Prospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Nov 27, 2019; 11(11): 407-413
Published online Nov 27, 2019. doi: 10.4240/wjgs.v11.i11.407
Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device
Robert Tyler, Amit Nair, Meagan Lau, James Hodson, Rizwan Mahmood, Jan Dmitrewski
Robert Tyler, Amit Nair, Meagan Lau, Jan Dmitrewski, Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
James Hodson, Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, United Kingdom
Rizwan Mahmood, Department of Gastroenterology, Russells Hall Hospital, Dudley DY1 2HQ, United Kingdom
Author contributions: Tyler R, Nair A and Dmitrewski J designed the research; Tyler R, Nair A, Lau M and Mahmood R performed the research; Tyler R and Hodson J analysed the data; Tyler R and Dmitrewski J wrote the manuscript; all authors critically reviewed and approved the manuscript.
Institutional review board statement: The study was registered No. CARMS 15403- 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.
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:
Corresponding author: Robert Tyler, MBChB, Surgeon, Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, United Kingdom.
Telephone: +44-12-13715883 Fax: +44-12-13715896
Received: May 18, 2019
Peer-review started: May 20, 2019
First decision: August 2, 2019
Revised: October 16, 2019
Accepted: November 4, 2019
Article in press: November 4, 2019
Published online: November 27, 2019
Research background

Anastomotic strictures are a highly morbid complication following oesophagectomy resulting in a reduced quality of life and a delay in returning to tolerating oral diet.

Research motivation

Heavy debate surrounds the topic of oesophageal anastomosis. Evidence of one anastomotic technique having a superior stricture rate over another is conflicting. Documenting the stricture rate with a circular stapled anastomosis and identifying predictive factors of stricture formation would help surgical decision making from here onwards. Earlier endoscopic assessment could prevent strictures from impairing quality of life.

Research objectives

The objectives of this study were therefore to evaluate the benign anastomotic stricture rate at one year, the median time to stricture and identify any factors which predicted stricture formation.

Research methods

We performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesphagectomy performed from 2004-2018 to determine the stricture rate. The database comprised a single-surgeon series of open, two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis. Clinicopathological variables were analysed to see if they could predict stricture formation by comparison of log-rank tests.

Research results

One hundred and fifty-four patients were available for analysis. A total of 15 patients developed strictures at a median of 99 d (interquartile range: 84-133) after surgery, giving a Kaplan-Meier estimated stricture rate of 10% at one year. The stricture rates were then compared across a range of factors, none of which were found to be significantly predictive of stricture.

Research conclusions

This study found a stricture rate of 10% at one year which was acceptable and comparable with other anastomotic techniques. This study found no factor to be predictive of stricture formation. Median time to stricture was 99 d, which stresses the importance of close clinical follow-up in the first six months to avoid missing this highly morbid complication. At the time of writing this is the largest study to specifically look at benign stricture rates using a circular stapling technique.

Research perspectives

First and foremost, this study documents a stricture rate associated with this technique which may influence surgical decision making. The median time to stricture of 99 d leads the authors to encourage open access clinic appointments in the first six months after surgery, to allow the prompt recognition and management of a stricture. It will inform large prospective multi-centre studies currently underway, such as the Oesophago-Gastric Anastomosis Audit, which aims to provide more detail on post-operative complications. The authors encourage large multi-centre collaboration in order to identify predictive factors for stricture formation, and definitively answer this research question.