Wolfgang Schröder1, Dimitri A Raptis2, Henner M Schmidt2, Suzanne S Gisbertz3, Johnny Moons4, Emanuele Asti5, Misha D P Luyer6, Arnulf H Hölscher1, Paul M Schneider2, Mark I van Berge Henegouwen3, Philippe Nafteux4, Magnus Nilsson7, Jari Räsanen8, Francesco Palazzo9, Stuart Mercer10, Luigi Bonavina5, Grard A P Nieuwenhuijzen6, Bas P L Wijjnhoven11, Piet Pattyn12, Peter P Grimminger13, Christiane J Bruns1, Christian A Gutschow2. 1. Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Germany. 2. Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland. 3. Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center, Amsterdam, the Netherlands. 4. Department of Thoracic Surgery, University Ziekenhuisen, Leuven, Belgium. 5. Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy. 6. Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands. 7. Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden. 8. Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Finland. 9. Department of Surgery, Thomas Jefferson University, Philadelphia, PA. 10. Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom. 11. Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands. 12. Department of Surgery, University Center, Ghent, Belgium. 13. Department of General, Visceral and Transplant Surgery, University Medical Center, Mainz, Germany.
Abstract
OBJECTIVE: The aim of this study was to describe anastomotic techniques used for total minimally invasive transthoracic esophagectomy (ttMIE) and to analyze the associated morbidity. BACKGROUND: ttMIE faces increasing application in surgical treatment of esophageal cancer. For esophagogastric reconstruction, different anastomotic techniques are currently used, but their effect on postoperative anastomotic leakage and morbidity has not been investigated. PATIENTS AND METHODS: Patients were selected from a basic dataset, collected during a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the Clavien-Dindo classification and the Comprehensive Complication Index (CCI). RESULTS: Five anastomotic techniques were identified in 966 patients after ttMIE: intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n = 90, purse-string n = 337), intrathoracic (n = 109) or cervical (n = 255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n = 175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs 17.2%, P = 0.601), but overall complications (56.7%% vs 63.7%, P = 0.029) and median 90-day CCI {21 [interquartile range (IQR) 0-36] vs 29 [IQR 0-40], P = 0.019} favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%), and cervical side-to-side linear-stapled esophagogastrostomies (11.8%) (P < 0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. CONCLUSION: Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.
OBJECTIVE: The aim of this study was to describe anastomotic techniques used for total minimally invasive transthoracic esophagectomy (ttMIE) and to analyze the associated morbidity. BACKGROUND: ttMIE faces increasing application in surgical treatment of esophageal cancer. For esophagogastric reconstruction, different anastomotic techniques are currently used, but their effect on postoperative anastomotic leakage and morbidity has not been investigated. PATIENTS AND METHODS: Patients were selected from a basic dataset, collected during a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the Clavien-Dindo classification and the Comprehensive Complication Index (CCI). RESULTS: Five anastomotic techniques were identified in 966 patients after ttMIE: intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n = 90, purse-string n = 337), intrathoracic (n = 109) or cervical (n = 255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n = 175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs 17.2%, P = 0.601), but overall complications (56.7%% vs 63.7%, P = 0.029) and median 90-day CCI {21 [interquartile range (IQR) 0-36] vs 29 [IQR 0-40], P = 0.019} favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%), and cervical side-to-side linear-stapled esophagogastrostomies (11.8%) (P < 0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. CONCLUSION: Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.
Authors: Philip C Müller; Diana Vetter; Joshua R Kapp; Christoph Gubler; Bernhard Morell; Dimitri A Raptis; Christian A Gutschow Journal: Int J Surg Protoc Date: 2021-03-18
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