Narrow Gastric Tube Research Articles

Risk Reduction of Severe Anastomotic Leakage by Evaluation of Blood Perfusion Using Indocyanine Green After Minimally Invasive Esophagectomy Followed by Narrow Gastric Tube Reconstruction

Risk Reduction of Severe Anastomotic Leakage by Evaluation of Blood Perfusion Using Indocyanine Green After Minimally Invasive Esophagectomy Followed by Narrow Gastric Tube Reconstruction

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.

High cervical anastomosis reduces leakage-related complications after a McKeown esophagectomy.

Anastomotic leak (AL) is one of the most serious complications after oesophageal cancer surgery. A high cervical anastomosis using a narrow gastric tube based on optimized procedures has the potential to reduce the AL after a McKeown oesophagectomy. A narrow gastric tube was defined as 2-2.5 cm in diameter. Meanwhile, we defined a high anastomosis (HA) and a normal anastomosis (NA) based on the position of the intraoperative cervical anastomosis above or below the level of the inferior thyroid artery, respectively. A total of 533 patients who had a McKeown oesophagectomy from March 2018 to March 2023 were included in this study, including 281 patients in the NA group and 252 patients in the HA group. Potential confounding factors in baseline characteristics were balanced by propensity score matching. After matching, 190 patients remained in both groups. When comparing the pathological and surgical results, we found that more lymph nodes, both in total number (21.1 ± 10.0 vs 15.8 ± 7.7, P = 0.001) and thoracic part (13.5 ± 7.8 vs10.8 ± 6.1, P = 0.005), were harvested from the HA group . The pathological T and TNM stages of patients in the HA group were earlier than those in the NA group (P = 0.001). Overall postoperative complications (P = 0.001), including pulmonary infection (P = 0.001), AL (P < 0.001), leakage-related pyothorax (P < 0.001), recurrent laryngeal nerve palsy (P = 0.031) and pleural effusion (P < 0.001), were all significantly lower in the HA group. Finally, multivariable logistic regression analysis indicated that HA was an independent protective factor for AL (odds ratio = 0.331, 95% confidence interval: 0.166-0.658; P = 0.002). For patients undergoing a McKeown oesophagectomy, a high cervical anastomosis using a narrow gastric tube can effectively reduce leakage-related complications.

Novel reconstruction method using long and narrow gastric tube in laparoscopic proximal gastrectomy for cancer: a retrospective case series study.

To clarify the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with our novel reconstruction methods. Novel method is a reconstruction with a long and narrow gastric tube with widening of the proximal side created by linear stapler, and esophagogastrostomy is performed by linear stapler. In conventional method, esophagogastrostomy is performed by a circular stapler. Short- and long-term outcomes of a novel method were compared with those of conventional method. A total of 44 patients whom LPG was performed were enrolled in this retrospective study. No cases of anastomotic leakage and stenosis were observed in both groups. The cases of postoperative reflux esophagitis (Grade B or higher) at 1 year after operation in the Novel group were less than those in the Conventional group (17% vs. 44%). LPG with novel reconstruction method can be easily performed, and may be feasible for the treatment of proximal gastric cancer.

Impact of zero anastomotic leakage after esophagectomy followed by whole stomach reconstruction for esophageal cancer: prospective cohort study.

The stomach is the most common organ which is used for reconstruction after esophagectomy for esophageal cancer. It is controversial which is better narrow gastric tube reconstruction or whole stomach reconstruction to prevent anastomotic leakage. From August 2022 to March 2023, we started a prospective cohort study of whole stomach reconstruction after esophagectomy. Until then (from January 2018 to July 2022), narrow gastric tube reconstruction was performed as a standard reconstruction. Narrow gastric tube reconstruction and whole stomach reconstruction were performed in 183 patients and 20 patients, respectively. The patient's characteristics were not significantly different between the narrow gastric tube group and the whole stomach group. In particular, for all patients in the whole stomach reconstruction group, retrosternal route and esophagogastrostomy by hand sewn were applied. There were no occurrences of AL through the continuous 20 cases in the whole stomach group, otherwise 42 (22.9%) patients in the narrow gastric group (P = 0.016). Postoperative hospital stays were significantly shorter in the whole stomach group than in the narrow gastric group (21days vs. 28days, P < .001). Blood perfusions were evaluated by indocyanine green for all cases, which had very good blood perfusion in all cases. Additionally, quantitative blood perfusion was examined by SPY-QP (Stryker, USA) for one case. Even the edge of the fornix showed more than 90% blood perfusion levels when the antrum was fixed as the reference point. Whole stomach reconstruction with excellent blood perfusion is considered to be safe and has the possibility to prevent from occurring AL after esophagectomy for esophageal cancer patients.

A case of Barrett’s esophageal adenocarcinoma and severe scoliosis with successful salvage esophagectomy after definitive chemoradiotherapy

BackgroundSevere scoliosis can cause reflux esophagitis, and is a risk factor for Barrett's adenocarcinoma of the esophagus. Severe scoliosis is associated with respiratory dysfunction, impaired operative tolerance, and anatomical difficulty in surgical manipulation, and is, therefore, considered a high surgical risk. In this report, we describe the case of a young patient with Barrett's esophageal adenocarcinoma with severe scoliosis who underwent salvage surgery after radical chemoradiotherapy.Case presentationThe patient was a 39-year-old male. Although he had severe scoliosis and paraplegia of both lower limbs since childhood, he was independent in activities of daily living. His previous doctor, who diagnosed the esophageal cancer, determined that surgery was not indicated due to the coexistence of severe scoliosis, so he underwent chemoradiotherapy with curative intent. After chemoradiotherapy, the patient was referred to our hospital for a second opinion because of a tumor remnant. After various additional examinations, thoracoscopic and laparoscopic subtotal esophagectomy for esophageal cancer was performed, along with ante-thoracic route reconstruction using a narrow gastric tube. Although the patient had symptoms associated with postoperative reflux, he recovered well overall and was discharged home about 4 weeks after surgery.ConclusionsWe report the case of an esophageal cancer patient with severe scoliosis at high surgical risk who underwent successful minimally invasive esophagectomy.

333. HIGH CERVICAL ANASTOMOSIS USING NARROW GASTRIC TUBE CAN REDUCE LEAKAGE AFTER MCKEOWN ESOPHAGECTOMY

Abstract Background Anastomotic leakage is one of the most serious complications after esophagectomy. High cervical anastomosis with narrow gastric tube has the potential to reduce the leakage after McKeown esophagectomy. Methods A total of 533 patients who received McKeown radical resection for esophageal cancer in Shanghai Chest Hospital from March 2018 to March 2023 were included in this study, including 281 patients in the normal anastomosis (NA) group and 252 patients in the high anastomosis (HA) group. Potential confounding factors in baseline characteristics were balanced by 1:1 propensity score matching (PSM). We compared the pathological and perioperative results before and after matching between the HA group and NA group, and finally used univariate and multivariate logistic analysis to analyze the independent risk factors of anastomotic leakage. Results After matching, 190 patients remained in both groups. In the comparison of pathological and surgical results, we found that the HA group had an advantage in lymph node harvest (Before matching: 21.3 ± 9.7 vs. 15.8 ± 7.5, p &amp;lt; 0.001; After matching: 21.1 ± 10.0 vs. 15.8 ± 7.7, p &amp;lt; 0.001). There were no significant differences in operation time, blood loss and R0 resection rate between the two groups after matching. The grade of tumor differentiation in HA group was better than that in NA group (p &amp;lt; 0.001), and the pathological staging was earlier than that in NA group (p &amp;lt; 0.001). Overall postoperative complications, including pulmonary infection (p &amp;lt; 0.001), anastomotic leakage (p &amp;lt; 0.001), recurrent laryngeal nerve paralysis (p = 0.031), and pleural effusion (p &amp;lt; 0.001), were significantly lower in the HA group than those in the NA group. Multivariate analysis indicated that age &amp;gt; 65 [odds ratio (OR) = 1.433, 95% confidence interval (CI) 1.248–1.753; p = 0.003], T4a (OR = 1.19, 95% CI 1.023–1.629; p = 0.016), Neoadjuvant treatment (OR = 0.075, 95% CI 0.038–0.150; p &amp;lt; 0.001) and HA (OR = 0.631, 95% CI 0.213–0.707; p = 0.014) were independent predictors for anastomotic leakage. Conclusions For patients undergoing McKeown esophagectomy, high anastomosis can effectively reduce the incidence of anastomotic leakage and reduce overall perioperative complications. It is a recommended optimized surgical procedure.

Effects of proximal gastrectomy with narrow gastric tube anastomosis compared with total gastrectomy with Roux-en-Y anastomosis on upper gastric cancer.

To investigate the clinical efficacy of proximal gastrectomy with narrow gastric tube anastomosis (PG-NGT) and total gastrectomy with Roux-en-Y anastomosis (TG-RY) for upper gastric cancer. One hundred sixty-three upper gastric cancer patients were enrolled into the PG-NGT group and TG-RY group. The propensity score matching method was used to conduct a one-to-one match between the two groups with 38 patients in each group. Compared with the TG-RY group, the PG-NGT group had significantly (P < 0.05) shorter operation time, shorter hospital stay, and less intraoperative blood loss. The TG-RY group had significantly (P = 0.009) more lymph nodes dissected and greater (P = 0.014) total cost than the PG-NGT group, but no significant difference existed in the surgical cost between the two groups (P = 0.214). There was no significant (P > 0.05) difference in the incidence of anastomotic stenosis (10.5% vs. 13.1%) or the reflux esophagitis rate (8.6% vs. 9.1%) in the PG-NGT group and the TG-RY group. One year after surgery, the weight and hemoglobin and albumin levels in the PG-NGT group were significantly (P < 0.05) higher than those in the TG-RY group. PG-NGT may be better than TG-RY in improving patient weight loss and hemoglobin and albumin levels, without increasing the rate of anastomotic stenosis and reflux symptoms.

529. ANALYSES OF CLINICAL FACTORS AFFECTING POSTOPERATIVE SYMPTOMS INCLUDING BODY WEIGHT LOSS, ORAL INTAKE, AND REFLUX AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Some patients complain of serious postoperative digestive symptoms after esophagectomy. However, it has not been clear what clinical factors are related to these symptoms. In this study, we investigate the relationships between postoperative digestive symptoms (body weight loss, subjective oral intake, and reflux) and clinical factors. Of 155 patients who underwent esophagectomy at our department from April 2019 to July 2021, 75 patients were eligible because they could be followed up at our outpatient clinic without relapse. Postoperative symptoms including body weight loss, oral intake ≥70%, and reflux were asked. Regarding clinical factors, age, sex, route of reconstruction, the width and the location of the gastric tube in CT images, and the location of pylorus ring in CT images were investigated retrospectively. The median body weight loss was 10.5%. Oral intake ≥70% was found in 37/61. 24/50 patients complained of reflux. The mean body weight loss was 6.2% in the intrathoracic anastomosis, 10.5% in the posterior mediastinal route, and 12.6% in the retrosternal route (p=0.04). Oral intake ≥70% was found in 20/29 of the wide gastric tube group and 16/31 of the narrow gastric tube group (p=0.197). The group with oral intake ≥70% was likely to be younger (p&amp;lt;0.01), and male is likely to have oral intake ≥70% (p=0.193). Regarding reflux, there were no difference in clinical factors. Although this is a retrospective study and biases in each group are found, body weight loss is less found in the intrathorax anastomosis and in the duodenostomy group via a retrosternal route. Oral intake is likely to be more in younger patients, in male, and in patients with wider gastric tube. On the other hand, no clinical factors were found related to reflux.

Circular stapling anastomosis with indocyanine green fluorescence imaging for cervical esophagogastric anastomosis after thoracoscopic esophagectomy: a propensity score-matched analysis

BackgroundThoracoscopic esophagectomy has been extensively used worldwide as a curative surgery for patients with esophageal cancer; however, complications such as anastomotic leakage and stenosis remain a major concern. Therefore, the objective of this study was to evaluate the efficacy of circular stapling anastomosis with indocyanine green (ICG) fluorescence imaging, which was standardized for cervical esophagogastric anastomosis after thoracoscopic esophagectomy.MethodsAltogether, 121 patients with esophageal cancer who underwent thoracoscopic esophagectomy with radical lymph node dissection and cervical esophagogastric anastomosis from November 2009 to December 2020 at Tottori University Hospital were enrolled in this study. Patients who underwent surgery before the anastomotic method was standardized were included in the classical group (n = 82) and patients who underwent surgery after the anastomotic method was standardized were included in the ICG circular group (n = 39). The short-term postoperative outcomes, including anastomotic complications, were compared between the two groups using propensity-matched analysis and the risk factors for anastomotic leakage were evaluated using logistic regression analyses.ResultsOf the 121 patients, 33 were included in each group after propensity score matching. The clinicopathological characteristics of patients did not differ between the two groups after propensity score matching. In terms of perioperative outcomes, a significantly higher proportion of patients who underwent surgery using the laparoscopic approach (P < 0.001) and narrow gastric tube (P = 0.003), as well as those who had a lower volume of blood loss (P = 0.009) in the ICG circular group were observed after matching. Moreover, the ICG circular group had a significantly lower incidence of anastomotic leakage (39% vs. 9%, P = 0.004) and anastomotic stenosis (46% vs. 21%, P = 0.037) and a shorter postoperative hospital stay (30 vs. 20 days, P < 0.001) than the classical group. According to the multivariate analysis, the anastomotic method was an independent risk factor for anastomotic leakage after thoracoscopic esophagectomy (P = 0.013).ConclusionsCircular stapling anastomosis with ICG fluorescence imaging is effective in reducing complications such as anastomotic leakage and stenosis.

Thoracoscopic esophagectomy in total pharyngolaryngoesophagectomy for esophageal cancer; A case series

BackgroundTotal pharyngolaryngoesophagectomy (TPLE) is associated with major complications and is extremely invasive. In 2011, our institution introduced thoracoscopic esophagectomy in the left hemi-prone position and laparoscopic reconstruction with a gastric tube in patients undergoing TPLE. Herein, we describe the use of this operative method in 26 patients, focusing on the technical aspects of the surgery. Materials and methodsFrom January 2011 to December 2018, 26 patients underwent minimally invasive TPLE with gastric tube reconstruction in our institute. The thoracoscopic procedure was performed with the patient in the semi-prone position. The patient was then moved to the supine position, and the laparoscopic procedure and pharyngolaryngectomy were started simultaneously. After pharyngolaryngectomy, microvascular anastomoses or free jejunal flap interposition were performed at the site of the gastric tube reconstruction. The data from these 26 patients were retrospectively analyzed. ResultsThe median age was 66 years, and 3.8% of the patients were female. The Union for International Cancer Control stages of esophageal cancer were 0 (n = 2), I (n = 4), II (n = 7), III (n = 8), and IV (n = 5). Eight patients had concomitant esophageal cancer and head and neck cancer. Reconstruction with only a narrow gastric tube was used in 16 patients, while free jejunal flap interposition was used in 10 patients. The surgical procedures resulted in minimal complications. Postoperative complications of Clavien-Dindo grade ≥1 included anastomotic leakage in two patients and pneumonia in one. ConclusionThoracoscopic esophagectomy in the left hemi-prone position and laparoscopic reconstruction with a gastric tube in patients undergoing TPLE was safe and effective. The complications were improved via the development of various procedures. Further improvement is necessary before this thoracoscopic approach is established as a standard procedure for TPLE.

Flexible Gastric Tube: A Novel Gastric Tube Formation Method to Prevent Anastomotic Leakage

Gastric tube reconstruction is now the method most frequently used for digestive tract reconstruction after the resection of esophageal carcinoma. In our institute, a "flexible" gastric tube designed to supply a sufficient amount of blood to the tip of the gastric tube (the same as a subtotal gastric tube) and simultaneously provide sufficient length for tension-free anastomosis in the cervical surgical field (the same as a narrow gastric tube) was introduced. This gastric tube formation method hascontributed to reducing the rate of anastomotic leakage.

The influence of anastomosis-induced gastric wall defects on the blood supply to the gastric tube

The influence of anastomosis-induced gastric wall defects on the blood supply to the gastric tube

Thyroid metastasis from esophageal adenocarcinoma: a case report and literature review

BackgroundThe incidence of metastatic spread of gastrointestinal malignancies to the thyroid gland is relatively low and most of these malignancies originate from the colorectum. Thyroid metastasis originating from the esophagus is poorly documented.Case presentationA 79-year-old man presented with hoarseness of voice and swallowing difficulty. Eighteen months earlier, he had undergone preoperative chemotherapy (S-1 and oxaliplatin [SOX] therapy) and subtotal esophagectomy with regional lymph nodes dissection and retrosternal narrow gastric tube reconstruction for advanced Barrett’s esophageal adenocarcinoma. In the ultrasonographic examination, there was a hypoechoic, indistinct border and heterogeneous nodule in the left lobe of the thyroid gland. Pathological examination of an ultrasound-guided fine-needle aspiration showed adenocarcinoma, supporting a diagnosis of esophageal adenocarcinoma metastases in the thyroid.ConclusionThis is a first case of a patient with thyroid metastasis from Barrett’s esophageal adenocarcinoma after subtotal esophagectomy.

Health-related quality of life and survival among 10-year survivors of esophageal cancer surgery: gastric tube reconstruction versus whole stomach reconstruction.

To compare the health-related quality of life (HRQL) and long-term survival between patients after oncologic esophagectomy with narrow gastric tube (NGT) reconstruction and whole stomach (WS) reconstruction. Between 2007 and 2008, a total of 104 patients undergoing esophagectomy were included in this research. Fifty-two patients were enrolled in NGT group and 52 in WS group. HRQL was assessed at 3 weeks, 6 months, 1 year, 2 years, 5 years and 10 years after surgery. The questionnaire was designed with reference to the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-QES18. For patients' baseline characteristics, there was no significant difference between groups. Patients in NGT group had significantly less postoperative reflux than those in WS group. Dysphagia is the only symptom that was significantly worse in WS group than in NGT group at 10 years follow-up. The number of patients presenting good HRQL between groups did not reveal significant differences at 10 years follow-up. The 10-year survival was 33.3% for patients in NGT group and 11.5% for patients in WS group (P<0.05). Because of a better long-term survival (P=0.027), gastric tube reconstruction may be a better choice for patients undergoing oncologic esophagectomy. HRQL recovers to a level comparable in most patients who survive 10 years after esophagectomy for cancer, although some digestive tract symptoms, like dysphagia, may last during the whole postoperative period and represent a poor prognosis.

Evaluation of the Associations between Gastric Tube Preparation Methods and the Incidence of Cervical Anastomotic Leakage after Esophagectomy for Thoracic Esophageal Cancer

Background: A gastric tube (GT) is most often selected as a reconstruction conduit in esophageal reconstruction. Although some leakage from esophagogastric anastomoses is induced by blood flow failure in reconstruction conduits, the association between the GT and the anastomotic leakage (AL) is unclear. Objectives: We retrospectively evaluated the incidence of AL according to the GT shape. Methods: Between February 2013 and September 2017, 188 consecutive patients who underwent esophagectomy with GT reconstruction were enrolled in this cohort study. We performed GT reconstruction using a narrow GT (Gr.N) until May 2016. Subsequently, we began preparing and using a stretched GT (Gr.S). Results: AL occurred in 29 of 188 (15.4%) patients. The frequency of AL was lower with Gr.S than with Gr.N (p = 0.034). Sex, body mass index, Brinkman index, hypertension, and anemia were significantly associated with AL (p = 0.033, 0.041, 0.003, 0.030, and 0.042, respectively). In a multivariate logistic regression analysis, the GT shape and the Brinkman index were shown to be independent risk factors for AL (p = 0.016 and 0.020, respectively). Conclusions: The GT preparation method is an independent risk factor for AL after cervical esophagogastrostomy. Thus, improved GT preparation methods could contribute to the reduction of AL after esophagectomy.

Impact of gastric tube diameter on quality of life of esophagus cancer patient after Ivor-Lewis esophagectomy

To explore the impact of the gastric tube diameter on quality of life of esophagus cancer patients after Ivor-Lewis esophagectomy. Clinical and follow-up data of 188 esophageal cancer patients who underwent Ivor-Lewis esophagectomy at Department of Cardio-Thoracic Surgery, Drum Tower Clinical Medicine College, Nanjing Medical University from January 2015 to June 2016 were retrospectively analyzed. Inclusion criteria included age <75 years old, good foundation health situation, no distant metastasis, complete follow-up data for one-year after surgery, and middle-lower esophageal squamous cell carcinoma (ESCC). According to the diameter of gastric tube formed during operation, 92 patients were assigned to narrow gastric tube group (NGT group, ≥2 cm to <4 cm), which were further divided into narrower group (≥2 cm to <3 cm, n=44) and medium narrow group (≥3 cm to <4 cm, n=48); 96 patients were assigned to wide gastric tube group(WGT group, ≥4 cm), which were further divided into medium wide group(≥4 cm to <5 cm, n=50) and wider group(≥5 cm, n=46). Postoperative patients were followed up by telephone or outpatient service for one year and then re-hospitalized to receive associated examinations, including lung function test, esophageal pressure measurement, 24-hour esophageal dynamic pH monitoring (total number of pH<4, number of pH<4 lasting more than 5 minutes, maximum duration of pH<4 and time percentage of pH<4) and dilatation measurement of gastric tube (the diameter measured by CT minus the diameter measured in surgery). During follow-up, postoperative quality of life(QoL) was assessed by questionnaire. These contents were compared and plotted as a chart. There were no statistically significant differences between NGT group and WGT group regard to preoperative baseline information, postoperative pathology and postoperative complications (residual gastric leakage, anastomotic leakage, anastomotic stenosis, pulmonary complications, atrial fibrillation and chylothorax) (all P>0.05). Compared with WGT group, the NGT group had better postoperative lung function, including percentage of vital capacity [(76.4±6.8)% vs. (73.2±7.7)%, t=2.168, P=0.033], percentage of maximal voluntary ventilation [(72.7±6.4)% vs. (69.3±6.8)%, t=2.409, P=0.018] and percentage of forced expiratory volume in the first second [(69.2±5.0)% vs. (66.7±6.2)%, t=2.033, P=0.045], higher plane pressure of anastomotic stoma [(5.4±3.1) mmHg vs. (4.2±2.4) mmHg, t=2.083, P=0.038], greater dilatation of gastric tube [(1.0±0.4) cm vs. (0.5±0.3) cm, t=5.888, P=0.000], milder gastroesophageal reflux according to the indices of 24-hour esophageal dynamic pH monitoring, including the total number of pH<4 (228.3±65.3 vs. 280.8±103.9, t=-2.920,P=0.004), the number of pH<4 lasting more than 5 minutes (19.9±8.5 vs. 30.6±15.6, t=-4.127,P=0.000), the maximum duration of pH<4[(32.5±9.4) minutes vs. (37.9±13.6) minutes, t=-2.232,P=0.028] and the time percentage of pH<4 [(23.4±10.2)% vs. (28.4±10.6)%, t=-2.303, P=0.024]. However, no significant difference was found in the scores of postoperative QoL between the two groups(P=0.051). According to the pairwise comparisons among the four subgroups, narrower group showed better performance on postoperative lung function, plane pressure of anastomotic stoma, the dilatation of gastric tube, indices of 24-hour esophageal dynamic pH monitoring and scores of postoperative QoL as compared to wider group (all P<0.05). There were no statistically significant differences among medium narrow group, medium wide group and wider group. Line charts showed that the larger of the gastric tube diameter, the worse of the postoperative lung function, the more severe of gastroesophageal reflux and the smaller degree of gastric tube dilatation. Narrow gastric tube with a diameter of 2-4 cm can improve the postoperative QoL of esophagus cancer patients after Ivor-Lewis esophagectomy without increasing the risk of postoperative complications.

RA05.03: THE INFLUENCE OF ANASTOMOSIS ON THE BLOOD SUPPLY OF STOMACH AND THE OPTIMIZATION OF WIDTH OF TUBULAR STOMACH IN END-TO-SIDE ESOPHAGEAL-GASTRIC ANASTOMOSIS

Abstract Background End-to-side esophageal-gastric anastomosis is the most commonly used method of anastomosis in esophagectomy. Narrow gastric tube, especially 3cm-wide one, is thought to improve the blood supply of stomach. But with the combine use of these two techniques, we found alimentary tract leakage became more common. The reason was obscure. Few have considered the influence of anastomosis-induced gastric wall defect on the blood supply of gastric tube (Figure 1). We carried out this research to prove this hypothesis and to find out method to resolve this problem. Methods Animal experiment and clinical cohort study have been carried out. Narrow gastric tube group (3cm wide) and baseball-bat-shaped gastric tube group (5cm in avascular area) were compared. In animal experiment, 3 pigs in each group. Impaired blood supply will slow down blood flow and cause metabolic acidosis. So blood gas analysis (with the blood collected in gastric wall distal or proximal to the anastomosis) and arteriography with methylene blue were performed. pH and BE(from blood gas analysis) and time required for methylene blue to reach the tip of gastric tube were used to evaluate the blood supply of these areas. In cohort study, 176 patients were enrolled with 24 in narrow gastric tube group and 152 in bat-like gastric tube group. The incidence of leakage was compared. Results In animal experiment, before anastomosis, no metabolic acidosis was found in both groups. But after anastomosis, methylene blue couldn’t reach the gastric wall distal to the anastomosis, and the blood gas analysis shows metabolic acidosis with the blood from the same area, only in narrow group, These indicated insufficient blood supply in this area. In the cohort study, the incidence of leakage was much higher in narrow group. Conclusion Anastomosis can influence the blood supply of the gastric tube distal to it. It's the reason of the increase of alimentary tract fistula incidence with the use of 3cm-wide narrow gastric tube. Widen the gastric avascular area is an effective way to prevent this. So for end-to-side anastomosis, 5cm-wide gastric tube is preferred, while narrower gastric tube is suitable for other mode of anastomosis which do not cause gastric wall defect Disclosure All authors have declared no conflicts of interest.

Risk Factors for Weight Loss 1 Year After Esophagectomy and Gastric Pull-up for Esophageal Cancer

BackgroundLoss of body weight is regarded as a marker of malnutrition after esophagectomy. This study investigated changes in body weight and risk factors for weight loss after esophagectomy for esophageal cancer. MethodsWe retrospectively reviewed records of 181 patients who underwent esophagectomy and gastric pull-up from 2012 to June 2016. Patients with operative mortality and recurrences were excluded. Percent change in body weight was defined as change in body weight (%)=(1-year body weight−preoperative body weight)×100/preoperative body weight. ResultsMean age of patients was 62.98±8.23 years with 164 men (90.6%). Mean preoperative body weight was 63.12±9.42 kg, and body weight at 1 year was 56.04±8.59 kg. Mean change in body weight was −10.95±7.50%, and 98 (54.1%) patients showed weight loss more than 10% compared to initial body weight. Univariable analysis showed that initial body weight, narrow gastric tube, thoracotomy, laparotomy, and postoperative vocal cord palsy (VCP) were related to more than 10% weight loss. Multivariable analysis showed that initial body weight (odds ratio [OR]=1.041, p=0.031) and postoperative VCP (OR=2.772, p=0.025) were adverse risk factors for weight loss 1 year after esophagectomy, whereas conduit type, route of reconstruction, postoperative complications, anastomotic complications, minimally invasive esophagectomy, and adjuvant therapy were not. ConclusionsInitial body weight and postoperative VCP were related to weight loss. Patients with VCP need additional nutritional monitoring and support.

Laparoscopic transhiatal lymphadenectomy in the lower mediastinum for adenocarcinoma of the esophagogastric junction.

Laparoscopic transhiatal esophagogastrectomy is difficult because the lower mediastinum is so deeply located that the operative field is narrow and restricted by surrounding organs. Therefore, we performed lymphadenectomy with opening of the bilateral mediastinal pleura to maintain safety and obtain better exposure of lymph nodes and important organs. We will present our technique for laparoscopic lower mediastinal lymphadenectomy and reconstruction for cancer of the esophagogastric junction. Five abdominal ports were used. Retraction of the left lobe of the liver exposed the esophageal hiatus. A long, narrow gastric tube (3cm wide) was formed, and regional abdominal lymph nodes (No. 1, 2, 3a, 7, 8a, 9, 19, and 20) were resected. The diaphragmatic hiatus was widely split and the opened bilateral mediastinal pleura enabled better exposure for lymph node dissection and reconstruction. The level where the inferior vena cava passed through the diaphragm into the chest was used as a landmark to identify supradiaphragmatic (No. 111) and lower thoracic paraesophageal nodes (No. 110), which were completely retrieved with this procedure. The posterior mediastinal nodes (No. 112pulR, 112pulL, and 112aoA) were also retrieved with bilateral opening of the mediastinal pleura and dissection of the inferior pulmonary ligaments. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis. This approach enabled safe and accurate laparoscopic lower mediastinal nodal dissection. With the advantage of a narrow gastric tube, the good working space made tension-free anastomosis possible.