Cervical Esophagogastric Anastomosis Research Articles

The totally mechanical Collard technique for cervical esophagogastric anastomosis reduces anastomotic stricture compared with triangular anastomosis in minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route: a propensity score-matched study.

Cervical esophagogastric anastomosis is conventionally performed using the McKeown esophagectomy. However, an optimal anastomotic technique has not yet been established. This study aimed to compare the clinical outcomes of triangular anastomosis (TA) and totally mechanical Collard anastomosis (TMCA) for cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route. In this matched- cohort study, 117 patients who underwent minimally invasive esophagectomy between 2019 and 2024 were divided into TA and TMCA groups. The TA technique was performed between September 2019 and December 2021, and the TMCA technique was performed between January 2022 and January 2024. We then compared the surgical outcomes and postoperative complications (pneumonia, recurrent laryngeal nerve palsy, anastomotic leakage, and stricture) between the two groups. Propensity score matching revealed that 40 patients were included in both the TA and TMCA groups. The rates of pneumonia, recurrent laryngeal nerve palsy, and anastomotic leakage were not significantly different between the two groups. However, the rate of anastomotic stricture was lower in the TMCA than in the TA group (2.5% vs. 27.5%, respectively, P = 0.003). Compared with the TA technique, the TMCA technique reduced the rate of anastomotic stricture when performing cervical esophagogastric anastomosis during minimally invasive esophagectomy with gastric conduit reconstruction through the retrosternal route.

438. TECHNIQUE OF COMPLETELY ROBOTIC MCKEOWN (3-HOLE) ESOPHAGECTOMY WITH INTRA-CORPOREAL GASTRIC CONDUIT CREATION, AND CERVICAL ESOPHAGO-GASTRIC ANASTOMOSIS FOR MID-ESOPHAGEAL ADENOCARCINOMA

Abstract Background Esophageal cancer is the 7th leading cause of cancer deaths, with an estimated total case of 22,370 in both males and females in 2024. Adenocarcinoma and squamous cell carcinoma account for over 90% of histology at diagnosis. The incidence of adenocarcinoma continues to rise due to the rising incidence and prevalence of obesity, gastro-esophageal reflux disease and Barrett's esophagus. Multi-modality treatment is currently the standard of care for locally advanced disease. This consists of neoadjuvant concurrent chemotherapy and radiation therapy, followed by esophagectomy. Minimally invasive approaches to esophagectomy are associated with decreased post-operative morbidities and overall satisfactory outcomes. While the Ivor Lewis esophagectomy with intra-thoracic anastomosis is the most common surgical approach to resection of distal esophageal and gastroesophageal (GE) junction tumors, the McKeown (3-hole) esophagectomy with cervical esophago-gastric anastomosis is best suited for tumors located in the proximal and mid-esophagus. Methods We describe our technique of robotic McKeown (3-hole) esophagectomy for mid-esophageal adenocarcinoma after neoadjuvant concurrent chemo-radiation therapy for clinical stage uT3N0M0 tumor. The thoracic esophagus is completely mobilized from the esophageal hiatus of the diaphragm up to the thoracic inlet via a right thoracoscopic approach, with harvesting of the regional lymph nodes together with the specimen. The left neck incision is made along the anterior border of the sternocleidomastoid muscle and the inferior belly of the omohyoid muscle is transected. The cervical esophagus is then completely mobilized into the wound and secured using a Penrose drain. Using a laparoscopic approach, the entire stomach is mobilized with division of the left gastric vessels but careful preservation of the right gastro-epiploic arcade while transecting the greater omentum and the short gastric vessels. An intra-corporeal creation of the gastric conduit then follows. The gastric conduit, secured to the proximal stomach at the resection staple line, is subsequently tunneled via the esophageal hiatus and through the mediastinum to exit at the left neck incision by applying traction on the cervical esophagus. The specimen is separated from the conduit, and the cervical esophagus is transected at the desired location for the anastomosis. A stapled end-to-side but functional end-to-end esophago-gastric anastomosis (Orringer's technique) is then created. Results A completely robotic technique of McKeown (3-hole) esophagectomy without the need to exteriorize the stomach to fashion the gastric conduit via a (mini)laparotomy is successfully accomplished in the majority of our patients with proximal or mid-esophageal tumors. An uneventful postoperative recovery was made. Fluoroscopic esophagram on post-operative day 5 did not demonstrate leakage from the anastomotic site. Gastric conduit emptying was satisfactory despite the lack of a routine gastric drainage procedure or injection of botulinum toxin into the pyloric ring. Conclusion Robotic-assisted thoracoscopic esophageal mobilization combined with laparoscopic completely intra-corporeal fashioning of gastric conduit with cervical esophago-gastric anastomosis is a technically feasible minimally invasive approach to performing McKeown esophagectomy with satisfactory post-operative outcomes and conduit functioning. https://www.dropbox.com/scl/fi/gzc1vzdzhzqn7niz95b8t/Robotic-McKeown-Esophagectomy-Video-3.mp4?rlkey=c4ja7s1aob10ah6ps500z7y29&dl=0

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.

Impact of nasogastric tube exclusion after minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study in India.

This study examines the impacts of omitting nasogastric tube (NGT) placement following cervical esophagogastric anastomosis (CEGA) in Enhanced Recovery After Surgery (ERAS) protocols, comparing outcomes to those from early NGT removal. In a retrospective cohort of esophagectomy patients treated for esophageal cancer, participants were divided into two groups: group 1 had the NGT inserted post-CEGA and removed by postoperative day 3, while group 2 underwent the procedure without NGT placement. We primarily investigated anastomotic leak rates, also analyzing hospital stay duration, pulmonary complications, and NGT reinsertion. Among 50 esophageal squamous cell carcinoma patients, 30 in group I were compared with 20 in group II. The baseline demographic and tumor characteristics were similar between both groups. The overall incidence of anastomotic leak was 14.0%, comparable in both groups (16.7% vs. 10.0%, p = 0.63). The postoperative hospital stay was significantly shorter in the no NGT group (median of 7 days vs. 6 days, p = 0.03) with similar major morbidity (Clavien-Dindo grade ≥IIIa; 13.3% vs. 5.0%, p = 0.63). There was no 30-day mortality, and one patient in each group had reinsertion of NGT for conduit dilatation. The exclusion of an NGT across CEGA after esophagectomy did not influence the anastomotic leak rate with comparable complications and a shorter hospital stay.

Impact of nasogastric tube exclusion after minimally invasive esophagectomy for esophageal cancer: a single-center retrospective study in India.

This study examines the impacts of omitting nasogastric tube (NGT) placement following cervical esophagogastric anastomosis (CEGA) in Enhanced Recovery After Surgery (ERAS) protocols, comparing outcomes to those from early NGT removal. In a retrospective cohort of esophagectomy patients treated for esophageal cancer, participants were divided into two groups: group 1 had the NGT inserted post-CEGA and removed by postoperative day 3, while group 2 underwent the procedure without NGT placement. We primarily investigated anastomotic leak rates, also analyzing hospital stay duration, pulmonary complications, and NGT reinsertion. Among 50 esophageal squamous cell carcinoma patients, 30 in group I were compared with 20 in group II. The baseline demographic and tumor characteristics were similar between both groups. The overall incidence of anastomotic leak was 14.0%, comparable in both groups (16.7% vs. 10.0%, p = 0.63). The postoperative hospital stay was significantly shorter in the no NGT group (median of 7 days vs. 6 days, p = 0.03) with similar major morbidity (Clavien-Dindo grade ≥IIIa; 13.3% vs. 5.0%, p = 0.63). There was no 30-day mortality, and one patient in each group had reinsertion of NGT for conduit dilatation. The exclusion of an NGT across CEGA after esophagectomy did not influence the anastomotic leak rate with comparable complications and a shorter hospital stay.

Multi-institutional beta testing of a novel cervical esophagogastric anastomosis simulator

ObjectiveA novel simulator developed to offer hands-on practice for the stapled side-to-side cervical esophagogastric anastomosis was tested previously in a single-center study that supported its value in surgical education. This multi-institutional trial was undertaken to evaluate validity evidence from 6 independent thoracic surgery residency programs. MethodsAfter a virtual session for simulation leaders, learners viewed a narrated video of the procedure and then alternated as surgeon or first assistant. Using an online survey, perceived value was measured across fidelity domains: physical attributes, realism of materials, realism of experience, value, and relevance. Objective assessment included time, number of sutures tearing, bubble test, and direct inspection. Comparison across programs was performed using the Kruskal-Wallis test. ResultsSurveys were completed by 63 participants as surgeons (17 junior and 20 senior residents, 18 fellows, and 8 faculty). For 3 of 5 tasks, mean ratings of 4.35 to 4.44 correlated with “somewhat easy” to “very easy” to perform. The interrupted outer layer of the anastomosis rated lowest, suggesting this task was the most difficult. The simulator was rated as a highly valuable training tool. For the objective measurements of performance, “direct inspection” rated highest followed by “time.” A total of 90.5% of participants rated the simulator as ready for use with only minor improvements. ConclusionsResults from this multi-institutional study suggest the cervical esophagogastric anastomosis simulator is a useful adjunct for training and assessment. Further research is needed to determine its value in assessing competence for independent operating and associations between improved measured performance and clinical outcomes.

Critical swallowing functions contributing to dysphagia in patients with recurrent laryngeal nerve paralysis after esophagectomy.

Recurrent laryngeal nerve paralysis (RLNP) after esophagectomy can cause aspiration because of incomplete glottis closure, leading to pneumonia. However, patients with RLNP often have preserved swallowing function. This study investigated factors that determine swallowing function in patients with RLNP. Patients with esophageal cancer who underwent esophagectomy and cervical esophagogastric anastomosis were enrolled between 2017 and 2020. Videofluoroscopic examination of swallowing study (VFSS) and acoustic voice analysis were performed on patients with suspected dysphagia including RLNP. Dysphagia in VFSS was defined as score ≥ 3 of the 8-point penetration-aspiration scale VFSS and acoustic analysis results related to dysphagia were compared between patients with and without RLNP. Among 312 patients who underwent esophagectomy, 74 developed RLNP. The incidence of late-onset pneumonia was significantly higher in the RLNP group than in the non-RLNP (18.9 vs. 8.0%, P = .008). Detailed swallowing function was assessed by VFSS in 84 patients, and patients with RLNP and dysphagia showed significantly shorter maximum diagonal hyoid bone elevation (10.62 vs. 16.75mm; P = .003), which was a specific finding not seen in patients without RLNP. For acoustic voice analysis, the degree of hoarseness was not closely related to dysphagia. The length of oral intake rehabilitation for patients with and without RLNP was comparable if they did not present with dysphagia (8.5 vs. 9.0days). Impaired hyoid bone elevation is a specific dysphagia factor in patients with RLNP, suggesting compensatory epiglottis inversion by hyoid bone elevation is important for incomplete glottis closure caused by RLNP.

A novel technique for lymphadenectomy along the left recurrent laryngeal nerve during minimally invasive esophagectomy: a retrospective cohort study

BackgroundIn the context of esophageal cancers, lymph nodes located along the left recurrent laryngeal nerve (RLN) exhibit significant involvement, posing significant challenges for lymphadenectomy. The objective of this study is to assess the safety and efficacy of a novel technique for lymphadenectomy called "elastic suspension of left RLN" method, comparing it with the conventional approach.MethodsBetween January 2016 and June 2020, a total of 393 patients who underwent minimally invasive esophagectomy with gastroplasty and cervical esophagogastric anastomosis were enrolled in the study. Among them, 291 patients underwent the "elastic suspension of left RLN" method, while 102 patients underwent the conventional method. We compared the number of harvested lymph nodes along the left RLN and assessed postoperative complications between these two groups. Additionally, the overall survival (OS) rate was calculated and analyzed for the entire cohort.ResultsIn comparison to the conventional group, the elastic suspension group exhibited a higher yield of harvested lymph nodes along the left RLN (5.36 vs 3.07, P < 0.001). Moreover, the incidence of postoperative hoarseness was lower in the elastic suspension group (10.65% vs 18.63%, P = 0.038). The average duration of lymphadenectomy along the left RLN was 11.85 min in the elastic suspension group and 11.51 min in the conventional group, although this difference was not statistically significant (P = 0.091). Notably, the overall 5-year OS was markedly higher in the elastic suspension group compared to the conventional group (64.1% vs. 50.1%, P = 0.020).ConclusionsThe findings suggest that the novel "elastic suspension of left RLN" method for lymphadenectomy along the left RLN in minimally invasive esophagectomy is both safe and effective. This technique holds promise for widespread adoption in esophagectomy procedures.

435. CIRCULAR-STAPLED ESOPHAGOGASTROSTOMY USING THE KEYHOLE PROCEDURE: TECHNICAL ASPECTS AND CLINICAL OUTCOMES

Abstract Background The optimal reconstruction method after radical esophagectomy for esophageal cancer has been under debate. For avoiding an anastomotic stricture, we developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler (LS) to enlarge the anastomotic opening made with a circular stapler (CS). We report the technique and the clinical outcomes. Methods We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery. Surgical procedures: After a 3.5 cm-wide gastric conduit was created, the blood supply was examined via indocyanine green fluorescence imaging. Usually, anastomosis was made at the site which was dominated by the last branch of the right epiploic artery owing to Kocher’s maneuver. The CS was inserted through the anterior wall of the gastric conduit, and the end-to-side anastomosis was established on the greater curvature side of the gastric conduit. Then, a 45-mm long LS was used to create a keyhole over the circular staples, and the entry hole was closed with a 60-mm long LS. Results Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). A smaller CS was used in the CS + K group (p &amp;lt; 0.001). The incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). The univariate analysis confirmed that CS ≤ 23 without a keyhole was a significant risk factor (p = 0.001). Conclusions The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in the cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

374. RADIOGRAPHICALLY-DETERMINED FRAILTY IS ASSOCIATED WITH IMPAIRED GASTRIC CONDUIT PERFUSION DURING ESOPHAGECTOMY

Abstract Background Frailty is considered a preoperative risk factor for complications after esophagectomy while impaired gastric conduit perfusion is associated with anastomotic leaks. Patients with impaired conduit perfusion may be candidates for gastric ischemic preconditioning, a surgical procedure performed prior to definitive esophagectomy to improve gastric conduit perfusion. The aim of this study was to investigate the association between radiographic determinants of frailty (morphomics) and gastric conduit perfusion assessed during esophagectomy. Methods Patients undergoing an esophagectomy with a cervical esophagogastric anastomosis (2015–2021) were included. Preoperative CT scans were processed using semiautomated algorithms (MATLAB; MathWorks, MA) to assess skeletal muscle (cross-sectional area, Martin’s criteria), subcutaneous fat (cross-sectional area, decreased when below the cut-off) and bone mineral density (decreased when below the cut-off). Indocyanine green perfusion was assessed intraoperatively (SPY Elite; Stryker, MI) and Ingress Index was calculated (standardized perfusion at the evaluated point). The morphomic index (MI), as an indicator of frailty, was determined using the number of decreased morphomic factors present (0–3). Multiple linear regression was used to analyze the data. Results One hundred and thirty-six patients were evaluated, with 25 patients developing anastomotic leaks (18.4%). Morphomic indices (MIs) of 2 or 3 were independently associated with reduced Ingress Index (p = 0.019 and 0.004, Table). In a sub-analysis for MI, MIs of 2 or 3 were associated with higher age (p = 0.029), lower BMI (p = 0.003), and cardiovascular disease (myocardial infarction, chronic heart failure, and vascular disease, p = 0.017). Other patient demographic factors including age, sex, and comorbidities did not affect Ingress Index. Conclusion Higher Morphomic Index (indicating lower than normal radiographic measures) were associated with impaired gastric conduit perfusion. More patients will be needed to investigate whether increased MI also is associated with development of anastomotic leaks. These findings may be useful in risk stratification and preoperative decision making in patients undergoing esophagectomy. Patients with MI of 2 or higher should be considered for gastric ischemic preconditioning.

358. CIRCULAR STAPLER METHOD FOR AVOIDING STRICTURE OF CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS, ‘NON-TENSIONING METHOD’

Abstract Background The weakness for the circular stapler technique of esophagogastric anastomosis for esophageal cancer is anastomotic stricture. This study was performed to verify the superiority of a new ‘non-tensioning method’ for avoiding stricture of the cervical esophagogastric anastomosis by circular stapling compared with the conventional method. Methods In 461 patients who underwent McKeown esophagectomy with gastric conduit (GC) reconstruction were reviewed. A GC was pulled up at the cervical site through the retrosternal route. The esophagogastrostomy site of the GC was planned as far caudally as possible on the greater curvature side. In the conventional method, the stapler was fired while pulling the GC to avoid tissue slack. In the new method, the stapler was fired through the natural thickness of the stomach wall. The blind end length was changed from 4 to 2 cm. Anastomotic stricture was compared between the two techniques, and adjustment was performed using propensity score matching. Results The conventional group comprised 315 patients, and the non-tensioning group comprised 146 patients. Anastomotic leakage occurred in 22 (7%) and 6 (4%) patients, respectively (P = 0.211) [and in 9 (3%) and 3 (2%) patients, respectively, if leakage at the blind end was excluded]. Anastomotic stricture occurred in 92 (29%) and 7 (5%) patients, respectively (P &amp;lt; 0.001). The propensity score-matching analysis including 134 pairs of patients confirmed a lower stricture rate in the non-tensioning than conventional group (4% vs. 27%, P &amp;lt; 0.001). Conclusions The non-tensioning technique, the natural thickness of the stomach wall was fired with the stapler, significantly reduced the incidence of anastomotic stricture compared with the conventional technique.

Successful resuscitation from acute coronary syndrome during mediastinoscope-assisted transhiatal esophagectomy: a case report

BackgroundAlthough unexpected cardiac arrest is a very rare intraoperative complication, strategies regarding preoperative screening and procedures to be taken in the event of an emergency need to be well established.Case presentationA man in his late 70 s diagnosed with thoracic esophageal cancer, cT3N1M0, and cStage III was admitted. His metabolic equivalents were 4 or more. Electrocardiogram (ECG), ultrasound cardiography, and hematological examinations revealed no severe abnormalities. Computed tomography (CT) showed highly calcified coronary arteries. We performed mediastinoscope-assisted transhiatal esophagectomy. Procedures in the mediastinum involving access from the neck and abdomen were completed uneventfully. Middle mediastinal lymph node dissection and gastrointestinal reconstruction with the patient in the prone position were scheduled for later. However, before the change in position, pulseless nonsustained ventricular tachycardia (VT) suddenly occurred and caused blood pressure to drop sharply to below 30 mmHg. The VT disappeared in approximately 20 s, and there was a return to sinus rhythm after cardiac resuscitation; however, the ECG showed a decrease in the ST segments of leads II, III, and aVF. Immediately thereafter, the patient was transferred to the cardiac catheterization laboratory for percutaneous coronary intervention. Cardiac catheterization revealed diffuse stenosis of 90% in the left anterior descending branch of the coronary artery (segment no. 6). Plain old balloon angioplasty and stent placement were performed. Dual antiplatelet therapy was needed. On the next day, thoracoscopic esophagectomy was performed in the left lateral decubitus position, followed by cervical esophagostomy in the supine position. He developed acute respiratory distress syndrome and thoracic aortic dissection on the 5th postoperative day (POD) and intraperitoneal bleeding on the 16th POD. On the 105th POD, laparoscopic-assisted cervical esophagogastric anastomosis was performed. Parkinson’s disease was diagnosed on the 126th POD. On the 313th POD, the patient was discharged.ConclusionSurgeons should be familiar with the guidelines for patient screening and management of intraoperative cardiac arrest. In patients with severe coronary artery calcification, further investigation such as coronary angiography CT may be necessary before esophagectomy. Furthermore, highly invasive surgery should be performed in well-equipped hospitals.

Esophageal replacement with pedunculated gastric conduit interposition and duodenal transection for refractory anastomotic leakage after esophagectomy

BackgroundLeakage of cervical esophagogastric anastomosis is a serious complication of esophagectomy. However, there is no established way to treat the anastomosis leakage.Case presentationThe case is a 69-year-old man with locally advanced esophageal and two early gastric cancers. After induction chemotherapy, we performed minimally invasive esophagectomy, but on postoperative day 11, the anastomotic leakage was observed. Nutritional therapy, negative-pressure wound therapy, and suture closure could not treat it. Therefore, we performed pedunculated gastric conduit interposition with duodenal transection. In this procedure, the main trunk of the right gastroepiploic artery and vein was preserved, and the duodenum and gastric antrum are resected with cutting the branch from the right gastroepiploic artery and vein to gastric antrum, which dramatically improved the flexibility of the gastric conduit, and it is pulled up through the subcutaneous route. Improved blood supply and flexibility of the gastric conduit enabled a tension-free and safe anastomosis.ConclusionsThe flexibility and favorable blood flow of pedunculated gastric conduit interposition with duodenal transection can be an effective treatment option for refractory anastomotic leakage after esophagectomy.

Management of esophageal perforations and postoperative leaks

: Esophageal perforations and postoperative leaks are challenging and life-threatening conditions, with a not well-defined management, yet. Perforation is defined as a full-thickness tear in the esophageal wall due to a trauma on the esophageal lumen or to a sudden increase of endoluminal pressure, like in spontaneous perforations. The most frequent causes are: iatrogenic injuries, spontaneous perforations, foreign body or caustic ingestion, trauma, tumors etc. The onset of symptoms varies depending on the location of perforation (cervical, intrathoracic or intraabdominal), the degree of tissue destruction and extension of contamination of surrounding organs, the cause, the timing of diagnosis and the presence of underlying esophageal disorders. Post-operative esophageal leaks have a different origin but a quite similar clinical presentation and treatment to esophageal perforations. The higher reported incidence is after cervical esophagogastric anastomosis, followed by intrathoracic anastomosis (above all after trans-hiatal one). It is already proven that short diagnostic timing and correct treatment can reduce mortality of 50%. Recent evidence also shows how better outcomes are achieved when the management is multidisciplinary, led by an expert team, and individualized treatments are adopted, involving all available modalities (medical, endoscopic and surgical). The purpose of this article is to review current standard practice, expert opinions and outcomes in the management of esophageal perforations and postoperative leaks.

Application of reversely connecting circular stapler technique in cervical esophagogastric anastomosis.

The incidence of anastomotic leakage is relatively high (6-26%) in esophagogastrocervical anastomosis. The traditional anastomotic mode has high tissue tension in the process of anastomosis, which can easily cause tissue tear in the anastomotic area and increase the incidence of anastomotic leakage. To investigate the usefulness of reversely connecting circular stapler technique for reducing anastomotic tension and injury of the esophageal and gastric wall, preventing anastomotic leakage in minimally invasive McKeown esophagectomy. A total of 133 patients with esophageal cancer who underwent minimally invasive McKeown esophagectomy from January 2021 to December 2021 were collected. Characteristics, surgical data, and outcomes of patients were recorded and retrospectively analyzed. There were 83 patients in the reverse order connecting circular stapler group and 50 patients in the conventional order connecting group. Anastomotic leakage was observed in 2 (2.4%) cases in the reverse order connecting circular stapler group. Compared with the conventional connection group, the reverse connecting group had lower incidence of anastomotic leakage, shorter anastomotic time, shorter hospital stay, and lower incidence of pulmonary and chest infections and hoarseness. The reversely connecting circular stapler technique could reduce the incidence of anastomotic leakage. The technique is simple to perform and easy to learn. Therefore, it is useful for the prevention of anastomotic leakage.

Wider Gastric Conduit Morphology Is Associated with Improved Blood Flow During Esophagectomy

BackgroundIt remains unclear what is the ideal conduit shape. The aim of this study was to evaluate association between specific gastric conduit morphology, considering width and length, with its perfusion and the incidence of anastomotic leaks after esophagectomy. MethodsPatients who underwent an esophagectomy with cervical esophagogastric anastomosis between 2015 and 2021 were evaluated. Indocyanine green angiography was performed to evaluate gastric conduit perfusion, and ingress index (arterial inflow) and ingress time (venous outflow) were measured. The conduit width at the middle of the conduit and the short gastric length as the length from the last gastroepiploic branch to the perfusion assessment point were measured. Propensity score matching was performed to compare wide conduits with narrow conduits. Narrow and wide conduits were defined as < 4 and ≥ 5 cm, respectively. ResultsThree hundred fifty-eight patients were reviewed. After applying matching, the wide conduits had higher ingress index (48.2 vs 33.3%, p < 0.001) and shorter ingress time (51.2 vs 66.3 s, p = 0.004) compared to the narrow conduits. Including the short gastric length in analysis, creating a wide conduit is a significant factor for better ingress index (p = 0.001), especially when the perfusion assessment point is 5 cm or farther from the last gastroepiploic branch. Anastomotic leaks did not differ between the groups. ConclusionsConduit width is a significant factor of gastric conduit perfusion, especially when the estimated anastomotic site was > 5 cm from the last gastroepiploic branch. Wide conduits seem to have better perfusion and creating a wider conduit might reduce anastomotic leaks.

Ulcer Scarring in the Gastric Conduit Is a Risk Factor for Anastomotic Leakage After Esophagectomy for Esophageal Cancer

BackgroundAnastomotic leakage (AL) is a serious complication after esophagectomy for esophageal cancer. The objective of this study was to identify the risk factors for AL. MethodsPatients with esophageal cancer who underwent curative esophagectomy and cervical esophagogastric anastomosis between 2009 and 2019 (N = 346) and those between 2020 and 2022 (N = 17) were enrolled in the study to identify the risk factors for AL and the study to assess the association between the risk factors and blood flow in the gastric conduit evaluated by indocyanine green (ICG) fluorescence imaging, respectively. ResultsAL occurred in 17 out of 346 patients (4.9%). Peptic or endoscopic submucosal dissection (ESD) ulcer scars were independently associated with AL (OR 6.872, 95% CI 2.112–22.365) in addition to diabetes mellitus. The ulcer scars in the anterior/posterior gastric wall were more frequently observed in patients with AL than in those without AL (75.0% vs. 17.4%, P = 0.042). The median flow velocity of ICG fluorescence in the gastric conduits with the scars was significantly lower than in those without the scars (1.17 cm/s vs. 2.23 cm/s, P = 0.004). ConclusionsPeptic or ESD ulcer scarring is a risk factor for AL after esophagectomy in addition to diabetes mellitus. The scars in the anterior/posterior gastric wall are significantly associated with AL, impairing blood flow of the gastric conduit. Preventive interventions and careful postoperative management should be provided to minimize the risk and severity of AL in patients with these risk factors.

Akiyama Procedure as a Surgical Option for Esophageal Cancer

Background The purpose of this study is to introduce our experience with the Akiyama procedure as a surgical option for treatment of esophageal cancer in the Mother Theresa Hospital Center of Tirana, Albania. Selection of the suitable site for anastomosis after esophagectomy, whether cervical or thoracic is the key for optimal oncological results. The goal is to minimize recurrence in oncological patients and to avoid complications related to surgery. Controversy still exists among surgeons as the optimal site for anastomosis as well as whether the anastomosis is done manually or with a stapler. Material and methods From October 2018 to June 2021, 27 surgical interventions of esophageal cancer were performed in our surgical unit. In 15 patients, subtotal esophagectomy Ivor-Lewis with a mediastinal esophago-gastric anastomosis was performed. In 8 patients, distal esophagectomy and proximal gastrectomy with an abdominal esophago-gastric anastomosis was performed. In 4 patients, subtotal esophagectomy with a cervical esophago-gastric anastomosis, Akiyama procedure was performed. In this study we are evaluating the Akiyama procedure with description of the technique, patient criteria of inclusion, oncological protocol and postoperative care. Discussion In our practice we used chemotherapy and radiotherapy as part of a multimodality treatment plan. All of our patients with carcinoma had radiation and chemotherapy prior to surgery. The use of stapler devices in cervical anastomoses in some studies is linked with higher rate of leakage but we consider it a preferential choice of the surgeon. We opted for a one-layer esophagogastric anastomosis in the neck as shown in some studies instead of the two-layer technique because of lower rates of stricture formation. The level of exposure in the cervical route is advantageous in making an accurate anastomosis. In our patients we used the retrosternal space for esophageal replacement to avoid local tumor recurrence in the posterior mediastinum. Conclusion As in other cancers there is a mandatory evaluation in congruence to the guidelines in order to each patient have a surgical or adjuvant therapy according to its stage. As per guidelines patients in a T1-2, N0 stage are treated with surgery alone and a close follow up for recurrence and patients in a T3 or N1/M1 stage should be considered for adjuvant therapy prior to surgery. In patients that have extensive disease and are not surgical candidates are considered for chemotherapy and radiation alone. It is advised that the type of surgery performed is the one in which the surgeon is more experienced and has the best outcome in terms of surgical strategy in terms of morbidity and mortality. Keywords: General surgery, Esophageal cancer, Akiyama procedure, Cervical esophago-gastric anastomosis. DOI: 10.7176/ALST/96-02 Publication date: December 31 st 2022

Modified Collard technique is more effective than circular stapled for cervical esophagogastric anastomosis in prevention of anastomotic stricture: a propensity score-matched study.

The anastomotic technique after esophagectomy is of great interest in the prevention of anastomotic complications that adversely affect postoperative recovery. This study aimed to compare the clinical outcomes of modified Collard (MC) and circular stapled (CS) anastomoses after esophagectomy. A total of 504 consecutive patients with thoracic esophageal cancer who underwent esophagectomy and cervical esophagogastric CS or MC anastomosis from January 2013 to December 2019 were enrolled. Out of 504 patients, 134 and 370 underwent CS and MC anastomoses. The frequency of anastomotic leakage and stricture was significantly lesser in the MC group than in the CS group (3.0 vs. 10.5%, P = 0.0014 and 11.1 vs. 34.3%, P < 0.001, respectively). CS anastomosis was an independent risk factor for anastomotic stricture (odds ratio, 4.89; P < 0.001). Oral intake was significantly higher in the group without anastomotic stricture than in the group with anastomotic stricture at 2, 3, and 6months postoperatively (P <0.001, P = 0.013, and P <0.001, respectively). The percentage body weight loss (%BWL) was -12.2% in the group with anastomotic stricture and -7.5% in the group without anastomotic stricture at 3months postoperatively (P = 0.0012). Anastomotic stricture was an independent factor associated with %BWL (odds ratio, 4.86; P = 0.010). Propensity score-matched analysis, which included 88 pairs of patients, confirmed a significantly lower anastomotic stricture rate in the MC group than in the CS group (10.2 vs. 35.2%, P < 0.001). MC anastomosis is better than CS anastomosis for reducing the frequency of anastomotic stricture, which may be useful for maintaining early postoperative nutritional status.

A case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for recurrent malignant melanoma of the esophagus

BackgroundThe treatment strategy for metastatic lesions of primary malignant melanoma of the esophagus (PMME) is currently determined on a case-by-case basis, based on the National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma. The NCCN guidelines state that resection should be considered in patients with resectable metastatic recurrence. Herein, we report a case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for the metastatic recurrence of PMME.Case presentationA 65-year-old female patient with PMME underwent thoracoscopic subtotal esophagectomy, gastric tube reconstruction via the posterior mediastinal route, and cervical esophagogastric anastomosis. Histopathological examination of the resected specimen revealed that the tumor was PMME with tumor invasion into the muscularis propria and no lymph node metastasis. At the age of 68 years, she developed intestinal invagination due to jejunal metastasis of malignant melanoma and underwent resection of the jejunum. Histopathological examination of the resected specimen revealed two metastases of malignant melanoma in the jejunum and one metastasis to the mesenteric lymph node. At the age of 75 years, a recurrence of malignant melanoma was found in the cervical esophagus. She underwent thoracoscopic mobilization of the gastric tube and esophagus followed by cervical esophagectomy and reconstruction with a free jejunum flap. She received 24 courses of nivolumab therapy for 1 year as a postoperative adjuvant therapy. Subsequently, at the age of 78 years, an enlarged left cervical lymph node and a mass in the right lower lobe of the lung were found. She underwent left cervical lymph node dissection and thoracoscopic wedge resection of the right lung. Histopathological examination of the resected specimens revealed that both tumors were metastases of malignant melanoma. At age 79 years, she received eight courses of nivolumab therapy as a second postoperative adjuvant therapy, with no sign of recurrence in a 9-month follow-up period after the third metastasectomy.ConclusionIn cases of metastatic recurrence of PMME, aggressive resection of oligometastasis with postoperative adjuvant nivolumab therapy may result in long-term survival.