Gastric Conduit Research Articles

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.

The role of fluorescence angiography in colonic interposition after esophagectomy.

Colonic interposition is an alternative for gastric conduit reconstruction after esophagectomy. Anastomotic leakage (AL) occurs in 15-25% of patients and may be attributed to reduced blood supply after vascular ligation. Indocyanine green fluorescence angiography (ICG-FA) can visualize tissue perfusion. We aimed to give an overview of the first experiences of ICG-FA and AL rate in colonic interposition. This study included all consecutive patients who underwent a colonic interposition between January 2015 and December 2021 at a tertiary referral center. Surgery was performed for the following indications: inability to use the stomach because of previous surgery or extensive tumour involvement, cancer recurrence in the gastric conduit, or because of complications after initial esophagectomy. Since 2018 ICG-FA was performed before anastomotic reconstruction by administration of ICG injection (0.1 mg/kg/bolus), using the Spy-phi (Stryker, Kalamazoo, MI). Twenty-eight patients (9 female, mean age 62.8), underwent colonic interposition of whom 15 (54%) underwent ICG-FA-guided surgery. Within the ICG-FA group, three (20%) AL occurred, whereas in the non-ICG-FA group, three AL and one graft necrosis (31%) occurred (P=0.67). There was a change of management due to the FA assessment in three patients in the FA group (20%) which led to the choice of a different bowel segment for the anastomosis. Mean operative times in the ICG-FA and non-ICG-FA groups were 372±99 and 399±113 minutes, respectively (P=0.85). ICG-FA is a safe, easy and feasible technique to assess perfusion of colonic interpositions. ICG-FA is of added value leading to a change in management in a considerable percentage of patients. Its role in prevention of AL remains to be elucidated.

ERAS guidelines-driven upper gastrointestinal contrast study after esophagectomy can detect delayed gastric conduit emptying and improve outcomes

BackgroundDelayed gastric conduit emptying can occur after esophagectomy and has been shown to be associated with increased risk for postoperative complications. Application of a standardized clinical protocol after esophagectomy including an upper gastrointestinal contrast study has the potential to improve postoperative outcomes.MethodsProspective cohort including all patients operated with esophagectomy at two high-volume centers for esophageal surgery. The standardized clinical protocol included an upper gastrointestinal contrast study on day 2 or 3 after surgery. All images were compiled and evaluated for the purpose of the study. Clinical data was collected in IRB approved institutional databases at the participating centers.ResultsThe study included 119 patients treated with esophagectomy of whom 112 (94.1%) completed an upper gastrointestinal contrast study. The results showed that 8 (7.1%) patients had radiological delayed gastric conduit emptying defined as no emptying of contrast through the pylorus. Partial conduit emptying was seen in 34 (30.4%) patients, and 70 (62.5%) patients had complete conduit emptying. Complete or partial emptying was associated with significantly earlier nasogastric tube removal (3 vs. 6 days) and hospital discharge 8 vs. 17 days, P < 0.001). Radiological signs of delayed gastric conduit emptying were shown to be associated with increased risk of postoperative complications. There was, however, no association with severe postoperative complications according to Clavien–Dindo score, pulmonary complications, anastomotic leak or need for intensive care.ConclusionThe results of the study demonstrate that postoperative upper gastrointestinal contrast studies can be used to assess the level of emptying of the gastric conduit after esophagectomy. Application of upper gastrointestinal contrast study in the ERAS guidelines-driven standardized clinical pathway after esophagectomy has the potential to improve postoperative outcomes.

Contrast-Enhanced Radiologic Evaluation of Gastric Conduit Emptying After Esophagectomy

BackgroundNasogastric tube (NGT) insertion is the standard of care in many hospitals after esophagectomy for gastric conduit decompression. An upper gastrointestinal contrast passage evaluation (UGI-CE) is a diagnostic test to evaluate passage through the gastric conduit. The authors hypothesized that introducing routine UGI-CE after esophagectomy results in earlier removal of the NGT and resumption of oral intake.MethodsThis retrospective study evaluated two consecutive series of patients undergoing esophagectomy, one before (control group) and one after the introduction of a routine UGI-CE on postoperative day (POD) 3 or 4 (UGI-CE group). If contrast passage was found on the UGI-CE, the NGT was capped and removed. In the control group, the NGT was routinely capped and removed on day 5 after surgery. The primary outcome was the POD on which oral diet was initiated. The secondary outcomes were the day of NGT removal, NGT reinsertions, postoperative complications, and length of hospital stay.ResultsEach cohort included 74 patients. In the UGI-CE group, the contrast test was performed on median POD 3.5 (IQR, 3–4). The median day of NGT removal, initiation of clear liquids, and full liquid and solid intake was 1 to 2 days earlier in the UGI-CE group than in the control group (i.e. POD 4, 4, 5, and 6 vs. POD 5, 5, 6.5, and 8; all p < 0.001). The study found no significant differences in NGT reinsertions, pneumonias, anastomotic leakages, or hospital stay.ConclusionThe routine use of a UGI-CE after esophagectomy led to earlier removal of the NGT and earlier resumption of oral intake.

Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis.

Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure. A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention. Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29). Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.

C-Reactive Protein as Predictor for Infectious Complications after Robotic and Open Esophagectomies.

Introduction: The value of C-reactive protein (CRP) as a predictor of anastomotic leakage (AL) after esophagectomy has been addressed by numerous studies. Despite its increasing application, robotic esophagectomy (RAMIE) has not been considered separately yet in this context. We, therefore, aimed to evaluate the predictive value of CRP in RAMIE. Material and Methods: Patients undergoing RAMIE or completely open esophagectomy (OE) at our University Center were included. Clinical data, CRP- and Procalcitonin (PCT)-values were retrieved from a prospectively maintained database and evaluated for their predictive value for subsequent postoperative infectious complications (PIC) (AL, gastric conduit leakage or necrosis, pneumonia, empyema). Results: Three hundred and five patients (RAMIE: 160, OE: 145) were analyzed. PIC were noted in 91 patients on postoperative day (POD) 10 and 123 patients on POD 30, respectively. Median POD of diagnosis of PIC was POD 8. Post-operative CRP-values in the robotic-group peaked one and two days later, respectively, and converged from POD 5 onward compared to the open-group. In the group with PIC, CRP-levels in the robotic-group were initially lower and started to differ significantly from POD 3 onward. In the open-group, increases were already noticed from POD 3 on. Procalcitonin levels did not differ. Best Receiver operating curve (ROC)-results were on POD 4, highest negative predictive values at POD 5 (RAMIE) and POD 4 (OE) with cut-off values of 70 mg/L and 88.3 mg/L, respectively. Conclusion: Post-operative CRP is a good negative predictor for PIC, after both RAMIE and OE. After RAMIE, CRP peaks later with a lower cut-off value.

260. EFFECT OF ENDOLUMINAL VACUUM THERAPY ON THE PERFUSION OF GASTRIC CONDUIT IN A PORCINE MODEL FOR ESOPHAGECTOMY

Abstract After esophagectomy, the postoperative rate of anastomotic leakage is between 5 and 30% and is the main driver of morbidity and mortality. Complication management is often based on endoluminal vacuum therapy (EndoVAC) with good success rates. Vacuum therapy has been shown to improve tissue perfusion in superficial wounds but this has not been shown for gastric conduits. The present study aimed to assess changes in gastric conduit perfusion in a porcine model for esophagectomy. Porcine model (n = 18) underwent gastric conduit formation and induction of partial conduit ischemia. In three experimental groups EndoVAC therapy was used in the gastric conduit (−40 mmHg, −125 mmHg and − 200 mmHg) with continuous suction. The changes in tissue perfusion and edema were assessed using hyperspectral imaging (HSI). During EndoVAC treatment with −125 mmHg a significant and stable increase in the oxygenation index from 44.9 ± 7.6% to 61.9 ± 5.5% and 62.9 ± 9.4%. (p = 0.02) was seen after 60 minutes and 120 minutes respectively. A similar trend was seen during EndoVAC treatment with −200 mmHg. There was a non-significant increase in tissue oxygenation during treatment with −40 mmHg. A significant increase of tissue water content from 40.8 ± 7.4 to 59.5 ± 10.3 (p = 0.004) was observed after 60 minutes of EndoVAC therapy with −200 mmHg. There were no significant differences in tissue water content during EndoVAC therapy with −40 mmHg and − 125 mmHg. EndoVAC treatment with a pressure of at least −125 mmHg significantly increases perfusion of partial ischemic gastric conduit. With better understanding of underlying physiology, the optimal use of EndoVac treatment can be guided and determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion. This can potentially be translated into clinical practice.

467. USEFUL ANASTOMOSIS AFTER ESOPHAGECTOMY USING ICG FLOW AND COLLARD MODIFIED METHOD

Abstract Risk of anastomotic leakage after esophagectomy is reported comorbidity, surgical technique, and others. One of management to reduce AL is to measure indocyanine green (ICG) of gastric conduit. It may be more sensitive and useful than traditional method. Furthermore, by changing the anastomotic technique with modified Collard method, AL rate was reduced from 15% to 4% and anastomotic stenosis was also reduced. In this study, we examined some marker of stomach roll depiction by ICG. We enrolled 52 cases for which ICG data were obtained from August 2019 to December 2021. The distance from stump of the stomach roll was measured by marking the line ICG 5mg stained after 30, 60 seconds We examined some data of arterial network between left and right gastroepiploic arteries, the depiction of gastric conduit, and intra andextramural vessels from the wall from the recorded images. We decided anastomotic line stained with ICG in 30 second. We reconstructed gastric conduit with 42 stomach roll and 10 subtotal stomach. The distance of gastric conduit stained with ICG was Mean ± SD: 47 ± 19 mm (0-80 mm) at 30 seconds and 28 ± 17 mm (0-60 mm) at 60 seconds. Arterial network between left and right gastroepiploic artery: yes/no (8:43), whole gastric wall depiction: yes/no (24/28), extramural blood flow: yes/no (44/7). There was no necrosis of gastric conduit, AL rate was 3.8% (2/52), and anastomotic stenosis requiring endoscopic bougie was 2%. Ten cases of subtotal stomach had no AL and stenosis. By using ICG, anastomotic line drawn in 30 second was shorter than 60 seconds and gastric conduit was shorter than traditional line. Determining good blood flow sites using ICG in gastric conduit and widening anastomotic caliber using modified Collard method may have reduced AL and stenosis. It is considered to be very simple procedure that does not depend on surgeon.

307. INGENUITY OF ESOPHAGOGASTRIC ANASTOMOSIS IN OUR DEPARTMENT -RECONSTRUCTED GASTRIC TUBE STUMP CLOSURE USING ENDO GIA RADIAL RELOAD

Abstract Anastomotic leakage is one of the three major complications after esophagectomy and can lead to surgery-related death. In our department, the standard surgical procedure is to elevate the gastric conduit via the posterior mediastinal pathway, and end-to-side anastomosis using a circular stapler for the residual esophagus and gastric conduit. In this study, we will report our reconstruction method and ingenuity, since Linear stapler was changed to Endo GIA Radial Reload and better outcomes were delivered. The lesser curvature of the gastric conduit stump is the site where blood flow is most reduced. When the gastric conduit stump is closed with Linear stapler, the blood flow may be further reduced, because the stapler on the lesser curvature of the gastric conduit and the stapler on gastric conduit stump intersect. Closing the gastric conduit stump using Radial Reload avoids the stapler intersect at the lesser curvature and the gastric conduit stump. In addition, since a natural curve is formed at the gastric conduit stump, the pressure applied to the gastric tube stump by coughing can be dispersed. Nine patients have undergone this reconstruction method, and no anastomotic leakage has been observed. It is important to constantly evaluate one’s own surgical technique, and to continue developing the surgical technique for further safety by making improvements.

625. PROPENSITY SCORE-MATCHED COMPARISON OF OUTCOMES BETWEEN POSTERIOR MEDIASTINAL AND RETROSTERNAL ROUTES OF RECONSTRUCTION FOLLOWING THREE-PHASE ESOPHAGECTOMY

Abstract The retrosternal (RS) and posterior mediastinal (PM) routes can be chosen for gastric conduit reconstruction following three-phase esophagectomy with cervical anastomosis. It is controversial if the choice of reconstruction route would affect the operative outcome. This study aims to evaluate the surgical outcome by comparing the routes of reconstruction. Between 2002 and 2019, patients who underwent esophagectomy with cervical anastomosis and gastric conduit reconstruction via the retrosternal (RS) or posterior mediastinal (PM) route for esophageal squamous cell cancer were included. Clinicopathological data were analyzed from a prospectively managed database. Postoperative morbidity and mortality rates, presence of recurrent tumor invasion of the conduit and overall survival were compared between the two groups. Further analyses were made after propensity score matching (PSM). There were 89 patients in the RS and 266 in PM groups. R0 resection rates were 47.2% and 89.1% in the RS and PM groups, respectively (p&amp;lt;0.01). Anastomotic leak occurred more frequently in RS group at 16.9% vs. 6.8%, (p=0.007) while cardiac complications were fewer; 19% vs. 32%, (p=0.02). 90-day mortality rates were &amp;lt;4% in both groups. Median survival was 20 and 64 months in RS and PM groups respectively (p&amp;lt;0.01). PSM yielded 60 patients in each group. Postoperative morbidities, and survival, were similar. Mediastinal tumor recurrences infiltrated the gastric conduit only in the PM group in 6.8% of patients. When corrected for selection biases, RS and PM routes did not differ in post-operative morbidity and mortality rates. Placing the gastric conduit in the RS route could avoid invasion by mediastinal tumor recurrence. RS is the preferred route of reconstruction after a three-phase esophagectomy.

19. ERAS GUIDELINES-DRIVEN UPPER GASTROINTESTINAL CONTRAST STUDY AFTER ESOPHAGECTOMY CAN DETECT DELAYED GASTRIC CONDUIT EMPTYING AND IMPROVE OUTCOMES

Abstract Delayed gastric conduit emptying can occur after esophagectomy and has been shown to be associated with increased risk for postoperative complications. Application of a standardized clinical protocol after esophagectomy including an upper gastrointestinal contrast study has the potential to improve postoperative outcomes. Prospective cohort including all patients operated with esophagectomy at two high-volume centers for esophageal surgery. The standardized clinical protocol included an upper gastrointestinal contrast study on day 2 or 3 after surgery. All images were compiled and evaluated for the purpose of the study. Clinical data was collected in IRB approved institutional databases at the participating centers. The study included 119 patients of whom 112 (94.1%) completed an upper gastrointestinal contrast study. The results showed that 8 (7.1%) patients had no emptying of contrast from the gastric conduit, partial emptying was seen in in 34 (30.4%) patients, and 70 (62.5%) patients had complete conduit emptying. Complete or partial emptying was associated with significantly earlier nasogastric tube removal (3 vs. 6 days) and hospital discharge 8 vs. 17 days, P &amp;lt; 0.001). Radiological signs of delayed gastric conduit emptying were shown to be associated with increased risk of postoperative complications. There was, however no association with severe postoperative complications according to Clavien-Dindo score, pulmonary complications, anastomotic leaks or need for intensive care. The results of the study demonstrate that postoperative upper gastrointestinal contrast studies can be used to assess the level of emptying of the gastric conduit after esophagectomy. Application of upper gastrointestinal contrast study in the ERAS guidelines-driven standardized clinical pathway after esophagectomy can improve postoperative outcomes.

657. COMPARISON BETWEEN GASTRIC TUBE AND COLOPLASTY IN ESOPHAGECTOMY AND ESOPHAGEAL BYPASS IN ESOPHAGEAL STENOSIS DUE TO INGESTION CORROSIVE SUBSTANCE

Abstract The treatment of ingestion of caustic agents is controversial in the literature. Surgical therapy has been shown to be the best way to proceed, but the surgical methodology has been varied according to the patient's involvement. This study aims to expose the experience of a single institution in relation to the methodology used for the surgical treatment of esophageal stenosis by ingestion of a caustic substance. A retrospective study was carried out in which data were collected from 27 patients who underwent a surgical procedure for the treatment of esophageal stenosis due to alkali ingestion at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo between 2010 and 2019 and their subsequent comparison between the conduits used in the surgical intervention. Fisher's test was performed to compare the groups regarding cervical leakage and post-surgical symptoms with a significance level of 5%. Of the 27 surgical procedures for esophageal stenosis due to alkali ingestion, 12 performed gastric conduits and 15 colon conduits. When comparing the groups regarding cervical leaks, no statistically significant difference was noted (p = 0.7060). There were also no statistically significant differences regarding the presence of symptoms in the postoperative period (p &amp;gt; 0.99...) Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control. Surgical intervention by both gastric and colon conduits showed no differences in cervical leakage and symptom control.

290. ANALYTIC MORPHOMIC INDEX AND QUANTITATIVE GASTRIC PERFUSION ASSESSMENT FOR RISK STRATIFICATION OF ANASTOMOTIC LEAKS FOLLOWING ESOPHAGECTOMY

Abstract Sarcopenia, a reduction in muscle mass, has been considered a preoperative risk factor for complications after esophagectomy while impaired perfusion of the gastric conduit has been associated with anastomotic leaks. The aim of this study was to stratify patients by their risk of anastomotic leak following esophagectomy using morphomic factors and quantitative assessment of gastric conduit perfusion. Patients who underwent an esophagectomy with a cervical anastomosis and gastric conduit from 2015–2021 were included. Preoperative CT scans were processed using semiautomated algorithms (MATLAB; MathWorks, MA). Indocyanine green perfusion was assessed intraoperatively (SPY elite; Stryker, MI). Sarcopenia was defined using skeletal muscle area (Martin’s criteria). Decreased subcutaneous fat, decreased bone mineral density, and impaired conduit perfusion were defined as below the cutoff value from the ROC curve. The morphomic index was determined using the number of decreased morphomic factors present (0–3). The Fisher exact test, the Mann–Whitney U test, and multivariable logistic regression were used to make statistical comparisons. 140 patients with both perfusion and morphomic data were evaluated (Leak n = 27; No leak n = 113). Decreased subcutaneous fat, decreased bone mineral density, and impaired gastric conduit perfusion were associated with an anastomotic leak (p = 0.041, 0.017, and 0.010). Neoadjuvant chemoradiation was significantly more common in the leak group (p = 0.048). On multivariable analysis, a higher morphomic Index and impaired gastric perfusion were risk factors for anastomotic leak. The incidence of anastomotic leaks with a high morphomic index (2 or 3) and impaired gastric perfusion was 40.6% compared to 9.4% with a low morphomic index and without impaired gastric perfusion (p = 0.006). Impaired gastric conduit perfusion and decreased preoperative subcutaneous fat area, bone mineral density, and skeletal muscle area, likely surrogates for increased frailty and poor nutritional status, were associated with an increased risk of anastomotic leaks especially when multiple morphomic factors were simultaneously decreased. These findings may be useful in risk stratification and intraoperative decision making in patients undergoing esophagectomy.

481. QUANTITATIVE ESTIMATION OF GASTRIC CONDUIT PERFUSION TO SELECT ESOPHAGECTOMY PATIENTS AT HIGH RISK OF IMPAIRED PERFUSION

Abstract Impaired gastric conduit perfusion is considered the most important factor of anastomotic leaks following esophagectomy. Gastric ischemic preconditioning (GIP) can improve conduit perfusion and may reduce anastomotic leaks; however, it remains unclear which patients could benefit from preconditioning. The aim of this study is to create a paradigm to select patients at high risk of impaired perfusion who may benefit from GIP. Patients undergoing an esophagectomy with gastric conduit reconstruction and indocyanine green fluorescence angiography from July 2015 to December 2021 (Cohort 1), as well as all patients receiving an esophagectomy from 2003 to 2021 (Cohort 2) were reviewed. Analyzed variables for Cohort 1 included patient pre-operative demographics and ingress index (quantitative assessment of blood perfusion). Multiple linear regression model for conduit perfusion was used to select significant preoperative factors and to build a formula to estimate conduit perfusion. The formula was applied to Cohort 2 to estimate the percentage of patients who could receive GIP prior to esophagectomy. 349 patients were in Cohort 1, and 1965 in Cohort 2. There was a significant correlation with older age and low body mass index (BMI) and impaired conduit perfusion. Other factors, such as heart disease, diabetes, and prior chemoradiation did not correlate (Table). Using only two variables “age” and “BMI”, we determined how many could have poor conduit perfusion, defined as a low ingress index of &amp;lt;40 (the median value from the Cohort 1). When applying the formula to Cohort 2, we estimated that 26.7% (525) of patients would be at risk for low perfusion and for anastomotic leaks. Using BMI and age, we are able to risk stratify patients who are likely to have low perfusion in their gastric conduits (Figure, higher risk in red). We feel that this group will be the most likely to benefit from pre-esophagectomy gastric ischemic conditioning.

532. INDOCYANINE GREEN FLUORESCENCE DETECTED THE IMPAIRED BLOOD FLOW IN THE GASTRIC CONDUIT WITH ULCER SCARS: A PROSPECTIVE PRELIMINARY STUDY

Abstract We previously identified the presence of peptic or endoscopic submucosal dissection (ESD) ulcer scars in the stomach as a risk factor for anastomotic leakage of esophagogastric anastomosis after esophagectomy. In this study, we investigated the association between peptic or ESD ulcer scars and blood flow at the gastric conduit using indocyanine green (ICG) fluorescence imaging. We prospectively enrolled 17 patients who underwent cervical esophagogastric anastomosis after esophagectomy for thoracic esophageal cancer (15 men and 2 women with a median age of 70 years). Blood flow in the wall of gastric conduit was evaluated using ICG fluorescence imaging detected by a near-infrared camera system during the operation. The flow velocity of ICG fluorescence in the gastric wall was calculated by dividing the distance (cm) by moving time of ICG fluorescence (second) from the pylorus to the point of final branch of the right gastroepiploic artery. In 17 patients, four had peptic or ESD ulcer scars in the stomach. One patient with ESD ulcer scars in the lesser curvature side resected during the creation of conduit was included in 13 without ulcer scars. The median flow velocity was significantly lower in patients with ulcer scars than that in patients without ulcer scars (1.15 cm/s vs. 2.17 cm/s, P &amp;lt; 0.01). Anastomotic leakage was occurred only in two patients; one had ESD ulcer scar in the greater curvature side with the velocity of 1.17 cm/s, and one had no ulcer scars with the velocity of 1.67 cm/s. Peptic or ESD ulcer scars were associated with the impaired blood flow in the wall of gastric conduit. Intraoperative ICG fluorescence imaging is a promising modality to evaluate the risk of anastomotic leakage after esophagectomy.

575. MANUAL LAYER EMBEDDED ANASTOMOSIS: A NEW TECHNIQUE TO REDUCE ANASTOMOSIS LEAKAGE AFTER ESOPHAGECTOMY

Abstract The suturing after esophagectomy includes mechanical anastomosis and hand-sewn anastomosis. At present, various of anastomosis methods with potential anastomosis leakage, the optimal anastomosis methods still remain debates. This study described a new technique for creation of an anastomosis in thought to reduce the incidence of anastomosis leakage. Between September 2020 to December 2021, the patients who received this new anastomosis technique enrolled into this retrospective study. The anastomosis method as follows. Firstly, the gastric conduit was shaped secondary to get adapt embedded length and anger. Secondary, the embedded posterior wall was sutured and layer sew anastomosis. And then, embedded the anastomosis after layer sew into gastric tube and suture the embedded anterior wall lastly. And the anastomosis was pushed into thorax from neck to ended this anastomosis procedure. A total of 56 patients enrolled into this study comprised 51 males and 5 females with mean age of 65.4 years. Among of them 9 patients received neoadjuvant therapy. And all of them performed minimally invasive surgery by thoracoscope combined laparoscopic. The median intraoperative blood loss volume was 79.8ml (range 20-150ml). The median operate time was 331 minutes (range 220-465 minutes). The median postoperative feeding time was 6.3 days (range 3-8 days). All the patients without anastomosis leakage. The incidence of anastomotic stricture and the acid reflux ration were lower than the average of literature reports. This new manual layered embedded esophagogastric anastomosis significantly reduce the incidence of anastomosis leakage and stricture, prevent the acid reflux. This technique has good short outcome and suitable for popularization and application.

409. RECONSTRUCTION OF A SEGMENTAL OESOPHAGEAL DEFECT WITH A TUBED RADIAL ARTERY FOREARM FREE FLAP GUIDED BY 3-DIMENSIONAL MODELLING

Abstract Segmental defects of the oesophagus are rare but complex. If the patient survives the initial insult, reconstructive techniques most commonly involve gastric pull-up or colonic interposition (1) however alternative techniques such as free flap reconstruction can be utilised if the former are unsuitable (2). The surgical field often is quite hostile in these cases, making pre-operative visualisation and planning critical in achieving a successful outcome. We describe our approach after a surgical complication in a 49-year-old man. cT3N2M0 GOJ adenocarcinoma, pre-operative FLOT4, three-stage oesophagectomy complicated by anastomotic leak and tracheo-gastric fistula. Cervical oesophagostomy and venting gastrostomy (via laparotomy) was performed (severe illness precluded one-lung ventilation). He improved and was discharged, but a persistent fistula from the gastric conduit to his trachea remained. Reconstruction was planned by a multidisciplinary team using detailed 3D modelling. Via right thoracotomy, the gastric conduit was reduced into the abdomen and the tracheal defect was repaired with an intercostal muscle flap. A retrosternal colonic interposition restored gastrointestinal continuity. The superior 2 cm infarcted and was replaced by a dual-paddled tubular radial forearm free flap. This complex surgical situation demonstrates how 3D visualisation of a segmental oesophageal defect can be extremely helpful in pre-operative planning. In particular, the precise anatomical location of the gastro-tracheal fistula and its relationship to the bony landmarks and surrounding vascular anatomy were critical in considering surgical access and reconstruction options. Whilst the literature describes applications of 3D visualisation for surgical planning in alternative contexts, there is minimal information of its use in upper gastrointestinal reconstruction. The use of 3D modelling and printing within the surgical context has frequently been associated with reduced operating times and improved medical outcomes (3). This case adds to the previously documented advantages of 3D modelling in surgical planning but applies them to an area not well covered in the literature. Additionally, it demonstrates the utility of an infrequently used technique (RAFF) for reconstructing a segmental oesophageal defect. Further research into quantifying the outcomes following the implementation of 3D modelling in visualisation and surgical planning would be useful in encouraging its integration into mainstream surgical practice.

199. FAVORABLE OUTCOMES OF JEJUNAL INTERPOSITION RECONSTRUCTION WITHOUT VASCULAR ANASTOMOSIS AFTER ESOPHAGECTOMY FOR CANCER: A SINGLE-CENTER EXPERIENCE OVER TWO DECADES

Abstract The standard esophageal replacement after esophagectomy for cancer treatment is a gastric conduit. However, when the stomach is not available, a jejunal interposition can be performed under such circumstances. The purpose of this study was to review our experience with this technique especially without requiring microvascular anastomosis of artery or vein, and assess the surgical outcomes. We retrospectively reviewed the medical records of patients with esophageal cancer who underwent jejunum interposition without vascular anastomosis at our institution from 2003 to 2020. Data pertaining to patient characteristics, operative technique, and postoperative outcomes were collected and analyzed. Factors affecting oncologic outcomes were assessed by Kaplan–Meier estimates and Cox proportional hazards regression analyses. Postoperative quality of life were evaluated by a standard questionnaire. After 38 months of median follow-up time, 132 patients (122 males and 10 females; aged 40 to 86 years) were included. More than half of the patients (55.3%, 73/132) were above stage III. The operation time required was 294.5 ± 89.7 min, and the drainage time was 8.0 ± 5.3d. Fiveteen patients underwent cervical anastomosis. The anastomotic leakage rate was only 4.5% (6/132) among all the patients. The 90-days mortality rate was 5.3% and the overall survival at 1, 3 and 5 years were 91.7%, 76.8% and 61.8%, respectively. The prognosis was mainly correlated with tumor stage and most patients showed good quality of life. This is the largest series of jejunal interposition in a single institution from China. The nearly 20-year follow-up data suggests that, even without vascular anastomosis, the procedure using jejunum as an alternative conduit is a feasible procedure for reconstruction after esophagectomy, resulting in low morbidity and favorable prognosis.

539. SURGICAL TECHNIQUES AND OUTCOMES OF GASTRIC CONDUIT RECONSTRUCTION FOLLOWING ESOPHAGECTOMY BY HAND-ASSISTED LAPAROSCOPIC SURGERY (HALS) FOR ESOPHAGEAL CANCER

Abstract After esophagectomy with reconstruction using a gastric conduit for esophageal cancer, anastomotic leak can cause serious complications and has a significant impact on the postoperative course. At our institution, gastric conduit reconstruction by hand-assisted laparoscopic surgery (HALS) is the first-line technique for reconstruction following esophagectomy due to its reliability and shortened operative time. In this study, we performed a retrospective review of the surgical outcomes. We reviewed characteristics and perioperative outcomes of 124 patients who underwent esophagectomy with gastric conduit reconstruction for esophageal cancer by HALS from February 2011 to December 2021. Surgical procedure: We created a gastric tube via the HALS incision. A 3-cm wide gastric tube was fashioned using the linear staplers. We mobilized and manually stretched the stomach to ensure the length of the gastric tube. Then the blood flow in the gastric tube was evaluated by ICG fluorescence method followed by esophagogastric anastomosis using a 25-mm circular stapler on the greater curvature side. Among the 124 patients, there were 99 males and 25 females with a median age of 70 years (range, 46 – 85 years). Neoadjuvant therapy was performed in 50 patients. The median operative time was 259 minutes (135-454 minutes). Complications related to the gastric conduit reconstruction included anastomotic leak in two patients (1.6%) and anastomotic stricture requiring dilatation in 39 patients (31.5%), of whom 15 (12.1%) underwent repeat dilatation. Gastric tube stenosis, gastric tube hemorrhage, and gastric tube-to-pulmonary fistula were also observed in one case each. In the present study, while the incidence of anastomotic leak was low (1.6%) in patients received HALS esophagectomy with gastric conduit reconstruction, almost one-third (31.5%) of the patients had anastomotic stricture and required dilatation.

640. ESOPHAGECTOMY FOR ESOPHAGEAL AND GASTROESOPHAGEAL JUNCTION ADENOCARCINOMA IN RYGB PATIENTS. A LITERATURE REVIEW ON OPERATIVE TECHNIQUES, SAFETY AND ONCOLOGIC OUTCOME

Abstract Roux-en-Y gastric bypass (RYGB) surgery changes the anatomy of the gastrointestinal tract, and thus renders the surgical management of esophageal and gastroesophageal junction adenocarcinoma cases technically confusing. No consensus exists regarding the the optimal surgical technique in terms of safety and oncologic outcomes in these cases. The aim of this study is to compile and analyze the available operative/technical data in the literature on surgical management of esophageal and gastroesophageal junction adenocarcinoma in RYGB patients. A literature review was performed in Cochrane Database, Embase, Medline, PubMed, and Scopus electronic databases to find all cases of esophagectomy for esophageal and gastroesophageal junction adenocarcinoma in RYGB patients. Keywords used were esophageal adenocarcinoma, esophagogastric junction adenocarcinoma, gastric bypass, bariatric surgery, esophagectomy, Ivor Lewis esophagectomy, transhiatal esophagectomy, and thoracoabdominal esophagectomy. All abstracts retrieved were screened, and for each one deemed relevant, the full text was obtained. Finally, 11 articles containing 17 cases were studied and analyzed. Extracted data included: Esophagectomy type, incision type, gastric pouch management, conduit used, Roux limb management, and most importantly complications and oncologic outcome. Esophagectomy was Ivor Lewis, transhiatal, and thoracoabdominal in 58.82%, 23.53% and 17.65% respectively. Esophagectomy was open in 46.67%, and minimally invasive in 53.33%. Gastric pouch was reconnected to the excluded stomach in 14.29%, while it was resected in 85.71%. Gastric, colonic and jejunal conduits were used in 87.5%, 6.25% and 6.25% respectively. In 63.64%, the Roux limb (RL) was connected to the abdominal wall and a feeding jejunostomy was placed. In the remaining 36.36%, the RL was either totally resected, or its proximal end was anastomosed to the distal end of the biliopancreatic limb. No complications were reported. No differences in oncologic outcome or safety were observed between open versus minimally invasive esophagectomy. Minimally invasive esophagectomy is safe and technically feasible with appropriate oncologic outcomes for esophageal and gastroesophageal junction adenocarcinoma patients with previous gastric bypass. Therefore open esophagectomy is not necessary. Post RYGB Esophageal and gastroesophageal junction adenocarcinoma might be underreported, and the number of cases will undoubtedly continue to increase in the coming years.