Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2019; 11(7): 308-321
Published online Jul 27, 2019. doi: 10.4240/wjgs.v11.i7.308
Vascular calcification does not predict anastomotic leak or conduit necrosis following oesophagectomy
Benjamin J Jefferies, Emily Evans, James Bundred, James Hodson, John L Whiting, Colm Forde, Ewen A Griffiths
Benjamin J Jefferies, James Bundred, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
Emily Evans, Colm Forde, Department of Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, United Kingdom
James Hodson, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, United Kingdom
John L Whiting, Ewen A Griffiths, Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
Ewen A Griffiths, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
Author contributions: Jefferies BJ, Forde C, Whiting JL and Griffiths EA designed the research; Jefferies BJ, Bundred J and Evans E performed the research; Jefferies BJ and Hodson J analysed the data; Jefferies BJ and Griffiths EA wrote the manuscript; all authors critically reviewed and approved the manuscript.
Institutional review board statement: The study was registered No. CARMS-15096 with University Hospitals Birmingham Clinical Audit Registration and Management System (CARMS), who granted ethical approval.
Informed consent statement: Local ethical review was obtained and confirmed that no consent was needed due to the non-interventional nature of the study.
Conflict-of-interest statement: The authors declare no conflicts of interest.
STROBE statement: The authors have read the STROBE checklist, and the manuscript was prepared and revised according to the STOBE statement checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Ewen A Griffiths, MD FRCS, Consultant Surgeon, Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, United Kingdom. ewen.griffiths@uhb.nhs.uk
Telephone: +44-12-13715883 Fax: +44-12-1371 5896
Received: May 2, 2019
Peer-review started: May 9, 2019
First decision: June 12, 2019
Revised: June 17, 2019
Accepted: July 24, 2019
Article in press: June 24, 2019
Published online: July 27, 2019
Abstract
BACKGROUND

Anastomotic leaks (AL) and gastric conduit necrosis (CN) are serious complications following oesophagectomy. Some studies have suggested that vascular calcification may be associated with an increased AL rate, but this has not been validated in a United Kingdom population.

AIM

To investigate whether vascular calcification identified on the pre-operative computed tomography (CT) scan is predictive of AL or CN.

METHODS

Routine pre-operative CT scans of 414 patients who underwent oesophagectomy for malignancy with oesophagogastric anastomosis at the Queen Elizabeth Hospital Birmingham between 2006 and 2018 were retrospectively analysed. Calcification of the proximal aorta, distal aorta, coeliac trunk and branches of the coeliac trunk was scored by two reviewers. The relationship between these calcification scores and occurrence of AL and CN was then analysed. The Esophagectomy Complications Consensus Group definition of AL and CN was used.

RESULTS

Complication data were available in n = 411 patients, of whom 16.7% developed either AL (15.8%) or CN (3.4%). Rates of AL were significantly higher in female patients, at 23.0%, compared to 13.9% in males (P = 0.047). CN was significantly more common in females, (8.0% vs 2.2%, P = 0.014), patients with diabetes (10.6% vs 2.5%, P = 0.014), a history of smoking (10.3% vs 2.3%, P = 0.008), and a higher American Society of Anaesthesiologists grade (P = 0.024). Out of the 14 conduit necroses, only 4 occurred without a concomitant AL. No statistically significant association was found between calcification of any of the vessels studied and either of these outcomes. Multivariable analyses were then performed to identify whether a combination of the calcification scores could be identified that would be significantly predictive of any of the outcomes. However, the stepwise approach did not select any factors for inclusion in the final models. The analysis was repeated for composite outcomes of those patients with either AL or CN (n = 69, 16.7%) and for those with both AL and CN (n = 10, 2.4%) and again, no significant associations were detected. In the subset of patients that developed these outcomes, no significant associations were detected between calcification and the severity of the complication.

CONCLUSION

Calcification scoring was not significantly associated with Anastomotic Leak or CN in our study, therefore should not be used to identify patients who are high risk for these complications.

Keywords: Oesophagectomy, Anastomotic leak, Gastric conduit necrosis, Calcification, Computed tomography, Ischaemia

Core tip: Vascular calcification does not predict anastomotic leak (AL) or gastric conduit necrosis (CN) following oesophagectomy for malignancy. There is no association between vascular calcification and severity of AL or CN. AL is significantly more common in female vs male patients. Gastric CN is significantly more common in females, patients with diabetes, a history of smoking and a higher American Society of Anaesthesiologists grade. Inter-rater reliability for calcification scoring of the vessels supplying the gastric tube is excellent.