastinal (PM) routes are the two most common for reconstruction after esophagectomy with cervical anastomosis. Recent evidence showed similar outcomes between the routes; thus, the superior choice remained controversial. This study aimed to compare the short-term outcomes of the ST to the PM route for reconstruction after esophagectomy for esophageal cancer (EC).MethodThis retrospective cohort study included 132 patients who underwent McKeown minimally invasive esophagectomy (MIE) with gastric conduit for EC between March 2015 and December 2022. Among these, 89 and 43 patients received the ST route and PM route for reconstruction, respectively. Short-term outcomes including operative characteristics, postoperative morbidity, and mortality were evaluated.ResultThere was no conversion from ST to PM route. The ST group had longer operating time (375 min vs. 341 min). Oral feeding initiation, postoperative hospital stays, and overall complication rates were comparable in the two groups. The rate and severity of anastomotic leakage were similar between the groups. The ST group had a significantly lower incidence of postoperative ICU admission and pneumonia compared to the PM group (5.6% vs. 16.3% and 19.1% vs. 37.2%, respectively). Azygos vein bleeding, obstruction at feeding jejunostomy site, and conduit–trachea fistula were severe complications that only occurred in PM route.ConclusionST route was superior to PM route in term of postoperative ICU admission and pneumonia. This route may prevent severe complications that only occur in PM route. ST route can be favorable option for reconstruction after McKeown MIE for EC.

Utility of Transanal Tube for Preventing Severe Anastomotic Leakage Following Low Anterior Resection for Patients With Diverting Stoma

Purpose The incidence of anastomotic leakage (AL) associated with sphincter-preserving surgery has increased. Diverting stoma (DS) and transanal tube (TT) placement have been reported to reduce the rate of AL. This multicenter study examined the efficacy of TT and DS for preventing AL in rectal cancer patients. Methods We reviewed 126 patients who underwent low anterior resection with double-stapling reconstruction between April 2016 and March 2020. Patients were divided into 2 groups according to presence (n = 90) or absence (n = 36) of a TT. Clinicopathologic features were compared between groups. Results Twenty-one patients (16.7%) experienced AL. Frequency of severe AL was significantly lower in the TT group (7.7%) than in the non-TT group (19.4%, P &amp;lt; 0.001). Performance status, operation time, blood loss, and hospital stay were similar between groups. Patients who experienced AL showed significantly longer hospital stays (29 days versus 15 days, P &amp;lt; 0.001). Multivariate analysis revealed placement of a TT as an independent predictor of no AL (odds ratio, 0.306; 95% confidence interval, 0.108–0.870; P = 0.026). Twenty-one patients received both DS construction and TT placement; none of them experienced severe AL. Conclusion The present multicenter study confirmed the efficacy of TT for preventing AL. Transanal tube may have synergistic effects against AL in selected patients with DS.

Characterization of Epidural Analgesia Interruption and Associated Outcomes After Esophagectomy

IntroductionInterruption of thoracic epidural analgesia may impact the postoperative course following esophagectomy. This study investigates the incidence and causes of epidural interruption in esophagectomy patients along with associated postoperative outcomes. MethodsThis single-institution retrospective analysis examined patients undergoing esophagectomy who received a thoracic epidural catheter from 2016 to 2020. Patients were stratified according to whether epidural catheter infusion was interrupted or not postoperatively. Outcomes were compared between the two groups, and predictors of epidural interruption and postoperative complications were estimated using multivariable logistic regression. ResultsOf the 168 patients who received a thoracic epidural before esophagectomy, 60 (35.7%) required epidural interruption and 108 (64.3%) did not. Interruption commonly occurred on postoperative day 1 and was due to hypotension 80% of the time. Heart failure (10.0% versus 0.9%, P = 0.009), atrial fibrillation (20.0% versus 3.7%, P = 0.002), preoperative opioid use (30.0% versus 16.7%, P = 0.043), and higher American Society of Anesthesiology classification (88.4% versus 70.4%, P = 0.008) were more prevalent in the epidural interruption cohort. The female gender was associated with epidural interruption on multivariable logistic regression (adjusted odds ratio [AOR] 2.45, P = 0.039). Patients in the epidural interruption cohort had a higher incidence of delirium (30.5% versus 13.9%, P = 0.010), sepsis (13.6% versus 3.7%, P = 0.028), and severe anastomotic leak (18.3% versus 7.4%, P = 0.032). On adjusted analysis, heart disease (AOR 4.26, P = 0.027), BMI <18.5 (AOR 9.83, P = 0.031), and epidural interruption due to hypotension (AOR 3.51, P = 0.037) were associated with severe anastomotic leak. ConclusionsEarly epidural interruption secondary to hypotension in esophagectomy patients may be a harbinger of postoperative complications such as sepsis and severe anastomotic leak. Patients requiring epidural interruption due to hypotension should have a low threshold for additional workup and early intervention.

The role of transanal drainage tube in preventing the anastomotic leakage in rectal cancer surgery without a defunctioning stoma: A meta-analysis

BackgroundAnastomotic leakage is a common and serious complication after rectal cancer surgery. The role of transanal drainage tube (TDT) in the prevention of anastomotic leakage is still controversial. The aim of this study was to evaluate the role of TDT in preventing anastomotic leakage. MethodsTwo reviewers individually searched the PubMed, Embase and Cochrane Library ranging from January 2000 to June 2022. The pooled odds ratio (ORs) and weighted mean difference (WMD) with the 95% confidence interval (95% CI) were used to assess anastomotic leakage and other parameters. ResultsA total of 3383 patients (1508 in the TDT group and 1875 in the cohort study group) were included in 13 studies. The study found that patients treated with TDT had a lower incidence of anastomotic leakage with or without neoadjuvant radiotherapy. Moreover, patients who received TDT had lower rates of reoperation and tended to reduce the severity of anastomotic leakage. ConclusionsFor rectal cancer patients without defunctioning stoma, TDT could reduce the incidence of anastomotic leakage, decrease the reoperation rate of patients, and tend to reduce the severity of anastomotic leakage. More RCT are needed to assess the role of TDT in rectal cancer surgery.

Techniques in prophylactic ileostomy reversal

In order to prevent and reduce the severity of anastomotic leakage after low rectal cancer surgery, prophylactic ileostomy is often performed by the clinician simultaneously. There are many controversies about prophylactic ileostomy in medicine, such as ileostomy indications, ileostomy complications, ileostomy reversal time, ileostomy reversal method and technique. Based on relevant literature and our own experience, we discussed the timing, method and complications of ileostomy reversal in this article to improve the diagnosis and treatment of ileostomy reversal as well as the life quality of the patients after ileostomy reversal.

Impact of a diverting ileostomy in total mesorectal excision with primary anastomosis for rectal cancer

BackgroundThe role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity.MethodsPatients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity.ResultsIn 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424–4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p < 0.001). Stoma reversal related morbidity rate was 17.9%.ConclusionsThe stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

221. ANASTOMOTIC LEAK AFTER A CARDIO-OESOPHAGECTOMY: A RETROSPECTIVE 12 YEAR EXPERIENCE OF A TERTIARY CENTRE

Abstract Anastomotic leak (AL) post cardio-oesophagectomy remains a significant complication which can impact morbidity and mortality. Incidences of anastomotic leakage after oesophagectomy range between 0 and 20%. Current clinical practice is driven by regional centres and anecdotal experience. We present our 12 year experience with managing patients with anastomotic leaks. This was a retrospective study using the electronic database to analyse the incidence of anastomotic leak in consecutive patients who underwent elective cardio-oesophagectomy from April 2009 to December 2021 in a Tertiary Upper GI cancer centre. The grade of the AL was determined according to the Clavien-Dindo Grade (CDG). A leak associated with Grade &amp;gt; III was categorised as severe anastomotic leak. We used Cox multivariable analysis to observe any link in the severity of the anastomotic leak and prognosis. A total of 560 patients underwent cardio-oesophagectomy. The median length of stay was 13 (Range 3 to 148 days) days and the median age was 66 (46–79) years. M/F 2:1. AL was seen in 26 cases (4.3%); of which 9 cases (0.7%) were classified as severe AL (CDG &amp;gt; 3). Our results are presented on the table attached. Statistical analysis does not show any link between the severity of the anastomotic leak, those who had neoadjuvant therapy and the survival outcome. Anastomotic leaks of all grades prolongs both ITU and hospital stay. This subsequently causes delays in adjuvant therapies affecting long term prognosis. Aggressive treatment early on for large leaks suggests no significant compromise on over-all long-term prognosis.

Safety and Feasibility of Temporary Ileostomy in Older Patients: A Retrospective Study

BACKGROUND: Temporary ileostomy reduces the incidence of severe anastomotic leakage and postoperative mortality. However, little is known about ileostomy-related complications in older adults. PURPOSE: To clarify the safety and feasibility of temporary ileostomy for rectal cancer in older patients. METHODS: Data were collected from a prospectively created database and complemented by secondary chart review for consecutive patients with rectal malignancy who underwent curative proctectomy with diverting loop ileostomy between 2013 and 2018. Ileostomy construction and closure were compared between two groups (defined as elderly and non-elderly patients). Data for 22 patients who were 75 years of age and older (elderly group) and 160 patients who were younger than 75 years (non-elderly group) were analyzed. RESULTS: The median maximum fecal output was significantly higher in the non-elderly group compared with the elderly group. No significant differences were observed between the two groups in postoperative intravenous hydration, creatinine ratio, and ileostomy-related complication rate. Although the elderly group had a higher rate of early stoma closure, the causes were not related to those complications. CONCLUSION: Temporary ileostomy was a safe and feasible procedure in this population of older patients with rectal malignancies.

Preoperative risk stratification of permanent stoma in patients with non-metastatic mid and low rectal cancer undergoing curative resection and a temporary stoma.

Although a temporary stoma can mitigate the severity of anastomotic leakage, some rectal cancer patients retain a permanent stoma after sphincter-preserving surgery. Therefore, this study aimed to identify independent preoperative risk factors for permanent stoma and establish a prediction model for mid-and low-rectal cancer patients who underwent sphincter-preserving surgery and temporary stoma. We retrospectively reviewed consecutive patients with non-metastatic rectal cancer between 2000 and 2015. The risk factors for permanent stomas were collected and analyzed. A total of 1020 rectal cancer patients with temporary stoma were included. The overall rate of permanent stoma was 17.5% (n = 179). Cancer progression and anastomotic complications are major causes of permanent stomas. Multivariate analysis showed that preoperative risk factors such as advanced age, male sex, preoperative CEA ≥ 10ng/ml, T4 stage, N stage, low rectal tumor, and ASA ≥ III were independent preoperative risk factors after adjustment. The ROC curve of the risk factors and permanent stoma showed an AUC of 0.689, a cut-off value of 2.5, a sensitivity of 0.689, and a specificity of 0.622. The permanent stoma rates were significantly higher between risk scores ≤ 2 and > 2 (29.9% vs. 11.3%, p < 0.001). Preoperative CEA ≥ 10ng/ml, T4 stage, N stage, low rectal tumor, advanced age, ASA ≥ III, and male sex were independent preoperative prognostic factors for a permanent stoma. The risk was higher with a score greater than two. Therefore, the risk of subsequent permanent stoma should be evaluated and informed to the patient prior to the primary surgery.

Outcomes after totally minimally invasive versus hybrid and open Ivor Lewis oesophagectomy: results from the International Esodata Study Group.

Large studies comparing totally minimally invasive oesophagectomy (TMIE) with laparoscopically assisted (hybrid) oesophagectomy are lacking. Although randomized trials have compared TMIE invasive with open oesophagectomy, daily clinical practice does not always resemble the results reported in such trials. The aim of the present study was to compare complications after totally minimally invasive, hybrid and open Ivor Lewis oesophagectomy in patients with oesophageal cancer. The study was performed using data from the International Esodata Study Group registered between February 2015 and December 2019. The primary outcome was pneumonia, and secondary outcomes included the incidence and severity of anastomotic leakage, (major) complications, duration of hospital stay, escalation of care, and 90-day mortality. Data were analysed using multivariable multilevel models. Some 8640 patients were included between 2015 and 2019. Patients undergoing TMIE had a lower incidence of pneumonia than those having hybrid (10.9 versus 16.3 per cent; odds ratio (OR) 0.56, 95 per cent c.i. 0.40 to 0.80) or open (10.9 versus 17.4 per cent; OR 0.60, 0.42 to 0.84) oesophagectomy, and had a shorter hospital stay (median 10 (i.q.r. 8-16) days versus 14 (11-19) days (P = 0.041) and 11 (9-16) days (P = 0.027) respectively). The rate of anastomotic leakage was higher after TMIE than hybrid (15.1 versus 10.7 per cent; OR 1.47, 1.01 to 2.13) or open (15.1 versus 7.3 per cent; OR 1.73, 1.26 to 2.38) procedures. Compared with hybrid and open Ivor Lewis oesophagectomy, TMIE resulted in a lower pneumonia rate, a shorter duration of hospital stay, but higher anastomotic leakage rates. Therefore, no clear advantage was seen for either TMIE, hybrid or open Ivor Lewis oesophagectomy when performed in daily clinical practice.

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

BackgroundAnastomotic leak is a major complication after esophagectomy. There is a paucity of data on long-term oncological outcomes of cervical anastomotic leak after esophagectomy for cancer. We evaluated the impact of such a leak on postoperative outcomes as well as on long-term oncological outcomes. MethodsA retrospective analysis of a prospectively maintained database of patients with esophageal cancer who underwent esophagectomy with a cervical esophagogastric anastomosis between 2010 and 2017. Patients were divided into 3 groups: patients with no anastomotic leak; patients with nonsevere (type 1 & 2) leak, and patients with severe (type 3) leak. A comparison of postoperative and long-term oncological outcomes was made between the groups. ResultsTwo hundred and eight patients were included in this study. Thirty-two (15%) patients had cervical anastomotic leak, of which 20 (63%) had type 1 and 2 (nonsevere) leak, and 12 (37%) had type 3 (severe) leak. Overall, 30-day mortality rate was 7%. Mortality rate was 4% in patients without leak, 15% in patients with nonsevere leak, and 25% in patients with severe anastomotic leak (P = .007). Overall median survival was 42 months. Patients with severe leak had poorer overall survival compared to patients with nonsevere and no anastomotic leak (6, 38, and 39 months, respectively, P = .011). There was no difference in disease-free survival of patients with or without anastomotic leak. ConclusionLeakage from cervical anastomosis after esophagectomy had no impact on disease-free survival of patients with esophageal cancer. Severe anastomotic leak was associated with lower overall survival, probably due to a high rate of postoperative mortality.

Risk of Outlet Obstruction Associated With Defunctioning Loop Ileostomy in Rectal Cancer Surgery.

The outlet obstruction (OO) rate is 5.4-18.4% after defunctioning ileostomy (DI) following rectal cancer resection to reduce the incidence and severity of anastomotic leakage; OO affects a patient's quality of life and prolongs hospitalization. A retrospective analysis was performed of patients who underwent anterior rectal resection and DI for rectal cancer. Among 100 patients undergoing anterior rectal resection with DI for rectal cancer, 28 (28%) developed OO. Anastomotic leakage and a rectus abdominis muscle thickness ≥10 mm on preoperative computed tomography were significantly associated with the risk of OO in univariate analysis. Multivariate analysis also demonstrated that anastomotic leakage (odds ratio=4.320, 95% confidence interval=1.280-14.60, p=0.019) and rectus abdominis muscle thickness ≥10 mm (odds ratio=3.710, 95% confidence intervaI=1.280-10.70, p=0.016) were significantly risk factors for OO. When OO is observed, an anastomotic leakage should be suspected, especially if there is a high rectus abdominis muscle thickness.

Clinical impact of the triple-layered circular stapler for reducing the anastomotic leakage in rectal cancer surgery: Porcine model and multicenter retrospective cohort analysis.

AimTo investigate the impact of the triple‐layered circular stapler compared with the double‐layered circular stapler on anastomotic leakage after rectal cancer surgery.MethodsThe bursting pressure was compared between porcine ileocolic anastomoses created using a double‐ or triple‐layered stapler. We also retrospectively analyzed the incidence of severe anastomotic leakage in 194 patients who underwent colorectal anastomosis using a double‐ or triple‐layered circular stapler during rectal cancer resection performed in two cancer centers between January 2015 and April 2021.ResultsIn the porcine model, the bursting pressure was higher in anastomoses created using the triple‐layered stapler than the double‐layered stapler (end‐to‐end anastomosis: 26.4 ± 6.2 mm Hg vs 14.5 ± 4.3 mm Hg, P = .0031; side‐to‐side anastomosis: 27.7 ± 5.0 mm Hg vs 18.0 ± 2.9 mm Hg, P = .0275). Intersectional leakage occurred in 41% and 83% of anastomoses created using the triple‐ or double‐layered stapler, respectively (P = .0821). In the clinical cohort, the double‐ and triple‐layered stapler was used in 153 and 41 patients, respectively. The incidence of anastomotic leakage was lower for anastomoses created using the triple‐layered stapler vs the double‐layered stapler (0.0% vs 5.8%, P = .0362). In multivariate analysis, the factors independently associated with a lower incidence of anastomotic leakage were female sex (odds ratio: 0.16, 95% confidence interval: 0.01‐0.90, P = .0354) and triple‐layered stapler usage (odds ratio: 0.00, 95% confidence interval: 0.00‐0.96, P = .0465).ConclusionAnastomoses created using a triple‐layered circular stapler had high bursting pressure, which might contribute to a lower incidence of anastomotic leakage after rectal cancer surgery.

130 SEVERITY OF ANASTOMOTIC LEAKAGE AFTER DIFFERENT TYPES OF ESOPHAGECTOMY: A NATIONWIDE COHORT STUDY

Abstract Orringer, McKeown and Ivor Lewis esophagectomy are the most commonly performed procedures for esophageal and gastro-esophageal junction cancer. Anastomotic leakage remains a major problem after all types of esophagectomy and it is currently unknown whether anastomotic leakage severity is different between the types of esophagectomy. The aim of this study was to investigate the relationship between surgical techniques and the severity of anastomotic leakage in patients after Orringer esophagectomy, McKeown esophagectomy or Ivor Lewis esophagectomy. Methods All esophageal and gastro-esophageal junction cancer patients with anastomotic leakage after Orringer, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). The primary outcome parameter was a composite endpoint of reoperation, intensive care unit (ICU) readmission and 30-day/in-hospital mortality. Secondary outcome parameters included postoperative complications, re-intervention rate, ICU and hospital length of stay. Results Data from 1034 patients with anastomotic leakage after Orringer (n = 287), McKeown (n = 397) and Ivor Lewis esophagectomy (n = 346) were evaluated. The primary endpoint occurred in 36.3% of patients with anastomotic leakage after Orringer esophagectomy, in 55.4% of patients with anastomotic leakage after McKeown esophagectomy and in 61.2% of patients with anastomotic leakage after Ivor Lewis esophagectomy (p &amp;lt; 0.001). When adjusting for potential confounding variables, the sequelae of anastomotic leakage after Orringer and McKeown esophagectomy remained less severe compared to anastomotic leakage after Ivor Lewis esophagectomy (OR 0.28, 95% CI 0.20–0.41, p &amp;lt; 0.001 and OR 0.71, 95% CI 0.52–0.97, p = 0.031, respectively). Conclusion Consequences of anastomotic leakage are most severe after Ivor Lewis esophagectomy, moderately severe after McKeown esophagectomy and least severe after Orringer esophagectomy. This study demonstrated that not only the incidence, but also the severity of anastomotic leakage should be considered in current clinical practice and in studies that compare leakage rates between different surgical techniques of esophagectomy.

388 TREATMENT OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY (TENTACLE—ESOPHAGUS) STUDY: FACTORS ASSOCIATED WITH ANASTOMOTIC LEAKAGE SEVERITY

Abstract Anastomotic leakage is a common and severe complication after esophagectomy. It is largely unknown which characteristics contribute to leakage severity. We aimed to investigate which factors are associated with leakage severity and to create an anastomotic leakage severity classification. Methods The TENTACLE—Esophagus is a multinational retrospective cohort study in which patients with anastomotic leakage after esophagectomy in the period 2011-2019 were included. Detailed data regarding casemix (e.g. age, sex, physical condition, comorbidity, tumor characteristics), surgical procedure (e.g. McKeown, Ivor Lewis, Orringer, anastomotic technique, omental wrap, pleural flap), leakage characteristics (e.g. contamination, drainage at leakage diagnosis, leak circumference) and treatment were collected. The primary outcome is 90-day mortality. Regression analysis will be used to analyze which leakage characteristics are associated with 90-day mortality and to compose an evidence-based anastomotic leakage severity score. The study protocol is accessible at www.tentaclestudy.com. Results Detailed data of 1407 patients with anastomotic leakage from 70 centers in 20 countries were collected. Anastomotic leakage occurred 0-43 days after surgery and 90-day mortality rate was 11.1%. The TENTACLE—Esophagus study data is currently being validated and it is awaiting full analysis. The results and the evidence based anastomotic leakage severity classification system will be ready for presentation at the ISDE meeting. Conclusion This is the largest study that investigates which factors contribute to anastomotic leakage severity after esophagectomy. The evidence-based anastomotic leakage severity classification system can be used by clinicians to grade severity of a given leak and might aid clinicians in choosing the most appropriate treatment.

792 OUTCOMES AFTER TOTALLY MINIMALLY INVASIVE VERSUS HYBRID OR OPEN IVOR LEWIS ESOPHAGECTOMY: RESULTS FROM THE INTERNATIONAL ESODATA STUDY GROUP.

Abstract To compare complications following totally minimally invasive (TMIE), laparoscopically assisted (hybrid) and open Ivor Lewis esophagectomy in patients with esophageal cancer. Three randomized trials have reported benefits for minimally invasive esophagectomy. Two studies compared TMIE versus open esophagectomy and another compared hybrid versus open Ivor Lewis esophagectomy. Only small retrospective studies compared TMIE with hybrid Ivor Lewis esophagectomy. Methods Data were used from the International Esodata Study Group assessing patients undergoing TMIE, hybrid or open Ivor Lewis esophagectomy. Primary outcome was pneumonia, secondary outcomes included incidence and severity of anastomotic leakage, (major) complications, length of stay, escalation of care and 90-day mortality. Data were analyzed using multivariate multilevel models. Results In total, 4733 patients were included in this study (TMIE:1472, hybrid:1364 and open:1897). Patients undergoing TMIE had lower incidence of pneumonia compared to hybrid (10.9% vs 16.3%, Odds Ratio (OR):0.56, 95%CI: 0.40–0.80) and open esophagectomy (10.9% vs 17.4%, OR:0.60, 95%CI: 0.42–0.84) and had shorter length of stay (median 10 days (IQR 8–16)) compared to hybrid (14 (11–19), p = 0.041) and open esophagectomy (11 (9–16), p = 0.027). Patients undergoing TMIE had higher rate of anastomotic leakage compared to hybrid (15.1% vs 10.7%, OR:1.47, 95%CI: 1.01–2.13) and open esophagectomy (7.3%, OR:1.73, 95%CI: 1.26–2.38). No differences were reported between hybrid and open esophagectomy. Conclusion Compared to hybrid and open Ivor Lewis esophagectomy, TMIE resulted in a lower pneumonia rate, a shorter hospital length of stay but a higher anastomotic leakage rate. The impact of these individual complications on survival and long-term quality of life should be further investigated.