There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy

Abstract

Introduction Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. Patients and methods 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. Results 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. Conclusion Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

Robot-assisted transthoracic hybrid esophagectomy versus open and laparoscopic hybrid esophagectomy: propensity score matched analysis of short-term outcome

“…However, a significant association between anastomotic leaks and the occurrence of DGE was not confirmed. None of the studies was able to show any influence of the surgical technique on the development of DGE following esophagectomy [21]. Thus, we are not able to provide any final sufficient explanation for this finding of our study.…”

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients

“…As the conduit recovers physiological function over time, pyloric procedures may not be needed in many patients 8 . Data on the impact of PP and PM on post-operative complications including anastomotic leak, respiratory complication and symptomatic DGCE are inconsistent, with some studies showing a reduction in complications, some showing no impact and some, in the case of BI, showing a possible increase in post-operative complications [9][10][11][12][13] . Furthermore, intra-operative pyloric drainage procedures are associated with increased symptomatic dumping and bile reflux 14 .…”

Gastric tube anatomic configuration after esophagectomy: An underestimated problem

“…This retrospective case study series brought several points contributing to delayed gastric emptying (leading to dysphagia, aspiration, and nutritional status), such as redundant or dilated conduit, endoscopic findings regarding pylorus status, and postoperative anatomical issues. 2 …”

“…However, the following points should be highlighted: (1) The assessment of gastric tube emptying is not clear in the literature, even for a dynamic x-ray swallowing contrast or technetium-99m scintigraphy; there are no parameters to determine it. 2 (2) The definition of pylorus functional obstruction and its assessment is uncertain. Most studies use endoscopic findings to suggest pylorus contraction or spasm, representing a subjective tool to state it.…”

“…Most studies use endoscopic findings to suggest pylorus contraction or spasm, representing a subjective tool to state it. 2 (3) Issues with gastric tube construction, such as wide conformation, twisted gastric pull-up, immediate postoperative gastric tube distension with axial direction deviation (simulating a sigmoid end-stage achalasia), and leakage anastomosis with stenosis. 3 (4) The time to adapt the new dietary habits to the new anatomical conformation (smaller amounts of food, more periods) is considerable.…”