Oesophagogastric Anastomosis Research Articles

Anastomotic leakage after intrathoracic versus cervical oesophagogastric anastomosis for oesophageal carcinoma in Chinese population: a retrospective cohort study

ObjectiveTo investigate the characteristics and predictors for anastomotic leakage after oesophagectomy for oesophageal carcinoma from the perspective of anastomotic level.DesignRetrospective cohort study.SettingsA single tertiary medical centre in China.ParticipantsFrom January 2010...

Transmural migration of azygous vein Hem-O-lok clip causing food bolus 3 months following uneventful minimally invasive oesophagectomy

Background: Hem-o-lok clips are widely deployed in various laparoscopic and robotic operations. Their migration is not very common and majority of reported cases are limited to biliary, prostatic and vesico-urethral cases.Methods: Herein, we would like to report the first case of transmural migration of Hem-o-lok clip from azygous vein stump following totally minimally invasive two-stage oesophagectomy for squamous cell carcinoma of the distal oesophagus, into the gastric conduit 3-months following uneventful discharge. The patient presented with 5-days history of worsening dysphagia.Results: The subsequent gastroscopy revealed normal gastric conduit with two Hem-o-lok clips containing the azygous vein stump within its lumen at the level of the oesophago-gastric anastomosis, propagating a food bolus obstruction. The foreign body was successfully removed and the patient was discharged the same day without any complications at 5 months follow up.Conclusion: Hem-o-lok clip migration trends to be a well-established event. However, their mechanism and exact incidence remains elusive to this date. To the best of our knowledge, their migration in oesophageal cancer surgery has not been reported.

Study of acquired oesophageal strictures

Background: We profiled the patients of acquired oesophageal strictures coming to our hospital in terms of causes, clinical presentation, efficacy of investigations and treatment modalities.Methods: In this two-year observational study, all patients presenting with complaint of difficulty in swallowing were enrolled and subjected to detailed history taking, examination, barium swallow study and other investigations. The patients were managed with surgical and/or non-surgical approaches, as indicated.Results: Out of total 46 eligible patients, 34 presented with malignant strictures while 12 presented with benign ones. Dysphagia was the commonest symptom in patients with malignant (31, 91.17%) as well as benign strictures (12, 100%). Shouldering with hold up of barium (19, 55.88%) was the most common finding noted in malignant strictures, while those with benign stricture had smooth tapering (7, 58.33%) as the commonest finding. On flexible endoscopy, the level of growth corroborated with the barium swallow findings in all 34 patients with malignant strictures and the lower one third (16, 47.05%) was observed to be the most common site of affection. Majority (21, 58.8%) of patients were having squamous cell carcinoma, with adenocarcinoma dominating in lower one third lesions (13 out of 16, 81.25%). No cases of adenocarcinoma were noted in middle and upper one third lesions.Conclusions: Majority of patients with malignant strictures were having squamous cell carcinoma, with adenocarcinoma dominating in lower one third lesions. Surgical resection led to relief from dysphagia in all the 6 cases of oesophagectomy with oesophagogastric anastomosis in malignant stricture cases with excellent long term survival and symptomatic relief

Intrathoracic versus cervical anastomosis and predictors ofanastomotic leakage after oesophagectomy for cancer.

BackgroundStudies comparing the anastomotic leak rate in patients with an intrathoracic versus a cervical anastomosis after oesophagectomy are equivocal. The aim of this study was to compare clinical outcome after oesophagectomy in patients with an intrathoracic or cervical anastomosis, and to identify predictors of anastomotic leakage in a nationwide audit.MethodsBetween January 2011 and December 2015, all consecutive patients who underwent oesophagectomy for cancer were identified from the Dutch Upper Gastrointestinal Cancer Audit. For the comparison between an intrathoracic and cervical anastomosis, propensity score matching was used to adjust for potential confounders. Multivariable logistic regression modelling with backward stepwise selection was used to determine independent predictors of anastomotic leakage.ResultsSome 3348 patients were included. After propensity score matching, 654 patients were included in both the cervical and intrathoracic anastomosis groups. An intrathoracic anastomosis was associated with a lower leak rate than a cervical anastomosis (17·0 versus 21·9 per cent; P = 0·025). The percentage of patients with recurrent nerve paresis was also lower (0·6 versus 7·0 per cent; P < 0·001) and an intrathoracic anastomosis was associated with a shorter median hospital stay (12 versus 14 days; P = 0·001). Multivariable analysis revealed that ASA fitness grade III or higher, chronic obstructive pulmonary disease, cardiac arrhythmia, diabetes mellitus and proximal oesophageal tumours were independent predictors of anastomotic leakage.ConclusionAn intrathoracic oesophagogastric anastomosis was associated with a lower anastomotic leak rate, lower rate of recurrent nerve paresis and a shorter hospital stay. Risk factors for anastomotic leak were co‐morbidities and proximal tumours.

Minimally invasive oesophagectomy in prone versus lateral decubitus position: A comparative study.

BACKGROUND:Thoracoscopic oesophageal mobilisation during a minimally invasive oesophagectomy (MIE) is most commonly performed with the patient placed in the lateral decubitus position (LDP). The prone position (PP) for thoracoscopic oesophageal mobilisation has been proposed as an alternative.MATERIALS AND METHODS:This was a retrospective, comparative study designed to compare early outcomes following a minimally invasive thoracolaparoscopic oesophagectomy for oesophageal cancer in LDP and in PP.RESULTS:During the study period, between January 2011 and February 2014, 104 patients underwent an oesophagectomy for cancer. Of these, 42 were open procedures (transhiatal and transthoracic oesophagectomy) and 62 were minimally invasive. The study group included patients who underwent thoracolaparoscopic oesophagectomy in LDP (n = 23) and in PP (n = 25). The median age of the study population was 55 (24-71) years, and there were 25 males. Twenty-one (21) patients had tumours in the middle third of the oesophagus, 24 in the lower third, and 3 arising from the gastro-oesophageal junction. The most common histology was squamous cell cancer (85.4%). The median duration of surgery was similar in the two groups; however, the estimated median intraoperative blood loss was less in the PP group [200 (50-400) mL vs 300 (100-600) mL; P = 0.01)]. In the post-operative period, 26.1% patients in the LDP group and 8% in the PP group (8%) developed respiratory complications. The incidence of other post-operative complications, including cervical oesophagogastric anastomosis, hoarseness of voice and chylothorax, was not different in the two groups. The T stage of the tumour was similar in the two groups, with the majority (37) having T3 disease. A mean of 8 lymph nodes (range 2-33) were retrieved in the LDP group, and 17.5 (range 5-41) lymph nodes were retrieved in the PP group (P = 0.0004). The number of patients with node-positive disease was also higher in the PP group (19 vs 10, P = 0.037).CONCLUSION:MIE in the PP is an effective alternative to LDP. The exposure obtained is excellent even without the need for a complete lung collapse, thereby obviating the need for a double-lumen endotracheal tube. A more meticulous dissection can be performed resulting in a higher lymph nodal yield.

PTU-137 A technique for circular stapled cervical anastomosis in three phase minimally-invasive oesophagectomy

Introduction Minimally-invasive oesophagectomy (MIO) is an increasingly popular strategy for oesophageal cancer resection in appropriately selected patients. In three-stage procedures, the oesophagus and stomach are mobilised thoracoscopically and laparoscopically, with a mini-laparotomy for conduit formation and specimen removal. The conduit is then delivered into the neck for construction of the oesophagogastric anastomosis. Traditionally the anastomosis is either entirely hand-sewn, or is semi-mechanical. Here, we discuss the use of fully mechanical anastomosis using a circular stapler (CS) in selected patients and report the clinical details, early outcomes. Method Patients undergoing MIO at our centre from November 2014 were considered for CS anastomosis using a gastrointestinal circular stapler (Ethicon™, UK). The clinical conditions necessary for use of CS were assessed at the time of surgery, the primary criterion being the availability of a sufficiently long conduit. All patients receiving a successful fully mechanical anastomosis are included. Results Four patients underwent CS anastomosis. Age range was 58–79 and included 2 male and 2 female patients. The first case had an area of proximal Barrett’s dysplasia which would have required a high hand sewn anastomosis. Another patient had very significant comorbid factors including rheumatoid arthritis and long-term corticosteroid and methotrexate use. In all of these cases, the anastomosis was successfully formed on first attempt. No early leaks occurred. Conclusion Use of CS is described for minimally invasive two phase and open oesophagectomy, and is occasionally reported for three-stage MIO. The majority of surgeons use the either fully hand-sewn or partially mechanical techniques for cervical anastomoses. We describe a simple technique for a stapled neck anastomosis which is faster to construct and enables a more proximal oesophageal resection without difficulty. Disclosure of interest None Declared. References Price TN, Nichols FC, Harmsen WS, Allen MS, Cassivi SD, Wigle DA, Shen KR, Deschamps C. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg. 2013;95(4):1154–60 Li J, Shen Y, Tan L, Feng M, Wang H, Xi Y, Leng Y, Wang Q. See comment in PubMed Commons belowCervical triangulating stapled anastomosis: technique and initial experience. J Thorac Dis. 2014;6(3):S350–4

OC-033 Outcomes following small intestinal and multivisceral transplantation at addenbrooke’s hospital, cambridge

<h3>Introduction</h3> Small intestinal transplantation was first undertaken in Cambridge in 1991 and with advances in immunosuppression agents, outcomes have improved. We present our survival figures from 2006 to 2014. <h3>Method</h3> A prospective database is used to record all patients who undergo small intestine (SB), liver/small intestine (LSB), modified multivisceral (MMVT – intestine and stomach) and multivisceral (MVT – intestine, stomach and liver) transplantation at Addenbrooke’s Hospital. All grafts may also contain pancreas, kidney and colon. The NHS Blood and Transplant service derived Kaplan-Meier survival curves for all patients undergoing their first transplant procedure between January 2006 and December 2014. <h3>Results</h3> 56 transplant procedures were performed on 50 patients (6 were re-transplanted, all are still alive). 1-year survival in patients transplanted is 92% (SB), 83% (MMVT), 67% (LSB) and 69% (MVT). 5-year survival is 92% (SB), 63% (MMVT) and 27% (MVT) – this data is not available for LSB transplants due to small numbers and follow-up duration of only 14 m. These data compare favourably with international transplant registry 5-year survival figures of 59% (SB) and 22% (MVT).¹Overall 1-year survival for all patients transplanted in our unit is 76% and 5-year survival is 46%. <h3>Conclusion</h3> Cambridge is one of 2 UK centres performing intestinal transplantation in adults and we are undertaking an increasing number of procedures – 16 in 2013 and 10 in 2014. We are particularly encouraged by our 92% 5-year survival in patients undergoing isolated SB transplantation and would advocate early referral for assessment in patients with Type 3 intestinal failure who develop complications from home parenteral nutrition. Colon is routinely included in the graft to aid fluid balance and does not preclude regular endoscopic surveillance for rejection. We have performed continuity surgery in a number of patients post transplant (transplanted colon to native colon anastomosis) with good outcomes and no anastomotic leaks. Due to complications of the oesophagogastric anastomosis, gastroparesis and increased morbidity and mortality of MVT we are moving towards performing more LSB transplants and will monitor outcomes with interest. Detailed pre-operative assessment, individualised procedures, patient optimisation and an emphasis on the multidisciplinary team are essential when managing these complex patients. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Intestinal Transplant Registry (ITR) – http://www.intestinaltransplant.org/itr/(Accessed May 2014)

Total mechanical stapled oesophagogastric anastomosis on the neck in oesophageal cancer - prevention of postoperative mediastinal complications.

Oesophagogastric anastomosis after oesophagus resection is commonly performed on the neck. Even though a few different techniques of oesophagogastric anastomosis have been previously detailed, both manual and mechanical procedures have been burdened with leakages and strictures. Our simple technique of oesophagogastric anastomosis is a modification of mechanical anastomosis with the use of a circular stapler in order to prevent postoperative leak and concomitant mediastinal complications.Since 2008, we have performed nine oesophagogastric anastomoses following oesophagus resection. The mean age of the operated patients was 54 years. There was no mortality among the operated patients in the early post-operative period. The mean follow-up period for the patients operated on in our department was 17 months until the time of the analysis. None of the patients showed any leakage or stricture, and no mediastinal complications were reported in the group.Following our own experience, mechanical anastomosis with the use of a circular stapler seems to decrease the time of the operation as well as significantly reducing the incidence of leakages from the anastomosis. This type of anastomosis may decrease the number of postoperative strictures and the most dangerous mediastinal infections.

Post Esophagectomy Hiatal Hernia; Expect the Unexpected.

We report a case of a 60-year-old gentleman who underwent transhiatal esophagectomy with gastric pull up and cervical oesophagogastric anastomosis for adenocarcinoma of lower end of oesophagus. The patient was started on jejunostomy feeds on third postoperative day (POD), which was gradually increased to full feeds by seventh POD. On eighth POD, he developed chylothorax and hence jejunostomy feeds were stopped. On tenth POD he developed intestinal obstruction. Chest and abdomen X-ray showed bowel loops in the left thorasic cavity [Table/Fig-1]. He underwent emergency laparotomy and was found to have herniation of transverse colon into left thorasic cavity through the hiatal defect. The contents were reduced and repair of the hiatal defect done. The colon showed congestion but peristalsis was noted. The patient subsequently developed septicaemia and multiorgan dysfunction and succumbed two days later. [Table/Fig-1]: Chest and abdomen X-ray PA showing bowel loops (arrow) in left thorasic cavity Hiatal hernia (HH) is an under-reported and potentially fatal complication, accounting for 0.3 - 4% of esophagectomy cases. It can follow trans thoracic or trans hiatal esophagectomy; may be immediate, early or delayed. The presentation can be myriad, with respiratory distress, intestinal obstruction, strangulation, chest pain or may be asymptomatic. A high index of suspicion is essential for prompt management [1]. Although anastomotic leak and pulmonary complications are known to occur following esophagectomy, HH is uncommon. It most frequently occurs into the left hemithorax. An important predisposing factor is excessive manipulation of the hiatus during surgery or resection of a portion of diaphgram for tumour clearance [2]. Imaging plays a pivotal role in recognition of HH. Chest X-ray confirms the diagnosis by presence of bowel loops in thorasic cavity. Ultrasonography has been shown to be useful, but multislice CT is most sensitive as it gives excellent anatomical details on contents of hernia and its complications such as strangulation [3]. Delayed diagnosis can lead to strangulation and perforation of bowel and high risk of mortality. Repair of HH by re-approximating the diaphragmatic crura and hitching the conduit to diaphragm may be performed. The defect may require repair using mesh prosthesis [4]. It is important to completely mobilize the crura posterior to the conduit, so that hiatus can be closed without tension. Recurrence rate after repair was 29% [5]. To conclude, HH is a rare but preventable complication of oesophageal surgery. For patients with gastrointestinal or pulmonary symptoms, an aggressive management approach should be pursued. Successful management depends on early diagnosis and timely surgical intervention.

Comparison of outcomes following end-to-end hand-sewn and mechanical oesophagogastric anastomosis after oesophagectomy for carcinoma: a prospective randomized controlled trial.

The effects of the use of the stapler or hand-sewn method in oesophagogastric anastomosis on postoperative morbidity, mortality and quality of life after oesophagectomy remain controversial. The purpose of his study was to compare clinical outcomes of hand-sewn and stapler techniques in oesophagogastric anastomosis after oesophagectomy for oesophageal carcinoma. We performed a prospective randomized controlled trial on 478 patients treated for oesophageal tumour between February 2009 and December 2011. Patients were randomly assigned to two treatment groups with 237 patients in the hand-sewn group and 241 patients in the circular stapler group (http://www.chictr.org: ChiCTR-TRC-13004428). The mean follow-up time was 18 months. The mean operating time of the stapled group and the hand-sewn group were 193 and 226 min, respectively (P < 0.001). Seventeen clinical and radiological leakages occurred in the hand-sewn group compared with 7 in the stapler group (P = 0.033). In the stapler group hospital mortality occurred in 10 patients (4.3%) and in the hand-sewn group in 9 patients (3.9%) (P = 0.837). Anastomotic strictures were noted in 31 patients from the stapler group (14.2%) and in 16 patients from the hand-sewn group (7.5%) (P = 0.027). Using the circular stapler method in oesophagogastric anastomoses had a lower anastomotic leakage rate and shorter operating time compared with the hand-sewn method. However, the circular stapler method was associated with a significantly increased risk of anastomotic strictures.

Omentoplasty for oesophagogastrostomy after oesophagectomy.

Oesophagectomy followed by oesophagogastrostomy is the preferred treatment for early-stage oesophageal cancer. It carries the risk of anastomotic leakage after oesophagogastric anastomosis, which causes considerable morbidity and mortality and is one of the most dangerous complications. Omentoplasty has been recommended by some researchers to prevent anastomotic leaks associated with oesophagogastrostomy. However, the value of omentoplasty for oesophagogastrostomy after oesophagectomy has not been systematically reviewed. To assess the effects of omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer. A comprehensive search to identify eligible studies for inclusion was conducted using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed and other reliable resources. Randomised controlled trials comparing omentoplasty versus no omentoplasty for oesophagogastrostomy after oesophagectomy in patients with oesophageal cancer were eligible for inclusion. Two review authors (Yong Yuan and Xiaoxi Zeng) independently assessed the quality of included studies and extracted data; disagreements were resolved through arbitration by another review author. Results of dichotomous outcomes were expressed as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous outcomes were expressed as mean differences (MDs) with 95% CIs. Meta-analysis was performed when available data were sufficiently similar. Subgroup analysis was carried out on the basis of different approaches to surgery. Three randomised controlled trials (633 participants) were included in this updated review. No significant differences in hospital mortality were noted between the study group (with omentoplasty) and the control group (without omentoplasty) (RR 1.28, 95% CI 0.49 to 3.39). None of the included studies reported differences in long-term survival between the two groups. The incidence of postoperative anastomotic leakage was significantly less among study participants treated with omentoplasty than among those treated without (RR 0.25, 95% CI 0.11 to 0.55), but the additional benefit was seen in the subgroup analysis only for participants undergoing a transhiatal oesophagogastrectomy (THE) procedure (RR 0.23, 95% CI 0.07 to 0.79); transthoracic oesophagogastrectomy (TTE) (RR 0.19, 95% CI 0.03 to 1.03); or three-field oesophagectomy (RR 0.33, 95% CI 0.09 to 1.19 ). Omentoplasty did not significantly improve other surgery-related complications, such as anastomotic stricture (RR 0.91, 95% CI 0.33 to 2.57). However, participants treated with omentoplasty could reduce the duration of hospitalisation compared with that seen in the control group (MD -2.13, 95% CI -3.57 to -0.69). Omentoplasty may provide additional benefit in decreasing the incidence of anastomotic leakage after oesophagectomy and oesophagogastrostomy for patients with oesophageal cancer without increasing or decreasing other complications, especially among those treated with THE. It also has the potential to reduce the duration of hospital stay after operation. Further randomised controlled trials are needed to investigate the influences of omentoplasty on the incidence of anastomotic leakage and anastomotic stricture, long-term survival, duration of hospital stay and quality of life after oesophagectomy and oesophagogastrostomy when different surgical approaches are used.

Extending the reach of stapled anastomosis with a prepared OrVil™ device in laparoscopic oesophageal and gastric cancer surgery.

The introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™). We conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications. Seventy-two patients were included in the study. Patient ages ranged from 45 to 92years (median±SD=69±10years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure (n=41; 57%). R 0 resection was achieved in 67 patients (93%). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8%) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique. Despite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction.

Application of Oesophagogastric Cervical Mechanical Anastomosis in Oesophagectomy for Cancer.

We aimed to explore the safety and the feasibility of the application of digestive tract-specific circular anastomats in oesophagogastric cervical anastomosis after oesophagectomy for cancer. We retrospectively analysed the clinical data of 241 patients undergoing oesophagogastric cervical anastomosis using disposable circular staplings after oesophagectomy in the People's Hospital of Henan Province, from August 2009 to July 2012. A total of 240 patients were anastomosed successfully. One patient had a partially torn oesophagus and underwent repair because the wrong stapler size was used. No operative death occurred. Seven patients (2.9%) had postoperative cervical anastomotic leakage but recovered after short-term conservative treatment, and three patients had obvious gastro-oesophageal reflux after eating. No intrathoracic anastomotic leakage or other anastomotic instrument-related complications occurred. During a median follow-up period of 13.8months, no anastomotic stricture was found in each patient. The application of oesophagogastric cervical anastomosis using circular anastomat after oesophagectomy for cancer was safe and feasible.

788 Long-Term Quality of Life After Oesophagectomy for Cancer - Comparison of Cervical Versus Mediastinal Anastomoses

Introduction With improvements in neoadjuvant therapy and earlier diagnosis, long-term survival after oesophagectomy for adenocarcinoma is becoming more frequent. With longer survival the quality of life (QOL) of patients post resection has become a greater priority. There has been extensive debate focusing on the long term effects of different sites for anastomosis. We aimed to examine if post-oesophagectomy QOL is affected by the site of the surgical anastomosis. Methods QORTC C-30 and OG-25 QOL questionnaires were analysed from post-oesophagectomy patients surviving >3 years. Data were available both from a prospective database and questionnaires sent to post-oesophagectomy patients. Surgery was completed by two surgical teams and data were analysed in subsets dependant on the site of oesophago-gastric anastomosis—either thoracic or cervical. No patients underwent formal pyloroplasty. Data were analysed using the Student t test on SPSS statistical software. QORTC C-30 data were compared against the reference tables for oesophageal cancer pre-treatment and a cohort of pre-surgical patients awaiting oesophagectomy. Ethical approval was granted by the local MREC. Results A total of 60 patients responded (82%, anastomosis: thoracic n=29, cervical n=31) with a median time post-surgery of 6.1 years (range 3–12 years). Cervical and thoracic anastomosis subgroups were equivalent in terms of age at time of surgery, time post op and cancer stage. No significant QOL difference was noted between cervical or chest anastomosis groups for any functional or symptom score, especially focusing on dysphagia (OG25, p=0.24), odynophagia (OG 25, p=0.68) and swallowing problems (OG25, p=0.73). The patients9 overall general health (QL2) score was 72.0±19.43 (mean±SD) compared with 74.8±20.57 for a cohort of 53 NNUH pre-op oesophagectomy patients and 71.2±22.4 for the QORTC general population reference data. Functional indices and symptom scores are improved for our cohort compared to the QORTC oesophageal cancer reference baseline except symptom scores for diarrhoea and dyspnoea which worsen post-operatively. Conclusion There is no significant difference in QOL scores between oesophagectomy patients with cervical or thoracic anastomosis at >3 years post-surgery when analysed using the QORTC C-30 and OG25 questionnaires. QOL in long-term survivors after oesophagectomy compares favourably with QORTC reference data for both pre-treatment oesophageal cancer and baseline general population data in our cohort, possibly due to the absence of pylorplasty. Further prospective QOL data collection is required to elucidate any long-term differences between the two anastomosis sites. Competing interests None declared.

Omentoplasty in preventing anastomotic leakage of oesophagogastrostomy following radical oesophagectomy with three-field lymphadenectomy

Anastomotic leakage is a major cause of mortality in oesophageal surgery. Whether omentoplasty after oesophagogastrostomy could reduce anastomotic leakage is still controversial. The aim of this study is to investigate the function of omentoplasty to reinforce cervical oesophagogastrostomy after radical oesophagectomy with three-field lymphadenectomy. A total of 184 patients who underwent radical oesophagectomy with three-field lymphadenectomy took part in this prospective study. Patients were randomized to receive either the omentoplasty or non-omentoplasty. In the omentoplasty group, the omentum was wrapped around the oesophagogastric anastomosis after oesophagogastrostomy. Age, gender, location of carcinoma, stage, body mass index, diabetes, coronary artery disease, peripheral vascular disease and performance of omentoplasty were recorded. The anastomotic leakage and stricture and recurrence site were followed up for three years after the operation. The two groups were comparable in terms of age, gender, location of carcinoma, stage, body mass index, diabetes, coronary artery disease and peripheral vascular disease (P > 0.05). In contrast to the non-omentoplasty group with a postoperative anastomotic leakage rate of 9.8%, the omentoplasty subjects demonstrated a significantly lower rate of 3.3% (P < 0.05). No lethal leakage was found in the omentoplasty group, while two non-omentoplasty patients developed incurable empyema and mediastinitis due to leakage and ultimately died. The rate of incidence of anastomotic stricture in the omentoplasty and non-omentoplasty groups were 4.3% and 2.2% respectively. Of the five cases of death during the hospital stay, two were found in the omentoplasty group and three in non-omentoplasty. There was no significant difference of lethal leakage, stricture and death rate between the two groups (P > 0.05). The hospital stay was significantly longer for non-omentoplasty patients, compared with that for the omentoplasty subjects (P < 0.05). Tumour recurrence in lymphatic- or haematogenous metastasis was similar in both groups (P > 0.05). Omentoplasty may prevent anastomotic leakage of oesophagogastrostomy following radical oesophagectomy with three-field lymphadenectomy.

PTU-187 Long-term quality of life after oesophagectomy for cancer: comparison of cervical vs mediastinal anastomoses

IntroductionWith improvements in neoadjuvant therapy and earlier diagnosis, long-term survival after oesophagectomy for adenocarcinoma is becoming more frequent. With longer survival the quality of life (QOL) of patients post resection...

Long‐term Outcomes of Extended Proximal Gastrectomy for Oesophagogastric Junctional Tumours

There is no consensus on the optimum approach for resection of oesophagogastric junctional (OGJ) tumours. We prospectively evaluated the efficacy of transabdominal radical extended proximal gastrectomy with oesophagogastric anastomosis (EPGOG) for selected tumours of the OGJ. Between 1998 and 2007, 66 selected consecutive patients with tumours of the OGJ underwent successful EPGOG. Selection was limited to tumours where the maximal proximal extent was 36 cm ab oral. Pre-, peri-, and postoperative outcomes together with long-term survival data for these patients were prospectively collected. Median theatre time was 242 min (range = 120-480), with a median blood loss of 300 ml (range = 50-1720). Eighty-nine percent of patients were extubated in theatre; major complications occurred in 9 (14%) patients, with an overall in-hospital mortality rate of 8%. Thirty-five (53%) patients had nodal disease and the median lymph node yield was 13 (range = 4-36), with an R0 resection rate of 80%. In terms of long-term outcomes, the 2- and 5-year actuarial survival rates were 54 ± 6% and 41 ± 6%. Extended radical proximal gastrectomy with oesophagogastric anastomosis for selected junctional tumours is a feasible technique which does not compromise oncological principles as evidenced by an excellent long-term survival rate.

Oesophagogastric anastomosis complications in the Ivor Lewis operation

IntroductionOesophagectomy is the principal treatment for cancer of the oesophagus. The oesophagogastric anastomotic leak is a serious complication of the Ivor Lewis operation, and is associated with increased mortality. The objective of this study is to analyse its incidence, its diagnosis and treatment results. Material and methodsA descriptive analysis of a consecutive series of oesophagectomies, carried out during a 5 year period, using the Ivor Lewis technique. All patients had hand sewn anastomosis. Data were collected on general morbidity, anastomosis leak, hospital mortality, survival, and stenosis of the anastomosis. ResultsA total of 41 intrathoracic anastomoses were performed. Complications, of any type, were observed in 49% of cases, of which 3 (7.3%) were anastomotic leaks, one of them asymptomatic. One patient was urgently reoperated, and two others were treated with drains and conservative treatment. The mortality of the series was 7.3%, none associated with the anastomotic leak. The survival at 5 years was 27%, and 34% of the patients developed stenosis of the anastomosis. ConclusionsIntrathoracic anastomosis after oesophagectomy, in our experience, can be performed with a low incidence of anastomotic leaks and without mortality due to this cause. Their treatment must be individualised and a considerable proportion do not require surgical intervention.

A safe and reproducible anastomotic technique for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with the trans-oral anvil

In expert hands, the intrathoracic oesophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardised 25 mm/4.8mm circular-stapled anastomosis using a trans-orally placed anvil. We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis oesophagectomy at a tertiary referral centre. The oesophago-gastric anastomosis was created using a 25-mm anvil (Orvil, Autosuture, Norwalk, CT, USA) passed trans-orally, in a tilted position, and connected to a 90-cm long polyvinyl chloride delivery tube through an opening in the oesophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (end-to-end anastomosis stapler (EEA XL) 25 mm with 4.8-mm staples, Autosuture, Norwalk, CT, USA) inserted into the gastric conduit. Primary outcomes were leak and stricture rates. Thirty-seven patients (mean age 65 years) with distal oesophageal adenocarcinoma (n=29), squamous cell cancer (n=5) or high-grade dysplasia in Barrett's oesophagus (n=3) underwent an Ivor Lewis oesophagectomy between October 2007 and August 2009. The abdominal portion was operated laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle-sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis. The circular-stapled anastomosis with the trans-oral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis oesophagectomy.

Comparison of Anastomotic Leakage and Stricture Formation following Layered and Stapler Oesophagogastric Anastomosis for Cancer: A Prospective Randomized Controlled Trial

The objective of this prospective, randomized, controlled trial, conducted from May 2002 to December 2007, was to compare post-operative anastomotic leakage and stricture formation following layered manual versus stapler oesophagogastric anastomosis in patients who underwent resection of oesophageal or gastric cardia carcinoma. Patients (n = 516) were randomized to receive either layered manual or circular stapled oesophagogastric anastomosis. Mean follow-up time was > 12 months. Anastomotic leakage occurred in one (0.4%) patient in the layered group and six (2.2%) in the stapler group; no statistically significant between-group difference. After operation, two (0.8%) patients in the layered group and 13 (5.0%) in the stapler group developed a benign oesophageal stricture; the difference between the groups was statistically significant. Compared with stapler anastomosis, layered manual anastomosis may significantly reduce the incidence of anastomotic strictures. This method is easy to apply and could be used as an alternative procedure for oesophagogastric anastomosis after resection for oesophageal or cardia carcinoma.