Patients Undergoing Ivor Lewis Esophagectomy Research Articles

Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2)

BackgroundManagement of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. MethodsPatients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. ResultsA total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. ConclusionThe incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Hybrid Minimally Invasive Esophagectomy vs. Open Esophagectomy: A Retrospective Propensity Score Matched Comparison.

Background and Objectives: Though widely used, only limited data is available that shows the superiority of hybrid minimally-invasive esophagectomy (HMIE) compared to open esophagectomy (OE). The present study aimed to analyze postoperative morbidity, mortality, and compare lengths of hospital stay. Materials and Methods: A total of 174 patients underwent Ivor Lewis esophagectomy in our surgical department, of which we retrospectively created a matched population of one hundred (HMIE n = 50, OE n = 50). Morbidity and mortality data was categorized, analyzed, and risk factor analyzed for complications. Results: The oncological results were found to be comparable in both groups. A median of 23.5 lymphnodes were harvested during OE, and 21.0 during HMIE. Negative tumor margins were achieved in 98% of OE and 100% of HMIE. In-hospital mortality rate showed no significant difference between techniques (OE 14.0%, HMIE 4.0%, p = 0.160). Hospital (OE Median 23.00 days, HMIE 16.50 days, p = 0.004) and ICU stay (OE 5.50 days, HMIE 3.00 days, p = 0.003) was significantly shorter after HMIE. The overall complication rate was 50%, but complications in general (OE 70.00%, HMIE 30%, p < 0.001) as well as severe complications (Clavien Dindo ≥ III: HMIE 16.0%, OE 48.0%, p < 0.001) were significantly more common after OE. In multivariate stepwise regressions the influence of OE proved to be independent for said outcomes. We observed more pulmonary complications in the OE group (46%) compared to HMIE patients (26%). This difference was statistically significant after adjustment for sex, age, BMI, ASA classification, histology, neoadjuvant treatment or not, smoking status, cardiac comorbidities, diabetes mellitus, and alcohol abuse (p = 0.019). Conclusions: HMIE is a feasible technique that significantly decreases morbidity, while ensuring equivalently good oncological resection compared to OE. HMIE should be performed whenever applicable for patients and surgeons.

421. THE STAPLED ANASTOMOSIS IN ESOPHAGECTOMY: NO DIFFERENCES IN LEAKAGE AND STRICTURE-RATES BETWEEN THE 25 MM AND 28 MM CIRCULAR STAPLER

Abstract For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and post- operative anastomotic strictures. Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. In 222 patients (64%), the 25 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

390. ACUTE NUTRITIONAL AND FUNCTIONAL STATUS CHANGES IN PATIENTS UNDERGOING ESOPHAGECTOMY FOR CANCER

Abstract Nutritional status of esophageal cancer patients who undergo esophagectomy is significantly exacerbated postoperatively. The aim of this study is to investigate changes in nutritional status and muscle function between preoperative period and the time of hospital discharge in cancer patients undergoing esophagectomy. The study sample consisted of 70 patients with esophageal (n = 13) and gastroesophageal junction cancer (n = 57) who were admitted for surgery in our Department between September 2015 and February 2020. Out of them, 52 patients underwent Ivor-Lewis esophagectomy, while 18 patients underwent McKewon esophagectomy. The preoperative evaluation of nutritional status was based on Patient Generated Subjective Global Assessment (PG-SGA), while the preoperative assessment of muscle function was based on Handgrip Strength (HG). Weight loss and anthropometric measurements were also recorded. Patients’ follow-up was done at the time of hospital discharge. Patients’ mean length of stay was 17.7 ± 12.5 days. Mean postoperative involuntary weight loss was 6% ± 3%. HG dominant hand was significantly lower at the time of discharge (−3.02 ± 3.80 kg, p &amp;lt; 0.001) compared to preoperative levels. Moreover, a significant change was observed for PG-SGA score (+2.61 ± 1.73) indicating greater rates of impaired nutritional status. There was a significant reduction in BMI (−3.7 ± 2.47 kg/m2, p &amp;lt; 0.001) and in arm circumference values (−0.8 ± 0.03 cm, p &amp;lt; 0.05), whereas no statistically significant alterations were observed in triceps skinfold measurements postoperatively (−0.007 ± 0.49, p = 0.368). Esophageal cancer patients who undergo esophagectomy exhibit overt deterioration of nutritional and functional status during the postoperative course. Timely nutritional interventions are of great significance in order to avoid patients underfeeding and improve patients’ postoperative outcome.

Short-term outcome of Ivor Lewis esophagectomy following neoadjuvant chemoradiation versus perioperative chemotherapy in patients with locally advanced adenocarcinoma of the esophagus and gastroesophageal junction: a propensity score-matched analysis

BackgroundPatients with locally advanced esophageal or gastroesophageal adenocarcinoma benefit from multimodal therapy concepts including neoadjuvant chemoradiation (nCRT), respectively, perioperative chemotherapy (pCT). However, it remains unclear which treatment is superior concerning postoperative morbidity.MethodsIn this study, we compared the postsurgical survival (30-day/90-day/1-year mortality) (primary endpoint), treatment response, and surgical complications (secondary endpoints) of patients who either received nCRT (CROSS protocol) or pCT (FLOT protocol) due to esophageal/gastroesophageal adenocarcinoma. Between January 2013 and December 2017, 873 patients underwent Ivor Lewis esophagectomy in our high-volume center. 339 patients received nCRT and 97 underwent pCT. After 1:1 propensity score matching (matching criteria: sex, age, BMI, ASA score, and Charlson score), 97 patients per subgroup were included for analysis.ResultsAfter matching, tumor response (ypT/ypN) did not differ significantly between nCRT and pCT (p = 0.118, respectively, p = 0.174). Residual nodal metastasis occurred more often after pCT (p = 0.001). Postsurgical mortality was comparable within both groups. No patient died within 30 or 90 days after surgery while the 1-year survival rate was 72.2% for nCRT and 68.0% for pCT (p = 0.47). Only grade 3a complications according to Clavien–Dindo were increased after pCT (p = 0.04). There was a trend towards a higher rate of pylorospasm within the pCT group (nCRT: 23.7% versus pCT: 37.1%) (p = 0.061). Multivariate analysis identified pCT, younger age, and Charlson score as independent variables for pylorospasm.ConclusionBoth nCRT and pCT are safe and efficient within the multimodal treatment of esophageal/gastroesophageal adenocarcinoma. We did not observe differences in postoperative morbidity. However, functional aspects such as gastric emptying might be more frequent after pCT.

The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler

BackgroundFor patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures. MethodsBetween February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. ResultsIn 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). ConclusionThere were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

Selective Decontamination of the Digestive Tract to Prevent Postoperative Pneumonia and Anastomotic Leakage after Esophagectomy: A Retrospective Cohort Study

Infectious complications occur frequently after esophagectomy. Selective decontamination of the digestive tract (SDD) has been shown to reduce postoperative infections and anastomotic leakage in gastrointestinal surgery, but robust evidence for esophageal surgery is lacking. The aim was to evaluate the association between SDD and pneumonia, surgical-site infections (SSIs), anastomotic leakage, and 1-year mortality after esophagectomy. A retrospective cohort study was conducted in patients undergoing Ivor Lewis esophagectomy in four Dutch hospitals between 2012 and 2018. Two hospitals used SDD perioperatively and two did not. SDD consisted of an oral paste and suspension (containing amphotericin B, colistin, and tobramycin). The primary outcomes were 30-day postoperative pneumonia and SSIs. Secondary outcomes were anastomotic leakage and 1-year mortality. Logistic regression analyses were performed to determine the association between SDD and the relevant outcomes (odds ratio (OR)). A total of 496 patients were included, of whom 179 received SDD perioperatively and the other 317 patients did not receive SDD. Patients who received SDD were less likely to develop postoperative pneumonia (20.1% vs. 36.9%, p < 0.001) and anastomotic leakage (10.6% vs. 19.9%, p = 0.008). Multivariate analysis showed that SDD is an independent protective factor for postoperative pneumonia (OR 0.40, 95% CI 0.23–0.67, p < 0.001) and anastomotic leakage (OR 0.46, 95% CI 0.26–0.84, p = 0.011). Use of perioperative SDD seems to be associated with a lower risk of pneumonia and anastomotic leakage after 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.

Does Circular Stapler Size in Surgical Management of Esophageal Cancer Affect Anastomotic Leak Rate? 4-Year Experience of a European High-Volume Center.

Simple SummaryOne of the most severe postoperative complications after a transthoracic esophagectomy for esophageal cancer is a leakage of the anastomosis created between the remnant esophagus and the stomach. There is substantial debate on which surgical technique and which stapler are the best. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively. Stapler size should be chosen according to the individual anatomical situation of the patient and may be of higher relevance in patients undergoing totally minimally invasive reconstruction.Anastomotic leak is one of the most severe postoperative complications and is therefore considered a benchmark for the quality of surgery for esophageal cancer. There is substantial debate on which anastomotic technique is the best for patients undergoing Ivor Lewis esophagectomy. Our standardized technique is a circular stapled anastomosis with either a 25 or 28 mm anvil. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively (p = 0.0925). Stapler size should be chosen according to the individual anatomical situation of the patient. Stapler size may be of higher relevance in patients undergoing totally minimally invasive reconstruction.

Effectiveness of jejunostomy for enteral nutrition during complete thoracoscopic and laparoscopic Ivor-Lewis esophagectomy in thoracic segment esophageal carcinoma

BackgroundAlthough jejunostomy is widely used in complete thoracoscopic and laparoscopic minimally invasive Ivor-Lewis esophagectomy, its clinical effectiveness remains undefined. This study aimed to assess the therapeutic and side effects of jejunostomy in patients undergoing Ivor-Lewis esophagectomy for thoracic segment esophageal carcinoma.MethodsA total of 1400 patients with esophageal carcinoma who underwent minimally invasive esophagectomy in the Thoracic Surgery of our hospital from 2015 to 2018 were retrospectively evaluated. Of these, 356 and 1044 were treated with nasojejunal feeding tubes (Nasojejunal group) and by jejunostomy (Jejunostomy group), respectively. Clinicopathologic factors, postoperative complications and tubule-related complications between the two groups were compared.ResultsBoth groups were well-balanced for clinicopathological data, except tumor location, which was significantly different (P < 0.001). Operation time (208.8 ± 53.5 min vs. 218.1 ± 43.2 min) was shorter in the Jejunostomy group compared with the Nasojejunal group, while intraoperative (26.6 ± 10.4 min vs 18.4 ± 9.1 min) and postoperative (38.6 ± 6.9 min vs 18.5 ± 7.6 min) indwelling times of nutrition tubes were prolonged (all P < 0.05). Postoperative pulmonary infection (17.0% vs 22.2%), incision infection (0.2% vs 1.1%), nutrient tube slippage (0.2% vs 5.1%) and nutrient reflux 1 (0.1% vs 5.6%) rates were reduced in the Jejunostomy group compared with the Nasojejunal group (P < 0.05). Meanwhile, ileus rates perioperatively (1.7% vs 0.3%) and at 3 postoperative months (1.7% vs 0.3%) were both higher in the Jejunostomy group compared with the Nasojejunal group.ConclusionsJejunostomy is a reliable enteral nutrition method in Ivor-Lewis esophagectomy for thoracic segment esophageal carcinoma.

A prospective trial of intraoperative tissue oxygenation measurement and its association with anastomotic leak rate after Ivor Lewis esophagectomy.

BackgroundAnastomotic leak following Ivor Lewis esophagectomy is associated with increased morbidity/mortality and decreased survival. Tissue oxygenation at the anastomotic site may influence anastomotic leak. Methods for establishing tissue oxygenation at the anastomotic site are lacking.MethodsOver a 2-year study period, 185 Ivor Lewis esophagectomies were performed. Study participants underwent measurement of gastric conduit tissue oxygenation at the planned anastomotic site using the wireless pulse oximetry device. Associations between anastomotic leaks or strictures and tissue oxygenation levels were analyzed using Wilcoxon rank sum test or Fisher’s exact test.ResultsAmong study participants (n=114), median gastric conduit tissue oxygenation level was 92% (range, 62–100%). There were 8 (7.0%) anastomotic leaks and 3 (2.6%) strictures. Analysis of tissue oxygenation as a continuous variable showed no difference in median tissue oxygenation in patients with and without leaks (98% and 92%; P=0.2) and stricture formation (89% and 92%; P=0.6). Analysis of tissue oxygenation as a dichotomous variable found no difference in anastomotic leak rates [7.5% (n=93) in >80% vs. 0% (n=20) in ≤80%; P=0.3]. There were no significant differences in leak rates in concurrent study nonparticipants.ConclusionsNo significant association was observed between intraoperative tissue oxygenation at the anastomotic site and subsequent anastomotic leak or stricture formation among patients undergoing Ivor Lewis esophagectomy.

Comparison of the surgical outcomes of McKeown minimally invasive esophagectomy and Ivor-Lewis esophagectomy for the treatment of middle esophageal cancer: A single-center retrospective study

BackgroundIn China, the esophageal cancer is the most common tumor type, and the main treatment is still surgical treatment. Over the past decade, thoracic laparoscopy combined with esophageal cancer resection and neck anastomosis---McKeown minimally invasive esophagectomy (MIE) has gained interest and known as a minimally invasive surgery for the middle esophageal cancer. However, the safety and operability of McKeown MIE remains to be confirmed clinically. The purpose of this article is to examine the clinical safety and operability of McKeown MIE, and compare the security and outcomes of McKeown MIE and Ivor-Lewis esophagectomy. Materials and methodsThe clinical data of 312 patients with middle esophageal cancer in Sir Run Run Shaw Hospital from January 2013 to December 2018 were retrospectively analyzed. Among them, 176 patients underwent Ivor-Lewis esophagectomy and 136 patients underwent McKeown MIE. Patients' demographics and perioperative outcomes were comparable between the two groups. ResultsThere were no significant differences in terms of operative time, postoperative hospital stay, restore fluid diet time, pathology, tumor node metastasis staging between the two groups. In the McKeown MIE group, the intraoperative blood loss was less than that in the Ivor-Lewis group (116.54 ± 80.99 ml vs 152.78 ± 115.35 ml, p = 0.001). The total number of lymph nodes and the number of lymph nodes dissection in bilateral recurrent laryngeal nerves were more than those in the Ivor-Lewis group (30.04 ± 14.08 vs 27.51 ± 11.34, p = 0.039; 5.74 ± 4.27 vs 1.80 ± 2.68, p < 0.001). There were no significant differences in the incidence of complications. The overall survival for the McKeown MIE group was higher than the Ivor-Lewis group (p = 0.013) and no significant difference was found on disease-free survival. ConclusionMcKeown MIE is safe and operational for middle esophageal cancer, which is consistent with the principle of tumor radicalization.

P141 IVOR LEWIS MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER : IMPACT OF THORACOSCOPY ON POST-OPERATIVE MORBIDITY

Abstract The aim of this study is to assess the impact of thoracoscopy versus conventional thoracotomy on postoperative and oncological outcomes in patients undergoing Ivor Lewis esophagectomy with laparoscopic gastric mobilisation for esophageal resectable cancer. Background &amp; Methods Esophagectomy for cancer is a complexe procedure associated with a high rate of mortality and morbidity1,2, especially respiratory, despite recent improvements in perioperative cares and advances in surgical techniques. Recently, minimally invasive esophagectomy has shown a benefit in decreasing postoperative respiratory complications in 2 randomized trials comparing firstly the hybrid approach (Ivor Lewis with laparoscopy and right thoracotomy) to the open approach (MIRO trial3) and secondly the totally minimally invasive approach with cervical anastomosis (McKeown with laparoscopy and thoracospy) to the open approach (TIME trial4). Few studies have focused on comparing specifically thoracosopic(TMIE) versus conventional thoracotomy approach(HYBRID) for intra-thoracic anastomosis. We performed a single-center retrospective study, including all patients undergoing either Ivor Lewis HYBRID or TMIE in our high-volume center between 2010 and 2019. The primary endpoint was major postoperative complications within 30 days (Dindo-Clavien grade≥III). Secondary endpoints included operative parameters, postoperative morbidity and mortality within 90 days and quality of oncological resection. Results 498 patients were included, 440 underwent HYBRID and 58 TMIE. Ninety-six patients(19.3%) had major postoperative complication, 11 patients(19%) in TMIE and 85 patients(19.3%) in HYBRID. Anastomotic leak (AL) rate was significantly higher in TMIE (36.2% versus 10.8%,p&lt;0.001). However AL in TMIE group were frequently less severe than in the HYBRID group (rate of AL type 2/3 respectively 23.8% and 50%;p=0.044). Respiratory complications were observed in 202 patients (45.9%) in the HYBRID group and in 14 patients (24.1%;p=0.002) in TMIE group, without significant difference in severe respiratory complications rate. The complete resection rate (R0 resection) (5.3% vs 3.7%) and the number of lymph nodes retrieved (25.26 vs 25.92) were comparable in both groups. Conclusion The TMIE approach is burdened with a significant AL rate, probably related to an unreached learning curve, which mitigates the benefit of this approach to respiratory complications. The technical difficulty caused by intrathoracic anastomosis, whose modalities are not well-established, remains a major concern.

P101 THE IMPACT OF PARATRACHEAL LYMPHADENECTOMY ON LYMPH NODE YIELD AND SHORT-TERM OUTCOMES IN ESOPHAGECTOMY: A NATIONAL PROPENSITY SCORE MATCHED ANALYSIS

Abstract Aim This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients undergoing esophagectomy for cancer. Background &amp; Methods Although the addition of paratracheal lymphadenectomy to a standard two-field lymphadenectomy possibly may provide survival benefits for patients undergoing esophagectomy for esophageal cancer, the required dissection along the recurrent laryngeal nerves might be associated with increased morbidity. To investigate the impact of paratracheal lymphadenectomy on short-term oncological outcomes and postoperative complications, this nation-wide population-based cohort study included esophageal cancer patients who underwent neoadjuvant chemoradiotherapy followed by elective transthoracic esophagectomy with at least subcarinal and para-esophageal lymphadenectomy from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, the lymph node yield and clinical outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not. Results Between 2011-2017, a total of 2128 patients were included. A total of 770 patients (n=385 vs. n=385) and 516 patients (n=258 vs. n=258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher total lymph node yield in both Ivor Lewis (23 vs. 19 nodes, P&lt;0.001) and McKeown (21 vs. 19 nodes, P=0.015) esophagectomy. In McKeown esophagectomy, paratracheal lymphadenectomy was associated with significantly more advanced pathological nodal staging (pN0; 57% vs. 69%, pN1; 25% vs. 16%, pN2; 12% vs. 11%, pN3; 6% vs. 3%, P=0.006). No significant differences were observed regarding recurrent laryngeal nerve injury, other postoperative complications, and mortality, although a higher re-intervention rate was found after paratracheal lymphadenectomy during McKeown esophagectomy (30% vs. 18%, P=0.002) In patients undergoing Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with increased length of stay (12 vs. 11 days, P&lt;0.048). Conclusion In patients undergoing transthoracic esophagectomy for cancer, the addition of paratracheal lymphadenectomy results in a higher lymph node yield with comparable complication and mortality rates.

PS02.152: DEVELOPMENT OF INTESTINAL PNEUMATOSIS AND PORTAL VENOUS GAS AFTER ESOPHAGECTOMY IS NOT INDICATIVE OF ISCHEMIC BOWEL AND CAN BE SUCCESSFULLY MANAGED NON-OPERATIVELY

Abstract Background Pneumatosis intestinalis has long been a marker of advanced bowel ischemia and prompts urgent laparotomy. In post-operative settings, the presence of pneumatosis represents a significant management dilemma. We share a case-series of post-esophagectomy patients with pneumatosis intestinalis and no corollary intra-abdominal pathologic findings on re-exploration. Methods January 2000 to December 2017, 1760 patients underwent Ivor-Lewis esophagectomy or gastrectomy with jejunostomy-tube placement. Charts were reviewed retrospectively to identify patients with pneumatosis intestinalis discovered in the post-operative period. Demographic data, operative details and postoperative course were reviewed including incidence and details of re-exploration. Results Eleven patients met inclusion criteria. Nine were male (81.8%) and mean age was 69 years. All patients had radiographic confirmation of pneumatosis intestinalis and in many cases portal venous gas (Figure 1). Clinical course was variable without discernable trends in vitals or laboratory values. Development of significant postoperative ileus along with delivery of enteral tube feeds through a jejunostomy tube preceded development of the pneumatosis in all patients. Nine patients were re-explored and none had evidence of bowel ischemia. Conclusion The finding of pneumatosis intestinalis in the post-operative setting can be alarming and pose a management dilemma. With the advent of improved and readily available imaging, there has been an increase in findings that have no corollary physical symptomatology. In this series of patients, despite dramatic radiographic findings, none had ischemic bowel. Pneumatosis intestinalis alone in patients who have undergone esophagectomy should not be considered an indication for emergency re-exploration. Disclosure All authors have declared no conflicts of interest.

Longitudinal study of esophageal mucosal damage after esophagectomy and gastric interposition: relationship between reflux-related mucosal injury and Notch signaling.

Esophagectomy with gastric interposition could serve as a good human reflux model to study the molecular pathogenesis of esophageal mucosal damage induced by gastroesophageal reflux. This study was to investigate the role of Notch signaling in reflux injury of esophageal mucosa. Patients undergoing Ivor-Lewis esophagectomy for early stage esophageal squamous cell carcinoma were included. Follow-ups were scheduled at 6, 18, 36 and 48 months postoperatively, including reflux symptom assessment, endoscopic and histological evaluation of esophageal mucosal damage. The expressions of Notch1 and its downstream target gene Hes1 were evaluated by real-time polymerase chain reaction (PCR) and immunohistochemistry (IHC). Forty-four out of 48 patients completed four follow-ups. Injuries of esophageal remnant confirmed by endoscopical and histological examinations were both more often with a longer postoperative period (P<0.05). The mRNA expression levels of Notch1 and Hes1 were decreased in a time-dependent manner after operation (P<0.001). Notch1 and Hes1 mRNA levels were significantly higher in normal squamous mucosa than in esophagitis, and higher in esophagitis than in metaplasia (P<0.05). Immunohistochemical study also demonstrated a similar protein expression pattern. Samples with endoscopic evidence of mucosal damage exhibited lower expression of Notch1 mRNA levels as compared to biopsies without visualized damage (P=0.035). This is the first longitudinal study on Notch signaling in human esophagectomy model, our preliminary findings suggest decreased Notch signaling might be involved in the development of mucosa damage caused by gastroesophageal reflux.

Evaluation of the surgical apgar score in patients undergoing Ivor-Lewis esophagectomy.

The Surgical Apgar Score is a simple outcome score based on intraoperative parameters. The scoring system is recently validated in patients undergoing esophagectomy but without comparable results. This study evaluated the ability of the original and modified Surgical Apgar Scores to predict major complications in a patient population undergoing Ivor-Lewis esophagectomy. We retrospectively examined 234 patients who successfully underwent Ivor-Lewis esophagectomy at Rigshospitalet, Copenhagen from November 23, 2011 till November 23, 2014. Major complications were defined as Clavien-Dindo grade IIIa or higher within 30 days after surgery. Univariate and multivariate analyses were performed to assess factors associated with major complications. Receiver operating characteristics were performed for determination of the predictive value of the Surgical Apgar Score scoring systems. There were 64 (27.4%) patients with at least one major complication and 4 (1.7%) deaths. The original and modified versions of the Surgical Apgar Score were not associated with major complications and the scoring systems showed no significant predictive value when receiver operating characteristics were performed. The original or modified versions of the Surgical Apgar Score could possibly be useful in some subgroups of esophagectomy patients, but should not be considered to have a general predictive value. J. Surg. Oncol. 2017;115:186-191. © 2017 Wiley Periodicals, Inc.

Simple Technique of Circular Stapled Anastomosis in Ivor Lewis Esophagectomy.

Advent of minimally-invasive esophagectomy necessitated the incorporation of stapled anastomotic techniques especially for intrathoracic anastomosis. We present our approach to the Ivor Lewis esophagectomy highlighting a simple modification in the anastomotic technique and review our experience with anastomotic outcomes. With IRB approval, patients who underwent Ivor Lewis esophagectomy with circular-stapled end-to-end anastomosis (EEA) were identified, divided into three equal sequential cohorts (A, B, and C), and compared for perioperative outcome. Cohorts were divided in a chronological order to have equal number of patients in each group. Seventy-five patients underwent Ivor Lewis esophagectomy with circular stapled (EEA-25/28) anastomosis. Group A had longer median postoperative hospital stay and median postoperative ICU stay compared to Groups B and C. Ten patients (13%) had anastomotic leak-one patient required redo-anastomosis and other patients were managed with endoscopic interventions. There was significant decrease in rate of anastomotic leak with experience (8 versus 1 versus 1, P = .004). There were two perioperative deaths, one each in Groups A and C, including one death due to anastomotic leak (Group A). Use of simple modifications to stapled EEA, as described here, has led to decrease in anastomotic leaks following Ivor Lewis esophagectomy.

Management of Tracheo- or Bronchoesophageal Fistula After Ivor-Lewis Esophagectomy.

The development of tracheo- or bronchoesophageal fistula (TBF) after Ivor-Lewis esophagectomy remains to be a rare complication associated with a high mortality rate. In this retrospective study, the charts of patients with TBF after esophagectomy were analyzed in terms of individual patient characteristics, esophagotracheal complications, respiratory function, management, and outcome. Between January 2000 and December 2014, 1204 patients underwent Ivor-Lewis esophagectomy for esophageal cancer; 13 patients (1.1%) developed a TBF. In all 13 patients, a concomitant leakage of the intrathoracic esophagogastrostomy was evident, either prior to diagnosis of TBF (metachronous TBF) or simultaneously (synchronous TBF). TBF was predominantly located in the left main bronchus (n=6, 46.1%) or trachea (n=5, 38.5%). Management of TBF included re-thoracotomy (n=7), interventional endoscopic (n=10) or bronchoscopic therapy (n=4). In the majority of patients (n=8), management consisted of two subsequent treatment modalities. In 3 out of four patients, TBF was successfully treated by endoscopic stenting only. Five patients (38.5%) died following a septic course with multiple organ failure. The development of TBF after Ivor-Lewis esophagectomy is always combined with anastomotic leakage of the esophagogastrostomy. Treatment options primarily depend on the vascularization of the gastric conduit, the severity of the concomitant aspiration pneumonia, and the volume of the air leakage.

Preoperative airway colonization prior to transthoracic esophagectomy predicts postoperative pulmonary complications.

Respiratory complications are responsible to a high degree for postoperative morbidity and mortality after Ivor-Lewis esophagectomy. The etiology of respiratory failure is known to be multifactorial with preoperative impaired lung function being the most important one. The aim of this study was to investigate the correlation between preoperative airway colonization (PAC) and postoperative respiratory complications. In this observational study, 64 patients with esophageal cancer were included. All patients underwent Ivor-Lewis esophagectomy with laparoscopic or open gastric mobilization. After induction of anesthesia and intubation with a double-lumen tube, bronchial exudate was collected by random endoluminal suction for further microbiological work-up. Length of postoperative mechanical ventilation (<24h, 24-72h, >72h), re-intubation, and tracheostomy were recorded as primary and secondary study endpoints. In 13 of 64 study patients (20.3%), pathological colonization of the bronchial airways could be proved prior to esophagectomy. Haemophilus species was the most frequently identified pathogen. PAC was associated with a longer history of smoking (p = 0.025), a lower preoperative forced expiratory volume (FEV1, p = 0.009) or vital capacity (VC, p = 0.038), a prolonged postoperative mechanical ventilation (p < 0.001), and a higher frequency of re-intubation (p < 0.001) and tracheostomy (p = 0.017). In the multivariate analysis, PAC was identified as an independent predictor of respiratory failure (hazard ratio 11.4, 95% confidence interval 2.6-54, p = 0.002). Mortality in the PAC group was 30.8% compared to 0% in patients without PAC (p < 0.0001). PAC is a significant risk factor for postoperative respiratory failure. A routine bronchoscopy and bronchoalveolar lavage as part of preoperative management prior to esophagectomy need to be discussed.