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Zhou J, Wang Z, Chen G, Li Y, Cai M, Pannikkodan FS, Qin X, Bai D, Lv Z, Gong L, Tian Y. A novel intraoperative Esophagus-Sparing Anastomotic Narrowing Revision (ESANR) technique for patients who underwent esophagojejunostomy: three case reports and a review of the literature. World J Surg Oncol 2024; 22:353. [PMID: 39736755 DOI: 10.1186/s12957-024-03647-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 12/23/2024] [Indexed: 01/01/2025] Open
Abstract
AIM The aim of this study was to introduce the Esophagus-Sparing Anastomotic Narrowing Revision (ESANR) technique for the intraoperative management of anastomotic narrowing and to conduct a literature review to provide an algorithm for the management of narrowing and strictures that may develop secondary to esophagojejunostomy. METHODS Three patients with anastomotic narrowing during esophagojejunostomy were analyzed between September 2019 and June 2024. The anastomotic narrowing was detected by intraoperative gastroscopy after reconstruction. The ESANR technique was performed for the management of anastomotic narrowing. We conducted a systematic search of PubMed, Embase, and Web of Science databases for studies published up to June 2024 related to the treatment of anastomotic stricture. Data on the number of patients, sex, age, type of anastomosis, treatment, and outcomes were collected. RESULTS The ESANR technique proved effective for the management of anastomotic narrowing in patients who underwent esophagojejunostomy during gastric cancer surgery. No anastomotic stricture or leakage was found following ESANR, and all three patients recovered without complications. 12 studies with a total of 174 patients were analyzed. The management of anastomotic stricture, which included Balloon Dilation (BD), Endoscopic Incision Therapy (EIT), stent placement, Endoscopic combination therapy (Needle-Knife stricturotomy NKS, Balloon Dilation with Triamcinolone Injection TAC), and re-do laparoscopic esophagojejunostomy. CONCLUSIONS In conclusion, the ESANR technique demonstrates potential advantages in addressing anastomotic narrowing in esophagojejunostomy. However, further clinical data and analyses are necessary to verify its effectiveness and establish robust statistical support.
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Affiliation(s)
- Jian Zhou
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Zhenhong Wang
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Guobiao Chen
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Yi Li
- Department of Plastic Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, China
| | - Min Cai
- Department of Stomatology, North Sichuan Medical College (University), Nanchong, China
| | - Fathima Shifly Pannikkodan
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Xiangzhi Qin
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Dan Bai
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Zhenbing Lv
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Lei Gong
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, China.
- Department of General Surgery, Beijing Anzhen Nanchong Hospital, Capital Medical University & Nanchong Central Hospital, Nanchong, China.
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Zhong Y, Sun R, Li W, Wang W, Che J, Ji L, Guo B, Zhai C. Risk factors for esophageal anastomotic stricture after esophagectomy: a meta-analysis. BMC Cancer 2024; 24:872. [PMID: 39030531 PMCID: PMC11264988 DOI: 10.1186/s12885-024-12625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/10/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND The aim of this study was to assess the risk factors for anastomotic stricture in esophageal cancer patients undergoing esophagectomy. Esophageal anastomotic stricture is the most common long-term complication for esophagectomy. The risk factors for esophageal anastomotic stricture still remain controversial. METHODS MEDLINE, Cochrane Library, and EMBASE were searched to identify observational studies reporting the risk factors for esophageal anastomotic stricture after esophagectomy. A meta-analysis was conducted to investigate the impact of various risk factors on esophageal anastomotic stricture. The GRADE [Grading of Recommendations Assessment, Development and Evaluation] approach was used for quality assessment of evidence on outcome levels. RESULTS This review included 14 studies evaluating 5987 patients.The meta-analysis found that anastomotic leakage (odds ratio [OR]: 2.75; 95% confidence interval[CI]:2.16-3.49), cardiovascular disease [OR:1.62; 95% CI: 1.22-2.16],diabete [OR: 1.62; 95% CI: 1.20-2.19] may be risk factors for esophageal anastomotic stricture.There were no association between neoadjuvant therapy [OR: 0.78; 95% CI:0.62-0.97], wide gastric conduit [OR:0.98; 95% CI: 0.37-2.56],mechanical anastomosis [OR: 0.84; 95% CI:0.47-1.48],colonic interposition[OR:0.20; 95% CI: 0.12-0.35],and transhiatal approach[OR:1.16; 95% CI:0.81-1.64],with the risk of esophageal anastomotic stricture. CONCLUSIONS This meta-analysis provides some evidence that anastomotic leakage,cardiovascular disease and diabete may be associated with higher rates of esophageal anastomotic stricture.Knowledge about those risk factors may influence treatment and procedure-related decisions,and possibly reduce the anastomotic stricture rate.
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Affiliation(s)
- Yuan Zhong
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Ruijuan Sun
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
- School of Nursing, Shandong Second Medical University, Weifang, Shandong, China
| | - Wei Li
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Weiqian Wang
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Jianpeng Che
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Linlin Ji
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China
| | - Bingrong Guo
- School of Clinical Medicine, Shandong Second Medical University, Weifang, Shandong, China
| | - Chunbo Zhai
- Department of Thoracic Surgery, Weifang People's Hospital, Weifang, Shandong, China.
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Comparison of the Efficacy and Safety of Endoscopic Incisional Therapy and Balloon Dilatation for Esophageal Anastomotic Stricture. J Gastrointest Surg 2021; 25:1690-1695. [PMID: 33051806 DOI: 10.1007/s11605-020-04811-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 09/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Benign esophageal anastomotic strictures have typically been treated using endoscopic methods, often with balloon dilatation (BD). However, recurrent esophageal strictures after BD have been reported. We evaluated the efficacy and safety of endoscopic incisional therapy (EIT) and BD for treating an anastomotic stricture after a total gastrectomy. METHODS Subjects who underwent EIT or BD as a first treatment for esophagojejunostomy anastomotic stricture after a total gastrectomy between January 2010 and December 2018 were eligible. The medical records of these cases were retrospectively reviewed. Stricture was defined as an inability to pass a normal diameter endoscope (10.2 mm). The stricture area was incised under direct vision with the nano-insulated-tip knife in a radial fashion parallel to the longitudinal axis of the esophagus. RESULTS Twenty-one patients in our database presented with benign anastomotic stricture after a total gastrectomy for advanced gastric cancer. The BD group included 12 patients. The remaining nine patients underwent EIT, and three of these cases received an immediate additional BD. The re-stricture rate was significantly different between the BD and EIT groups (41.7% vs. 0%, respectively; P = 0.045). There were no significant differences in procedure time, interval from surgery to first stricture, hospitalization period, or complication rates between the groups. One patient developed a microperforation during BD and was treated without surgical intervention. CONCLUSIONS EIT is a safe and effective primary treatment modality compared with BD for esophagojejunostomy anastomotic stricture after a total gastrectomy as it shows a significantly lower re-stricture rate.
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Chen M, Cao J, Huang D, Zhang B, Pan L, Zhang Z, Wang Z, Ye Y, Xiu D, Li D, Cai X. End-to-end intestinal anastomosis using a novel biodegradable stent for laparoscopic colonic surgery: a multicenter study. Surg Today 2019; 49:1003-1012. [PMID: 31256255 DOI: 10.1007/s00595-019-01841-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 06/02/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Our animal studies have demonstrated the safety and feasibility of end-to-end intestinal anastomosis using a stent for laparoscopic colonic surgery. Therefore, we designed a non-inferiority trial to investigate the outcomes of stent anastomosis (SA) vs. those of conventional hand-sewn anastomosis (CA). METHODS A multicenter randomized controlled trial was conducted between December, 2016 and April, 2018. The primary outcome was the healing condition of the anastomoses, evaluated by endoscopy 6 months postoperatively. The secondary outcomes were the anastomotic completion time, anastomotic leak, intestinal obstruction, peritoneal effusion, and bleeding. Quality of life (QOL) was evaluated by questionnaires. RESULTS The subjects of this study were 60 patients, randomly divided into a SA group (n = 30) and a CA group (n = 30). There were no differences in anastomotic healing conditions (P = 1.00). The stent procedure was associated with a significantly shorter anastomosis time than the hand-sewn anastomosis (13.517 ± 4.281 vs. 20.333 ± 2.998 min, respectively; P < 0.001). There were no significant differences in anastomotic leakage, intestinal obstruction, peritoneal effusion, or bleeding between the groups. Questionnaires revealed almost no discrepancy between baseline QOL scores and those assessed 2, 4, 8, 12, and 24 weeks postoperatively in either group. CONCLUSIONS Intestinal anastomosis with a stent is a non-inferior strategy for laparoscopic colonic surgery, which requires less time for the anastomosis.
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Affiliation(s)
- Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
- Key Laboratory of Endoscopic Technique Research of Zhejiang Province, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Diyu Huang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Bin Zhang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Long Pan
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100032, China
| | - Zhenjun Wang
- Department of Anorectal Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100032, China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, 100089, China
| | - Dechuan Li
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, 310011, China
| | - Xiujun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China.
- Key Laboratory of Endoscopic Technique Research of Zhejiang Province, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China.
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Wang Y, Zhang X, Jiang Y, Ma G, Wang Z, Xue X, Sang S, Zhang L. Comparison of hand-sewn versus mechanical esophagogastric anastomosis in esophageal cancer: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15676. [PMID: 31169669 PMCID: PMC6571278 DOI: 10.1097/md.0000000000015676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Many studies have been conducted to compare the hand-sewn and mechanical staples in esophageal cancer (EC) patients who received esophagogastric anastomosis. However, the results remain controversial. Hence, the purpose of the meta-analysis is to evaluate the impact of different anastomosis methods on the early and long-term outcomes. METHODS We will perform a systematic electronic search of the PubMed, Embase, Cochrane Library, Web of Science for relevant articles published in English language. Pooled odds ratios will be calculated for the effect on discrete variables including anastomotic leakage, anastomotic strictures, 30-day mortality, quality of life, cardiac and pulmonary complications. The weighted mean difference was calculated for the effect size on continuous variables such as operative time and bleeding amount. We will use the software Review Manager 5.3 and STATA 14.0 to perform the meta-analysis to calculate the data synthesis. RESULTS The review will provide a high-quality synthesis of current evidence of the impact of different anastomosis methods on postoperative course in ECs after esophagectomy. The results will be published in a peer-reviewed journal. CONCLUSION This systematic review and meta-analysis will compare the different anastomosis methods in EC patients. The results will better offer some specific suggestions for esophagogastric anastomosis. PROSPERO REGISTRATION NUMBER This systematic review protocol has been registered in the PROSPERO network (No. CRD 42019109523).
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Affiliation(s)
| | - Xiangwei Zhang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Yuanzhu Jiang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Guoyuan Ma
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Zhaoyang Wang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
| | - Xianbiao Xue
- Department of Thoracic Surgery, Juye County People's Hospital, Juye
| | - Shaowei Sang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, People's Republic of China
| | - Lin Zhang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan
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Zhou P, Wang YL, Liu Q, Li JS. Fallback technique with circular stapler prevents anastomotic obstruction after esophagectomy: A case report of surgical approach. Medicine (Baltimore) 2019; 98:e13571. [PMID: 30813121 PMCID: PMC6408128 DOI: 10.1097/md.0000000000013571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE While performing esophago-ileal anastomosis after esophagectomy with circular staplers, the mucosal folds of the ileum can complicate stapling and lead to obstruction, especially when the diameter of the circular stapler is equal or greater than that of the small bowel lumen. PATIENT CONCERNS A 53-year-old man, presented with complaints of difficulty in swallowing for 2 weeks. Fifteen years previously, he had undergone partial gastrectomy for gastric ulcers. DIAGNOSIS The endoscopy showed that there was a large ulcer in the middle-third of the esophagus, about 28 to 32 cm from the incisors. Biopsy of the ulcer confirmed esophageal squamous cell carcinoma. INTERVENTIONS We performed an esophageal replacement using the right colon with circular staplers, but anastomotic site occurred due to stacking of the mucosa ahead of the stapler. To revise the anastomosis, we inserted the stapler 2 to 3 cm farther into the lumen than the intended site of anastomosis, and then pulled it back and rotated the stapler to complete the anastomosis. Consequently, the obstruction was corrected. OUTCOMES With nearly 16 months' follow-up duration until now, the patient has no difficulty swallowing and has twice received chemotherapy, and returned to his normal life relatively. LESSONS In the event of potential anastomotic obstruction due to accumulated mucosa, the stapler fallback technique can be successfully used achieve patent anastomosis.
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Affiliation(s)
| | - Ya-Li Wang
- Department of Pediatric Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Jie MM, Hu CJ, Tang B, Xie X, Lin H, Yu J, Yang SM. Circular incision and cutting, a novel treatment for patients with esophageal cancer with anastomotic stricture after esophagectomy. J Dig Dis 2019; 20:25-30. [PMID: 30484968 DOI: 10.1111/1751-2980.12689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/19/2018] [Accepted: 11/23/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic balloon dilation (EBD) is still considered the standard treatment for patients with anastomotic strictures after esophagectomy. However, repeated dilation sessions are often required to maintain the lumen patency. We therefore developed a novel method called circular incision and cutting (CIC) and compared the efficacy of CIC and EBD among patients with anastomotic strictures after esophagectomy or gastrectomy. METHODS In this retrospective study, 71 consecutive patients with esophageal cancer with anastomotic strictures after esophagectomy or gastrectomy between January 2011 and December 2016 were included. Among them, 22 patients received CIC therapy and 49 were treated with EBD. RESULTS The dysphagia in all patients immediately ameliorated and no serious adverse events requiring further intervention were observed after CIC therapy. Compared with EBD, CIC exhibited a greater score in the difference of dysphagia before and after treatment (1.73 vs 1.16, P = 0.03). Moreover, the interval of restenosis and 6-month lumen patency in CIC had a better effect than that in EBD (88.07 days vs 62.76 days, P = 0.001; dysphagia score 0.63 vs 1.44, P = 0.007). CONCLUSION The CIC method may be an effective and safe option for patients with esophageal cancer with anastomotic strictures after esophagectomy.
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Affiliation(s)
- Meng Meng Jie
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Chang Jiang Hu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Bo Tang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xia Xie
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Hui Lin
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jing Yu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Shi Ming Yang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, Chongqing, China
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Patel PK, Shah M, Patni S, Saini S. Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer. Indian J Cancer 2018; 54:669-672. [PMID: 30082555 DOI: 10.4103/ijc.ijc_381_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Anastomosis in gastrointestinal (GI) surgery is a commonly performed procedure. Irrelevant various methods of intestinal anastomosis were followed - recent advance is the use of a stapler as a device for GI anastomosis. Due to the use of staplers, technical failures are a rarity, anastomosis is more consistent and can be used at difficult locations. MATERIALS AND METHODS : Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy or video-assisted thoracoscopic surgery with linear stapler anastomosis. RESULTS The average follow-up was approximately 9 months. Anastomotic leakage was observed in three patients. On follow-up, two patients presented with difficulty in swallowing, and on upper GI endoscopy, they were found to have anastomotic site stricture. There was no perioperative mortality. CONCLUSION The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. As in this technique only two linear staplers are used in comparison to other techniques where three or more staplers are used, it is also cost-effective. The procedure deserves more attention and further application.
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Affiliation(s)
- Parth Kanaiyalal Patel
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Mishal Shah
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Sanjeev Patni
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Shashikant Saini
- Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
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Ishibashi Y, Fukunaga T, Mikami S, Oka S, Kanda S, Yube Y, Kohira Y, Enomoto T, Otsubo T. Triple-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis. Esophagus 2018; 15:88-94. [PMID: 29892931 PMCID: PMC5884892 DOI: 10.1007/s10388-017-0599-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 12/11/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far. METHODS The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap. RESULTS The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680-320 min). The intraoperative blood loss volume was 104.4 mL (range 240-30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II. CONCLUSIONS TRIQ can be performed easily and safely, and good short-term outcome can be expected.
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Affiliation(s)
- Yuji Ishibashi
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Tetsu Fukunaga
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Shinya Mikami
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shinichi Oka
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Satoshi Kanda
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Yukinori Yube
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Yoshinori Kohira
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University Hospital, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431 Japan
| | - Takeharu Enomoto
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Takehito Otsubo
- Division of Gastroenterological and General Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
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Singhal S, Kailasam A, Akimoto S, Masuda T, Bertellotti C, Mittal SK. Simple Technique of Circular Stapled Anastomosis in Ivor Lewis Esophagectomy. J Laparoendosc Adv Surg Tech A 2016; 27:288-294. [PMID: 27705608 DOI: 10.1089/lap.2016.0443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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). CONCLUSION Use of simple modifications to stapled EEA, as described here, has led to decrease in anastomotic leaks following Ivor Lewis esophagectomy.
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Affiliation(s)
- Saurabh Singhal
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona
| | - Aparna Kailasam
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Shunsuke Akimoto
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Takahiro Masuda
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona
| | - Carrie Bertellotti
- 2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
| | - Sumeet K Mittal
- 1 Norton Thoracic Institute, Dignity Health, Creighton University School of Medicine , Phoenix, Arizona.,2 Department of Surgery, Creighton University School of Medicine , Creighton Univesity Medical Center, Omaha, Nebraska
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Abstract
Survival for esophageal cancer has improved over the past four decades, probably as a result of a combination of more accurate staging, improved surgical outcomes, advances in adjuvant and neoadjuvant therapies, and the increasing implementation of multimodality treatment. Surgical resection still remains the mainstay in the treatment of localized esophageal adenocarcinoma. Multiple techniques have been described for esophagectomy, which are based on either a transthoracic or transhiatal approach. Despite proponents of each technique touting potential advantages such as superior oncologic resection with more extensive transthoracic lymphadenectomy compared to the relatively limited morbidity and mortality with a transhiatal resection, the superiority of one technique over another is not clear and may be relegated to a topic of historical significance in the era of minimally invasive surgery. With the increased acceptance of neoadjuvant multimodality therapy, both approaches have been shown to have acceptable outcomes. And in the hands of experienced surgeons, both techniques can provide excellent short-term results. Moreover, surgeon and hospital volume have shown to be strongly associated with improved operative morbidity and oncologic outcomes, which may supersede the type of approach selected for an individual patient.
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Affiliation(s)
- Jukes P Namm
- 1 Department of Surgery, Loma Linda University Health , Loma Linda, California
| | - Mitchell C Posner
- 2 Department of Surgery, University of Chicago Medicine , Chicago, Illinois
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Qiu B, Feng F, Gao S. Partial esophagogastrostomy with esophagogastric anastomosis below the aortic arch in cardiac carcinoma: characteristics and treatment of postoperative anastomotic leakage. J Thorac Dis 2015; 7:1994-2002. [PMID: 26716038 DOI: 10.3978/j.issn.2072-1439.2015.11.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Anastomotic leakage is a severe and common complication for surgeries of cardiac cancer. Here we explore the clinical features, diagnosis, and treatment strategies of anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis. METHODS From January 2009 to December 2013, 1,196 patients with cardiac carcinoma underwent esophagectomy and esophagogastric anastomosis in Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences. Of them, 25 patients developed symptomatic anastomotic leakage. Their clinical data were retrospectively reviewed. RESULTS Among these 25 patients with anastomotic leakage, three died after active treatment and fifteen healed with thoracic drainage time 18-115 days. The left seven patients who did not heal until discharge developed chronic infection sinus of anastomotic leakage. Without infection symptoms, they were discharged 30-100 days after surgery with nasoenteral tube and thoracic drainage. CONCLUSIONS Anastomotic leakage in cardiac carcinoma patients after esophagogastric anastomosis can be classified into five subtypes: occult type, left thoracic type, right thoracic type, mediastinal type, and mixd type. Subtyping of anastomotic leakage is useful and convenient for diagnosis and treatment.
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Affiliation(s)
- Bin Qiu
- Department of Thoracic Surgery, Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100021, China
| | - Feiyue Feng
- Department of Thoracic Surgery, Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100021, China
| | - Shugeng Gao
- Department of Thoracic Surgery, Cancer Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100021, China
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The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects. Arch Plast Surg 2015; 42:815-8. [PMID: 26618141 PMCID: PMC4660007 DOI: 10.5999/aps.2015.42.6.815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 07/14/2015] [Accepted: 09/07/2015] [Indexed: 11/16/2022] Open
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Avcioglu U, Ölmez Ş, Pürnak T, Özaslan E, Altıparmak E. Evaluation of efficacy of endoscopic incision method in postoperative benign anastomotic strictures of gastrointestinal system. Arch Med Sci 2015; 11:970-7. [PMID: 26528338 PMCID: PMC4624736 DOI: 10.5114/aoms.2015.52347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 10/27/2013] [Accepted: 12/04/2013] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Postoperative benign anastomotic strictures (POBAS) which develop after surgical resections of the gastrointestinal system (GIS) present with symptoms depending on location of the stricture. Diagnosis is confirmed by endoscopic and radiological methods. Although bougie or balloon dilatation is preferred in management, the endoscopic incision method (EIM) is also used with considerable success. In this trial, we aimed to evaluate EIM, which is one of the endoscopic dilatation techniques used in postoperative anastomotic stricture of GIS. MATERIAL AND METHODS A total of 20 POBAS patients, 12 men and 8 women, subjected to EIM intervention for strictures, were enrolled in the trial. The number of patients with upper GIS strictures was 6 (30%), while the number of cases with lower GIS strictures was 14 (70%). RESULTS Dilatation of the stricture was achieved in 15 (75%) patients with one treatment session, while more than one session of EIM was needed in 5 (25%) cases. Mean duration of follow-up of patients was 10.65 ±5.86 (0-25) months. Procedure-related complications developed in 8 patients. Among them, 7 were minor complications and improved without any treatment. In only 1 (5%) patient, perforation was observed as a major complication. Following EIM, recurrence of POBAS was observed in 5 (25%) patients. The following parameters were found to have an impact on successful outcome in EIM: presence or absence of a tortuous lumen in POBAS (p = 0.035) and length of stricture (p = 0.02), complications during the procedure (if any), and presence of single or multiple strictures. CONCLUSIONS Endoscopic incision method may be regarded as a favorable approach among first choice treatment alternatives in uncomplicated anastomotic strictures of GIS, or it may be used as an adjunctive dilatation method.
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Affiliation(s)
- Ufuk Avcioglu
- Department of Gastroenterology and Hepatology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Şehmus Ölmez
- Department of Gastroenterology and Hepatology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Tuğrul Pürnak
- Department of Gastroenterology and Hepatology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Ersan Özaslan
- Department of Gastroenterology and Hepatology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Emin Altıparmak
- Department of Gastroenterology and Hepatology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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Deng XF, Liu QX, Zhou D, Min JX, Dai JG. Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: A meta-analysis. World J Gastroenterol 2015; 21:4757-4764. [PMID: 25914488 PMCID: PMC4402326 DOI: 10.3748/wjg.v21.i15.4757] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 09/30/2014] [Accepted: 12/08/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcomes of hand-sewn (HS) and linearly stapled (LS) esophagogastric anastomosis for esophageal cancer.
METHODS: Before beginning this study, a rigorous protocol was established according to the recommendations of the Cochrane Collaboration. Databases and references were searched for all randomized controlled trials and comparative clinical studies that compared LS with HS esophagogastric anastomosis for esophageal cancer. The primary outcomes compared were anastomotic leak and stricture. Subgroup analyses were performed according to site of anastomosis.
RESULTS: Fifteen studies were used, comprising 3203 patients (n = 2027 LS and 1176 HS). Primary outcome analysis revealed a significant decrease in anastomotic leakage (RR = 0.51, 95%CI: 0.41-0.65; P < 0.00001) associated with LS anastomosis. A significantly reduced rate of anastomotic stricture associated with LS was also found (RR = 0.56, 95%CI: 0.49-0.64; P < 0.00001). A subgroup analysis according to the site of anastomosis revealed a significantly reduced rate of anastomotic stricture (P < 0.00001). Although there was no significant difference in the decrease in thoracic anastomotic leakage, there was a significant decrease in cervical anastomotic leakage associated with LS (P < 0.00001).
CONCLUSION: This meta-analysis indicates that the LS technique contributes to a reduced rate of leakage and stricture compared with the HS method.
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A randomized controlled Phase II/III study comparing endoscopic balloon dilation combined with steroid injection versus radial incision and cutting combined with steroid injection for refractory anastomotic stricture after esophagectomy: Japan Clinical Oncology Group Study JCOG1207. Jpn J Clin Oncol 2015; 45:385-9. [DOI: 10.1093/jjco/hyv006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Liu QX, Min JX, Deng XF, Dai JG. Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis. World J Gastroenterol 2014; 20:17218-17226. [PMID: 25493038 PMCID: PMC4258594 DOI: 10.3748/wjg.v20.i45.17218] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/24/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.
METHODS: A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electronic database search, hand search, and reference search were used to retrieve all randomized controlled trials that compared hand-sewn and mechanical esophagogastric anastomoses.
RESULTS: This study included 15 randomized controlled trials with a total of 2337 patients. The results revealed that there was no significant difference in the incidence of anastomotic leakage between the methods [relative risk (RR) = 0.77, 95% confidence interval (CI): 0.57-1.04; P = 0.09], but a subgroup analysis yielded a significant difference for the sutured layer and year of publication (Ps < 0.05). There was also no significant difference in the incidence of postoperative mortality (RR = 1.52, 95%CI: 0.97-2.40; P = 0.07). However, the anastomotic strictures rate was increased in the stapler group compared with the hand-sewn group (RR = 1.45, 95%CI: 1.11-1.91; P < 0.01) in the end-to-side subgroup, while the incidence of anastomotic strictures was decreased (RR = 0.34, 95%CI: 0.16-0.76; P < 0.01) in the side-to-side subgroup.
CONCLUSION: The stapler reduces the anastomotic leakage rate compared with hand sewing. End-to-side stapling increases the risk of anastomotic strictures, but side-to-side stapling decreases the risk.
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18
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Manson JM, Beasley WD. A personal perspective on controversies in the surgical management of oesophageal cancer. Ann R Coll Surg Engl 2014; 96:575-8. [PMID: 25350177 PMCID: PMC4474096 DOI: 10.1308/003588414x13946184901605] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2013] [Indexed: 11/22/2022] Open
Abstract
Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis.
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Affiliation(s)
- J McK Manson
- Abertawe Bro Morgannwg University Health Board, UK
| | - WD Beasley
- Abertawe Bro Morgannwg University Health Board, UK
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19
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Li GC, Xu Y, Zhang YC, Zhang FC, Wang Q, Ma QJ. Efficacy of single-layer continuous suture of the posterior wall in anastomosis involving a difficult location of the digestive tract. Oncol Lett 2014; 8:1567-1574. [PMID: 25202369 PMCID: PMC4156267 DOI: 10.3892/ol.2014.2397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 06/19/2014] [Indexed: 01/31/2023] Open
Abstract
Surgery for digestive tract disease predominantly consists of reconstruction and anastomosis. Due to the difficult location, anastomosis is extremely challenging and the risk of complication increases accordingly. Traditional manual anastomosis and the application of a stapling device are insufficient. Therefore, the aim of this study was to investigate the feasibility and safety of a novel manual method in a difficult anastomotic location, consisting of a single-layer continuous suture in the posterior wall. In total, 15 beagle dogs were included in the study; eight underwent surgery with the novel manual method for reconstruction and anastomosis of the digestive tract, while seven underwent surgery with the stapler device as a control. The subsequent postoperative complications were observed and, three months later, the anastomotic ports were excised, and the pathological formation and morphological changes were evaluated. No statistically significant differences were identified between the total (50.0 vs. 57.1%; P=0.782) and anastomotic (0.0 vs. 28.6%; P=0.200) complication rates in the manual suture and staple suture groups, respectively. Compared with the control group, the operative expenditure was lower in the manual group (1726.7±33.5 vs. 2135.7±43.1 renminbi; P=0.001), the diameter of the anastomotic port was larger in the manual group (3.04±0.07 vs. 2.24±0.25 cm; P=0.004) and the thickness of the anastomotic port (in cm) was thinner in the manual group (2.94±0.06 vs. 5.07±0.85; P=0.002). Furthermore, the pathological formation of the anastomositic port in the manual group was improved. The results of the current study suggest single-layer continuous suture of the posterior wall in anastomosis of the digestive tract to be a novel method with feasibility and safety, particularly in difficult anastomotic locations.
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Affiliation(s)
- Guo-Cai Li
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
| | - Yong Xu
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
| | - Yu-Chun Zhang
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
| | - Fang-Cheng Zhang
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
| | - Qi Wang
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
| | - Qing-Jiu Ma
- Department of General Surgery, Xi'an Gao Xin Hospital, Xi'an Jiao Tong University, Xi'an, Shaanxi 710075, P.R. China
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Li GC, Zhang YC, Xu Y, Zhang FC, Huang WH, Xu JQ, Ma QJ. Single-layer continuous suture contributes to the reduction of surgical complications in digestive tract anastomosis involving special anatomical locations. Mol Clin Oncol 2014; 2:159-165. [PMID: 24649327 DOI: 10.3892/mco.2013.215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/25/2013] [Indexed: 01/31/2023] Open
Abstract
The key point of digestive cancer surgery is reconstruction and anastomosis of the digestive tract. Traditional anastomoses involve double-layer interrupted suturing, manually or using a surgical stapler. In special anatomical locations, however, suturing may become increasingly difficult and the complication rate increases accordingly. In this study, we aimed to investigate the feasibility and safety of a new manual suturing method, the single-layer continuous suture in the posterior wall of the anastomosis. Between January, 2007 and August, 2012, 101 patients with digestive cancer underwent surgery in Xi'an Gaoxin Hospital. Of those patients, 27 underwent surgery with the new manual method and the remaining 74 underwent surgery using traditional methods of anastomosis of the digestive tract. Surgical time, intraoperative blood loss, drainage duration, complications, blood tests, postoperative quality of life (QOL) and overall expenditure were recorded and analyzed. No significant differences were observed in surgical time, intraoperative blood loss, temperature, blood tests and postoperative QOL between the two groups. However, compared with the control group, the new manual suture group exhibited a lower surgical complication rate (7.40 vs. 31.08%; P=0.018), lower blood transfusion volume (274.07±419.33 vs. 646.67±1,146.06 ml; P=0.053), shorter postoperative hospital stay (14.60±4.19 vs. 17.60±6.29 days; P=0.038) and lower overall expenditure (3,509.85±768.68 vs. 6,141.83±308.90 renminbi; P=0.001). Our results suggested that single-layer continuous suturing for the anastomosis of the digestive tract is feasible and safe and may contribute to the reduction of surgical complications and overall expenditure.
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Affiliation(s)
- Guo-Cai Li
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Yu-Chun Zhang
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Yong Xu
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Fang-Cheng Zhang
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Wei-Hua Huang
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Jian-Qing Xu
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
| | - Qing-Jiu Ma
- Department of General Surgery, Xi'an Gaoxin Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi 710075, P.R. China
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Kopelman D, Hatoum OA, Kimmel B, Monassevitch L, Nir Y, Lelcuk S, Rabau M, Szold A. Compression gastrointestinal anastomosis. Expert Rev Med Devices 2014; 4:821-8. [DOI: 10.1586/17434440.4.6.821] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kayani B, Garas G, Arshad M, Athanasiou T, Darzi A, Zacharakis E. Is hand-sewn anastomosis superior to stapled anastomosis following oesophagectomy? Int J Surg 2013; 12:7-15. [PMID: 24239928 DOI: 10.1016/j.ijsu.2013.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 10/17/2013] [Accepted: 11/02/2013] [Indexed: 12/19/2022]
Abstract
A best evidence topic was written according to a structured protocol. The question addressed was: In patients undergoing oesophagectomy is stapled anastomosis (STA) superior to hand-sewn anastomosis (HSA) with respect to post-operative outcomes. In total, 82 papers were found suitable using the reported search and 14 of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Existing evidence shows that STA is associated with reduced time to anastomotic construction and decreased intra-operative blood loss but increased risk of benign stricture formation compared to HSA. There is no difference between HSA and STA with respect to cardiac or respiratory complications, anastomotic leakage, duration of hospital admission or 30-day mortality. In HSA, increasing surgical experience and intra-operative air leakage testing after anastomotic creation are associated with reduced risk of anastomotic leakage. Further adequately powered studies will enable identification of other local and systemic factors influencing anastomotic healing, which will lead to improved patient and anastomotic technique selection for optimal surgical outcomes.
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Affiliation(s)
- Babar Kayani
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK.
| | - George Garas
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Mubarik Arshad
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK
| | - Emmanouil Zacharakis
- Department of Surgery and Cancer, Imperial College London, Praed Street, London W2 1NY, UK.
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Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg 2013; 257:238-48. [PMID: 23001084 DOI: 10.1097/sla.0b013e31826d4723] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection. BACKGROUND DATA Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined. METHODS A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration. RESULTS Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66-1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95-2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16-2.42), and (3) reduced the length of the operation time (mean: -15.3 minutes, range: -28.1 to -2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration. CONCLUSION The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.
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Price TN, Nichols FC, Harmsen WS, Allen MS, Cassivi SD, Wigle DA, Shen KR, Deschamps C. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg 2013; 95:1154-60; discussion 1160-1. [PMID: 23395626 DOI: 10.1016/j.athoracsur.2012.11.045] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 11/19/2012] [Accepted: 11/19/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Little consensus exists and varying outcomes are reported when the 4 most common esophagogastric anastomotic techniques are compared: circular stapled (CS), hand sewn (HS), linear stapled (LS) (longitudinally stapled anastomosis), and modified Collard (MC) (combined linear and transverse stapled anastomosis). This report analyzes outcomes of these anastomotic techniques. METHODS From July 2004 through December 2008, all intrathoracic and cervical esophagogastric anastomoses at our institution were reviewed. RESULTS There were 432 patients (358 men, 74 women) who underwent primary esophagogastric operations. Median age was 64 years (range, 23-90 years). The approach was an Ivor Lewis esophagectomy in 254 patients (59%), transhiatal esophagectomy in 115 patients (27%), McKeown (3-hole) esophagectomy in 49 (11%) patients, minimally invasive esophagectomy in 9 (2.1%) patients, and thoracoabdominal esophagectomy in 6 (1.4%) patients. There were 268 intrathoracic (62%) and 164 cervical (38%) anastomoses. Anastomotic techniques included LS in 260 (60%) patients MC in 67 (16%) patients, HS in 57 (13%) patients, and CS in 48 (11%) patients. Operative mortality was 3.7%. Anastomotic leak occurred in 50 patients (11%). Grade III or IV leaks occurred in 21 patients (4.9%), including 13 in the chest (4.8%) and 8 in the neck (4.9%). Grade III or IV leaks occurred in 12 patients (4.6%) with LS anastomoses, in 4 (7.0%) patients with HS anastomoses, in 3 (6.2%) patients with CS anastomoses, and in 2 (3.0%) patients with MC anastomoses. HS anastomoses had the highest odds of leakage (p=0.01) and LS anastomoses had the lowest risk of stricture (p=0.006). CONCLUSIONS When performing an esophagogastric anastomosis, clinically significant leaks occur with similar frequency in both cervical and intrathoracic locations. The HS technique has the highest leak rate and the LS technique had the lowest rate of stricture formation.
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Affiliation(s)
- Theolyn N Price
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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Randomized trial comparing side-to-side stapled and hand-sewn esophagogastric anastomosis in neck. J Gastrointest Surg 2012; 16:1287-95. [PMID: 22528571 DOI: 10.1007/s11605-012-1885-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 04/03/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Leak from cervical esophagogastric anastomosis (CEGA) following esophagectomy is associated with morbidity and poor functional outcome. To address this issue, we conducted a randomized trial comparing "hand-sewn" with "stapled side-to-side" CEGA. METHODS Of 174 patients who underwent esophageal resection and CEGA between 2004 and 2010, 87 each were randomized to "hand-sewn" and "stapled side-to-side" CEGA [ www.Clinical Trials.gov: NCT00497549]. The primary outcome measure was anastomotic leak rate. The secondary outcome measures included CEGA construction time and occurrence of anastomotic stricture during follow up. RESULTS The overall anastomotic leak rate was 17.2% (major leaks: 8 %). The leak rate was similar among the two groups (hand-sewn: 14/87, stapled: 16/87; p=0.33). The stapled anastomotic technique was faster (25 ±.5 min vs. 27 ± 5.5 min; p=0.02). The overall operative mortality and morbidity rates were 6.3 % and 40.8 %, respectively. At a median follow up of 12 (6-42) months, anastomotic stricture occurred in 24 (14.7 %) patients and was significantly more common in the "hand-sewn" group (17/82 vs. 7/81; p=0.045). CONCLUSION There were no differences in the leak rates and postoperative outcome between the two CEGA techniques. At follow up, anastomotic strictures occurred less frequently following stapled CEGA. The ideal CEGA technique remains elusive.
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Khan N, Bangash A, Sadiq M. Prognostic indicators of surgery for esophageal cancer: a 5 year experience. Saudi J Gastroenterol 2010; 16:247-52. [PMID: 20871187 PMCID: PMC2995091 DOI: 10.4103/1319-3767.70607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND/AIM To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer. MATERIALS AND METHODS This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSS R for Windows. RESULTS Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl (P < 0.05) and Geansler's index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant (P = 0.051) on multivariate analysis. CONCLUSION Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler's index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer.
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Affiliation(s)
- Nadim Khan
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan
| | - Adil Bangash
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan,Address for correspondence: Dr. Adil Bangash, Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan. E-mail:
| | - Muzaffaruddin Sadiq
- Department of Surgery, Lady Reading Hospital, Post Graduate Medical Institute, Peshawar, N.W.F.P, Pakistan
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Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 2010; 101:527-33. [PMID: 20401920 DOI: 10.1002/jso.21510] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Anastomotic complications are responsible for significant morbidity and mortality following esophagectomy for cancer. Conflicting reports exist regarding the superiority of hand-sewn versus stapled techniques. This systematic review identified eight randomized clinical trials examining this issue. None of the studies reported significant differences in leak rate or early mortality. One study demonstrated a difference in stricture rates, with fewer for hand-sewn anastomoses. There is insufficient evidence to recommend one anastomotic technique over the other.
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Affiliation(s)
- Roger H Kim
- Division of Surgical Oncology, Department of Surgery, Louisiana State University Health Sciences Center in Shreveport, Feist-Weiller Cancer Center, Shreveport, Louisiana 71130-3932, USA.
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Primary incisional therapy with a modified method for patients with benign anastomotic esophageal stricture. Gastrointest Endosc 2009; 69:1029-33. [PMID: 19215919 DOI: 10.1016/j.gie.2008.07.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 07/04/2008] [Indexed: 01/10/2023]
Abstract
BACKGROUND Benign anastomotic esophageal stricture after surgical resection is not uncommon and requires repeated dilation sessions to maintain patency because of the significant recurrence rate with bougie or balloon dilation. OBJECTIVE Our study was designed to evaluate whether a modified method of incisional therapy is effective and maintains a good patency in a benign anastomotic esophageal stricture. DESIGN A prospective outcome study. SETTING Tertiary-care academic medical centers. PATIENTS A total of 24 patients with benign anastomotic esophageal strictures after esophagojejunostomy. INTERVENTIONS Under direct vision through a transparent hood, radial incisions parallel to the longitude of the esophagus were performed by pulling up the Iso-Tome or insulated-tip-knife. MAIN OUTCOME MEASUREMENTS Efficacy, safety, and long-term patency after procedures were evaluated. RESULTS During 24 months of follow-up observations, 21 of 24 patients (87.5%) who received only 1 dilation session resumed eating solid meals and had no dysphagia. Only 3 patients (12.5%) developed restricture at a mean of 1.6 months. Of the patients with a recurrence, 2 experienced no recurrence after one additional dilation session, and another patient was refractory and underwent 5 dilation sessions. The occurrence of restricture after incisional therapy was statistically more prevalent in long-segment stricture (>1 cm) (2/3 [66.7%]) than short-segment stricture (<1 cm) (1/21 [4.8%]) (P = .032). There were no significant procedure-related complications. LIMITATION Our study included a small number of patients. Therefore, further prospective randomized controlled trials are needed. CONCLUSIONS A modified method of incisional therapy as a primary treatment is safe and feasible, and appears to maintain a longer duration of patency in benign anastomotic esophageal stricture.
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Marjanovic G, Schrag HJ, Fischer E, Hopt UT, Fischer A. Endoscopic bougienage of benign anastomotic strictures in patients after esophageal resection: the effect of the extent of stricture on bougienage results. Dis Esophagus 2008; 21:551-7. [PMID: 18430180 DOI: 10.1111/j.1442-2050.2008.00819.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of our retrospective study was to determine the incidence of benign anastomotic strictures (BAS) in patients after esophageal resection and to examine the influence of the extent of BAS on the results of bougienage therapy. From January 2001 to July 2006, 79 patients at risk of BAS development were included in the study. BAS was diagnosed with a median delay of 8 weeks (4-26) postoperative in 23 patients (29%). A median of 4 bougienage sessions (2-20) was needed for success (success rate 100%). The mean follow-up time was 22 months [range 3-47]. There were no late recurrences of BAS. Five patients had an anastomosis diameter <5.5 mm and 14 patients >5.5 mm. There was no difference in median number of bougienage procedures in these subgroups (4.5 [2-9] vs. 4 [2-20]). Patients who presented with BAS earlier than 6 weeks postoperative had more procedures (median 8 [2-20] vs. 4 [2-9]) than those presenting later. Patients in whom first bougienage was possible to only 16 mm diameter needed more procedures than patients in whom first dilation was possible to more than 16 mm (median 5.5 [3-20] vs. 3 [2-9]). In conclusion, both early BAS development and the diameter of bougienage at first endoscopy, but not the extent of stricture, seem to be predictive factors for longer bougienage therapy. In order to influence the BAS formation early, we now routinely examine every patient after esophageal resection endoscopically in the 6th postoperative week.
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Affiliation(s)
- G Marjanovic
- Department of General and Visceral Surgery, University Hospital of Freiburg, Freiburg, Germany.
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30
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Blackmon SH, Correa AM, Wynn B, Hofstetter WL, Martin LW, Mehran RJ, Rice DC, Swisher SG, Walsh GL, Roth JA, Vaporciyan AA. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg 2007; 83:1805-13; discussion 1813. [PMID: 17462404 DOI: 10.1016/j.athoracsur.2007.01.046] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2006] [Revised: 01/22/2007] [Accepted: 01/23/2007] [Indexed: 12/14/2022]
Abstract
BACKGROUND A cervical side-to-side stapled esophagogastric anastomosis appears to decrease morbidity compared with traditional hand-sewn techniques. We evaluated our experience with this novel technique in intrathoracic anastomoses and compared the outcome with circular-stapled or hand-sewn techniques. METHODS All patients undergoing transthoracic esophagectomy from 1999 to 2005 for esophageal cancer with gastric replacement were reviewed. A prospective quality improvement database, telephone interview, and chart review were used to collect data. A side-to-side stapled anastomosis was done in 44 patients, circular-stapled anastomosis in 147, and hand-sewn anastomosis in 23. Propensity scores were generated from 14 variables, which were then used to generate 23 patient triplets. End points included leak, dysphagia, stricture, other major complications, and overall survival. Follow-up was available on all patients. RESULTS For matched triplet comparison, no significant difference was noted in anastomotic leaks (8.7% with side-to-side stapled, 4.3% with circular-stapled, and 4.3% with hand-sewn; p = 0.78). Postoperative dysphagia was significantly higher in hand-sewn anastomoses at 56.5% versus 26.1% with side-to-side stapled and 21.7% with circular-stapled (p = 0.04). Stricture requiring esophageal dilation was also increased in hand-sewn at 34.8% versus 8.7% with side-to-side stapled and 8.7% with circular-stapled (p = 0.04). No difference was noted in perioperative mortality, long-term survival, or locoregional recurrences between techniques. CONCLUSIONS In this carefully matched group of patients, intrathoracic use of the side-to-side stapled esophagogastric anastomosis in esophageal cancer patients is safe and effective. Postoperative dysphagia and need for stricture dilation may be decreased using a stapled compared with a traditional hand-sewn anastomosis.
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Affiliation(s)
- Shanda H Blackmon
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Takeyama H, Sawai H, Sato M, Akamo Y, Yamamoto M, Funahashi H, Manabe T. A new technique for intestinal isoperistaltic anastomosis utilizing a linear stapler for enlargement after anastomosis performed with a circular stapler. Surg Endosc 2007; 21:1891-4. [PMID: 17436044 DOI: 10.1007/s00464-007-9336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Revised: 10/29/2006] [Accepted: 11/20/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND The high incidence of anastomotic stenosis after gastrointestinal surgery using circular staplers is a major problem. In response, we have developed a new technique that uses a linear stapler to enlarge an anastomotic opening made using a circular stapler. METHODS Anastomoses were created by the new technique or by the conventional approach using a circular stapler in pig small intestine. The method was also applied in treatment of a colon cancer patient. RESULTS The area of the anastomotic opening obtained with the new technique was more than 3 times that in the control (p < 0.001), with no significant difference between the methods in a leak test. Follow-up of the patient undergoing surgery with this approach revealed an uneventful course with a widely patent anastomosis confirmed after 3 months. CONCLUSIONS This procedure provides a larger anastomotic opening than conventional anastomosis with circular staplers, without impairing the integrity of the anastomosis.
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Affiliation(s)
- H Takeyama
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-ku, Nagoya, 467-8601, Japan.
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Abstract
This study was conducted to evaluate the mid-term results of cervical esophagogastric anastomosis using a side-to-side stapled anastomosis method for treatment of patients with malignant esophageal disease. A total of 13 patients were reviewed retrospectively from January 2001 to November 2005 who underwent total esophagectomy through a right thoracotomy, gastric tube formation through a midline laparotomy and finally a cervical esophagogastric anastomosis. Average patient age was 62.6 yr old and the male to female ratio was 11:2. The mean anastomosis time was measured to be about 32.5 min; all patients were followed for about 22.8+/-9.9 months postoperatively. There were no early or late mortalities. There were no complications of anastomosis site leakage or conduit necrosis. A mild anastomotic stricture was noted in one patient, and required two endoscopic bougination procedures at postoperative 4th month. Construction of a cervical esophagogastric anastomosis by side-to-side stapled anastomosis is relatively easy to apply and can be performed in a timely manner. Follow up outcomes are very good. We, therefore, suggest that the side-to-side stapled anastomosis could be used as a safe and effective option for cervical esophagogastric anastomosis.
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Affiliation(s)
- Won-Min Jo
- Department of Thoracic and Cardiovascular Surgery, Ansan Hospital, Korea University School of Medicine, Seoul, Korea.
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33
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Abstract
Anastomotic leaks continue to be a source of considerable morbidity and mortality after esophageal resection. Careful attention to the contributing factors to the development of a leak, particularly conduit ischemia and anastomotic technique, can reduce the incidence of anastomotic complications postoperatively. Selective management of leaks, including non-operative treatment when indicated, will maximize the chance for a successful outcome.
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Affiliation(s)
- John D Mitchell
- Section of Thoracic Surgery, University of Colorado School of Medicine, Denver 80262, USA.
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Taylor BL, Smith GB, McQuillan PJ, Caldwell MTP, Walsh TN, Hennessy TPJ, Watson A, Allen PR. Timing of extubation after oesophagectomy. Br J Surg 2005. [DOI: 10.1002/bjs.1800810753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- B L Taylor
- Department of Intensive Care Medicine, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - G B Smith
- Department of Intensive Care Medicine, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - P J McQuillan
- Department of Intensive Care Medicine, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
| | - M T P Caldwell
- Department of Clinical Surgery, St James's Hospital, Dublin 8, Ireland
| | - T N Walsh
- Department of Clinical Surgery, St James's Hospital, Dublin 8, Ireland
| | - T P J Hennessy
- Department of Clinical Surgery, St James's Hospital, Dublin 8, Ireland
| | - A Watson
- The Wellington Hospital, Wellington Place, London NW8 9LE, UK
| | - P R Allen
- The Wellington Hospital, Wellington Place, London NW8 9LE, UK
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35
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Behzadi A, Nichols FC, Cassivi SD, Deschamps C, Allen MS, Pairolero PC. Esophagogastrectomy: the influence of stapled versus hand-sewn anastomosis on outcome. J Gastrointest Surg 2005; 9:1031-40; discussion 1040-2. [PMID: 16269373 DOI: 10.1016/j.gassur.2005.06.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2005] [Accepted: 06/06/2005] [Indexed: 01/31/2023]
Abstract
Successful anastomosis is essential for favorable esophagogastrectomy outcomes. Before July 2002, almost all esophagogastric anastomoses at our institution were hand-sewn. We then began using linear stapled anastomotic techniques. This review compares patient outcomes with both techniques. From July 2001 to June 2004, 280 consecutive esophagogastrectomy patients (235 men and 45 women) were reviewed (median age, 65 years). The anastomosis was intrathoracic in 206 patients (74%) and cervical in 74 (26%). Anastomoses were hand-sewn in 205 patients (73%) and linear stapled in 75 (27%). Stapled anastomoses were intrathoracic in 33 patients (16%) and cervical in 42 (57%). Anastomotic leaks occurred in 30 patients (11%); 26 (12.7%) in the hand-sewn and 4 (5.3%) in the linear stapled group (P = .008). Leaks were asymptomatic in 17 patients (57%). Dilatation was required in 70 hand-sewn anastomoses (34%) and in 11 stapled (14.6%) (P = .001). Hand-sewn anastomoses were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67-19.27) and 3.58 (1.66-8.34), respectively. A linear stapled anastomosis is safe and associated with both a significantly lower leak rate and the need for dilatation compared with hand-sewn anastomosis. This nonrandomized series suggests that linear stapled anastomosis is the preferred technique regardless of anastomotic location.
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Affiliation(s)
- Abdollah Behzadi
- Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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36
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Ercan S, Rice TW, Murthy SC, Rybicki LA, Blackstone EH. Does esophagogastric anastomotic technique influence the outcome of patients with esophageal cancer? J Thorac Cardiovasc Surg 2005; 129:623-31. [PMID: 15746747 DOI: 10.1016/j.jtcvs.2004.08.024] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE We sought to compare the outcome of patients with esophageal cancer who had either modified Collard or standard hand-sewn cervical esophagogastric anastomoses in reconstruction during esophagectomy. METHODS From March of 1996 to October of 2002, 274 patients with esophageal cancer underwent esophagectomy with gastric replacement and cervical esophagogastric anastomosis. Beginning in March of 2001, a modified Collard technique (stapled) was used in most patients (n = 86) for cervical esophagogastric anastomosis; a standard hand-sewn technique (sewn) was used in all others (n = 188). Using a propensity score based on 8 variables (age, gender, race, surgeon, surgical approach, pathologic stage, histologic cell type, and induction chemoradiotherapy), 85 patient pairs were matched and followed for time-related events. Outcome comparisons included cervical wound infection, cervical anastomotic leak, other hospital complications, length of stay, anastomotic dilatation, reflux symptoms, and survival. RESULTS At 30 days, freedom from cervical wound infection was 92% for stapled versus 71% for sewn anastomoses ( P = .001), and freedom from cervical anastomotic leak was 96% versus 89% ( P = .09), respectively. Other hospital complications occurred in 58% and 49%, respectively ( P = .17). Median length of stay was 10 days for both ( P = .3). At 2 years, freedom from anastomotic dilatation was 34% for stapled versus 10% for sewn anastomoses ( P < .0001), and the mean number of dilatations per patient was 2.4 versus 4.1 ( P = .0001), respectively. Reflux was rare for both. Thirty-day, 6-month, and 24-month survivals were 98%, 91%, and 77% for stapled anastomoses and 98%, 88%, and 69% for sewn anastomoses ( P = .3). CONCLUSIONS The modified Collard anastomotic technique dramatically reduces morbidity after esophagectomy. It should replace hand-sewn esophagogastric anastomoses.
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Affiliation(s)
- Sina Ercan
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA
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Martin ZL, Sweeney KJ, Gorey TF. Peroral and transgastric esophageal anastomosis with flexible shaft remote-control stapler (SurgASSIST). Surg Laparosc Endosc Percutan Tech 2004; 14:230-3. [PMID: 15472555 DOI: 10.1097/01.sle.0000136661.58292.5b] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Stapled cervical esophageal anastomoses are technically challenging and are associated with relatively high complication rates, particularly in leaks and anastomotic strictures. We describe the use of a flexible shaft, remote-control, circular stapling device in forming high esophageal anastomoses in 2 patients. Retrograde transgastric and prograde peroral approaches are evaluated comparing ease of technical application and outcomes. Both procedures were performed after total esophagectomy for cancer in a 72-year-old male patient with preoperative down-staging and a 78-year-old female who proceeded directly to surgery. The introduction of rigid staplers in the esophagus by either route can be difficult and technical pointers and the potential applications of the flexible SurgASSIST device are discussed. Potential benefits include shorter time for constructing the anastomosis and a wider lumen resulting in possible cost benefit. Both patients had uneventful technical construction of stapled anastomoses, and the only complication in the female was a leak in the gastric close-off at the site of introduction of the flexshaft. Both are alive and well without recurrence at 2 years and 22 months.
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38
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Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic complications following esophagectomy. Semin Thorac Cardiovasc Surg 2004; 16:124-32. [PMID: 15197687 DOI: 10.1053/j.semtcvs.2004.03.011] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Since the first reports of esophageal resection for the treatment of various esophageal diseases and disorders, morbidity related to the anastomosis and the chosen replacement conduit have remained a frequent nemesis, a constant concern, and an ongoing area of research and experimentation. In this review of this key component of esophageal resection, an analysis is presented of the most frequent complications related to the anastomosis and conduit: anastomotic leak, conduit necrosis, and conduit stricture. In each case, a review of the current pertinent literature and experience is reported with a view to providing management recommendations to minimize or prevent occurrences, to improve timely diagnosis and to best treat these complications when they arise.
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Affiliation(s)
- Stephen D Cassivi
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Caporossi C, Cecconello I, Aguilar-Nascimento JE, Venço F, Gama-Rodrigues JJ. Hand-sewn and stapled esophageal anastomosis: experimental study in dogs. Acta Cir Bras 2004. [DOI: 10.1590/s0102-86502004000400002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
PURPOSE: To compare experimentally, the healing of cervical oesophageal anastomoses performed either with stapler or 2-layer hand-sewn sutures. METHODS: Thirty six dogs were randomised to two groups: stapled anastomoses (n = 18); hand-sewn anastomoses (n = 18). Each group was divided into three subgroups, corresponding to the day of sacrifice (3rd, 7th and 14th postoperative day). Healing was assessed by: a) anatopathology b) anastomotic resistance to bursting pressure test; c) quantification of hidroxyproline RESULTS: Group 1 heal by second intention, group 2 showed a healing by first intention. Bursting pressure was similar between groups at day 3, though group 1 animals showed it significantly higher at day 7and day 14 compared with group 2. Statiscally, there were no interaction between the day of sacrifice and groups, as well as there was no difference among the dates of observation regarding the results of hidroxyproline CONCLUSIONS: a) mechanical suture is more resistant than hand-sewn; b) In stapler anastomoses, healing was as secondary union, whereas in hand-sewn anastomoses, healing was by first intention; c) no correlation was found in the results of bursting pressure and hidroxyproline quantification.
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40
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Rizk NP, Bach PB, Schrag D, Bains MS, Turnbull AD, Karpeh M, Brennan MF, Rusch VW. The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma. J Am Coll Surg 2004; 198:42-50. [PMID: 14698310 DOI: 10.1016/j.jamcollsurg.2003.08.007] [Citation(s) in RCA: 288] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Efforts to improve surgical outcomes have traditionally focused on improving preoperative patient selection and reducing the risk of postoperative medical complications. Strategies to optimize surgical technique have been less well studied. We sought to assess the relation between complications related to surgical technique and outcomes after esophagogastrectomy for cancer. STUDY DESIGN Medical records of 510 consecutive patients undergoing esophagogastrectomy for invasive squamous cell carcinoma or adenocarcinoma at Memorial Sloan-Kettering Cancer Center from 1996 to 2001 were reviewed. Data on diagnosis, stage of disease, therapies received, surgical approach, patient comorbidities, technical complications, and postoperative medical complications and outcomes including length of stay and overall survival were determined by one reviewer of the medical records. The primary predictor was surgical complications and the primary outcome was survival. RESULTS Of the 150 patients studied 138 (27%) had complications directly attributable to surgical technique, such as an anastomotic leak, a paralyzed vocal cord, or chylothorax. At 3 years 43 of 138 patients (31%) with technical complications were alive, whereas 179 of 372 patients (48%) without technical complications were alive. Technical complications were associated with increased length of stay (median 23 days versus 11 days, p < 0.001), increased in-hospital mortality (12.3% versus 3.8%, p < 0.001), and a higher rate of medical complications (77.5% versus 47.3%, p < 0.001). After controlling for age, medical comorbidities, use of induction therapy, tumor stage, histology, and location, and completeness of resection the presence of a technical complication was highly predictive of poorer overall survival; the multivariable hazard ratio was 1.41 (1.22 to 1.63, p = 0.008). CONCLUSIONS Technical complications have a large negative impact on survival after esophagogastrectomy for cancer. Strategies to optimize surgical technique and minimize complications should improve outcomes in this cancer operation.
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Affiliation(s)
- Nabil P Rizk
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA
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41
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Takeyama H, Sato M, Akamo Y, Tanaka M, Hayakawa T, Hasegawa M, Sawai H, Yamamoto M, Ohara E, Manabe T. Keyhole procedure: a new technique for intestinal anastomosis with a large opening and less tissue trauma, using both circular and linear staplers. Surgery 2003; 133:345-8. [PMID: 12660653 DOI: 10.1067/msy.2003.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND We designed a new technique, termed the keyhole procedure, that uses a linear stapler to enlarge the anastomotic opening made with a circular stapler. The present study was performed to evaluate this technique in terms of maximum bursting pressure and area of anastomotic opening and compare it with conventional anastomosis using a circular stapler in an animal model. METHODS Anastomoses were created by the new technique or by the conventional method in swine small intestine. Anastomosis integrity was assessed by the air leakage test. Anastomotic openings were photographed and measured with an image analyzer. RESULTS It was found that the area of the anastomotic opening obtained with the new technique was more than 3 times that of the control (P <.001). There was no significant difference between the methods in maximum bursting pressure. CONCLUSIONS The keyhole procedure provides a larger anastomotic opening than conventional anastomosis with a circular stapler, without impairing the integrity of anastomosis.
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Affiliation(s)
- Hiromitsu Takeyama
- First Department of Surgery, Nagoya City University Medical School, Japan
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Abstract
Esophageal strictures from a variety of benign and malignant causes require dilation therapy when patients develop symptoms of dysphagia. Dilation can be accomplished using a variety of dilating devices and adjunctive techniques. The approach to management of esophageal strictures is reviewed with a focus on dilation technique and special considerations for various stricture types.
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Affiliation(s)
- Ronald J Lew
- Medicine Division of Gastroenterology, University of Pennsylvania Health System, Philadelphia, Pennsylvania, U.S.A
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Yannopoulos P, Katsoulis I, Chatzikonstantinou G, Veloudis G. Massive distension of the esophageal stump after cervical esophagogastrostomy in psychiatric patients. Dis Esophagus 2001; 13:248-50. [PMID: 11206643 DOI: 10.1046/j.1442-2050.2000.00121.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We present two similar cases of huge distension of the esophageal stump after cervical esophagogastrostomy in two psychotic patients. Chronic use of anti-psychotic drugs, in combination with prolonged mild anastomotic stricture, may have contributed to this situation.
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Affiliation(s)
- P Yannopoulos
- 2nd Surgical Department of the Evangelismos General Hospital, Athens, Greece
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Mathew G, Myers JC, Watson DI, Devitt PG, Jamieson GG. Motility across esophageal anastomoses after esophagectomy or gastrectomy. Dis Esophagus 2000; 12:276-82. [PMID: 10770362 DOI: 10.1046/j.1442-2050.1999.00072.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The esophageal motility of 23 patients who underwent esophagectomy or gastrectomy for carcinoma of the esophagus or gastroesophageal junction was recorded daily during the immediate post-operative period for high-pressure transients or other motility disturbances. Patients were divided into three subgroups according to the level of the esophageal anastomosis: group 1, neck (n = 4); group 2, thoracic (n = 14); group 3, diaphragmatic hiatus (n = 5). Peristalsis was absent in all patients studied during ventilation and sedation in the intensive care unit (five patients). Early post-operative esophageal motility after esophageal anastomosis varied somewhat with the length of residual esophagus. With short lengths of residual esophagus, no consistent motility pattern emerged. With longer lengths, early peristaltic activity was evident, but diminished over the first few post-operative days. Esophageal resection and anastomosis is associated with loss of peristalsis in the initial post-operative period, consistent with the concept of an esophageal ileus.
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Affiliation(s)
- G Mathew
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, South Australia, Australia
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Abstract
Anastomotic failure remains to be one of the main problems in esophageal surgery with leakage rates up to 30% being reported currently. We addressed that problem by modifying the gastric-tube formation in utilizing all of the gastric fundus and omitting the resection of the lesser gastric curvature and accompanying vessels. Experimentally, those fundus-rotation gastroplasties were significantly longer and better perfused than conventional gastroplasties. In a clinical series of 53 patients (45 male, eight female, range 42-83 years) undergoing esophageal resection (49 malignancies, four non-malignant esophageal disease), four anastomotic leakages were found (7.5%). Three patients died due to a bronchial leak and adult respiratory distress syndrome, one with a complete gastric-tube necrosis and one with a colon perforation, sepsis and multiorgan failure. Eight patients developed a significant anastomotic stricture requiring repeated endoscopic dilatations. From our experimental and clinical experience, we conclude that the favorable length and perfusion of fundus-rotation gastroplasties allow for safe anastomosis at either the cervical or thoracic level.
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Affiliation(s)
- M K Schilling
- Department for Visceral and Transplantation Surgery, University of Bern, Inselspital, Switzerland
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Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000; 119:277-88. [PMID: 10649203 DOI: 10.1016/s0022-5223(00)70183-8] [Citation(s) in RCA: 229] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Although the acute postoperative complications of a cervical esophagogastric anastomosis are less than those with an intrathoracic esophageal anastomosis, the long-term sequelae of a cervical anastomotic leak are not as minor as initially reported. Nearly 50% of cervical anastomotic leaks result in an anastomotic stricture, and the subsequent need for chronic dilatations negates the merits of an operation intended to restore comfortable swallowing. OBJECTIVE This study was undertaken to determine whether construction of a side-to-side stapled cervical esophagogastric anastomosis after transhiatal esophagectomy could reliably eliminate the majority of anastomotic leaks. METHODS In 114 consecutive patients undergoing transhiatal esophagectomy, a functional side-to-side cervical esophagogastric anastomosis was constructed with the Auto Suture Endo-GIA II stapler (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn) applied directly through the cervical wound. This side-to-side stapled anastomosis has 3 rows of staples. Early postoperative anastomotic morbidity, subsequent need for anastomotic dilatations, and patient satisfaction with swallowing were evaluated. RESULTS Before the side-to-side stapled anastomosis, the incidence of cervical esophagogastric anastomosis leak in over 1000 patients undergoing transhiatal esophagectomy having a manually sewn anastomosis varied from 10% to 15%. Among the 111 survivors of transhiatal esophagectomy and a side-to-side stapled anastomosis, there were 3 (2.7%) clinically significant anastomotic leaks. This lowered incidence of leaks has contributed to reduction in the average length of stay after an uncomplicated transhiatal esophagectomy to 7 days and has provided more comfortable swallowing, ease of subsequent esophageal dilatations, and greater patient satisfaction. CONCLUSIONS Construction of the cervical esophagogastric anastomosis with a side-to-side stapled anastomosis greatly reduces the frequency of anastomotic leaks and later strictures. The side-to-side stapled anastomosis is a major technical advance in the progression of refinements of transhiatal esophagectomy and a cervical esophagogastric anastomosis.
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Affiliation(s)
- M B Orringer
- Section of General Thoracic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI 48109, USA.
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Tarui T, Murata A, Watanabe Y, Kim SP, Inoue M, Shiozaki H, Taenaka N, Monden M. Earlier prediction of anastomotic insufficiency after thoracic esophagectomy by intramucosal pH. Crit Care Med 1999; 27:1824-31. [PMID: 10507605 DOI: 10.1097/00003246-199909000-00020] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the value of using intramucosal pH (pHi) measurements to evaluate the viability of the gastric tube after thoracic esophagectomy, and to determine whether these measurements may be used for early prediction of anastomotic insufficiency. DESIGN Prospective, observational study. SETTING University hospital in Japan. PATIENTS Thirty-nine patients who had undergone thoracic esophagectomy as a treatment for esophageal cancer. INTERVENTIONS The blood flow within the gastric tube was measured using a laser Doppler flowmeter during surgery. Periodic measurement of the pHi within the gastric tube (gastric pHi) began during surgery and continued until the second postoperative day. In 30 patients, the pHi within the rectum (rectal pHi) was measured simultaneously with the gastric pHi. The patients were divided into two groups: those patients who experienced anastomotic insufficiency constituted the leakage(+) group (n = 13); those patients who did not experience these complications were designated the leakage(-) group (n = 26). MEASUREMENTS AND MAIN RESULTS The gastric pHi values correlated significantly with simultaneous measurements of the blood flow at the anastomotic site (p < .01). The postoperative gastric pHi values increased gradually in the leakage(-) group but stopped increasing after surgery in the leakage(+) group. The rectal pHi values increased gradually after surgery in both groups. Furthermore, there was a significant difference between the two groups when their gastric pHi values were subtracted from their rectal pHi values from the morning of the first postoperative day until the morning of the second postoperative day (p < .05). CONCLUSIONS The gastric pHi values well reflected the viability of the gastric tube, especially when combined with the rectal pHi values. By measuring pHi, we can more accurately predict the risk of anastomotic insufficiency earlier after surgery and therefore give those patients who need it additional care to improve the viability of the gastric tube.
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Affiliation(s)
- T Tarui
- Department of Surgery II, Osaka University Medical School, Suita, Japan.
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Bisgaard T, Wøjdemann M, Larsen H, Heindorff H, Gustafsen J, Svendsen LB. Double-stapled esophagogastric anastomosis for resection of esophagogastric or cardia cancer: new application for an old technique. J Laparoendosc Adv Surg Tech A 1999; 9:335-9. [PMID: 10488828 DOI: 10.1089/lap.1999.9.335] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In colorectal surgery, the double-stapled technique is used extensively, because it is a fairly safe and simple procedure and is useful in relatively inaccessible areas. For these reasons, we adapted the procedure to the upper gastrointestinal tract. The present study reports our first experiences of the surgical efficacy using an esophagogastric double-stapled end-to-end anastomosis for subtotal esophagectomy and cardia resection. We retrospectively studied 31 patients treated between January 1991 and January 1997 with respect to hospital mortality, anastomotic leakage, cancer recurrence, and benign stricture rate. No hospital mortality was seen. One nonfatal anastomotic leak occurred (3%). In three patients, esophageal resection was not radical (10%). Of the remaining 28 patients, one had an anastomotic cancer recurrence (4%). Eleven of the remaining 27 patients (41%) developed a benign anastomotic stricture. All achieved normal swallowing after a median of two endoscopic dilatation procedures using TTS balloons. In conclusion, the double-stapled end-to-end anastomosis technique after resection for esophagogastric or cardia cancer is a simple and expeditious procedure, carrying an acceptable perioperative morbidity and cancer recurrence rate. Larger staplers are recommended to lower the high stricture rate observed after the usage of a 21-mm stapler in this study.
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Affiliation(s)
- T Bisgaard
- Department of Surgical Gastroenterology, Rigshospitalet, The National University Hospital, Copenhagen, Denmark.
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Pickleman J, Watson W, Cunningham J, Fisher SG, Gamelli R. The failed gastrointestinal anastomosis: an inevitable catastrophe? J Am Coll Surg 1999; 188:473-82. [PMID: 10235574 DOI: 10.1016/s1072-7515(99)00028-9] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND There is a great deal of conflicting data regarding risk factors for anastomotic leakage, with most studies being small and looking only at anastomoses performed at one level of the gastrointestinal (GI) tract. Surgeons have looked at patient and technical variables with inconsistent findings. The purpose of this study was to evaluate the incidence, possible predictive factors, and results of treatment of anastomotic dehiscence in patients undergoing operations at all levels of the GI tract. STUDY DESIGN We evaluated the records of 2,842 patients undergoing esophagogastrectomy, total or partial gastrectomy, enterectomy, and partial or subtotal colectomy over a 12-year period. Complete demographic data, comorbidity, and details regarding anastomotic technique were collected on all patients sustaining leaks along with diagnostic methods used, treatment modalities, and outcomes data. Using age and gender-matched case control methodology, we compared patients sustaining an anastomotic leak to those undergoing successful anastomoses. RESULTS Fifty-one of 2,842 patients (1.8%), ranging from 1.1% of enterectomy patients to 4.8% of total gastrectomy patients, sustained an anastomotic dehiscence. Foregut procedures were accompanied by a significantly increased rate of leakage, and depending on location, diagnosis was made between the 6th and 9th postoperative day. For each procedure, deaths from factors other than leakage far exceeded deaths from leaks. Standard risk stratifiers did not predict occurrence of leakage. Overall, 24% of patients sustaining a leak died, and this complication necessitated multiple reoperations and significantly increased length of hospital stay. CONCLUSIONS In view of these findings, standard preoperative strategies to prepare these patients for operation may prove unsuccessful, because minimizing the incidence of anastomotic leaks will have little overall impact on survival. In addition, efforts to accomplish early hospital discharge may prove hazardous, because many of these patients manifest their leaks later in the postoperative period than is generally assumed. Improved management of GI tract disruption, including aggressive attempts at diagnosis, ICU care, antibiotics, and nutritional support may further increase survival in these patients.
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Affiliation(s)
- J Pickleman
- Department of Surgery, Loyola University Medical Center, Maywood, IL 60153, USA
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50
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Pierie JP, de Graaf PW, van Vroonhoven TJ, Obertop H. Healing of the cervical esophagogastrostomy. J Am Coll Surg 1999; 188:448-54. [PMID: 10195730 DOI: 10.1016/s1072-7515(99)00003-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- J P Pierie
- Department of Surgery, University Hospital Utrecht, The Netherlands
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