Thoracic Anastomosis Research Articles

304. OUTCOMES OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY BEFORE AND AFTER IMPLEMENTATION OF ENDOSCOPIC VACUUM THERAPY IN A TERTIARY REFERRAL CENTER

Abstract Background Anastomotic leakage (AL) after esophagectomy is associated with severe morbidity and a high mortality. Endoscopic vacuum therapy (EVT) has recently been established as a promising endoscopic treatment option for AL, with success rates of higher than 80%. The aim of this study was to compare outcomes of AL after esophagectomy, before and after implementation of EVT. Methods For this cohort study, consecutive patients with AL after transthoracic esophagectomy with gastric conduit reconstruction with cervical or thoracic anastomosis from two different time periods (before the implementation phase of EVT [2013–2017, pre-EVT], and after [2020–2023, EVT]) were included. Data was collected from a prospectively maintained database. Outcome measures included initial treatment modality, re-operation, intensive care unit (ICU) admission, hospital stay, and complications, classified according to Clavien-Dindo. Results 100 patients with AL were included, with 50 patients in the pre-EVT group and 50 patients in the EVT group. In the pre-EVT group, initial treatment of AL consisted of conservative therapy (n=20, 40%), endoscopic stenting (n=13, 26%), endoscopic drainage (n=6, 12%) or surgery (n=11, 22%). In the EVT group, initial treatment of AL consisted of conservative therapy (n=5, 10%), surgery (n=2, 4%) or EVT (n=43, 86%). Other baseline characteristics showed no differences. The EVT group had a significantly lower initial surgical treatment rate compared to the pre-EVT group (respectively 2 [4%] vs. 11 [22%], p=0.03). Furthermore, the EVT group had a significantly lower ICU admission rate than the pre-EVT group (respectively 16 [32%] vs. 35 [70%], p<0.001). Clavien-Dindo classification differed significantly between the two groups (p = 0.033), with less Grade IIIa and more Grade IVa in the pre-EVT group, compared to the EVT group. Reoperations occurred in 17 patients (34%) in the pre-EVT group and 9 (18%) in the EVT group, which was not statistically significant. No statistically significant difference was observed in length of hospital stay. Conclusion The implementation of EVT as treatment option for AL after esophagectomy in this tertiary referral center may have led to a lower ICU admission rate. Taking this into consideration, EVT may be associated with long term health benefits for the patient and reduced healthcare costs.

Management of Leakage after Gastroesophageal Anastomosis

Abstract Background Esophagectomy is needed for a variety of esophageal disorders, the most common indication is cancer esophagus, however, it is needed in benign disorders as postcorrosive strictures & endstage achalasia with esophageal dilatation. Anastomotic leakage is one of the most severe complications leading to significant morbidity and increased risk of mortality. Objective To evaluate different approaches in management of leakage after gastroesophageal anastomosis in Upper GIT surgery unit in Ain Shams University Hospitals. Patients and Methods This study was conducted at General surgery department, Ain Shams University Hospitals. Approval of the Ethical Committee was obtained. The study was conducted over patients with postoperative gastroesophageal leakage during the period from 3/2019 to 3/2021. Results Patients managed after cervical anastomosis leakage needed less time to start oral intake& had shorter hospital stay in comparison to those managed after thoracic leakage. There was a higher perioperative morbidity and mortality in patients who underwent surgical intervention as compared with patients who underwent conservative treatment. Conclusion Anastomotic leak after surgery for esophageal diseases can vary in location, onset time, size, and extent. For local management, personalized treatment should be decided based on patient’s particular situations. Cervical anastomosis leakage has less morbidity & mortality compared to thoracic anastomosis. Conservative treatment is safe and successful in many cases, in cervical leakage conservative management is effective in most cases. Stent implantation is an effective method with other emerging endoscopic techniques. Resurgery should be considered carefully and reserved to uncontrolled leakage or patients with failed conservative management.

Postoperative complications analysis of circular stapled versus linear stapled anastomosis for patients undergoing esophagectomy: a systematic review and meta-analysis

BackgroundThe choice of anastomosis technique after esophagectomy is closely associated with the postoperative complications. Whether circular stapled or linear stapled anastomosis is the optimal technique has not been established. Therefore, we conducted this meta-analysis to show the latest and most comprehensive published assessment of circular stapled anastomosis in comparison with linear stapled anastomosis in postoperative complications.MethodsDatabases (PubMed, Embase, Web of science, Cochrane Library) were searched for all randomized controlled trials and comparative studies comparing circular stapled anastomosis with linear stapled anastomosis after esophagectomy. The odd ratio and mean difference with 95% confidence interval were calculated. We used the Higgins I² statistics to assess the statistical heterogeneity between studies. Review manager (version 5.4) software was used in this analysis.ResultsSixteen studies with 2322 patients were included in our study. The study demonstrated that the use of linear stapled technique after esophagectomy could reduce the risk of both anastomotic leakage (P = 0.0003) and stricture (P < 0.00001) compared with circular stapled technique. Stratification by anastomotic site showed that no matter what kind of anastomotic site (cervical or thoracic anastomosis) was used, linear stapled anastomosis could effectively reduce the anastomotic stricture in comparison with circular stapled anastomosis. Moreover, linear stapled anastomosis could decrease the risk of thoracic anastomotic leakage. There were no significant differences between circle stapled anastomosis and linear stapled anastomosis in reflux esophagitis (P = 0.17), pneumonia (P = 0.91), operation time (P = 0.41) and hospital stay (P = 0.38).ConclusionsThe study suggested that linear stapled anastomosis could be considered to be an optimal treatment associated with a reduced risk of anastomotic leakage and stricture in comparison with circular stapled anastomosis.

Comparison of Side to Side Staple Versus Hand Sewn Gastro Esophageal Anastomosis in Cases of Oesophagectomy in CA Esophagus

Objective: To compare outcomes of side to side staple versus hand-sewn esophago-gastric anastomosis in esophagectomy patients with carcinoma of esophagus after subtotal esophagectomy along with gastric tube reconstruction.&#x0D; Study Design: Retrospective cross-sectional study.&#x0D; Place and Duration of Study: Lady Reading Hospital, Peshawar Pakistan, from July 2019 to June 2020.&#x0D; Methodology: After ethical approval, medical records of patients that underwent stapled/hand sewn gastro esophageal anastomosis due to carcinoma esophagus were included. Inoperable Ca esophagus and with thoracic anastomosis were excluded. Each anastomotic technique was applied on 50 patients randomly. The variables of study included demographic,anastomotic leak, anastomotic stricture, operative time, and other complications. All the cases were followed up for 1 year.SPSS version 26.0 was used for data analysis.&#x0D; Result: From 100 patients, 56 were males and 34 females. Age ranged from 15 to 80 years with mean age of 48.5 and 51.1 respectively in two groups. In 42 cases tumor was present in lower end, middle third in 30 and middle lower third of gastro esophageal junction in 28 cases. Histo-pathologically 58 cases were adenocarcinoma, 31 squamous cell carcinoma and 11 adeno squamous carcinoma. The anastomosis time in group I was 6.8±.22 minutes while in group II was 13.2±1.71 minutes (p0.04). None of the patients in group I, having stapled anastomosis were found to have anastomotic leakage or stricture formation after 1 year of follow up while 04 patients in group II were reported to have anastomotic leakage and 06 patients had anastomotic stricture formation (p-&lt;0.01).&#x0D; Conclusion: Side by side stapled anastomosis technique was far superior to hand-sewn technique in terms of the time taken for anastomosis to be completed and patient outcomes (anastomotic leakage and stricture formation).

Robotic versus thoraco-laparoscopic minimally invasive Ivor Lewis esophagectomy, a matched-pair single-center cohort analysis.

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7days, P< 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience.

36: ANASTOMOTIC STRICTURE AFTER IVOR LEWIS OESOPHAGECTOMY—AN EVALUATION OF INCIDENCE, RISK FACTORS AND TREATMENT

Abstract Background and aim Anastomotic stricture is a recognised complication after oesophagectomy. It can impact on patient quality of life with some patients requiring multiple dilatations. The aim of this study was to evaluate the frequency of strictures, contributing factors and the long-term outcomes of management in patients undergoing oesophagectomy with thoracic anastomosis using a standardised circular stapled technique. Methods All patients who underwent a two-stage transthoracic oesophagectomy with curative intent between January 2010 and December 2019 at the Northern Oesophago-Gastric Unit (NOGU) in Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using a gastric conduit were included. Stricture incidence, number of dilatations to treat strictures and refractory stricture rate were recorded. Results Overall 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, two and three dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%) and 20 (16.3%) patients respectively. Multivariable analysis identified the occurrence of an anastomotic leak (OR 1.906, 95% CI 1.088–3.341, P = 0.024) and circular stapler size less than 28 mm (OR 1.462, 95% CI 1.033–2.070, P = 0.032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs. 4.7%, OR 3.089, 95% CI 1.349–7.077, P = 0.008). Conclusion This study highlighted that 27.2% of patients having a circular stapled anastomosis required dilatation after surgery. However, most strictures were successfully treated after two dilatations, but 5% of patients had longer-term problems with refractory strictures.

P-OGC47 Anastomotic stricture after Ivor Lewis Oesophagectomy - An evaluation of incidence, risk factors and treatment

Abstract Background Anastomotic stricture is a recognised complication after oesophagectomy. It can impact the patient’s quality of life and may require recurrent dilatations. The aim of this study was to evaluate the frequency of benign strictures, contributing factors, and the long-term outcomes of management in patients undergoing oesophagectomy with thoracic anastomosis using a standardised circular stapler technique. Methods All patients who underwent a two-stage transthoracic oesophagectomy with curative intent between January 2010 and December 2019 at this single, high volume centre were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Those with variations to anastomotic technique or those not having a transthoracic anastomosis were excluded to reduce heterogeneity. Patients who developed malignant anastomotic strictures and patients who died in hospital were excluded from the analysis. Benign stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded and analysed. Results Overall, 705 patients were included with 192 (27.2%) developing benign strictures. Refractory strictures occurred in 38 patients (5.4%). One, two, and three dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients respectively. Multivariable analysis identified the occurrence of an anastomotic leak (OR 1.906, 95% CI 1.088-3.341, p = 0.024) and circular stapler size &amp;lt;28mm (OR 1.462, 95% CI 1.033-2.070, p = 0.032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs. 4.7%, OR 3.089, 95% CI 1.349-7.077, p = 0.008). Conclusions This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery for a benign anastomotic stricture. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures. Smaller circular stapler size and anastomotic leak have been identified as independent risk factors for developing a benign anastomotic stricture following oesophagectomy, and these patients should be monitored closely for symptomatology following surgery.

Trimodality therapy for esophageal cancer: The role of surgical and radiation treatment parameters in the development of anastomotic complications.

BackgroundHere, we investigated the relationship between clinical parameters, including the site of surgical anastomosis and radiation dose to the anastomotic region, and anastomotic complications in esophageal cancer patients treated with trimodality therapy.MethodsBetween 2007 and 2016, esophageal cancer patients treated with trimodality therapy at a tertiary academic cancer center were identified. Patient, treatment, and outcome parameters were collected. Radiation dose to the gastric regions were extracted. Anastomotic complication was defined as leak and/or stricture. We used Fisher's exact and Wilcoxon rank‐sum tests to compare the association between clinical parameters and anastomotic complications.ResultsOf 89 patients identified, the median age was 63 years, 82% (n = 73) were male, and 82% had distal (n = 47) or gastroesophageal junction (n = 26) tumors. Median follow‐up was 25.8 months. Esophagectomies were performed with cervical (65%, n = 58) or thoracic anastomoses (35%, n = 31). Anastomotic complications developed in 60% (n = 53). Cervical anastomosis was associated with anastomotic complications (83%, n = 44/53, p < 0.01). Radiation to any gastric substructure was not associated with anastomotic complications (p > 0.05). In the subset of patients with distal/gastroesophageal junction tumors undergoing esophagectomy with cervical anastomosis where radiation was delivered to the future neoesophagus, 80% (n = 35/44) developed anastomotic complications. In this high‐risk subgroup, radiation was not associated with anastomotic complications (p > 0.05).ConclusionsOur analysis did not demonstrate an association between radiation dose to gastric substructures and anastomotic complications. However, it showed an association between esophagectomy with cervical anastomosis and anastomotic complications. Patients with distal/gastroesophageal junction tumors who undergo esophagectomy with cervical anastomosis have higher rates of anastomotic complications unrelated to radiation to gastric substructures.

672 OESOPHAGOGASTRIC ANASTOMOTIC LEAK IN THE THORAX TREATED WITH COVERED METAL STENTS: SAFE AND HIGHLY SUCCESSFUL

Abstract Anastomotic leak (AL) develops in 5–22% of cases following oesophagectomy, and results in additional morbidity, and reduction in overall survival. The management of AL has evolved significantly with advances in endoscopic therapies. Covered cylindrical metal stents have been increasingly used, and insertion techniques have improved over time. We aimed to investigate the effectiveness and safety of modern metal stents in the management of AL. Methods All patients who underwent oesophagectomy with thoracic anastomosis between 2006–2020, and subsequently developed AL were retrospectively identified. Initially, treatment details and patient outcomes were assessed for the subgroup of patients where the AL was initially managed using a stent. In all cases, these were cylindrical covered metal stents. Those patients that progressed to surgery after treatment with a stent were then excluded, with the remainder compared to the subgroup of patients that underwent conservative (i.e., non-interventional) treatment for AL. Results Of 63 patients with AL, primary management was with stents in 32 (57%). Technical success was achieved in all stenting procedures, although three patients (9%) developed complications (stent migration). After stenting, six cases (19%) subsequently required escalation to operative management (thoracotomy). The remainder (N = 23) were then compared to those managed conservatively (N = 26) and were found to have a significantly longer length of hospital stay (median: 37 vs. 20 days, p = 0.003). The AL healing rate was 96% in both groups (p = 1.000); one conservatively managed patient died before healing, and one stented patient refused further treatment. Conclusion Endoscopic treatment of oesophageal AL with cylindrical covered metal stents is safe, with a high technical success rate, and low rates of stent-related morbidity. Treatment with stents also avoids the need for operative management including oesophageal disconnection in the majority of cases, whilst leading to successful healing of the AL. However, treatment with stents does significantly increase hospital stay over conservative management, particularly where multiple procedures are required.

477 MINIMALLY INVASIVE MEDIASTINOSCOPIC IVOR-LEWIS ESOPHAGECTOMY WITH CERVICAL ANASTOMOSIS FOR ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA PATIENT UNDER INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING

Abstract In early 2000s, cervical anastomosis after esophagectomy was associated with a higher rate of recurrent nerve trauma than thoracic anastomosis. Recently, new technologies have been developed that reduce surgical complications. Mediastinoscopic esophagectomy is reportedly less invasive and allows faster recovery than thoracoscopic esophagectomy. Intraoperative nerve monitoring (IONM) prevents recurrent laryngeal nerve (RNL) palsy. We present the case of minimally invasive mediastinoscopic Ivor-Lewis Esophagectomy (MMIE) under IONM performed on an elderly esophagogastric junction (EGJ) adenocarcinoma patient. Methods An 84-year old man was consulted for adenocarcinoma of GEJ without lymphnode metastasis. Despite his advanced age, he had no comorbidities. We planned to perform MMIE under IONM. The procedure started with a patient lithotomy, and three trocars plus small incision were made in the upper abdomen. Celiac lymphadenectomy was performed. Subsequently, a 35 mm incision was made in the left side of the neck and a monitor was attached to left vagus nerve. Three trocars were placed with single incision surgical devices and pneumomediastinum was noticed. Mediastinoscopic esophagectomy was performed. Gastric tube reconstruction via mediastinum with cervical anastomosis was performed. Results The operation was successful. Total operation time was 393 minutes, with an estimated blood loss of 5 mL. There were no intraoperative and postoperative complications, and no RLN palsy occurred. Conclusion MMIE with cervical anastomosis under IONM is safe and less invasive especially for the respiratory system as a thoracotomy is unnecessary. Video https://www.dropbox.com/s/9yqkzg3pm619pf6/%E7%B8%A6%E9%9A%94%E9%8F%A12%E5%88%8656%E7%A7%92.mp4?dl=0.

Anastomotic stricture after Ivor Lewis esophagectomy: An evaluation of incidence, risk factors, and treatment

BackgroundAnastomotic stricture is a recognized complication after esophagectomy. It can impact the patient’s quality of life and may require recurrent dilatations. Thus, the aim of this study was to evaluate the frequency of strictures, contributing factors, and long-term outcomes of management in patients undergoing esophagectomy with thoracic anastomosis using a standardized circular stapled technique. MethodsAll patients who underwent a 2-stage transthoracic esophagectomy with curative intent between January 2010 and December 2019 at NOGU, Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded. ResultsOverall, 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, 2, and 3 dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients, respectively. Multivariable analysis identified the occurrence of an anastomotic leak (odds ratio 1.906, 95% confidence interval 1.088–3.341, P = .024) and circular staple size <28 mm (odds ratio 1.462, 95% confidence interval 1.033–2.070, P = .032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs 4.7%, odds ratio 3.089, 95% confidence interval 1.349–7.077, P = .008). ConclusionThis study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures.

Hand-sewn versus stapled anastomoses for esophagectomy: We will probably never know which is better

ObjectiveEsophagectomy remains the mainstay of treatment for nonmetastatic esophageal cancer. The optimal technique for anastomosis after esophagectomy remains unknown. The purpose of this systematic meta-analysis is to combine the available high-quality evidence to provide esophageal surgeons with an evidence base for their decision making. MethodsA systematic search of multiple databases was conducted to find randomized controlled trials of esophageal anastomotic techniques. A meta-analysis of the pooled data was conducted. ResultsA total of 19 studies with 2123 patients were included in the meta-analysis. The pooled analysis revealed a 102% higher incidence of anastomotic leak after hand-sewn anastomosis compared with stapled anastomosis (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.48-2.75). Anastomotic stricture rate was also 31% higher with hand-sewn anastomosis (OR, 1.31; 95% CI, 1.00-1.7). Thirty-day mortality did not show statistical difference favoring one anastomosis technique to another (OR, 0.68; 95% CI, 0.45-1.04). None of anastomotic leak rate, anastomotic stricture rate, or 30-day overall survival differed between anastomotic techniques in studies with only thoracic anastomoses. In cervical position hand-sewn anastomosis was associated with higher rate of anastomotic leak (OR, 2.02; 95% CI, 1.33-3.05) and stricture (OR, 1.77; 95% CI, 1.15-2.72), but no difference in 30-day mortality. ConclusionsThis meta-analysis showed a signal of higher rate of leak and stricture in hand-sewn anastomoses, but sensitivity analyses did not show a consistent outcome, so these results should be interpreted with caution.

Coronary artery bypass grafting for an anomalous origin of the right coronary artery: is it a valid surgical procedure?

The right internal thoracic artery to the right coronary artery bypass with ligation of the proximal native vessel is a simple and reliable option for the treatment of an anomalous aortic origin of the right coronary artery arising from the left sinus of Valsalva without an intramural course. Coronary artery bypass grafting is an uncomplicated option for elderly patients, those with connective tissue diseases, and those for whom combined aortic valve procedures are planned. Herein, we present four cases of this anomaly that underwent right internal thoracic artery anastomosis to the distal right coronary artery along with proximal right coronary artery ligation using a surgical clip. There was no occurrence of complications such as hypoperfusion syndrome, graft occlusion, recurrent symptoms, or late cardiac events.

Predictors of Patient-Reported Reflux After Esophagectomy

Patient-reported reflux is among the most common symptoms after esophagectomy. This study aimed to determine predictors of patient-reported reflux and to ascertain whether a preserved pylorus would protect patients from symptomatic reflux. A prospective clinical study recorded patient-reported reflux after esophagectomy from August 2015 to July 2018. Eligible patients were at least 6 months from creation of a traditional posterior mediastinal gastric conduit, had completed at least 1 reflux questionnaire, and had the pylorus treated either temporarily (≥100 IU Botox [onabotulinumtoxinA]) or permanently (pyloromyotomy or pyloroplasty). Of the 110 patients meeting inclusion criteria, the median age was 65 years, and 88 of the 110 (80%) were male. Botox was used in 15 (14%) patients, pyloromyotomy in 88 (80%), and pyloroplasty in 7 (6%). A thoracic anastomosis was performed in 78 (71%) patients, and a cervical anastomosis was performed in 32 (29%). Esophagectomy was performed for malignant disease in 105 of 110 (95%), and 78 of 110 (71%) patients were treated with perioperative chemoradiation. Multivariable linear regression analysis revealed that patient-reported reflux was significantly worse in patients with shorter gastric conduit lengths (P= .02) and in patients who did not undergo perioperative chemoradiation (P= .01). No significant difference was found between patients treated with pyloric drainage and those treated with Botox. The absence of perioperative chemoradiation therapy and a shorter gastric conduit were predictors of patient-reported reflux after esophagectomy. Although few patients had Botox, preservation of the pylorus did not appear to affect patient-reported reflux. Further objective studies are needed to confirm these findings.

Effect of thoracic versus cervical anastomosis on anastomotic leak among patients who undergo esophagectomy after neoadjuvant chemoradiation

ObjectiveTo assess the rate and effect of anastomotic leak among patients who undergo esophagectomy with either thoracic or cervical anastomosis after neoadjuvant chemoradiation. MethodsWe conducted a retrospective cohort study using data from the National Surgical Quality Improvement Program Esophagectomy Data File. We included adult patients who underwent esophagectomy for esophageal cancer (2016-2017) after neoadjuvant chemoradiation. We used inverse probability of treatment weighted regression adjustment to compare 30-day anastomotic leak and mortality rates among patients with cervical or thoracic anastomoses. We accounted for confounding due to patient-, surgeon-, and procedure-related variables. ResultsOf the 908 patients who met inclusion criteria, 528 (58%) had a thoracic anastomosis and 119 (13%) experienced anastomotic leak. There was no statistically significant difference in leak rate for patients who underwent thoracic (12%) compared with cervical anastomoses (14%) in the inverse probability of treatment weighted regression adjustment analysis (P = .09). Although overall 30-day mortality was low (2.3%), it was significantly higher among patients who had an anastomotic leak (8.4% vs 1.4%; P < .01). Among patients with a leak, there was no significant difference in length of stay, mortality, or type of required intervention for patients with cervical versus thoracic anastomoses. ConclusionsAnastomosis type does not affect leak rates or mortality after esophagectomy in patients who have undergone neoadjuvant chemoradiation. Patient risk factors and surgeon experience should determine the ideal surgical approach for each patient.

Using Benchmarking Standards to Evaluate Transition to Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) is performed in nearly 50% of patients worldwide. The effectiveness of the technique arises from a single randomized control trial and multiple single series cohorts. Consistent reporting of complications is varied. We describe our experience of transitioning to MIE compared with open esophagectomy (OE) with the use of Esophageal Complications Consensus Group (ECCG) standardized complication benchmark definitions. Between 2007 and 2017, all patients undergoing esophagectomy were identified with the use of a prospectively curated database. Complications were defined by the ECCG and graded with the Clavien-Dindo (most severe complication) and comprehensive complication index (complexity of complications during hospital stay). Of 383 patients, 299 (76%) were men with a median age of 64.5 years (range, 56-72 years). MIE was performed in 49.6%. No differences were found in age, histologic finding (P= .222), pT stage (P= .136), or nodal positivity (P= .918). Stage 3 cancers accounted for 42.0% of OEs and 47.9% of MIEs. A thoracic anastomosis was more frequent in MIEs (156 of 190; 82.1%) than in OEs (113 of 193; 58.5%; P= .001). Frequency, severity (Clavien-Dindo), and complexity (comprehensive complication index) of complications were better in the MIE group, without compromising operative outcomes. No differences were identified in individual complication groupings or grade in MIEs compared with OEs (pneumonia: 19.5% versus 26.9% ([P= .09]; intensive care unit readmission: 7.4% versus 9.3% [P= .519]; atrial fibrillation: 11.1% versus 6.7% [P= .082], or grade of leak [P= .99]). These results compare favorably to those reported by ECCG. MIE can be the standard approach for surgical management of esophageal cancer. Introduction of the approach in each surgeon's practice should be benchmarked to international standards.

Performance of the transoral circular stapler for oesophagogastrectomy after induction therapy.

Patients undergoing oesophageal anastomosis may be at an increased risk for leak after induction therapy for oesophageal cancer, with intrathoracic leaks having significant morbidity. The outcomes of utilizing transoral circular stapler for the creation of a thoracic anastomosis have not been well studied in this patient population. Patients with oesophageal cancer undergoing induction chemotherapy/radiation followed by Ivor Lewis oesophagogastrectomy were evaluated. All thoracic anastomoses were constructed with transoral circular stapler. Primary outcomes evaluated were the rates of anastomotic leak and stricture. Over 7 years, 87 consecutive patients were evaluated, among whom 69 (79%) were male. The median age was 63 years, median body mass index (BMI) was 27 kg/m2 and median age-adjusted comorbidity index was 5. Median operative blood loss was 400 ml and median operative time was 300 min. Major complications (grade ≥3) were seen in 19 (22%), including anastomotic leak in 2 (2.3%), both successfully treated with temporary covered metal stent. The median duration of hospital stay was 10 days, and 1 (1.2%) death was reported at 90 days due to cancer recurrence. Stricture occurred in 8 (9.2%), and median time to dilation was 109 days and median number of dilations was 1. Univariable analysis found BMI to be significantly higher in patients with an anastomotic leak versus those without (43 vs 27 kg/m2, P = 0.002). No variables were found to be predictive of anastomotic stricture. The use of the transoral circular stapler for thoracic anastomosis results in a consistent formation of the anastomosis, with low leak and stricture rates in the setting of induction chemotherapy/radiation. Leaks that do occur appear to be amenable to stent therapy.

Optimal mobilization of the stomach and the best place in the gastric tube for intrathoracic anastomosis.

Esophagectomy with gastric tube reconstruction is a highly complex surgical procedure. With regard to mobilization of the stomach and optimal gastric tube preparation and anastomosis, there are several important intraoperative steps that can influence the outcome of the operation. This study aims to describe the optimal mobilization of the stomach for gastric tube reconstruction and explore the best place in the gastric tube for intrathoracic anastomosis after esophagectomy. A search of the literature was performed and results are described in a descriptive review. Based on literature and our own experience we describe important operating steps for laparoscopic stomach mobilisation for gastric tube reconstruction. Steps to create additional length include preserving the left gastroepiploic artery, transecting the right gastric artery, extended duodenal mobilization, and duodenal diversion with roux-Y reconstruction. Several techniques for intrathoracic anastomosis are described in literature. Several imaging techniques, of which fluorescence imaging is the most commonly used, are available to assess the vascularization of the gastric tube and to assist in determining the best place in the gastric tube for intra thoracic anastomosis. Although there is little evidence of exact technique on stomach mobilization and location for an intrathoracic anastomosis, many techniques are used by different authors with varying results.

Anastomotic leak and neoadjuvant chemoradiotherapy in esophageal cancer.

Anastomotic leaks (AL) cause significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (UFS) and NCR patients. An esophagectomy database was queried for UFS and NCR patients treated between 1996 and 2015. Predictors of AL rate were identified using univariate and multivariate (MVA) analysis and propensity score matching (PSM). We identified 820 patients (UFS, 288; NCR, 532). Overall AL rate was 5.4%. Decreased AL rate was observed in NCR patients on MVA (8.0% vs. 4.1%; P=0.02) but no difference was seen after PSM (7.7% vs. 4.2%; P=0.14). MVA of factors associated with decreased AL in UFS patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic. Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM. MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. There is no difference in the AL rate between UFS and NCR patients. Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.

PS02.213: PREDICTING ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY: THE VALUE OF C-REACTIVE PROTEIN. A NATIONWIDE REGISTER STUDY

Abstract Background Anastomotic leakage (AL) after oesophageal surgery is a serious complication, leading to increased postoperative mortality. Early detection and treatment is essential. The aim of this study was to investigate if inflammatory serum parameters in the early postoperative course after oesophageal cancer surgery, could predict development of an AL. Methods All patients in Sweden with AL after thoraco-abdominal surgery for oesophageal or gastroesophageal junction cancer from 2006–01-01 to 2017–01-31 were collected from the Swedish National Registry for esophageal and gastric cancer (NREV). Two matched controls for each AL-patient were also selected from the registry. Pre-, per- and postoperative variables were collected from NREV. The following parameters were collected from patient charts: number of days from surgery to AL, diagnostic modality, method of treatment, serum levels of C-reactive protein (CRP), White blood cell count (WBC) and serum-Albumin taken on postoperative day 1 to 7 (POD1–7). Thoracic- and cervical anastomosis were analysed separately. Perioperative data and inflammatory markers were compared between controls and AL-patients. Receiver Operating Characteristic (ROC) curves was constructed to identify optimal cut-off values and a multivariate analysis was performed to identify independent risk factors. Results A total of 155 patients with AL and 307 controls (n = 462) were analysed. In patients with thoracic anastomosis median levels of CRP and WBC were significantly different on POD 2–7 and on POD 4–7 comparing AL-patients to controls. In patients with cervical anastomosis there was a significant difference in WBC levels on POD 1–7. ROC-curve analysis identified CRP on POD3 (cut-off 221) and POD4 (cut-off 203) as the best candidates for predicting AL in patients with a thoracic anastomosis, displaying an area under curve of 0.754 (Sensitivity 59%, Specificity 83%) and 0.731 (Sensitivity: 57%, Specificity 82%). Conclusion In this nation-wide register study we found that a model combining S-CRP levels on POD 3 and POD 4 after a thoraco-abdominal esophagectomy, could identify patients with increased risk of anastomotic leakage several days before it was diagnosed. However, since the sensitivity of this test is relatively low for predicting AL, it must be assessed in a larger clinical context. Disclosure All authors have declared no conflicts of interest.