Cervical Anastomotic Leakage Research Articles

466. ROBOT-ASSISTED CERVICAL ESOPHAGECTOMY (RACE) FOR ESOPHAGEAL CANCER: THE FIRST TWO CASES OF AN ITALIAN HIGH-VOLUME CENTER

Abstract Background Closed thorax esophagectomy is an alternative to conventional two or three-field esophagectomy in patients with esophageal cancer and pulmonary comorbidities, previous thoracic surgery or cervical tumor spread without thoracic involvement. We describe our first two cases of robotic trans-hiatal and trans-cervical esophagectomy. Methods We performed a robotic assisted abdominal D2 lymphadenectomy and trans-hiatal esophageal dissection until the tracheal carina with en bloc mediastinal lymphadenectomy. Then we did left cervicotomy and, using a gelPort, we continued robotic esophageal dissection in superior mediastinum until the carina, preserving left recurrent nerve. Subsequently, in abdomen, we completed esophageal dissection and gastric tubulization. After section of the esophagus we pulled up the gastric conduit and in one case we performed a esophago-gastric 23 mm termino-lateral mechanical circular anastomosis and in the other hypopharyngeal-gastric handsewn double layer anastomosis. Results One patient had distal esophageal adenocarcinoma and we chose RACE because of previous pleuritis. Pathology reported ypT2N1 (35 lymph nodes retrieved) with R0 resection. Post operative complications were cervical anastomotic leak, chylous ascites and atrial fibrillation treated conservatively; total length of stay (LOS) was 25 days. The second patient had cervical squamous cell carcinoma spreading to the neck without thoracic involvement. In addition to RACE, we performed tracheostomy after cervical lymphadenectomy. Pathology reported ypT0N0 (17 lymph nodes) with R0 resection. A post-operative Bernard Horner syndrome was noted; total LOS was 16 days. Conclusion Our first experience in performing RACE with the Da Vinci Xi robotic system shows that this can be a feasible procedure with adequate surgical and oncological outcomes. Further comparison studies are needed.

303. VACUUM-STENT TREATMENT FOR TRANSMURAL DEFECTS IN THE UPPER GASTRO-INTESTINAL TRACT: CASE SERIES AND NEW INSIGHTS IN A TERTIARY REFERRAL CENTER

Abstract Background Transmural defects in the upper gastro-intestinal (GI) tract are associated with severe morbidity and mortality. Endoscopic vacuum therapy (EVT) has recently been established as promising endoscopic treatment option for such defects and is most often applied using endoscopically placed vacuum-sponges. The vacuum-stent is a novel device to apply EVT, combining the advantages of negative pressure wound therapy and an intraluminal stent, allowing for oral intake. Methods The aim of this prospective cohort study is to describe the experiences of, and lessons learned by a tertiary referral center with EVT experience since 2018, regarding the vacuum-stent for transmural defects in the upper GI tract. All patients treated with a vacuum-stent between November 2022 and October 2023 were included. Outcome measures included successful defect closure, reasons of treatment failure, adverse events and strictures. Results 31 patients were included. Baseline characteristics and outcomes are displayed in Table 1. Success rates of combined vacuum-stent and –sponge treatment and vacuum-stent treatment alone were respectively 83% and 78%. In this cohort, some notable reasons of failure were observed: a defect too close to the upper esophageal sphincter (UES), inadequate vacuum on the esophago-jejunal anastomosis, a carcinoma at a persisting perforated ulcer, and adverse events. Two adverse events occurred (6%): two patients developed a secondary defect at the site of the proximal vacuum-stent flange, of whom one had a cervical anastomosis with a narrow proximal esophagus and one Boerhaave syndrome. Three out of four patients with a severe structure had underwent a McKeown esophagectomy. Conclusion The vacuum-stent is a valuable treatment option for AL after Ivor Lewis esophagectomy, Boerhaave syndrome and iatrogenic defects with success rates of 78-83%. Treating cervical anastomotic leaks is not recommended by us, due to the narrow lumen of the proximal esophagus, the proximity of the UES and high risk of severe strictures. Furthermore, caution is recommended in case of a narrow esophagus. In our experience, vacuum-stent and –sponge treatment complement each other and might be indicated in different situations. Sharing experiences on the topic is important to assess the best techniques and indications, to be able to reach the full potential of the vacuum-stent and further increase the success rate.

553. CIRCULAR STAPLED CERVICAL ESOPHAGO-GASTROSTOMY, A VALUABLE OPTION AFTER TOTALLY MINIMALLY INVASIVE MCKEOWN ESOPHAGECTOMY?

Abstract Background The optimal choice of anastomotic technique for cervical esophagogastric anastomosis after esophagectomy remains unclear. The incidence of cervical anastomotic leak after esophagectomy can be up to 30%, which is the highest among all types of gastrointestinal anastomosis. Anastomotic stricture is another complication that can decrease the postoperative quality of life with an incidence of 9.1–46.0%. Few studies directly compared circular stapled (CS) and hand sewn (HS) cervical esophago-gastric anastomosis, with mixed results. We aim to compare the two techniques in a pre-post cohort study. Methods Medical record of all patients that underwent minimally invasive subtotal esophagectomy and cervical esophago-gastrostomy in our institution from January 2018 to January 2024 were reviewed from a prospectively collected database. We routinely performed hand sawn anastomoses until February 2022, then switched to circular stapled, with the aim of reducing the incidence of anastomotic leaks. We compared clinical data of patients who received hand sewn cervical anastomosis and circular stapled anastomosis. Primary endpoints were anastomotic leaks and strictures. Results We identified 101 patients who met the inclusion criteria. HS anastomosis was performed in 67 patients, while 34 received CS anastomosis. Anastomotic leak rate was 22.4% in the HS group and 8.8% in the CS group (OR 0.34, p=0.092). Anastomotic stricture rate was 26.9% in the HS group and 14.7% in the CS group (OR 0.47, p=0.17). Median length of stay was 18 (IQR 15-22) days in the HS group and 13.5 (IQR 12-14.5) days in the CS group (p=0.001). Severe complication rate (CD>2) was 16.4% in the HS group and 11.8% in the CS group (OR 0.68, p=0.53). Conclusions In our experience, the introduction of circular stapled cervical esophago-gastrostomy was feasible and safe, and resulted in a lower incidence of anastomotic leak and stricture compared to hand sewn anastomosis, though not statistically significant, possibly because of the small sample size. No difference in other major postoperative outcomes was observed. We found cervical CS anastomosis a reliable, reproducible and technically less demanding procedure, even for very high esophageal cancers. We believe that this anastomotic technique could spread even in Western countries where it has hardly ever been explored.

Effect of sternocleidomastoid flap repair and endoscopic injection of emulsified adipose tissue stromal vascular fraction in the treatment of refractory cervical anastomotic leak contaminating mediastinum.

Mediastinal infection caused by anastomotic leak is hard to cure, mainly because the poor drainage at the site of mediastinal infection leads to persistent cavity infection, which in turn becomes a refractory mediastinal abscess cavity after minimally invasive esophagectomy (MIE)-McKeown. Herein, we explored sternocleidomastoid (SCM) muscle flaps and emulsified adipose tissue stromal vascular fraction containing adipose-derived stem-cells to address this issue. We studied 10 patients with esophageal cancer who underwent MIE-McKeown + 2-field lymphadenectomy and developed anastomotic and mediastinal leak and received new technology treatment in the Affiliated Cancer Hospital of Zhengzhou University from June 2018 to March 2022. The clinical data and prognosis of the patients were collected and analyzed. A total of 5 patients received this surgery, and no other complications occurred during the perioperative period. Among the 5 patients, 1 patient was partially cured, and 4 patients were completely cured. During the follow-up 3 months postoperatively, all these 5 patients could eat regular food smoothly, and no relapse of leak and mediastinal infection occurred. The new surgical method has achieved good results in the treatment of anastomotic leak. Compared with the traditional thoracotomy, it is a less invasive and feasible surgical approach, which can be used as a supplement to the effective surgical treatment of cervical anastomotic leak contaminating the mediastinum.

Pilot Trial on Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer: Feasibility and Impact on Anastomotic Leakage (TIGOAL-I).

To evaluate the feasibility, safety, and effectiveness of gastric conditioning using preoperative arterial embolization (PAE) before McKeown esophagectomy at a tertiary university hospital. Cervical anastomotic leakage (AL) is a common complication of esophagectomy. Limited clinical evidence suggests that gastric conditioning mitigates this risk. This pilot randomized clinical trial was conducted between April 2016 and October 2021 at a single-center tertiary hospital. Eligible patients with resectable malignant esophageal tumors, suitable for cervical esophagogastrostomy, were randomized into 2 groups: one receiving PAE and the other standard treatment. The primary endpoints were PAE-related complications and incidence of cervical AL. The study enrolled 40 eligible patients. PAE-related morbidity was 10%, with no Clavien-Dindo grade III complications. Cervical AL rates were similar between the groups (35% vs 25%, P = 0.49), even when conduit necrosis was included (35% vs 35%, P = 1). However, AL severity, including conduit necrosis, was higher in the control group according to the Clavien-Dindo ≥IIIb (5% vs 30%, P = 0.029) and Comprehensive Complication Index (20.9 vs 33.7, P = 0.01). No significant differences were found in other postoperative complications, such as pneumonia or postoperative mortality. PAE is a feasible and safe method for gastric conditioning before McKeown minimally invasive esophagectomy and shows promise for preventing severe AL. However, further studies are required to confirm its efficacy.

Nomogram prediction model of cervical anastomotic leakage after esophageal cancer surgery

Objective: To retrospectively analyze the risk factors of anastomotic leakage in the neck after esophageal cancer and establish a nomogram prediction model that can accurately predict the occurrence of anastomotic leakage in the neck of the patient. Methods: The study retrospectively analyzed 702 patients who underwent radical esophageal cancer surgery between January 2010 and May 2015 at Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. A multivariate logistic regression model was used to determine the risk factors for neck anastomotic leak, and a nomogram model was constructed, internal validation methods were used to evaluate and verify the predictive effectiveness of the nomogram. Results: There were 702 patients in the whole group, 492 in the training group and 210 in the validation group. The incidence of postoperative cervical anastomotic leak was 16.1% (79/492) in 492 patients with esophageal cancer in the training group. Multifactorial analysis revealed calcification of the descending aorta (OR=2.12, 95% CI: 1.14, 3.94, P=0.018), calcification of the celiac artery (OR=2.29, 95% CI: 1.13, 4.64, P=0.022), peripheral vascular disease (OR=5.50, 95% CI: 1.64, 18.40, P=0.006), postoperative ventilator-assisted breathing (OR=5.33, 95% CI: 1.83, 15.56, P=0.002), pleural effusion or septic chest (OR=3.08, 95% CI: 1.11, 8.55, P=0.031), incisional fat liquefaction and infection (OR=3.49, 95% CI: 1.68, 7.27, P=0.001) were independent risk factors for the development of cervical anastomotic leak after esophageal cancer surgery. The results of the nomogram prediction model showed that the consistency indices of the training and external validation groups were 0.73 and 0.74, respectively (P<0.001), suggesting that the prediction model has good predictive efficacy. Conclusion: The nomogram prediction model can intuitively predict the incidence of postoperative cervical anastomotic leakage in patients with high prediction accuracy, which can help provide a clinical basis for preventing cervical anastomotic leak and individualized treatment of patients.

Anastomotic leak after esophagectomy

Background: Esophageal anastomotic leakage (AL) remains a frequent and feared postoperative complication, associated with high mortality and impaired quality of life. The aim of this study was to assess AL rates after esophagectomy with anastomosis at neck for esophageal and gastroesophageal junction cancer (GEJ), and compare the impact of AL on oncological outcome. Methods: Patients with squamous cell carcinoma and adenocarcinoma of esophagus/ gastroesophageal junction who underwent surgery between 2001-2018 were analyzed for cervical anastomotic leak. Results: 419 patients underwent esophagectomy with anastomosis placed at neck during 2001-2018. AL rate was 16%. AL was not found to be associated with anastomotic technique, surgical approach and technique, organ of conduit and route of conduit. A subgroup of patients (n=93) who had undergone neoadjuvant chemoradiation followed by surgery had AL of 30% vs 12% in rest of the treatment modality group (p&lt;0.001). Median survival was 26 months and 34 months in patients with AL and without AL, respectively (p=0.03). AL was managed successfully in all patients. Conclusion: Cervical AL after esophagectomy for cancer of esophagus and GEJ can be treated successfully without major complications.

315. LAPAROSCOPIC GASTRIC PULL-UP WITH GASTROJEJUNOSTOMY AS AN ALTERNATIVE TO COLON-TRANSPOSITION FOR CORROSIVE STRICTURE INVOLVING OESOPHAGUS AND ANTROPYLORIC REGION OF STOMACH

Abstract Background Various gastrointestinal segments are used for replacement of the scarred oesophagus following corrosive ingestion. Colon is preferred if scarring involves both the oesophagus and the stomach, however, in some patients only the antral part of the stomach maybe involved (in addition to the oesophagus), and a gastric pull-up with a roux en Y gastrojejunostomy may also be feasible. Methods Retrospective analysis of corrosive strictures managed surgically between 2020–2023. The short and long-term outcomes of laparoscopic gastric pull-up with roux en Y gastrojejunostomy (LGPU-GJ) were compared with colonic pull-up. Results During the study period, 45 patients underwent surgical management for corrosive injury to the oesophagus and stomach. Of these, 7 patients underwent a LGPU-GJ (group A) and 20 patients underwent a colonic pull-up (Group B) and formed the study group. The mean operative time and blood loss was (195.7 ± 55 and 322 ± 63 min, p = 0.001; 48.5 ± 24 and 108 ± 30.8 mL p &amp;lt; 0.001) in Group A and B respectively. One patient in Group A had a gastric staple line leak which was managed with intercostal drainage and antibiotics, 3 patients in Group B had cervical anastomotic leak which was managed conservatively. There was no mortality. Over a median followup of 18 months, 2 patients in Group A and 7 in Group B required at least one session at endoscopic anastomotic dilatation. There were no significant reflux symptoms reported and all patients were able to tolerate a standard Indian diet. Conclusion In a select group of patients with concomitant oesophageal and isolated gastric antral stricture a laparoscopic gastric pull-up with roux en Y gastrojejunostomy may be a feasible alternative to the more complex colonic pull-up with shorter operative times, less blood loss and equivalent outcomes.

Outcomes of Resection Surgery in Corrosive Esophageal Stricture

Background: Esophageal stricture is a rarely encountered but a significant issue of worry throughout the world. Treatment options for esophageal stricture include endoscopic dilatation and surgery along with proton pump inhibitors. Surgery is performed if there is failure of enough dilatation and if recurrence occurs despite multiple dilatations. Objective: This study was designed to determine the outcome of resection surgery in adult patients presenting with Corrosive Esophageal Strictures. Material and Methods: A descriptive cross sectional study was carried out at surgery department, DHQ hospital Gujranwala, from December 2019 to June 2020. 60 consecutive patients, of age 20-60 years of either gender with presence of esophageal strictures caused by intake of corrosive substances and failed to undergo endoscopic dilatation due to difficulty in passing endoscope across the esophageal stricture, were included in the study. All study participants underwent resection surgery procedure under general anesthesia by a single surgical team. The marginal arcade alongside colon was conserved in all cases in which colon was utilized. Feeding jejunostomy was placed in all patients. Duration of surgery was noted. After surgery, patients were followed-up in surgical wards for 48 hours and examined on ultrasound for cervical anastomotic leak. Then patients were followed-up in OPD for 15 days and if dysphagia reoccurred, it was also noted. Results: The mean age of patients was 31.80 ± 7.74 years. There were 47(78.3%) male and 13(21.7%) female cases. There were 33.3% case who took acid, 16.7% took alkalis, 16.7% cases ingested metal salts, 21.7% had formalin, 6.7% cases had iodine tincture and 5.0% cases had other types of corrosive material. The mean operative time was 3.80 ± 0.80 hours. There were 11(18.3%) cases who had cervical anastomotic leak and 10(16.7%) cases had dysphagia related problem. No statistically significant difference (p≥0.05) was found in the outcomes of resection surgery across various groups based on age, gender, BMI, duration of corrosive intake, and type of corrosive substance ingested. Also, No significant difference (p≥0.05) was found in mean operative time in any stratum. Conclusion: It is concluded that outcome of resection surgery in adult patients presenting with Corrosive Esophageal Strictures was favorable with less complications. Hence these cases can be managed with standard surgical procedure to save their life and improve the quality of life. Keywords: Corrosives, Esophageal Stricture, Resection Surgery, Dysphagia, Cervical Anastomotic leak

A New Risk Factor for Cervical Anastomotic Leakage-Role of The Relative Gastric Length in the Surgical Treatment of Esophageal Cancer.

Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice? Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G). A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group. RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.

The Radiation Dose to the Left Supraclavicular Fossa is Critical for Anastomotic Leak Following Esophagectomy - A Dosimetric Outcome Analysis.

PurposeFor locally advanced esophageal cancer, definitive concurrent chemoradiotherapy (CCRT) with a radiation dose of 50–50.4 Gy/25-28 Fx is prescribed, followed by adjuvant esophagectomy for better local control or salvage treatment if locoregional recurrence occurs. However, radiation injury before surgery may delay wound healing. We performed cervical anastomosis directly inside the left supraclavicular fossa (SCF), the irradiation target for esophageal cancer. The significance of radiation injury in patients with cervical anastomotic leak (AL) remains unclear. Thus, we assessed the influence of radiation on cervical AL in patients undergoing preoperative CCRT followed by esophagectomy.Patients and MethodsWe defined the SYC zone, a portion of the region overlapping the left SCF. The radiation dose to the SYC zone was analyzed and correlated with AL in patients with locally advanced esophageal squamous cell carcinoma (ESCC) who were administered preoperative CCRT (radiation dose with 50–50.4 Gy/25-28 Fx to the primary esophageal tumor) followed by esophagectomy between October 2009 and January 2018. Receiver operating characteristic curve analysis and logistic regression were used to identify the optimal radiation factor to predict AL and the cutoff value.ResultsThe optimal radiation factor to predict AL was the mean dose to the SYC zone (area under the curve (AUC)=0.642), and the cutoff point of the mean dose was 48.55 Gray (Gy). For a mean SYC zone dose ≥48.55 Gy, the AL risk was sevenfold greater than that for <48.55 Gy (OR = 7.805; 95% CI: 1.184 to 51.446; P value = 0.033).ConclusionRecognizing the SYC zone as an organ at risk and performing radiation evaluation are meaningful. A reduced mean dose of the SYC zone below 48.55 Gy results in a lower cervical AL rate following esophagectomy.

RESULTS OF PREVENTIVE METHODS OF OCCURRENCE CERVICAL ANASTOMOTIC COMPLICATIONS IN ESOPHAGOPLASTY

The aim: The aim of the study was to improve the results of surgical treatment in patients with corrosive esophageal strictures using the designed comprehensive surgical management program in esophagoplasty to decrease cervical anastomotic complications. Materials and methods: The results of surgical treatment of 116 patients with esophageal strictures were studied. 45 patients had post-burn corrosive strictures, 17 – postoperative corrosive strictures, 10 - peptic strictures due to reflux esophagitis and 44 patients - esophageal cancer. All patients were divided into two groups: the control group, consisting of 55 patients who underwent conventional surgical treatment of corrosive esophageal strictures during 2005-2011, and experimental group involving 61 patients operated on during 2012- 2020, in whom an individual approach to the choice of surgical method was applied using diagnostic and treatment algorithm as well as the designed surgical management program. Results: In early postoperative period the proportion of specific and non-specific complications was significantly lower in experimental group as compared to the control group: cervical anastomotic leak - 16.36 % versus 4.392 %; strictures of cervical anastomosis – 20.0% versus 6.56 % (p&lt;0.05). There were six postoperative deaths - four in the control group and two in experimental group. Conclusions: To prevent the development of cervical anastomotic complications and mortality in esophagoplasty proper therapeutic approach with consideration of all prognostic criteria and risk factors should be chosen and designed surgical management program should be applied.

Management of caustic pharyngoesophageal injuries in Korle Bu Teaching Hospital, Accra, Ghana: a 12-year retrospective review of 29 cases.

caustic pharyngoesophageal strictures are life-threatening injuries with important management difficulties, lacking clear therapeutic guidelines. The aim of this study is to evaluate the surgical procedures and outcomes of severe caustic pharyngoesophageal strictures in our institution. a total of 29 patients who underwent surgery for severe caustic pharyngoesophageal injury at the National Cardiothoracic Center from June 2006 to December 2018 were retrospectively reviewed. The age distribution, sex, management procedures, complications after surgery, and the outcome were analyzed. there were 17 males. The mean age was 11.7 years (range 2- 56 years). All patients accidentally swallowed caustic soda, except the oldest patient who ingested an unidentified substance. The treatment procedures included colopharyngoplasty in 15 (51.7%) patients, colon-flap augmentation pharyngoesophagoplasty (CFAP) in 10 (34.5%), and colopharyngoplasty with tracheostomy in 4 (13.8%). There was one case of graft obstruction from a retrosternal adhesive band and one case of postoperative reflux with nocturnal regurgitation. No cervical anastomotic leak occurred. Rehabilitative training for oral feeding was required for less than a month in most patients. Follow-up period ranged from one to twelve years. Four patients died within this period; two were immediate post-operative deaths and two occurred late. One patient was lost to follow-up. outcome of surgery for caustic pharyngoesophageal stricture is satisfactory. Colon-flap augmentation pharyngoesophagoplasty reduces the need for tracheostomy before surgery, and our patients start eating early without aspiration.

A randomized trial of negative pressure wound therapy technology combined with intermittent instillation in the treatment of neck anastomotic leakage after esophageal cancer surgery.

This study aimed to examine the effects of applying the negative pressure wound therapy (NPWT) combined with intermittent instillation (NPWTi) in patients with cervical anastomotic leakage (AL) after esophageal cancer surgery. From July 2019 to June 2021, 64 patients undergoing AL after esophageal cancer surgery were selected from our Hospital's Thoracic Department, and randomly allocated to the conventional nursing group (20 patients), the hospital central NPWTi group (23 patients), and the portable NPWTi group (21 patients). The hospital central NPWTi group was treated with central negative pressure combined with intermittent instillation, and the portable NPWTi group was treated with portable negative pressure combined with intermittent instillation. Indicators of fistula healing, healing days, treatment costs, comfort, and nursing satisfaction were examined in each group. The fistula healing rate, healing days, nursing satisfaction, and comfort level of the hospital central NPWTi group and the portable NPWTi group were better than those of the conventional nursing group (P<0.05). There was no difference in the fistula healing rates and healing days between the hospital central NPWTi group, and the portable NPWTi group (P>0.05). The treatment costs of the hospital central NPWTi group were lower than those of the portable NPWTi group (P<0.05). Negative pressure treatment technology combined with the intermittent instillation of the neck anastomotic fistula improved the fistula microenvironment, strengthened the sterilization effect, drained the leachate effectively, shortened the fistula healing time, improved the fistula cure rate, and increased patients' satisfaction with nursing. In relation to the negative pressure source, there was no difference in the therapeutic effects of hospital central NPWTi compared to the portable negative pressure meter, but the hospital central NPWTi treatment costs were lower and patients' acceptance of NPWT instillation was higher. Thus, central NPWT instillation treatment is worthy of promotion. Chinese Clinical Trial Registry ChiCTR2100052240.

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.

29 SIZE OF THE THORACIC INLET SPACE AS A PREDICTOR OF CERVICAL ANASTOMOTIC LEAK AFTER RETROSTERNAL RECONSTRUCTION FOLLOWING ESOPHAGECTOMY

Abstract Although anastomotic leak is a common postoperative complication following an esophagectomy, it is not well known whether anatomical factors increase the risk for anastomotic leak after the procedure. The purpose of this study was to clarify whether a narrow thoracic inlet is an independent predictor of cervical anastomotic leak after retrosternal reconstruction following esophagectomy. Methods A total of 212 patients who underwent esophagectomy with gastric conduit retrosternal reconstruction between January 2013 and March 2019 were included in this study. Computed tomography was used to measure the thickness of the sternum (TS), the thickness of the clavicle (TC), the interclavicular distance, the sternum-trachea distance (STD), the sternum-vertebral body distance (SVD), and the sternum-trachea distance/sternum-vertebral body distance ratio (STD/SVD ratio). The correlation between various factors was analyzed using Spearman’s correlation coefficient. Tree-based analysis was performed to define cutoff values. Multivariate logistic regression was used to analyze the association between various predictors and anastomotic leak. Results Anastomotic leak occurred in 26 patients (12.26%). Tree-based analysis identified an optimal TS cutoff value of 20.84 mm, a TC cutoff value of 23.63, and a STD/SVD ratio cut off value of 0.2138 to predict anastomotic leak. There were significant associations between the STD, STD/SVD ratio and thoracic inlet area (STD × ICD). According to multivariate analysis, STD/SVD ratio, TS, TC, and diabetes mellitus were significantly associated with increased incidence of anastomotic leak. Conclusion STD/SVD ratio, TS, TC, and diabetes mellitus were associated with higher rates of cervical anastomotic leak after retrosternal gastric conduit reconstruction following esophagectomy. In patients with a small thoracic inlet, posterior mediastinal reconstruction and intrathoracic anastomosis should be considered.

Anastomotic leakage and postoperative mortality in patients after esophageal cancer resection

ObjectiveEsophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. This study aimed to investigate the risk factors of cervical anastomotic leakage and postoperative mortality.MethodsIn this retrospective, observational study, we recruited 1010 patients with esophageal cancer. Cox regression analysis was performed to identify factors affecting anastomotic leakage and postoperative mortality. After propensity score matching, the Kaplan–Meier curve was used to evaluate the effect of leakage on postoperative mortality.ResultsThe number of patients with cervical anastomotic leakage, in-hospital mortality, 30-day postoperative mortality, and 60-day postoperative mortality was 194 (19.2%), 13 (1.3%), 12 (1.2%), and 16 (1.6%), respectively. The total length of hospital stay and hospital stay postoperatively were 29.7 ± 21.1 and 21.3 ± 20.3 days, respectively. Diabetes, stage IV, and an upper thoracic tumor were significant risk factors for leakage. Leakage and diabetes were significant risk factors for postoperative mortality. After propensity score matching, leakage also significantly affected postoperative mortality.ConclusionsPatients with tumors in the upper thoracic segment of the esophagus may be more prone to developing anastomotic leakage compared with those with tumors in the middle or lower thoracic segment. Anastomotic leakage may prolong the length of hospital stay and increase postoperative mortality.

Tocilizumab in SARS-COVID19 following postoperative laparoscopic transhiatal esophagectomy for the adenocarcinoma of esophagogastric tumor: A case report.

Introduction and importanceEsophagectomy for esophageal cancer is one of the most challenging surgical procedures, with high rates of morbidity, especially from respiratory complications. SARS-COVID19 represents a health threat nowadays. Peri-operative SARS-COVID19 infection after esophagectomy might negatively affect the postoperative outcomes. The use of tocilizumab as an alternative to reduce the inflammatory response in SARS-COVID19 is an option that has not been described in the literature after esophagectomy.Case presentationA SARS-COVID19-vaccinated (CORONAVAC) 73-year-old man with pulmonary emphysema, coronary artery disease, previous asymptomatic pulmonary embolism, and adenocarcinoma of the esophagogastric junction tumor was submitted to laparoscopic transhiatal esophagectomy (ypT2N0M0) after perioperative neoadjuvant chemotherapy. He was also infected with SARS-COVID19, confirmed by PCR test at the 14th postoperative day. During follow-up, mild hypoxemia persisted without evidence of infection except for SARS-COVID19, and a high-flow cannula was required to maintain oxygenation. Tocilizumab was administered following high parameters of a high-flow cannula, and invasive mechanical ventilation was avoided.DiscussionBesides of the risk of secondary infection, after administration of tocilizumab, the parameters of oxygen supplementation were systematically reduced, and he stayed in the ICU for seven days. He was discharged from the ward six days later. He developed late cervical anastomotic leakage, which was treated with conservative therapy.ConclusionAlthough the patient had high-risk comorbidities, esophagectomy, and SARS-COVID19 infection, the use of tocilizumab was safe and improved the pulmonary recovery.

A New Esophagogastric Anastomosis for McKeown Esophagectomy in Esophageal Cancer

For McKeown esophagectomy, hand-sewn and mechanical esophagogastric anastomosis techniques have been improved for constructing esophagogastrostomy. However, postoperative anastomosis-related complication rates remain high in patients undergoing cervical anastomosis. Here, we report an original and reliable hand-sewn cervical tunnel esophagogastric anastomosis technique to maximally reduce cervical anastomotic leakage and stricture rates after McKeown esophagectomy. The key features and innovations of cervical tunnel esophagogastric anastomosis are the right gastroepiploic artery as the center for the esophagogastric anastomosis to reduce ischemia, sufficient width of the anastomotic site for anastomosis without stricture, enfolding of the anastomotic site by the tunnel, and tension- and rotation-free anastomosis.

Evaluation of Fibrin Sealant in Prevention of Cervical Anastomotic Leakage After McKeown Esophagectomy: A Single-Center, Retrospective Study.

Anastomotic leakage remains an issue after esophagectomy for patients with esophageal or esophagogastric junction cancer. Previous studies have indicated that the intraoperative application of fibrin sealant may reduce the incidence of postoperative anastomotic leakage. This retrospective study was aimed to evaluate the efficacy and safety of fibrin sealant in the prevention of anastomotic leakage in patients undergoing McKeown esophagectomy. We designed a single-center, retrospective study. Between January 2018 and December 2019, 227 patients with esophageal or esophagogastric junction cancer undergoing McKeown esophagectomy performed by our team were retrospectively identified, of whom 86 patients were included in the FS group and 141 patients were included in the control group. Intraoperatively, 2.5 ml of porcine fibrin sealant was applied circumferentially to the cervical anastomosis after the anastomosis was created in the FS group. The primary outcome was the incidence of cervical anastomotic leakage within the first three months after surgery. The differences in baseline clinical characteristics between the two groups were not significant except for a history of drinking. In the FS group, the postoperative cervical anastomotic leakage rate was lower (FS group: 4.7% [4 of 82] vs. control group: 19.9% [28 of 141], p < 0.01). Multivariate logistic regression showed that the intraoperative application of fibrin sealant was an independent protective factor for anastomotic leakage (OR 0.169, 95% CI 0.055-0.515, p=0.002). The intraoperative application of fibrin sealant could possibly prevent cervical anastomotic leakage after McKeown esophagectomy with satisfactory safety. Further prospective clinical trials are warranted.