Risk Factors For Anastomotic Stricture Research Articles

Waiting for bile duct dilation before repair of bile duct injury: a worthwhile strategy?

Hepaticojejunostomy (HJ) is the gold standard procedure for repairing major bile duct injury (BDI). Dilation status of the BD before repair has not been assessed as a risk factor for anastomotic stricture. This retrospective single-centre study was performed on a population of 87 patients with BDI repaired by HJ between 2007 and 2021. Dilation status was assessed preoperatively, and dilation was defined as the presence of visible peripheral intrahepatic BDs with remaining BD diameter > 8mm. The short- and long-term outcomes of HJ were assessed according to preoperative dilation status. Before final repair, the BDs were dilated (dBD) in 56.3% of patients and not dilated (ND) in 43.7%. Patients with ND at the time of repair had more severe BDI injury than those with dBD (94.7% vs. 77.6%, p = 0.026). The rate of preoperative cholangitis was lower in patients with ND than in those with dBD (10.5% vs. 44.9%, p = 0.001). The rate of short-term morbidity after HJ was 33.3% (ND vs. dBD: 38.8% vs. 26.3%, p = 0.32). Long-term anastomotic stricture rate was 5.7% with a mean follow-up period of 61.3months. There were no differences in long-term biliary complications according to dilation status (ND vs. dBD: 12.2% vs. 10.5%, p = 1). Dilation status of the BD before HJ for BDI seemed to have no impact on short- or long-term outcomes. Both surgical and radiological external biliary drainages after BDI appear to be acceptable options to reduce cholangitis before repair without increasing risk for long-term anastomotic stricture.

Risk Factors of Anastomosis Stricture After Esophagectomy and the Impact of Anastomosis Technique

BackgroundAnastomosis complications after esophagectomy are related to postoperative survival and quality of life. This is a retrospective observational study to identify risk factors for anastomotic stricture after esophageal cancer surgery and the effect of different anastomosis techniques on stricture development. MethodsThis study included 737 patients who underwent esophagectomy for esophageal cancer that used stomach conduits. Four types of anastomoses were used: manual sewing (n = 221, 30%), circular stapling (n = 172, 23%), hybrid linear stapling with a 45-mm stapler (HLS; n = 155, 21%), and triangular linear stapling with 60-mm staplers (TLS; n = 189, 26%). Multivariate analysis was performed to evaluate the risk factors for stricture. ResultsStrictures that required endoscopic dilatation within 1 year after surgery occurred in 105 patients (14%), and 13% of the strictures were related to leakage. Multivariate analysis revealed that chronic obstructive pulmonary disease (hazard ratio [HR] 1.726, P = .017), leakage (HR 2.502, P = .015), and anastomosis techniques other than TLS (manual sewing: HR 9.588; circular stapling: HR 6.516; HLS HR 5.462, all P < .001) were significant risk factors for stricture. TLS significantly reduced the stricture rate (3.2%) compared with other techniques (manual sewing: 22.2%; circular stapling:, 14.5%; HLS: 16.1%; P < .001). Stricture rate was lower in the TLS group in patients without leakage (P < .001); however, the effect disappeared with leakage. ConclusionsAnastomosis stricture occurred in 14% of esophagectomy patients. Chronic obstructive pulmonary disease, leakage, and anastomosis technique are risk factors for stricture. A large anastomosis area with the TLS technique using 60-mm length linear staplers prevented stricture, especially when leakage was not observed.

Modified Collard technique is more effective than circular stapled for cervical esophagogastric anastomosis in prevention of anastomotic stricture: a propensity score-matched study.

The anastomotic technique after esophagectomy is of great interest in the prevention of anastomotic complications that adversely affect postoperative recovery. This study aimed to compare the clinical outcomes of modified Collard (MC) and circular stapled (CS) anastomoses after esophagectomy. A total of 504 consecutive patients with thoracic esophageal cancer who underwent esophagectomy and cervical esophagogastric CS or MC anastomosis from January 2013 to December 2019 were enrolled. Out of 504 patients, 134 and 370 underwent CS and MC anastomoses. The frequency of anastomotic leakage and stricture was significantly lesser in the MC group than in the CS group (3.0 vs. 10.5%, P = 0.0014 and 11.1 vs. 34.3%, P < 0.001, respectively). CS anastomosis was an independent risk factor for anastomotic stricture (odds ratio, 4.89; P < 0.001). Oral intake was significantly higher in the group without anastomotic stricture than in the group with anastomotic stricture at 2, 3, and 6months postoperatively (P <0.001, P = 0.013, and P <0.001, respectively). The percentage body weight loss (%BWL) was -12.2% in the group with anastomotic stricture and -7.5% in the group without anastomotic stricture at 3months postoperatively (P = 0.0012). Anastomotic stricture was an independent factor associated with %BWL (odds ratio, 4.86; P = 0.010). Propensity score-matched analysis, which included 88 pairs of patients, confirmed a significantly lower anastomotic stricture rate in the MC group than in the CS group (10.2 vs. 35.2%, P < 0.001). MC anastomosis is better than CS anastomosis for reducing the frequency of anastomotic stricture, which may be useful for maintaining early postoperative nutritional status.

Predictors of anastomotic strictures following œsophageal atresia repair

ObjectivesTo identify the risk factors for anastomotic, refractory and recurrent strictures and to establish whether anastomotic stricture is associated with antireflux surgery.DesignThis prospective national multicentre study included all infants born...

Nomogram for benign anastomotic stricture after surgery for rectal cancer

Benign anastomotic stricture remains among the most prevalent complications following surgery for rectal cancer. This study is aimed at identifying risk factors of anastomotic stricture as well as generating an effective nomogram for the stricture. Design: This is a retrospective study. This study was conducted from January 2015 to December 2019 in a single tertiary center for rectal cancer. A total of 117 rectal cancer patients after surgery without recurrence were enrolled in this study, of which 39 with anastomotic stricture and 78 without stricture. Their clinical and pathological data were collected. Multiple logistic regression analysis was conducted to identify risk factors for anastomotic stricture and to generate the nomogram prediction model. Multivariate analysis of the primary cohort led to the identification of LCA (left colic artery) preservation (OR, 0.074; P=0.0015), protective stoma (OR, 5.353; P=0.012), anastomotic leakage (OR, 12.027; P=0.005), and anastomotic distance (OR, 7.578; P=0.012) as independent risk factors for anastomotic stricture. The following predictive model was derived: Logit (anastomotic stricture)=0.074∗ LCA+5.353∗ Protective stoma+12.027∗ Anastomotic leakage+7.578∗ Anastomotic distance. Assessment of the predictive model revealed that the area under the curve (AUC) was 0.871, while the cutoff value was 15.444 with a sensitivity of 64.1% and a specificity of 94.8%. The main limitation is the research design of a retrospective and case-controlled study with a small sample size from a single center. LCA preservation, protective stoma, anastomotic leakage, and anastomotic distance may affect the occurrence of anastomotic stricture following surgery for rectal cancer. The nomogram model generated in the present study can be valuable in the prediction of anastomotic stricture. This study has been registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/, ChiCTR 2100043775).

Mucosal Congestion on the First Day Following Endoscopy Predicts Anastomotic Stricture After Esophagectomy.

Anastomotic stricture is a relatively common postoperative complication after esophagectomy. Previous studies have indicated that impaired perioperative blood perfusion at the anastomosis is associated with the occurrence of stricture. Therefore, we analyzed the association between endoscopically assessed blood perfusion during the early postoperative period and anastomotic stricture. This retrospective study evaluated patients who underwent esophagectomy at Tokyo Medical and Dental University between 2010 and 2015. The patients had undergone nasal endoscopy on the 1st and 8th postoperative days. The findings were used to evaluate blood perfusion at the anastomosis and gastric tube, which was classified based on mucosal color as ischemia (white) or congestion (blue or black). Univariate and multivariable logistic regression analyses were performed to identify risk factors for anastomotic stricture. The study included 197 patients and anastomotic stricture was observed in 60 patients (30.4%). The multivariable analysis revealed that postoperative gastric tube congestion was a risk factor for stricture (odds ratio [OR]: 6.440, 95% confidence interval [CI]: 2.660-15.600; p < 0.001). Lower risks of anastomotic stricture were associated with pathological stage III-IV disease (OR: 0.325, 95% CI: 0.161-0.656; p = 0.002). This study revealed that endoscopically detected congestion at the anastomosis on the first postoperative day was a risk factor for anastomotic stricture.

P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis

Abstract Background After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI. Methods This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI. Results The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p &amp;lt; 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate. Conclusions Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.

Anastomotic Stricture in End-to-End Anastomosis-Risk Factors in a Series of 261 Patients with Esophageal Atresia.

To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2-8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.

Is Hypertrophic or Keloid Wound Scar a Risk Factor for Stricture at Esophagogastric Anastomosis Site after Esophageal Cancer Operation?

Anastomotic stricture at the esophagus and the conduit anastomosis site after the surgical resection of esophageal cancer is relatively common. This study examined whether a hypertrophic scar or keloid formation at a surgical wound is related to an anastomotic stricture. From March 2007 to July 2017, 59 patients underwent curative surgery for esophageal cancer. In 38 patients, end-to-end anastomosis (EEA) of the esophagus and the conduit was performed using EEA 25 mm. A hypertrophic wound scar was defined when the width of the midline laparotomy wound scar exceeded 2 mm. The relationship between the hypertrophic scar and stricture and the other risk factors for anastomotic stricture in these 38 patients was analyzed. Of the 38 patients, eight patients (21.1%) had an anastomotic stricture, and a hypertrophic skin scar was observed in 14 patients (36.8%). Univariate analysis revealed lower BMI and hypertrophic scars as risk factors (p=0.032, p=0.001 respectively). Multivariate analysis revealed a hypertrophic scar as an independent risk factor for an anastomotic stricture (p=0.010, OR=27.06, 95% CI 2.19-334.40). Hypertrophic wound scars can be a risk factor for anastomotic stricture after surgery for esophageal cancer. An earlier prediction of anastomotic stricture by detecting hypertrophic wound healing in patients undergoing esophagectomy may improve the patients' quality of life and surgical outcomes by earlier treatments.

393 What Are the Risk Factors for Anastomotic Stricture After Bile Duct Injury Repair? A Systematic Review and Meta-Analysis

Abstract Introduction Hepaticojejunostomy (HJ) is the standard repair following major bile duct injury (BDI), but anastomotic stricture can result in long-term morbidity. There is a need to assimilate high-level evidence to establish risk factors for the development of anastomotic stricture after HJ for BDI. Method A systematic review of studies reporting the rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Meta-analyses of proposed risk factors were then performed. Results Meta-analysis included five factors (n = 2,198 patients, 17 studies). Vascular injury (OR 2.71; 95%CI 1.37-5.35; p = 0.004), postoperative bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003), previous repair (OR: 5.36; 95%CI 1.04-27.76;p=0.05) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p &amp;lt; 0.0001) were associated with HJ stricture after BDI. Strasberg injury grade was not associated with HJ stricture (OR: 1.05; 95%CI 0.63-1.75; p = 0.86). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate. Conclusions This meta-analysis identifies factors that significantly increase the rate of anastomotic stricture after HJ for BDI. Knowledge of these risk factors will allow risk stratification in terms of follow-up for individual cases, better informed consent, and guidance for medico-legal cases.

Impact of a Long Linear Staplers on the Incidence of Stricture after Triangulating Esophagogastric Anastomosis.

Various techniques have been reported for esophagogastric anastomosis to prevent anastomotic leakage. Recently, not only postoperative anastomotic leakage but also anastomotic stricture is considered important because stricture contributes to the patient's postoperative quality of life. However, the best procedure for anastomosis has not been established. The authors divided 101 patients with thoracic or abdominal esophageal cancer who underwent cervical triangulating esophagogastric anastomosis using a linear stapler between May 2017 and May 2020 into 2 groups: surgery with a short (45 mm) linear stapler (SS group, n=59) or a long (60 mm) stapler (LS group, n=42). The frequencies of anastomotic leakage and stricture were compared between the 2 groups. The incidence of anastomotic leakage and stricture without leakage were significantly lower in the LS versus SS group (respectively: leakage: 15% vs. 0%, P=0.01; stricture: 36% vs. 7%, P=0.01). A short linear stapler and anastomotic leakage were independent risk factors for anastomotic stricture in the multivariate analysis (short stapler: odds ratio, 3.27; 95% confidence interval, 1.08-9.9; P=0.03; anastomotic leakage: odds ratio, 2.78; 95% confidence interval, 1.02-8.5; P=0.04). A long linear stapler is preferable for cervical triangulating esophagogastric anastomosis.

Gender and birth weight as risk factors for anastomotic stricture after esophageal atresia repair: a systematic review and meta-analysis

BackgroundAnastomotic stricture (AS) is the most frequently occurring complication that occurs after esophageal atresia (EA) repair. Nevertheless, the pathogenesis remains primarily unknown and there is inadequate knowledge regarding the risk factors for AS. Therefore, a systematic review of the literature and a meta-analysis was performed to investigate whether gender and birth weight were risk factors for the development of AS following EA repair.MethodsThe main outcome measure was the occurrence of AS. Forest plots with odds ratios (OR) and 95% confidence intervals (CI) were generated for the outcomes. Quality assessment was performed using the Newcastle–Ottawa scale.ResultsSix studies with a total of 495 patients were included; 59% males, and 37 and 63% of the patients weighed < 2500 g and ≥ 2500 g, respectively. Male gender (OR, 0.96; 95% CI, 0.66–1.40; p = 0.82) and birth weight < 2500 g (OR, 0.74; 95% CI, 0.47–1.15; p = 0.18) did not increase the risk of AS. The majority of the included studies were retrospective cohort studies and the overall risk of bias was considered to be low to moderate.ConclusionNeither gender nor birth weight appear to have an impact on the risk of AS development following EA repair.

Risk factors for digestive morbidities after esophageal atresia repair.

Esophageal atresia with/without tracheoesophageal fistula (EA/TEF) is a congenital digestive tract anomaly that represents a major therapeutic challenge. Postoperative digestive morbidities such as gastroesophageal reflux disease (GERD) and esophageal stricture are common. The aim of this study was to identify the incidence of and potential risk factors for digestive morbidities after EA/TEF repair. We retrospectively reviewed all EA/TEF patients who underwent repair at a single institution between January 1999 and December 2018, excluding patients who died prior to discharge. Patient demographics, perioperative management, and postoperative GERD and esophageal stricture rates were collected. We performed univariate and multivariate analyses to examine risk factors associated with postoperative GERD and esophageal stricture. The study enrolled 58 infants (58.6% male, 17.2% with type A EA/TEF, 62.1% with associated anomalies). Postoperative GERD occurred in 67.2% of patients and was the most common digestive morbidity. Esophageal stricture occurred in 37.9% of patients after EA/TEF repair. Multivariate analysis showed that long-gap EA/TEF and postoperative GERD were independent risk factors for esophageal stricture after repair surgery.Conclusion: The incidence of postoperative GERD and esophageal stricture was 67.2% and 37.9%, respectively. The risk factors for postoperative esophageal stricture were long-gap EA/TEF and postoperative GERD. What is Known: • EA/TEF is a congenital digestive tract anomaly with a high postoperative survival rate but can be complicated by many long-term morbidities. What is New: • Long-gap EA/TEF and postoperative GERD are risk factors of anastomotic stricture after repair. • Surgeons and pediatricians should be highly experienced in managing anastomotic tension and the GERD.

Can we define reliable risk factors for anastomotic strictures following radical prostatectomy?

To identify risk factors for anastomotic strictures in patients after radical prostatectomy. In all, 140 prostate cancer patients with one or more postoperative anastomotic strictures after radical prostatectomy were included. All patients underwent transurethral anastomotic resection at the University Hospital of Munich between January 2009 and May 2016. Clinical data and follow-up information were retrieved from patients' records. Statistical analysis was done using Kaplan-Meier curves and log rank-test with time to first transurethral anastomotic resection as endpoint, Chi-square-test, and Mann-Whitney-U test. In all, 140 patients with a median age of 67 years (IQR: 61-71 years) underwent radical prostatectomy. Median age at time of transurethral anastomotic resection was 68 years (IQR: 62-72). Patients needed 2 surgical interventions in median (range: 1-15). Median time from radical prostatectomy to transurethral anastomotic resection was 6 months (IQR: 3.9-17.4). Median duration of catheterization after radical prostatectomy was 10 days (IQR: 8-13). In all, 26% (36/140) received additional radiotherapy. Regarding time to first transurethral anastomotic resection, age and longer duration of catheterization after radical prostatectomy with a cutoff of 7 days showed no statistically significant differences (p = 0.392 and p = 0.141, respectively). Tumor stage was no predictor for development of anastomotic strictures (p = 0.892), and neither was prior adjuvant radiation (p = 0.162). Potential risk factors were compared between patients with up to 2 strictures (low-risk) and patients developing > 2 strictures (high-risk): high-risk patients had more often injection of cortisone during surgery (14% vs 0%, p < 0.001) and more frequently advanced tumor stage pT > 2 (54% vs 38%, p = 0.055), respectively. Other risk factors did not show any significant difference compared to number of prior transurethral anastomotic strictures. We could not identify a reliable risk factor to predict development of anastomotic strictures following radical prostatectomy.

Robotic hepaticojejunostomy: surgical technique and risk factor analysis for anastomotic leak and stenosis

BackgroundA variety of techniques have been described for the construction of the HJ (hepaticojejunostomy). Due to its technical challenges, HJ is rarely performed in a pure laparoscopic setting. In stark contrast, the increasing availability of the robotic platform has sparked new interest in pursuing this procedure in a minimally invasive fashion. The aim of our study was to describe our surgical technique and to identify risk factors for anastomotic leak and stenosis following robotic surgery. MethodsWe performed a retrospective analysis of a prospectively collected database, including all consecutive HJ carried out for different indications over a 10 year period. ResultsOne hundred fifty-two patients undergoing robotic HJ performed by the same surgeon were analyzed. Bile leak occurred in 2.6% of the patients. Stricture rate was 3.3%. The median follow up was 25.5 months. There was no mortality related to anastomotic complications. On univariate analysis, patient's age less than 65 years was the only risk factor for anastomotic stricture. On multivariate analysis, no predictor factors for leak or stenosis were identified. ConclusionHJs carried out in a robotic fashion allow highly satisfactory results. No independent risk factors for bile leak of stenosis were identified on multivariate analysis.

DOZ047.01: Risk factors for anastomotic strictures in the first year after esophageal atresia repair: data from a prospective multicentric cohort

Abstract Objectives and study Anastomotic stricture (AS) is a frequent complication of the surgery for œsophageal atresia (OA) during the first year of life. The primary objective of this study was to evaluate the prevalence of AS before 1 year old in infants with type A and C OA who were operated on. Secondary objectives were to determine risk factors for AS in OA, for recurrent and refractory AS, and to establish if AS is associated with antireflux surgery. Methods A prospective national multicentric study was conducted including all infants born with OA between 2008 and 2015. Patients deceased before one year old, OA types B and E, and patients for whom data about AS were missing were excluded from the study. Data were collected at birth and at 12 months of age. Anastomosis under tension was defined by the surgeon and a delayed anastomosis was defined by an anastomosis after 15 days of life. Recurrent stricture was defined by the need of ≥3 dilations and refractory stricture was defined by the need of ≥5 dilations. Univariate and multivariate statistical analyses were conducted. Results Of the 1258 eligible patients (84%), 1054 were included in the study from 38 centers. The prevalence of AS in the first year of life was 23.3% [20.7–28.9]. Anastomosis under tension (AUT) and delayed anastomosis (DA) were found to be independent risk factors for AS (respectively 2.5 [1.73–3.45] and 3.7 [1.95–7.2] (OR [CL 95%])) in the total population. Neither sex, birth weight, prematurity, intrauterine growth retardation, associated malformations, type A OA, nor the type of surgical approach was a risk factor for AS. In type C OA, DA was the only risk factor for AS (OR: 3.1 [1.65–5.86]). The group with AS had 2.5-fold more fundoplication compared to the patients without AS (P = 0.0005) in the total population and in type C OA. AUT and DA were found to be independent risk factors for recurrent stricture (OR: 2.4 [1.47–3.9] and 4.7 [2.2–10.4], respectively) and DA was the only risk factor for refractory stricture (OR: 6.23 [2.4–16.2]). Conclusion Surgical factors at the time of first repair of OA are the only risk factors for AS.

The Impact of Circular Stapler Size on the Incidence of Cervical Anastomotic Stricture After Esophagectomy.

Cervical anastomotic stricture after esophagectomy is a serious complication that adversely affects postoperative recovery, nutritional status and quality of life. Cervical anastomosis by a circular stapler (CS) has been widely accepted as a simple and convenient method, but anastomotic strictures are likely to occur. The aim of this study was to investigate an association between CS size and the incidence of anastomotic stricture after cervical esophagogastric anastomosis performed by a CS. Between April 2011 and March 2016, 236 consecutive patients underwent cervical esophagogastric anastomosis by a CS via a retrosternal route after esophagectomy for esophageal cancer. These patients were divided into according to CS size for the procedure as follows: small-sized (25mm) CS group (SG, n = 116) and large-sized (28 or 29mm) CS group (LG, n = 120). The clinical data of patients were analyzed retrospectively to compare the two groups. Overall, anastomotic strictures were observed in 90 patients (38%). The incidence of anastomotic stricture was significantly lower in the LG than the SG (23% vs. 53%, p < 0.001) (Table3). Chronic obstructive pulmonary disease (COPD: FEV1.0% <70%) (OR 2.35, 95% CI = 1.09-5.14; p = 0.029), anastomotic leakage (OR 8.97, 95% CI = 2.69-41.30; p < 0.001), and a small-sized CS (OR 3.42, 95% CI = 1.82-6.62; p < 0.001) were independent risk factors for anastomotic stricture in the multivariate analysis. If possible, a large-sized CS should be used to prevent cervical anastomotic strictures when performing cervical anastomoses by CS.

Surgical outcomes and risk assessment for anastomotic complications after laparoscopic proximal gastrectomy with double-flap technique for upper-third gastric cancer.

Double-flap technique (DFT) has received increased attention as an anastomotic procedure preventing reflux esophagitis after laparoscopic proximal gastrectomy (LPG) for upper-third gastric cancer. However, incidence of anastomotic stricture still remains high. This study was a retrospective review aimed to demonstrate details of surgical outcomes and to assess risk factors for anastomotic complications using pre-operative CT image after LPG with DFT (LPG-DFT). Patient background data, surgical outcomes, post-operative courses, and complications for patients who underwent LPG-DFT from January 2013 to June 2017 were collected. In addition to the details of short-term outcomes, risk factors for anastomotic stricture and gastroesophageal reflux were analyzed. The study sample was 147 patients, including 139 patients with upper-third gastric cancer and 8 patients with submucosal tumor of the upper-third stomach. The overall morbidity rate was 12.2% (18/147), and 97.3% (143/147) of the patients achieved R0 resection. Twelve (8.3%) patients required endoscopic balloon dilatation for anastomotic stenosis, and six (4.2%) suffered regurgitation grade ≥ B in the Los Angeles classification. Multivariate analysis revealed that diameter of the esophagus < 18mm on pre-operative CT image and the presence of short-term complications were found to be independent risk factors for post-operative anastomotic stenosis. No specific risk for gastroesophageal reflux was identified. The incidence rate of anastomotic complications after LPG-DFT was far lower than that reported after conventional esophagogastrostomy. Alternative anastomotic method may be considered for patients with diameter of the esophagus < 18mm on pre-operative CT image. Prevention of short-term complications may lessen post-operative stricture.

An analysis of the risk factors of anastomotic stricture after esophagectomy.

Anastomotic stricture after esophagectomy is a major cause of long-term morbidity and a poor quality of life. The aim of this study was to identify the risk factors for the development of anastomotic stricture after esophagectomy. The study subjects were 213 patients who underwent esophagectomy for squamous cell carcinoma of the esophagus between 2012 and 2014. Anastomotic stricture was defined as stenosis at the site of anastomosis that required endoscopic dilation. Refractory stricture was defined as that requiring more than four sessions of dilations. Univariate and multivariate logistic regression analyses were used to identify the potential risk factors for the development of anastomotic stricture. In this retrospective study, 29 patients (13.6%) developed anastomotic stricture within a median period of 108 postoperative days and required a median of 2 dilations. Tumors located in the upper part of the esophagus (p = 0.004), the presence of cardiovascular disease (p = 0.024) and anastomotic leakage (p = 0.002) were identified as independent risk factors for the development of anastomotic stricture. The time to the diagnosis of refractory stricture (85 ± 33 days) was significantly shorter than that of non-refractory stricture (171 ± 22 days, p = 0.038). Patients with squamous cell carcinoma in the upper esophagus with cardiovascular disease who develop postoperative anastomotic leakage should be carefully monitored to prevent the development of benign anastomotic stricture.

Anastomotic stricture after ultralow anterior resection or intersphincteric resection for very low-lying rectal cancer.

Anastomotic stricture following colorectal cancer surgery is not a rare complication, but proper management of anastomotic stricture located close to the anal verge is uncertain. This study aimed to investigate risk factors and management strategies for anastomotic stricture after ultralow anterior resection (ULAR). We retrospectively reviewed a database of patients with rectal cancer who underwent surgery between January 2007 and June 2015, and included patients with an anastomosis within 4cm from the anal verge. Clinical outcomes and risk factors for anastomotic stricture were investigated. Among the 586 patients included, 46 (7.8%) were diagnosed as having anastomotic stricture. Multivariable logistic regression analysis revealed that intersphincteric resection (ISR) with hand-sewn anastomosis (odds ratio [OR]=3.070; 95% confidence interval [CI] 1.247-7.557) and postoperative radiotherapy (OR 6.237; 95% CI 1.961-19.841) were independent risk factors of anastomotic stricture. Forty-one (89.1%) underwent anastomotic dilatation with a Hegar dilator; while three patients (6.5%) underwent endoscopic balloon dilatation and two (4.3%) underwent surgery initially. Among the patients with initial nonoperative management (n=44), 21 (47.7%) were completely cured with nonoperative management alone, 12 (27.3%) experienced complications, such as bowel perforation, anastomotic rupture, and perirectal abscess; and 21 (47.7%) underwent further surgical management. Fifteen patients (32.6%) eventually had permanent stoma. ISR with a hand-sewn coloanal anastomosis, compared to ULAR with double-stapling anastomosis, and postoperative radiotherapy were independent risk factors of anastomotic stricture after surgery for very low-lying rectal cancer. Nonoperative anastomotic dilatation showed poor clinical outcome, with high complication rates, and subsequent surgical management. Therefore, nonoperative management of such patients should be carefully selected.