Gastric Conduit Reconstruction Research Articles

Gastric conduit reconstruction after esophagectomy.

A high risk of complications still accompanies gastric conduit reconstruction after esophagectomy. In this narrative review, we summarize the technological progress and the problems of gastric conduit reconstruction after esophagectomy. Several types of gastric conduits exist, including the whole stomach and the narrow gastric tube. The clinical outcomes are similar between the two types of conduits. Sufficient blood supply to the conduit is mandatory for a successful esophageal reconstruction. Recently, due to the availability of equipment and its convenience, indocyanine green angiography has been rapidly spreading. When the blood perfusion of the planning anastomotic site is insufficient, several techniques, such as the Kocher maneuver, pedunculated gastric tube with duodenal transection, and additional microvascular anastomosis, exist to decrease the risk of anastomotic failure. There are two different anastomotic sites, cervical and thoracic, and mainly two reconstructive routes, retrosternal and posterior mediastinal routes. Meta-analyses showed no significant difference in outcomes between the anastomotic sites as well as the reconstructive routes. Anastomotic techniques include hand-sewn, circular, and linear stapling. Anastomoses using linear stapling is advantageous in decreasing anastomosis-related complications. Arteriosclerosis and poorly controlled diabetes are the risk factors for anastomotic leakage, while a narrow upper mediastinal space and a damaged stomach predict leakage. Although standardization among the institutional team members is essential to decrease anastomotic complications, surgeons should learn several technical options for predictable or unpredictable intraoperative situations.

A approach of gastric conduit via the anterior of pulmonary hilum route during minimally invasive McKeown esophagectomy

BackgroundThe gastric conduit is the most commonly used replacement organ for reconstruction after minimally invasive McKeown esophagectomy. Although the optimal route of gastric conduit remains controversial, the posterior mediastinal route is physiologically preferable but is not without disadvantages. Here, we report the safety and efficacy of a method of gastric conduit reconstruction via the anterior of the pulmonary hilum route.MethodsWe have used the anterior of the pulmonary hilum route since 2021. This procedure involves pulling the gastric conduit up through a substernal tunnel between the right thoracic cavity and the abdominal cavity and passing it into the neck via the anterior of the pulmonary hilum route. In this retrospective study, we compared the clinical outcomes between 20 patients who underwent this procedure and 20 patients who underwent the posterior mediastinal route from 2021 to 2022.ResultsNo mortality was reported in either group. No significant differences were observed between the two groups in duration of surgery, blood loss, incidence of postoperative complications, and postoperative hospital stay. As a result of the anterior of the pulmonary hilum route, the primary tumor bed and lymph node drainage area were effectively bypassed, which facilitates postoperative adjuvant radiotherapy or chemoradiotherapy. The distance of the gastric conduit accompanying the airway was significantly shorter in the anterior of the pulmonary hilum route group.ConclusionsOur method is considered to be a safe and useful technique for the reconstruction of gastric conduit.

Quantification of fluorescence angiography for visceral perfusion assessment: measuring agreement between two software algorithms

BackgroundIndocyanine green fluorescence angiography (ICG-FA) may reduce perfusion-related complications of gastrointestinal anastomosis. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for visceral perfusion assessment between two independently developed quantification software implementations.MethodsThis retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analyzed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland–Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations.ResultsSeventy pre-anastomosis ICG-FA recordings were included in the study. The Bland–Altman analysis indicated a mean relative difference of + 58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < 0.001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively).ConclusionThis is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.

Randomized controlled trial of nasogastric tube use after esophagectomy: study protocol for the kinetic trial.

Esophagectomy is a complex and complication laden procedure. Despite centralization, variations in perioparative strategies reflect a paucity of evidence regarding optimal routines. The use of nasogastric (NG) tubes post esophagectomy is typically associated with significant discomfort for the patients. We hypothesize that immediate postoperative removal of the NG tube is non-inferior to current routines. All Nordic Upper Gastrointestinal Cancer centers were invited to participate in this open-label pragmatic randomized controlled trial (RCT). Inclusion criteria include resection for locally advanced esophageal cancer with gastric tube reconstruction. A pretrial survey was undertaken and was the foundation for a consensus process resulting in the Kinetic trial, an RCT allocating patients to either no use of a NG tube (intervention) or 5days of postoperative NG tube use (control) with anastomotic leakage as primary endpoint. Secondary endpoints include pulmonary complications, overall complications, length of stay, health related quality of life. A sample size of 450 patients is planned (Kinetic trial: https://www.isrctn.com/ISRCTN39935085). Thirteen Nordic centers with a combined catchment area of 17 million inhabitants have entered the trial and ethical approval was granted in Sweden, Norway, Finland, and Denmark. All centers routinely use NG tube and all but one center use total or hybrid minimally invasive-surgical approach. Inclusion began in January 2022 and the first annual safety board assessment has deemed the trial safe and recommended continuation. We have launched the first adequately powered multi-center pragmatic controlled randomized clinical trial regarding NG tube use after esophagectomy with gastric conduit reconstruction.

Blood flow ratio in the gastric conduit measured by laser Doppler flowmetry: A predictor of anastomotic leakage after esophagectomy.

Anastomotic leakage after esophagectomy is a common complication. Laser Doppler flowmetry (LDF) can quantitatively evaluate the blood flow in the gastric conduit. A total of 326 patients who underwent thoracoscopic/robot-assisted esophagectomy followed by gastric conduit reconstruction and end-to-side anastomosis were enrolled. We divided the gastric conduit into zones I (dominated by the right gastroepiploic vessels), II (dominated by the left gastroepiploic vessels), and III (perfused with short gastric vessels). Before pulling up the gastric conduit to the neck, LDF values were measured at the pylorus, the border between zones I and II (zone I/II), the border between zones II and III (zone II/III), and the gastric conduit tip (tip). The blood flow ratio was calculated as the LDF value divided by the LDF value at the pylorus. Anastomotic leakage developed in 32 of 326 patients. Leakage was significantly associated with the blood flow ratio at the tip (p < 0.001), but not at zone I/II, zone II/III, and the anastomotic site. The receiver-operating characteristic curve analysis identified an anastomotic leakage cutoff ratio of 0.41 (at the tip). A multivariate Cox analysis showed that a blood flow ratio <0.41 at the tip was an independent risk factor for anastomotic leakage (p < 0.001). Anastomotic leakage after esophagectomy was significantly associated with the blood flow ratio at the tip of the gastric conduit. Preservation of the blood supply to the tip via the gastric wall might contribute to a decreased incidence of anastomotic leakage.

OGC O08 Quantification of fluorescence angiography for visceral perfusion assessment in gastric conduit reconstruction: measuring agreement between two software algorithms

Abstract Background Building evidence suggests that fluorescence angiography is capable of reducing anastomotic leakage rates. Many software-based quantification algorithms have been developed aiming to obtain an objective measure for intraoperative visceral perfusion at the anastomotic site. Validation and comparison of these models in the current literature is scarce. The aim of this study was to measure agreement between two independently developed software algorithms for the quantitative assessment of visceral perfusion using indocyanine green fluorescence angiography. Methods 81 video recordings from patients who underwent fluorescence angiography-guided Ivor Lewis esophagectomy with gastric conduit reconstruction between August 2020 and February 2022 were available for analysis. In this dataset, we standardized patient, theatre, camera and imaging display variables. Recordings were analyzed retrospectively based on intraoperatively selected regions of interest using two software based-quantification algorithms (AMS and CPH). Quantitative parameters derived from the fluorescence time curve (FTC) were recorded. The comparison focused on the predefined primary outcome variable for quantitative perfusion assessment "normalized maximum slope". Agreement between the two software algorithms was evaluated in a Bland-Altman analysis. Quantitative parameters in patients with anastomotic leakage were compared to those without. Results Out of 81 video recordings, 70 could be processed using both algorithms. The output values for the normalized maximum slope from the AMS and the CPH software held a moderate-to-strong correlation in a linear regression model (R-squared: 0.544, p&amp;lt;0.001). The Bland-Altman plot indicated a mean±SD difference of 0.037±0.018 arbitrary units for the normalized maximum slope, with significant differences between the two software measurements (p&amp;lt;0.001). Proportional bias was observed using linear regression in the Bland-Altman plot (R-squared=0.715, p&amp;lt;0.001). Disparities between the two measurement methods became proportionally larger among higher mean values. Neither of the two software methods showed a significant difference in perfusion measurement between the anastomotic leakage and no leakage groups (p=0.32 and p=0.51). Differences in signal processing, such as smoothing techniques and window selection, were identified as potential factors contributing to the disparity in outcomes. Conclusions The two software-based quantification methods for visceral perfusion demonstrated significant differences. Varying agreement among quantification methods should be considered while interpreting studies that report quantitative parameters and derived thresholds for clinical endpoints, as there may be a limited external validity.

Major Intraoperative Complications During Minimally Invasive Esophagectomy

BackgroundStudies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer.MethodsData were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction.ResultsAmongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%.ConclusionsThis study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Duodenal diversion surgery in management of intractable tracheobroncho-gastric fistula after esophagectomy

BackgroundTracheobroncho-gastric fistula (TGF), a rare but potentially fatal complication following esophagectomy with gastric conduit reconstruction, has conventionally been treated with surgical repair and/or airway stenting. However, satisfactory therapeutic outcomes with these modalities have yet to be obtained because of difficulty in controlling persistent inflammation caused by digestive juice reflux.Case presentationWe adopted duodenal diversion (DD), a classic anti-reflux surgical method, as an additional option for TGF management and have experienced two cases undergoing DD surgery for post-esophagectomy TGF (all male, 76–77 years old). TGF was developed after gastric conduit necrosis and anastomotic leakage, respectively, in these patients. In both cases, the DD procedure combined with surgical fistula repair was feasible with no DD-related complications. These operations achieved a good effect in terms of preventing gastroduodenal reflux and ameliorating respiratory status. Reconstructive surgery after DD was performed and oral dietary intake was successfully resumed in one case.ConclusionDD appears to be a valid evacuation therapy when airway contamination with gastroduodenal reflux is not amenable to the conventional approach alone, and can usefully be included in the TGF treatment strategy in appropriate cases.

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

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

378. GASTRIC FILLING IN NEOADJUVANT CHEMORADIOTHERAPY FOR OESOPHAGEAL CANCER

Abstract Background Neoadjuvant Chemoradiotherapy (nCRT) for locally advanced oesophageal cancer improves survival. Currently, there is equipoise in the survival benefit of nCRT versus neoadjuvant chemotherapy. Excessive radiotherapy to the gastric conduit prior to surgery has long been a concern. Recent studies have linked radiation doses to the gastric fundus around 30 Gy to an increased risk of anastomotic leak. This study reviews a simple process aiming to reduce radiation dose to the gastric fundus. Methods This is a single-centre, retrospective analysis of 63 adult patients treated with nCRT (CROSS protocol) then oesophagectomy with a gastric conduit reconstruction. The Gastric Fill (GF) arm were given 500 mL of water prior to radiotherapy planning and treatment. The control group were consecutive patients prior to the implementation of the GF protocol. The fundus was mapped on radiotherapy software and planned to treat it like other organs at risk. Radiation dose to the fundus was recorded and compared between the two groups. Results The GF arm included 25 patients, with 38 patients in the control arm. Patients drank 350–800 mL of water prior to planning and treatment. There were no reported aspiration events. Radiotherapy techniques included VMAT and 3DCRT. All GF patients were treated with VMAT. There was a higher proportion of mid-oesophageal tumours in the control group (21% compared with 4%). The mean volume of gastric fundus in the GF group (mean = 215 cc, SD 144) was higher than the control group (mean = 155 cc, SD 100). The proportion of gastric fundus receiving &amp;gt;30 Gy was lower in the GF group (mean = 10.9% SD = 16.0) compared with the control group (mean = 19.1% SD = 24.8). Conclusion Analysis did not show statistically significant difference between the groups, however, there was a trend suggesting radiation to the gastric fundus was reduced in the GF group. This study shows the feasibility of a simple and low risk intervention in reducing the radiation to the future gastric conduit. Further review with a larger cohort, and impact on anastomotic complications would be of interest for future review.

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.

241. EVALUATION OF THE PYLORUS FOLLOWING GASTRIC CONDUIT RECONSTRUCTION IN OESOPHAGECTOMY USING IMPEDANCE PLANIMETRY—A SYSTEMATIC REVIEW WITH META-ANALYSIS

Abstract Gastric conduit dysfunction (GCD) is one of the most challenging late complications of oesophagectomy and can have a significant detrimental effect on patient’s quality of life. Functional obstruction at the pylorus may be a contributory factor, however, few studies have directly examined the physiology of the pylorus in the gastric conduit. This review aims to determine if impedance planimetry (IP), using EndoFLIP®, can be used to demonstrate a significant alteration in pyloric physiology following oesophagectomy. We conducted a systematic literature search using EMBASE and MEDLINE to identify studies that compared results of IP analysis using EndoFLIP® in healthy volunteers with patients following oesophagectomy for oesophageal cancer. Selection of studies was conducted in line with the PRISMA guidelines against pre-determined inclusion criteria and the review was registered with PROSPERO (CRD42023401664). Meta-analysis, using a pooled mean and mean difference, was conducted to determine whether there was a significant difference in mean pyloric distensibility index (DI), a widely used and validated measure of sphincter functioning, following oesophagectomy with gastric conduit reconstruction compared to healthy volunteers. A total of 2751 studies were identified following database search and four studies were deemed eligible for inclusion. All studies reported mean pyloric DI values following oesophagectomy and protocols for EndoFLIP® analysis were consistent. The pooled mean pyloric DI from all studies (n = 109) was 9.12mm2/mmHg following oesophagectomy, compared to a pre-validated normal value of 25.2mm2/mmHg in healthy volunteers. Mean difference calculation, using a fixed effects model, from two studies including original results for healthy volunteers (n = 42) and patients following oesophagectomy (n = 14), showed that pyloric distensibility was 14.41mm2/mmHg higher in healthy volunteers compared to those post-oesophagectomy (95% CI 11.81–17.00, p &amp;lt; 0.00001). Studies suggest that pyloric distensibility is significantly reduced following oesophagectomy compared to healthy volunteers. A lack of pyloric distensibility may adversely affect gastric conduit emptying and contribute to GCD. It remains unclear whether DI measurements will correlate with severity of GCD or show changes pre- and post-operatively for individual patients. The effect of surgical pyloroplasty on pyloric distensibility and physiology needs to be examined as a potential means of reducing the incidence of GCD.

Surgical treatment of esophago-tracheobronchial fistulas after esophagectomy.

The aim of this study was to evaluate the surgical treatment of esophago-tracheobronchial fistulas (ETBFs) that occurred after esophagectomy with gastric conduit reconstruction in a tertiary referral center for esophageal surgery. All patients who underwent surgical repair for an ETBF after esophagectomy with gastric conduit reconstruction were included in a tertiary referral center. The primary outcome was successful recovery after surgical treatment for ETBF, defined as a patent airway at 90days after the surgical fistula repair. Secondary outcomes were details on the clinical presentation, diagnostics, and postoperative course after fistula repair. Between 2007 and 2022, 14 patients who underwent surgical repair for an ETBF were included. Out of 14 patients, 9 had undergone esophagectomy with cervical anastomosis and 5 esophagectomy with intrathoracic anastomosis after which 13 patients had developed anastomotic leakage. Surgical treatment consisted of thoracotomy to cover the defect with a pericardial patch and intercostal flap in 11 patients, a patch without interposition of healthy tissue in 1 patient, and fistula repair via cervical incision with only a pectoral muscle flap in 2 patients. After surgical treatment, 12 patients recovered (86%). Mortality occurred in two patients (14%) due to multiple organ failure. This study evaluated the techniques and outcomes of surgical repair of ETBFs following esophagectomy with gastric conduit reconstruction in 14 patients. Treatment was successful in 12 patients (86%) and generally consisted of thoracotomy and coverage of the defect with a bovine pericardial patch followed by interposition with an intercostal muscle.

Quantitative assessment of gastric ischemic preconditioning on conduit perfusion in esophagectomy: propensity score weighting study.

Gastric ischemic preconditioning prior to esophagectomy has been studied as a method to improve gastric conduit perfusion and reduce anastomotic complications, without conclusive results. The aim of this study is to evaluate the feasibility and safety of gastric ischemic preconditioning in terms of post-operative outcomes and quantitative gastric conduit perfusion. Patients who underwent an esophagectomy with gastric conduit reconstruction between January 2015 and October 2022 at a single high-volume academic center were reviewed. Patient characteristics, surgical approach, post-operative outcomes, and indocyanine green fluorescence angiography data (ingress index for arterial inflow and ingress time for venous outflow, and the distance from the last gastroepiploic branch to the perfusion assessment point) were analyzed. Two propensity score weighting methods were used to investigate whether gastric ischemic preconditioning reduces anastomotic leaks. Multiple linear regression analysis was used to evaluate the conduit perfusion quantitatively. There were 594 esophagectomies with gastric conduit performed, with 41 having a gastric ischemic preconditioning. Among 544 with cervical anastomoses, leaks were seen in 2/30 (6.7%) in the ischemic preconditioning group and 114/514 (22.2%) in the control group (p = 0.041). Gastric ischemic preconditioning significantly reduced anastomotic leaks on both weighting methods (p = 0.037 and 0.047, respectively). Ingress index and time of the gastric conduit with ischemic preconditioning were significantly better than those without preconditioning (p = 0.013 and 0.025, respectively) after removing the effect of the distance from the last gastroepiploic branch to the perfusion assessment point. Gastric ischemic preconditioning results in a statistically significant improvement in conduit perfusion and reduction in post-operative anastomotic leaks.

Perfusion assessment by fluorescence time curves in esophagectomy with gastric conduit reconstruction: a prospective clinical study

BackgroundIntraoperative perfusion assessment with indocyanine green fluorescence angiography (ICG-FA) may reduce postoperative anastomotic leakage rates after esophagectomy with gastric conduit reconstruction. This study evaluated quantitative parameters derived from fluorescence time curves to determine a threshold for adequate perfusion and predict postoperative anastomotic complications.MethodsThis prospective cohort study included consecutive patients who underwent FA-guided esophagectomy with gastric conduit reconstruction between August 2020 and February 2022. After intravenous bolus injection of 0.05-mg/kg ICG, fluorescence intensity was registered over time by PINPOINT camera (Stryker, USA). Fluorescent angiograms were quantitatively analyzed at a region of interest of 1 cm diameter at the anastomotic site on the conduit using tailor-made software. Extracted fluorescence parameters were both inflow (T0, Tmax, Fmax, slope, Time-to-peak) as outflow parameters (T90% and T80%). Anastomotic complications including anastomotic leakage (AL) and strictures were documented. Fluorescence parameters in patients with AL were compared to those without AL.ResultsOne hundred and three patients (81 male, 65.7 ± 9.9 years) were included, the majority of whom (88%) underwent an Ivor Lewis procedure. AL occurred in 19% of patients (n = 20/103). Both time to peak as Tmax were significantly longer for the AL group in comparison to the non-AL group (39 s vs. 26 s, p = 0.04 and 65 vs. 51 s, p = 0.03, respectively). Slope was 1.0 (IQR 0.3–2.5) and 1.7 (IQR 1.0–3.0) for the AL and non-AL group (p = 0.11). Outflow was longer in the AL group, although not significantly, T90% 30 versus 15 s, respectively, p = 0.20). Univariate analysis indicated that Tmax might be predictive for AL, although not reaching significance (p = 0.10, area under the curve 0.71) and a cut-off value of 97 s was derived, with a specificity of 92%.ConclusionThis study demonstrated quantitative parameters and identified a fluorescent threshold which could be used for intraoperative decision-making and to identify high-risk patients for anastomotic leakage during esophagectomy with gastric conduit reconstruction.A significant predictive value remains to be determined in future studies.

Efficacy and Postoperative Outcomes of Laparoscopic Retrosternal Route Creation for the Gastric Conduit: Propensity Score-Matched Comparison to Posterior Mediastinal Reconstruction.

Retrosternal reconstruction has lower risks for severe postoperative morbidities, such as gastro-tracheal fistula or esophageal hiatal hernia. We have previously reported the laparoscopic retrosternal route creation (LRRC) method, but its safety and efficacy remain unclear. In total, 374 patients with esophageal carcinoma who underwent minimally invasive McKeown esophagectomy in the prone position between 2010 and 2021 were retrospectively reviewed. We performed a propensity score-matched analysis with the simple, nearest-neighbor method and no calipers to compare postoperative outcomes and reconstructed gastric conduit functionality between patients who underwent LRRC and counterparts who underwent posterior mediastinal reconstruction. After matching, 62 patients were included in the laparoscopic retrosternal group (LR group) or posterior mediastinal group (PM group). No significant differences were observed between the groups, apart from the number of robot-assisted surgeries, the extent of lymph node dissection, and the method of cervical anastomosis. There were no significant differences in the incidence of Clavien-Dindo grade ≥ 2 complications. Gastro-tracheal fistula (n = 1) and esophageal hiatal hernia (n = 2) occurred in the PM group but not in the LR group. There were no differences in the incidence of pulmonary embolism between the groups (5% vs. 5%). The postoperative anastomotic stenosis rate was similar (16% vs. 27%, p = 0.192). Endoscopic findings of reflux esophagitis (modified Los Angeles classification≥ M) at 1 year after surgery were significantly better in the LR group (p = 0.037). LRRC for gastric conduit reconstruction is safe and valuable. It is associated with good reconstructed gastric conduit function.

A quantitative assessment of perfusion of the gastric conduit after oesophagectomy using near-infrared fluorescence with indocyanine green

IntroductionAnastomotic leakage is a severe complication after oesophageal resection with gastric conduit reconstruction. Poor perfusion of the gastric conduit plays an important role in the development of anastomotic leakage. Quantitative near-infrared (NIR) fluorescence angiography with indocyanine green (ICG-FA) is an objective technique that can be used for perfusion assessment. This study aims to assess perfusion patterns of the gastric conduit with quantitative ICG-FA. MethodsIn this exploratory study, 20 patients undergoing oesophagectomy with gastric conduit reconstruction were included. A standardized NIR ICG-FA video of the gastric conduit was recorded. Postoperatively, the videos were quantified. Primary outcomes were the time-intensity curves and nine perfusion parameters from contiguous regions of interest on the gastric conduit. A secondary outcome was the inter-observer agreement of subjective interpretation of the ICG-FA videos between six surgeons. The inter-observer agreement was tested with an intraclass correlation coefficient (ICC). ResultsIn a total of 427 curves, three distinct perfusion patterns were recognized: pattern 1 (steep inflow, steep outflow); pattern 2 (steep inflow, minor outflow); and pattern 3 (slow inflow, no outflow). All perfusion parameters were significantly different between the perfusion patterns. The inter-observer agreement was poor – moderate (ICC:0.345,95%CI:0.164–0.584). DiscussionThis was the first study to describe perfusion patterns of the complete gastric conduit after oesophagectomy. Three distinct perfusion patterns were observed. The poor inter-observer agreement of the subjective assessment underlines the need for quantification of ICG-FA of the gastric conduit. Further studies should evaluate the predictive value of perfusion patterns and parameters on anastomotic leakage.

Nutrition management by a multidisciplinary team for prevention of nutritional deficits and morbidity following esophagectomy

This study evaluated the effects of perioperative nutrition management by a multidisciplinary team on nutrition and postoperative complications of patients with esophageal cancer. A total of 239 patients with esophageal cancer who underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between February 2019 and February 2020 were included in the study. They were divided into the experimental group (120 patients) and the control group (119 patients) using the random number table method. Control group patients received routine diet management and experimental group patients received perioperative nutrition management by a multidisciplinary team. The differences of nutriture and postoperative complications between the two groups were compared. At 3 and 7 days after surgery, the experimental group patients had higher total protein and albumin levels (P<0.05), shorter postoperative anal exhaust time (P<0.05), lower incidence of postoperative gastrointestinal adverse reactions, pneumonia, anastomotic fistula, hypoproteinemia (P<0.05), and lower hospitalization costs (P<0.05) than the control group. Nutrition management by a multidisciplinary team effectively improved the nutriture of patients, promoted the rapid recovery of postoperative gastrointestinal function, reduced postoperative complications, and reduced hospitalization costs.

C-Reactive Protein Levels After Esophagectomy are Associated with Increased Surgical Complications and Poor Prognosis in Esophageal Squamous Cell Carcinoma Patients.

C-reactive protein (CRP) levels are reported to predict complications and survival after surgery in various cancers. However, the relationship between postoperative CRP levels and short- and long-term outcomes of esophageal squamous cell carcinoma (ESCC) patients after esophagectomy is unclear. We reviewed the records of 543 ESCC patients who underwent subtotal esophagectomy with gastric conduit reconstruction at Kumamoto University Hospital between August 2010 and July 2021. Blood tests for CRP were done on postoperative days (PODs) 1, 3, 5 or 6, and 7 or 8. The mean CRP levels on day 1, day 3, day 5/6, and day 7/8 were 6.68±0.13 mg/dL, 11.49±0.27 mg/dL, 7.48±0.26 mg/dL, and 5.38±0.22 mg/dL, respectively. Mean CRP levels were highest on day 3, and CRP levels after day 3 correlated with grade >2 complications based on the Clavien-Dindo classification. Receiver operating characteristic curve analysis established the optimal cut-off value for CRP day 3 levels to be 12.19 mg/dL. Multivariate logistic regression analyses found that high CRP day 3 levels significantly correlated with grade >2 complications (odds ratio [OR] 3.77, 95% confidence interval [CI] 2.56-5.35; p<0.001). Moreover, high day 7/8 CRP levels (>3.52) correlated with postoperative survival, and based on multivariate logistic regression analyses, were significantly associated with poor prognosis (hazard ratio 1.67, 95% CI 1.14-2.43; p = 0.008). Our findings suggest CRP day 3 levels as a potential biomarker for predicting postoperative complications and that CRP day 7/8 levels have potential prognostic value for ESCC patients after esophagectomy.

Additional Microvascular Anastomosis to Gastric Conduit During Esophagectomy Reduces Anastomotic Leaks: Propensity Score Weighting Study.

Impaired gastric conduit perfusion during esophagectomy and reconstruction is considered a key risk factor of anastomotic leaks. The aim of this study is to evaluate the indication and feasibility of additional microvascular anastomosis (AMA) to the gastric conduit in esophageal cancer surgery. Patients who received an esophagectomy with gastric conduit reconstruction between July 2008 and July 2021 at a single center were reviewed. Patient characteristics, anastomotic viability index (AVI) of the gastric conduit measured with thermal imaging, and operative outcomes were analyzed using Fisher's exact test and Mann-Whitney U test. Two propensity score weighting methods (inverse probability of treatment weighting and overlap weighting) were applied to investigate whether AMA reduces anastomotic leaks. Of the 293 patients who underwent an esophagectomy over the study period, 26 received AMA. AVI in the AMA group was significantly lower than that in the control group (0.64 vs. 0.74, p = 0.026). Overall anastomotic leak rates were 3.8% in the AMA group and 12.4% in the control group. Using two different propensity score weighting methods, the same conclusion was obtained that AMA significantly reduced anastomotic leaks after esophagectomy (both p < 0.001). The logistic regression model for estimating probability of anastomotic leaks provided AVI criteria for AMA application and revealed that AMA significantly reduced the estimated leak rates by a maximum of 49%. Additional microvascular anastomosis significantly reduced anastomotic leaks after esophagectomy. The proposed AVI criteria for AMA application can help guide surgeons as to when AMA is needed.