Ivor-Lewis Esophagectomy For Cancer Research Articles

Impact of anastomotic leak vs pneumonia on failure to rescue after transthoracic esophagectomy for cancer.

Data about failure to rescue (FTR) after esophagectomy for cancer and its association with patient and procedure-related risk factors are limited. This study aimed to analyze such aspects, particularly focusing on the effect of pneumonia and anastomotic leak on FTR. Patients who underwent an Ivor Lewis esophagectomy for cancer between 2008 and 2022 in 2 tertiary European centers were prospectively identified. Patients were classified and compared according to the type of operation (open, laparoscopic hybrid, robotic hybrid, minimally invasive, or robotic minimally invasive). FTR was defined as in-hospital death after a major complication. Risk factors for FTR were identified using a univariate model. Mortality after pneumonia and anastomotic leak were calculated and compared between the groups. A total of 708 patients were included. There were 355 open procedures (50.1%), 204 laparoscopic hybrid procedures (28.8%), 121 hybrid robotic procedures (17.1%), 15 standard minimally invasive procedures (2.1%), and 11 robotic minimally invasive procedures (1.6%). The overall morbidity was 60.0%, and the FTR rate was 4.5%. Anastomotic leak, pneumonia, postoperative bleeding, sepsis, pulmonary embolism, arrhythmia, and need for blood transfusion were the risk factors significantly associated with in-hospital mortality (P <.05). There was no particular type of operation significantly associated with mortality (P =.42). Pneumonia- and leak-associated FTR rates did not significantly differ among the groups (P =.99). Anastomotic leak and pneumonia are equally dangerous complications after esophagectomy for cancer. If performed in high-volume centers, hybrid or minimally invasive methods do not seem to negatively affect the FTR rates. Further efforts should be made to improve both tailored-approach and postoperative care.

Surgical Technique and Implementation of Total Minimally Invasive (Laparo-Thoracoscopic) Ivor Lewis Esophagectomy for Cancer.

Esophagectomy represents a major oncological operation due to the surgical involvement of both the abdominal and thoracic cavities. The minimally invasive technique has been developed to minimize the operative impact on patients undergoing esophageal resections, often presenting with nutritional deterioration and poor functional reserves. The present article provides an illustrative description of the total minimally invasive (laparo-thoracoscopic) Ivor Lewis esophagectomy for cancer integrated with complementary components of perioperative clinical management. This standardized surgical technique of two-field esophagectomy (i.e., laparoscopy and thoracoscopy) was depicted based on the experience of a tertiary center for esophageal cancer care with more than 1500 cases operated on, and in accordance with the SUPER reporting guidelines. The accomplishment of the following descriptive and illustrative content allowed the development of remarks on the strengths and possible flaws of this specific procedure, providing a measurable opportunity to absorb technical details of the most widespread surgical resection for esophageal cancer worldwide.

The Near-Infrared Visualization and Preemptive Ligation of the Thoracic Duct Effectively Reduce the Chyle Leak Incidence After Minimally Invasive Esophagectomy.

The aim of the present study is to assess the effectiveness of indocyanine-green (ICG)-guided lymphography (ICG-Lg) in reducing the incidence of chyle leak (CL) after esophagectomy. Chylothorax may severely impact esophageal cancer surgery, and the pre-emptive ligation of the thoracic duct (TD) is the most widespread control of this complication. Intraoperative ICG-Lg has been recently embedded in minimally invasive esophagectomy to facilitate TD detection and pre-emptive ligation. This retrospective analysis included consecutive patients who underwent minimally invasive Ivor Lewis esophagectomy for cancer at a tertiary referral center between January 2018 and August 2023. Patients were routinely submitted to extended lymphadenectomy with TD ligation and removal. All patients treated after January 2021 underwent ICG-Lg for TD identification and ligation (ICG group) and compared with the previous series (no-ICG group). The primary outcome was the incidence of postoperative CL, while univariate and backward stepwise multivariate logistic regression models were performed to identify associated factors. After including 320 patients, 151 (ICG group) were submitted to ICG-Lg before the pre-emptive TD ligation. Both groups presented similar characteristics, except for neoadjuvant therapy ( P <0.001) and preoperative comorbidities ( P =0.045). Intraoperative ICG-Lg significantly reduced the incidence of postoperative CL (11.8% vs 4.6%, P =0.026) and was significantly associated with shorter median length of hospital stay (13 vs 9 d, P =0.006). However, CL after ICG-Lg was more likely to require repairing reoperation ( P =0.050). Intraoperative ICG-Lg demonstrated significantly lower rates of CL after total minimally invasive esophagectomy and, therefore, it should be routinely embedded in the standardized surgical technique of high-volume centers for esophageal cancer.

Anatomic patterns of anastomotic leaks after Ivor Lewis esophagectomy for cancer: Impact on management and outcomes

BackgroundAnastomotic leakage presentation after Ivor Lewis esophagectomy may vary on imaging. Such variations may influence anastomotic leakage management and outcomes. MethodsAll consecutive patients who underwent Ivor Lewis esophagectomy for cancer between 2012 and 2019 in 2 referral centers were included. Anatomical patterns of anastomotic leakage were defined on imaging as follows: eso-mediastinal anastomotic leakage was a leak contained in the posterior mediastinum, eso-pleural anastomotic leakage was a leak involving the pleural cavity, and eso-bronchial anastomotic leakage was a leak communicating with the tracheobronchial tract. According to the Esophageal Complications Consensus Group definition, management and 90-day mortality were evaluated according to these patterns. ResultsAmong 731 patients, 111 (15%) developed anastomotic leakage consisting of eso-mediastinal anastomotic leakage (n = 87, 79%), eso-pleural anastomotic leakage (n = 16, 14%) and eso-bronchial anastomotic leakage (n = 8, 7%). There was no difference among these groups regarding preoperative characteristics or time to anastomotic leakage diagnosis. There was a significant difference in initial management according to anastomotic leakage anatomic patterns (P = .001). More than half of patients who experienced eso-mediastinal anastomotic leakage (n = 46, 53%) were initially treated conservatively without requiring intervention (Esophageal Complications Consensus Group type I), whereas most patients with eso-pleural anastomotic leakage (n = 14, 87.5%) and all with eso-bronchial anastomotic leakage (n = 8, 100%) initially required interventional or surgical treatment (Esophageal Complications Consensus Group type II–III). Anastomotic leakage anatomic patterns had a statistically significant impact on 90-day mortality, intensive care unit stay, and total hospital stay (P < .001). ConclusionAnastomotic leakage anatomic patterns after Ivor Lewis esophagectomy influence outcomes. Further studies are warranted to validate it in a prospective setting. Anastomotic leakage anatomic patterns may help in guiding anastomotic leakage management.

Intrathoracic Robotic-Sewn Anastomosis During Ivor Lewis Esophagectomy for Cancer: Back to Basics?

BackgroundTo assess the feasibility, clinical utility, and safety of intrathoracic robotic-sewn esophageal anastomosis (IrEA) during Ivor Lewis esophagectomy for adenocarcinoma of the lower third of the esophagus, or cancer at the gastro-esophageal junction type I (Siewert classification). MethodsA protocol for completely robotic Ivor Lewis esophagectomy (CrIE) and intrathoracic robotic-sewn anastomosis (IrEA) was established at the authors’ institutions from January 2015 through December 2019. Overall surgery-related postoperative complications were analyzed. Overall survival and disease-free survival analysis were performed using standard methods. ResultsThe study population consisted of 40 patients. Median operative time was 320 min (sd 62, range 235–500 min), and conversion to open rate was 0%. Anastomotic leak rate was 10%. The mean number of examined lymph nodes (ELN) was 19 (IQR 11–29), and the mean number of positive lymph nodes (PLN) was 3 (IQR 0–5). Short- and long-term surgical and oncological outcomes were comparable at a medium follow-up of 37 months. The median overall survival was 48 months while the mean disease-free survival was 29 months. ConclusionThis pilot series, in which an intrathoracic robotic-sewn anastomosis (IrEA) was performed during CrIE, demonstrated the safety and feasibility of this approach. Compared to the current standard of care at a high-volume center, IrEA was associated with better postoperative surgical outcomes and similar oncological outcomes to those reported worldwide today. These results call for further validation in a prospective and controlled setting to be fully incorporated into clinical practice.

Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer.

Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.

Diaphragmatic hernia after Ivor Lewis esophagectomy for cancer: a retrospective analysis of risk factors and post-repair outcomes.

BackgroundEsophageal cancer surgery has historically been associated with high levels of postoperative morbidity and mortality. Post-esophagectomy diaphragmatic hernia (PEDH) represents a potentially life-threatening surgical complication, with incidence and risk factors not clearly demonstrated. This study evaluates presenting characteristics and repair outcomes in PEDH after Ivor Lewis esophagectomy for cancer.MethodsAll consecutive patients who underwent esophageal cancer surgery between March 1997 and April 2018 at two high-volume centers were included. The patients underwent Ivor Lewis esophagectomy and were managed according to a standardized follow-up care plan. The primary outcomes included PEDH incidence, risk factor identification, and surgical results after hernia repair. Patient characteristics and perioperative data were collected and a multivariate analysis was performed to identify risk factors for PEDH.ResultsA total of 414 patients were enrolled and 22 (5.3%) were diagnosed with PEDH during a median follow-up period of 16 (range, 6–177) months. All patients underwent surgical repair and 16 (73%) required treatment within 24 hours. PEDH repair was mainly performed through a laparoscopic approach (77.3%), with an overall postoperative morbidity of 22.7% and one mortality case. The median length of hospital stay was 6 (range, 2–95) days, and no early recurrences were observed, although three (13.6%) cases relapsed over a median follow-up of 10.1 months after hernia repair. Univariate analysis demonstrated a statistically significant association between PEDH and neoadjuvant chemoradiotherapy (P=0.016), pathological complete response (P=0.001), and lymph node harvest (P=0.024). On the other hand, multivariate analysis identified pathological complete response [3.616 (1.384–9.449), P=0.009] and lymph node harvest [3.029 (1.140–8.049), P=0.026] as the independent risk factors for developing PEDH.ConclusionsPEDH represents a relevant surgical complication after Ivor Lewis esophagectomy for cancer, including a 5.3% incidence and requiring surgical repair. Pathological complete response and lymph node harvest were found to be independent risk factors for PEDH, independently of the esophagectomy technique.

Short-term outcomes after Ivor Lewis oesophagectomy for cancer during the COVID-19 pandemic.

Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24-48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.

O50 DIAPHRAGMATIC HERNIA AFTER IVOR-LEWIS OESOPHAGECTOMY: ANALYSIS OF RISK FACTORS AND SURGICAL REPAIR RESULTS

Abstract Backgrounds and aim oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (PODH) represents a potentially life-threatening complication with an underestimated occurrence rate and unclear related risk factors. Aim of this study was to identify possible risk factors of PODH and results of surgical treatment from experience of two tertiary referral centers. Methods all patients affected by a clinically resectable oesophageal cancer (any T, any N and M0) and submitted to Ivor-Lewis oesophagectomy, regardless of technique (open, hybrid or totally minimally invasive) between 1997 and 2017 at our Institutions were selected for this study. Demographic, clinical pre, intra, post-operative, and follow-up data were prospectively collected in an electronic database. A retrospective analysis was conducted in order to evaluate the incidence of PODH, associated risk factors and surgical repair results. Results 414 patients underwent Ivor-Lewis oesophagectomy for cancer in the study period and 22 (5.3%) developed PODH at a median follow-up time of 16 months (6 - 177). Surgical repair was mainly conducted by laparoscopic approach (77%) with a conversion rate of 24%. Postoperative morbidity was 22.7% and mortality 4.5%. Median postoperative hospital stay was 6 days (2 - 95). 3 recurrences (13.6%) occurred at a median follow-up time of 10.1 months. A wide univariate analysis identified statistically significant associations between PODH occurrence and the administration of preoperative chemoradiation, a complete pathological response (CPR) and a harvested lymph-nodes number (HLN) larger than 33 (p-value 0.016, 0.001 and 0.024 respectively). A significant association with a large HLN number was confirmed by the multivariable analysis (0.026) along with CPR which could however be considered as a longer survival-related bias. Conclusions The minimally invasive surgery and the neoadjuvant chemoradiation, in contrast to results of other authors, in our experience are not associated with PODH development, while a HLN number larger than 33 resulted to be an independent risk factor, probably mirroring the extent of surgical demolition in oesophagectomy. Surgical repair can be safely and effectively performed trough laparoscopy but recurrences can frequently occur.

Robotic Side‐to‐Side and End‐to‐Side Stapled Esophagogastric Anastomosis of Ivor Lewis Esophagectomy for Cancer

Both linear-stapled side-to-side esophagogastric anastomosis (LSEA) and circular-stapled end-to-side esophagogastric anastomosis (CEEA) are frequently used following esophagectomy. The aims of the present study were to review our experience of robotic intrathoracic alimentary tract reconstruction and to compare the short-term surgical outcomes of LSEA and CEEA in robotic Ivor Lewis esophagectomy. A prospectively collected dataset from 79 consecutive patients who underwent robot-assisted Ivor Lewis esophagectomy from February 2016 to December 2018 was retrospectively analyzed. Two groups (LSEA and CEEA) were classified according to the anastomotic mode. Demographic data, intraoperative characteristics and short-term surgical outcomes were compared between the two groups. Two patients were converted to laparotomy. The remaining 77 patients (68 males and 9 females, mean age of 61.7years) were successfully treated with completely robotic Ivor Lewis esophagectomy. According to the anastomotic procedure performed, 35 patients were categorized into the LSEA group and 42 patients were categorized into the CEEA group. The mean anastomotic time in the LSEA group was longer than that in the CEEA group (63.0 ± 9.0 vs. 44.2 ± 8.5min, p < 0.001). No significant difference was detected in anastomotic complications, including leakage (8.6% with LSEA and 4.8% with CEEA, p = 0.83) and postoperative dysphagia (5.7% with LSEA and 16.7% with CEEA, p = 0.26). No statistical difference was observed for the other surgical outcomes. There was no incidence of in-hospital mortality and 30-day mortality in both groups. In robotic Ivor Lewis esophagectomy, both LSEA and CEEA were feasible and safe to be performed and surgeons can select either LSEA or CEEA based on their own technical expertise.

Totally minimally invasive vs hybrid Ivor Lewis esophagectomy for cancer: A comparative prospective study on safety and efficacy

Totally minimally invasive vs hybrid Ivor Lewis esophagectomy for cancer: A comparative prospective study on safety and efficacy

PS01.204: ANASTOMOTIC LEAKS AFTER IVOR-LEWIS ESOPHAGECTOMY: INDOCYANINE GREEN NEAR-INFRERED ANGIOGRAPHY FOR GASTRIC CONDUIT BLOOD SUPPLY EVALUATION

Abstract Background Indocyanine Green—Angiography (ICG-A) has been recently introduced for visceral perfusion evaluation. Aim of this study is to assess whether the intraoperative use of ICG-A can improve the evaluation of blood supply of the gastric conduit in Ivor-Lewis esophagectomy for cancer. Methods This is an interim analysis of a prospective interventional study ongoing at our Institution, on 160 Ivor-Lewis esophagectomy patients. After an intravenous bolus of ICG during the abdominal and thoracic stage, the gastric conduit perfusion was evaluated by means of a near infrared ICG-A and graded as ‘well’, ‘hypo-perfused’ or ‘ischemic’. If present, the ischemic or hypo-perfused area was resected. Demographic and clinical parameters and others, such as conduit perfusion speed, intra or post-operative hypotensive episodes have been analyzed. Results Currently 26 patients have been enrolled. An anastomotic leak of any grade was identified in 7 patients. Patients were divided in Group A (7 patients) who developed a leak and Group B (19 patients) who do not. No statistically significant differences were evidenced on demographic and preoperative clinical features, except for higher cigarette smoking history incidence in Group A. Those who developed a leak had an ‘hypo-perfused’ conduit at ICG-A in 71.4% and those who do not in only 15.8% (p 0.014). Median time from ICG injection to appearance of fluorescence at the basis of the gastric conduit was significantly longer in Group A than in Group B, 36 sec. (32–43.5) vs 28 sec. (20–39.8) (p 0.04) but median gastric conduit perfusion speed was similar. Patients in Group B had a higher median width of the conduit than Group A, 5cm (5.0–6.0) vs 4 (4.0–5.0) (p 0.032). Post-operative prolonged hypotensive episodes were seen more frequently in Group A than Group B (p 0.028). No differences were evidenced in terms of fluids infusions, blood loss, conduit length or intraoperative hypotensive episodes. Conclusion Preliminary results seem to show the usefulness of ICG-A in identifying patients at risk of leakage. Nevertheless no reduction of leakage incidence was induced by surgical strategy modification, probably because post-operative events may affect clinical course too. Definitive data have to be awaited. Disclosure All authors have declared no conflicts of interest.

PS01.224: MODIFIED INTRATHORACIC ESOPHAGOGASTROSTOMY AT MINIMALLY INVASIVE ROBOT-ASSISTED IVOR-LEWIS ESOPHAGECTOMY FOR CANCER

Abstract Background The intrathoracic esophagogastrostomy played important role in minimally invasive Ivor-Lewis esophagectomy for cancer. The methods of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy mostly included hand-sewn, and circular stapler (anvil placement via OrVil system or transthoracically), which were still technically challenging. In this study, we modified the techniques of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy for cancer, in order to seek to simplify this complicated intrathoracic procedure. Then retrospective comparison between robotic and thoracoscopic cohorts was conducted. Methods We modified techniques focused on the ‘side-insertion’ anvil placement and purse string suture of intrathoracic robot-assisted esophagogastric anastomosis. The consecutive records of patients who underwent minimally invasive Ivor-Lewis esophagectomy for cancer via robot-assistant and thoracoscopic procedures in our department between January 2015 and November 2017 were retrospectively analyzed. Results Totally 47 patients were enrolled including 20 patients (male: 17, female: 3) in robot-assisted group and 27 patients (male: 21, female: 6) in thoracoscopic group. There was no conversion to open thoracotomy in both two groups. Mean operation duration of robotic group was 412.5 ± 63.5 min, significantly higher than 363.0 ± 53.3 min in thoracoscopic group (P = 0.006). Estimated blood loss in robotic group was less than that in thoracoscopic group (107.5 ± 63.5ml vs. 188.9 ± 94.3ml, respectively, P = 0.002). One patient (5.0%) in robotic group and two patients(7.4%) in thoracoscopic group had anastomotic leak. No postoperative reoperation or mortality (in-hospital or within 30 days after surgery) occurred in both groups. Conclusion Robot-assisted Ivor-Lewis esophagectomy was safe and feasible. Our modified procedure highlighting the ‘side-insertion’ method could simplify the process of intrathoracic anvil placement and purse string suture for the robot-assisted esophagogastric anastomosis. Robot-assisted Ivor-Lewis esophagectomy was nearly equivalent to thoracoscopic Ivor-Lewis esophagectomy at short-term outcomes, except higher operation time and less blood loss. Disclosure All authors have declared no conflicts of interest.

PS02.181: RISK FACTORS AND TREATMENT OF DIAPHRAGMATIC HERNIA FOLLOWING IVOR-LEWIS OESOPHAGECTOMY FOR CANCER

Abstract Background Oesophagectomy is the mainstay of curative treatment for oesophageal cancer and post-oesophagectomy diaphragmatic hernia (PODH) represents a potentially life-threatening surgical complication characterized by an underestimated occurrence rate and unknown related risk factors. This study analyses the experience of two tertiary designated centers in order to evaluate key elements concerning development and treatment of PODH. Methods A cohort of consecutive patients affected by a clinically resectable oesophageal cancer (any T, any N and M0) underwent Ivor-Lewis oesophagectomy between March 1997 and April 2017 according to three different approaches: totally open incision procedure (OILO), hybrid (HILO) and totally mininvasive to esophagectomy (MILO). All patients were retrospectively observed in the context of a postoperative calendarised follow-up in order to record the incidence and postrepair results of PODH. Results 414 patients underwent Ivor-Lewis oesophagectomy for cancer and 22 (5.3%) developed PODH within a median follow-up period of 16 months (6 - 177). Surgical repair was generally applied by the mean of laparoscopic cruroplasty (77%) with a conversion rate of 24%. Postoperative morbidity did not include early recurrences but exclusively cardio-pulmonary complications (5 patients) with one case of respiratory failure leading to death. The discharge was reached after a median hospital stay of 6 days (2 - 95) while 3 recurrences (14%) occurred over a median follow-up period of 10.1 months. A wide univariate analysis identified statistically significant associations between PODH occurrence and the administration of preoperative chemoradiotherapy, the complete pathological response (CPR) and a lymph node harvest (LNH) larger than 33 stations (p-value of 0.016, 0.001 and 0.024 respectively). The strong influence of an extended LNH was confirmed by the multivariable analyses (0.026) along with CPR which should however be considered as longer survival-related bias. Conclusion The minimally invasive surgery and the neoadjuvant chemoradiotherapy represent a considerable part of multimodal treatment for oesophageal cancer presenting a not statistically significant association with PODH development while a LNH including more than 33 nodes resulted to be an independent risk factor mirroring the extent of surgical demolition in oesophagectomy. Disclosure All authors have declared no conflicts of interest.

Long-term outcome of open versus hybrid minimally invasive Ivor Lewis oesophagectomy: a propensity score matched study†.

OBJECTIVES: It has been suggested that laparoscopic Ivor Lewis (IL) oesophagectomy reduces postoperative morbidity and mortality rates. However, data related to the long-term outcomes of this hybrid minimally invasive procedure are scarce. METHODS: All of the patients who had an IL oesophagectomy for cancer were extracted from a prospective database. Patients were matched one to one according to the surgical approach (laparoscopy versus laparotomy) and on the basis of a propensity score including eight variables: age, gender, American Society of Anaesthesiologists score, forced expiratory volume in 1 s, surgery (first-line treatment, after neoadjuvant treatment and salvage surgery), histology, location and pathological stage. The first end point was the assessment of the 5-year survival and disease-free survival rates. The secondary end points were R0 resection rate, number of resected lymph nodes (LNs) and patterns of recurrence. RESULTS: Over a 12-year period, 272 IL oesophagectomies were performed. A total of 140 patients were matched in two homogeneous groups: laparotomy (n = 70) and laparoscopy (n = 70). The 5-year overall survival and disease-free survival rates were 65% and 48% in laparotomy group and 73% and 51% in the laparoscopy group (P = 0.891; P = 0.912). R0 resection rates were, respectively, 93% vs 97% (P = 0.441). The number and distribution of resected LNs were similar between the groups except at the level of the celiac axis (P < 0.001). Depending on the surgical approach, the patterns of recurrence were similar in both groups. CONCLUSIONS: Laparoscopic IL oesophagectomy does not compromise the long-term oncological outcome compared to open IL oesophagectomy. The quality of the operations is similar for both techniques except for the number of resected LNs at the level of the celiac trunk. Further randomized controlled trials are necessary to confirm these results.

Aortic Calcification Increases the Risk of Anastomotic Leakage After Ivor-Lewis Esophagectomy

Anastomotic leakage is associated with increased morbidity and mortality after esophagectomy. Calcification of the arteries supplying the gastric tube has been identified as a risk factor for leakage of the cervical anastomosis, but its potential contribution to the risk of intrathoracic anastomotic leakage has not been elucidated. This study evaluated the relationship between calcification and the occurrence of leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy. Consecutive patients who underwent minimally invasive esophagectomy for cancer at 2 institutions were analyzed. Diagnostic computed tomography images were used to detect calcification of the arteries supplying the gastric tube (eg, aorta, celiac axis). Multivariable logistic regression analysis was used to determine the relationship between vascular calcification and anastomotic leakage. Of 167 included patients, anastomotic leakage occurred in 40 (24%). In univariable analysis, leakage wasmost frequently observed in patients with calcification of the aorta (major calcification: 37% leakage [16of43]; minor calcification: 32% [18 of 56]; no calcification: 9% [6 of 70], p < 0.001). Calcification of other studied arteries was not significantly associated withleakage. A significant association with leakage remained for minor (odds ratio, 5.4; 95% confidence interval, 1.7 to 16.5) and major (odds ratio, 7.0; 95% confidence interval, 1.9 to 26.4) aortic calcifications in multivariable analysis. Atherosclerotic calcification of the aorta is an independent risk factor for leakage of the intrathoracic anastomosis after Ivor-Lewis esophagectomy for cancer. The calcification scoring system may aid in patient selection and lead to earlier diagnosis of this potentially fatal complication.

Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus

ObjectiveChylothorax is a major complication after esophagectomy. As recent studies refer to heterogeneous patient cohorts and surgical procedures, this study was conducted to report the incidence and evaluate the optimal management of chylous fistula in patients treated with transthoracic esophagectomy and 2-field lymphadenectomy for esophageal cancer. MethodsFrom January 2005 to December 2013, a total of 906 patients underwent transthoracic esophageal resection for esophageal carcinoma at our institution. En bloc esophagectomy was performed with routine supradiaphragmatic ligation of the thoracic duct. The incidence of chylothorax, and associated morbidity and mortality, were analyzed, and subsequent therapeutic management was reviewed. ResultsChylothorax after Ivor Lewis esophagectomy was observed in 17 (1.9%) patients. Fifteen patients required surgical intervention with rethoracotomy and repeat duct ligation. Thoracic duct ligation was successful in all patients. Two patients died within 90 days after primary esophageal resection. The median time between initial tumor resection and rethoracotomy was 13 days. Average daily chest-tube output at time of reoperation was 1900 mL. In 2 patients, pleural effusion did not exceed 1000 mL per day. In these cases, conservative management with additional thoracic drainage and total parenteral nutrition led to complete resolution of chylous fistula. ConclusionsOccurrence of chylothorax after prophylactic thoracic duct ligation during transthoracic esophagectomy for esophageal cancer is rare. In patients with high-output chylous fistula, an early rethoracotomy with repeat ligation of the thoracic duct is safe and helps to shorten recovery time. In cases of low-volume drainage, a conservative approach is feasible.

Functional outcome after Ivor Lewis esophagectomy for cancer.

Little is known on functional outcome after Ivor Lewis esophagectomy (ILE) with intrathoracic anastomosis. Patients who underwent ILE were identified from a prospective database. Clinicopathological data were retrieved and compared with functional outcome data based on patient self-assessment by a standard questionnaire. Predictive factors for selected functional complaints were identified with logistic regression analyses. Three hundred and twenty-two patients (80.4% male, mean age 62 years) were studied. Indications for surgery were adenocarcinoma (62.4%), squamous cell carcinoma (28%), and HG Barrett dysplasia (7%). Preoperative chemoradiation (CRT) was administered to 42.5% of patients. Anastomotic leakage occurred in 5.6% and was associated with higher age and diabetes mellitus. Functional symptoms identified were reflux (39%), delayed gastric emptying (37%), dumping (21.4%), and anastomotic stenosis (16%). In the multivariate models, anastomotic stenosis was associated with smaller stapler diameter and presence of esophagitis. Postoperative reflux was associated with higher BMI, whereas dumping was predicted by female gender and age. The quality of life questionnaires revealed a good general health status in 82% of the patients. Functional complaints after ILE consist of reflux, delayed gastric emptying, dumping, and dysphagia, and are affected by age, gender, BMI, diabetes mellitus, and stapler diameter.

Robotic Esophagectomy for Cancer: Early Results and Lessons Learned

Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

PWE-157 Reducing anastomotic leak rate in ivor lewis oesophagectomy – testing a change from mechanical to semi-mechanical anastomosis

Introduction The reduction in mortality after oesophagectomy seen over the last decade has not been matched by a reduction in anastomotic leaks with a leak rate of 5–10% accepted as a standard of care. Leaks increase postoperative mortality, morbidity and length of stay and reduce cancer survival. We present the results of a modified semi-mechanical intrathoracic anastomotic technique (SM) originally described by Orringer et al 1 for the cervical anastomosis. Method Centralisation of oesophagogastric cancer surgery took place in our region in January 2010, bringing together five surgeons from three surgical units. For consistency, all five surgeons used a standard circular stapled anastomotic technique (CS) from 2010, but the leak rate was deemed too high. As a result, three of the five surgeons (A, B, and C) changed to a modified SM technique (surgeon A changed in November 2011, surgeon B in December 2011 and surgeon C in May 2013). This anastomosis joins the obliquely cut end of the oesophagus to the side of the proximal gastric conduit with a single 25 mm firing of a 45 mm linear stapler posteriorly (ATS45, Blue cartridge, Ethicon), the remainder of the anastomosis being completed with single layer inverting interrupted 3/0 PDS. The other two surgeons (D and E) continued to use the CS technique. Anastomotic leak rates, mortality and length of stay were evaluated to test this change in technique. Results Between Jan 2010 and February 2015 inclusive 376 patients underwent curative intent, 2-stage Ivor Lewis oesophagectomy for cancer. One patient died in hospital (0.27% mortality). The anastomotic leak rate Surgeons A, B and C using CS was 16.8%(15/92) and SM 0.8%(1/127) for surgeons D and E the rate was 10.2%(16/157). The median post-operative length of stay between groups was 11(7–56), 10(6–58) and 12(7–51) respectively. Conclusion There was a profound reduction in anastomotic leak rate for all three surgeons who changed from circular to semi-mechanical anastomosis. Disclosure of interest None Declared. Reference Orringer MB, et al . Eliminating the cervical esophagogastric anastomotic leak rate with a side to side stapled anastomosis. J Thorac Cardiovasc Surg . 2000 Feb;119(2):277-88