Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer.

Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.

Outcomes of Patients with Anastomotic Leakage After Transhiatal, McKeown or Ivor Lewis Esophagectomy: A Nationwide Cohort Study.

BACKGROUND: Anastomotic leakage has a great impact on clinical outcomes after esophagectomy. It has never been studied whether anastomotic leakage is of equal severity between different types of esophagectomy (i.e., transhiatal, McKeown and Ivor Lewis) in terms of postoperative mortality and morbidity. METHODS: All esophageal cancer patients with anastomotic leakage after transhiatal, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) registry. The primary outcome was 30-day/in-hospital mortality. Secondary outcomes included postoperative complications, re-operation and ICU readmission rate. RESULTS: Data from 1030 patients with anastomotic leakage after transhiatal (n=287), McKeown (n=397) and Ivor Lewis esophagectomy (n=346) were evaluated. The 30-day/in-hospital mortality rate was 4.5% in patients with leakage after transhiatal esophagectomy, 8.1% after McKeown and 8.1% after Ivor Lewis esophagectomy (P=0.139). After correction for confounders, leakage after transhiatal resection was associated with lower mortality (OR 0.152-0.699, P=0.004), but mortality after McKeown and Ivor Lewis esophagectomy was similar. Re-operation rate was 24.0% after transhiatal, 40.6% after McKeown and 41.3% after Ivor Lewis esophagectomy (P<0.001). ICU readmission rate was 24.0% after transhiatal, 37.8% after McKeown and 43.4% after Ivor Lewis esophagectomy (P<0.001). CONCLUSION: This study in patients with anastomotic leakage confirms a strong association between severity of clinical consequences and different types of esophagectomy. It supports the hypothesis that cervical leakage is generally less severe than intrathoracic leakage. The clinical impact of anastomotic leakage should be taken into account, in addition to its incidence, when different types of esophagectomy are compared by clinicians or researchers.

Propensity Score-Matched Analysis Comparing Minimally Invasive Ivor Lewis Versus Minimally Invasive Mckeown Esophagectomy.

INTRODUCTION: Totally minimally invasive esophagectomy (TMIE) is increasingly used in treatment of patients with esophageal carcinoma. However, it is currently unknown if McKeown TMIE or Ivor Lewis TMIE should be preferred for patients in whom both procedures are oncologically feasible. METHODS: The study was performed in 4 high-volume Dutch esophageal cancer centers between November 2009 and April 2017. Prospectively collected data from consecutive patients with esophageal cancer localized in the distal esophagus or gastroesophageal junction undergoing McKeown TMIE or Ivor Lewis TMIE were included. Patients were propensity score matched for age, body mass index, sex, American Society of Anesthesiologists classification, Charlson Comorbidity Index, tumor type, tumor location, clinical stage, neoadjuvant treatment, and the hospital of surgery. The primary outcome parameter was anastomotic leakage requiring reintervention or reoperation. Secondary outcome parameters were operation characteristics, pathology results, complications, reinterventions, reoperations, length of stay, and mortality. RESULTS: Of all 787 included patients, 420 remained after matching. The incidence of anastomotic leakage requiring reintervention or reoperation was 23.3% after McKeown TMIE versus 12.4% after Ivor Lewis TMIE (P = 0.003). Ivor Lewis TMIE was significantly associated with a lower incidence of pulmonary complications (46.7% vs 31.9%), recurrent laryngeal nerve palsy (9.5% vs 0.5%), reoperations (18.6% vs 11.0%), 90-day mortality (7.1% vs 2.9%), shorter median intensive care unit length of stay (2 days vs 1 day) and shorter median hospital length of stay (12 vs 11 days) (all P < 0.05). R0 resection rate was similar between the groups. The median number of examined lymph nodes was 21 after McKeown TMIE and 25 after Ivor Lewis TMIE (P < 0.001). CONCLUSIONS: Ivor Lewis TMIE is associated with a lower incidence of anastomotic leakage, 90-day mortality and other postoperative morbidity compared to McKeown TMIE in patients in whom both procedures are oncologically feasible.

Learning Curve and Associated Morbidity of Minimally Invasive Esophagectomy: A Retrospective Multicenter Study.

OBJECTIVE: To investigate the morbidity that is associated with the learning curve of minimally invasive esophagectomy. BACKGROUND: Although learning curves have been described, it is currently unknown how much extra morbidity is associated with the learning curve of technically challenging surgical procedures. METHODS: Prospectively collected data were retrospectively analyzed of all consecutive patients undergoing minimally invasive Ivor Lewis esophagectomy in 4 European expert centers. The primary outcome parameter was anastomotic leakage. Secondary outcome parameters were operative time and textbook outcome ("optimal outcome"). Learning curves were plotted using weighted moving average and CUSUM analysis was used to determine after how many cases the plateau was reached. Learning associated morbidity was calculated with area under the curve analysis. RESULTS: This study included 646 patients. Three of the 4 hospitals reached the plateau of 8% anastomotic leakage. The length of the learning curve was 119 cases. The mean incidence of anastomotic leakage decreased from 18.8% during the learning phase to 4.5% after the plateau had been reached (P < 0.001). Thirty-six extra patients (10.1% of all patients operated on during the learning curve) experienced learning associated anastomotic leakage, that could have been avoided if patients were operated by surgeons who had completed the learning curve. The incidence of textbook outcome increased from 28% to 53% and the mean operative time decreased from 344 minutes to 270 minutes. CONCLUSIONS: A considerable number of 36 extra patients (10.1%) experienced learning associated anastomotic leakage. More research is urgently needed to investigate how learning associated morbidity can be reduced to increase patient safety during learning curves.

Postoperative Outcomes of Minimally Invasive Gastrectomy Versus Open Gastrectomy During the Early Introduction of Minimally Invasive Gastrectomy in the Netherlands: A Population-based Cohort Study.

OBJECTIVE: To compare postoperative outcomes of minimally invasive gastrectomy (MIG) to open gastrectomy (OG) for cancer during the introduction of MIG in the Netherlands. BACKGROUND: Between 2011 and 2015, the use of MIG increased from 4% to 53% in the Netherlands. METHODS: This population-based cohort study included all patients with curable gastric adenocarcinoma that underwent gastrectomy between 2011 and 2015, registered in the Dutch Upper GI Cancer Audit. Patients with missing preoperative data, and patients in whom no lymphadenectomy or reconstruction was performed were excluded. Propensity score matching was applied to create comparable groups between patients receiving MIG or OG, using year of surgery and other potential confounders. Morbidity, mortality, and hospital stay were evaluated. RESULTS: Of the 1697 eligible patients, 813 were discarded after propensity score matching; 442 and 442 patients who underwent MIG and OG, respectively, remained. Conversions occurred in 10% of the patients during MIG. Although the overall postoperative morbidity (37% vs 40%, P = 0.489) and mortality rates (6% vs 4%, P = 0.214) were comparable between the 2 groups, patients who underwent MIG experienced less wound complications (2% vs 5%, P = 0.006). Anastomotic leakage occurred in 8% of the patients after MIG, and in 7% after OG (P = 0.525). The median hospital stay declined over the years for both procedures (11 to 8 days, P < 0.001). Overall, hospital stay was shorter after MIG compared with OG (8 vs 10 days, P < 0.001). CONCLUSIONS: MIG was safely introduced in the Netherlands, with overall morbidity and mortality comparable with OG, less wound complications and shorter hospitalization.

A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands.

OBJECTIVE: The aim of this study was to compare open esophagectomy (OE) with minimally invasive esophagectomy (MIE) in a population-based setting. BACKGROUND: Randomized controlled trials and cohort studies have shown that MIE is associated with reduced pulmonary complications and shorter hospital stay as compared to OE. METHODS: Patients who underwent transthoracic esophagectomy for cancer between 2011 and 2015 were selected from the national Dutch Upper Gastrointestinal Cancer Audit. Hybrid, transhiatal, and emergency procedures were excluded. Patients who underwent OE were compared with those treated by MIE. Propensity score matching was used to correct for differences in baseline characteristics. The primary endpoint was postoperative pulmonary complications; secondary endpoints were morbidity, mortality, convalescence, and pathology. RESULTS: Some 1727 patients were included. After propensity score matching the percentage of patients with 1 or more complications was 62.6% after OE (N = 433) and 60.2% after MIE (N = 433) (P = 0.468). Pulmonary complication rate did not differ between groups: 34.2% (OE) versus 35.6% (MIE) (P = 0.669). Anastomotic leak (15.5% vs 21.2%, P = 0.028) and reintervention rates (21.1% vs 28.2%, P = 0.017) were higher after MIE. Mortality was 3.0% in the OE group and 4.7% in the MIE group (P = 0.209). Median hospital stay was shorter after MIE (14 vs 13 days, P = 0.001). Percentages of R0 resections (93%) did not differ between groups. The median (range) lymph node count was 18 (2-53) (OE) versus 20 (2-52) (MIE) (P < 0.001). CONCLUSIONS: This population-based study showed that mortality and pulmonary complications were similar for OE and MIE. Anastomotic leaks and reinterventions were more frequently observed after MIE. MIE was associated with a shorter hospital stay.

Using the Comprehensive Complication Index to Assess the Impact of Neoadjuvant Chemoradiotherapy on Complication Severity After Esophagectomy for Cancer.

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery for patients with esophageal or junctional cancer has become a standard of care. The comprehensive complication index (CCI) has recently been developed and accounts for all postoperative complications. Hence, CCI better reflects the burden of all combined postoperative complications in surgical patients than the Clavien-Dindo score alone, which incorporates only the most severe complication. This study was designed to evaluate the severity of complications in patients treated with nCRT followed by esophagectomy versus in patients who underwent esophagectomy alone using the comprehensive complication index. STUDY-DESIGN: All patients included in the CROSS trial-a randomized, clinical trial on the value of nCRT followed by esophagectomy-were included. Complications were assessed and graded using the Clavien-Dindo classification. CCI was derived from these scores, using the CCI calculator available online ( www.assessurgery.com ). CCI of patients who underwent nCRT followed by surgery was compared with the CCI of patients who underwent surgery alone. RESULTS: In both groups 161 patients were included. The median (and interquartile range) CCI of patients with nCRT and surgery was 26.22 (17.28-42.43) versus 25.74 (8.66-43.01) in patients who underwent surgery alone (p = 0.58). There also was no difference in CCI between subgroups of patients with anastomotic leakage, pulmonary complications, cardiac complications, thromboembolic events, chyle leakage, and wound infections. CONCLUSIONS: Neoadjuvant chemoradiotherapy according to CROSS did not have a negative impact on postoperative complication severity expressed by CCI compared with patients who underwent surgery alone for potentially curable esophageal or junctional cancer.

A Quantified Scoring System for Postoperative Complication Severity Compared to the Clavien-Dindo Classification.

BACKGROUND/AIMS: Esophagectomies are associated with high morbidity. To assess the complication severity, the Clavien-Dindo classification (CDC) grades the most severe complication. However, it ignores additional complications that are equal or less severe. The comprehensive complication index (CCI) incorporates all complication severities. It might therefore be a better system to assess the severities. The aim of this study was to validate the CCI compared to the CDC. METHODS: A prospective database was used to analyze 621 patients, who underwent an esophagectomy between 1993 and 2005. The CCI was calculated and the relation with traditional parameters was assessed and compared to the relation of the CDC with these parameters. RESULTS: Complications occurred in 429 patients (69.1%). The correlation between the CCI and the CDC was r = 0.987, p < 0.01. The relation of the CCI with 3 out of 7 parameters was not significantly different compared to the relation of the CDC (p > 0.05). There was a significantly stronger relation (p < 0.05) of the CCI with length of stay (LOS) (r = 0.663 vs. 0.646), a prolonged LOS (r = 0.542 vs. 0.530), reintervention, (r = 0.437 vs. 0.422) and reoperation rate (0.489 vs. 0.471) than the CDC. CONCLUSION: Therefore, the CCI could be a promising scoring system that could be used to identify risks in surgical patient groups.

Improved Clinical and Survival Outcomes After Esophagectomy for Cancer Over 25 Years.

BACKGROUND: In recent decades, there have been major developments in the curative treatment of esophageal cancer, such as the implementation of positron emission tomography with computed tomography, neoadjuvant chemoradiotherapy, minimally invasive surgery, and postoperative care programs. This observational study examined clinical and survival outcomes after esophagectomy for cancer over 25 years. METHODS: Consecutive patients who underwent esophagectomy for cancer at a tertiary referral center between 1993 and 2018 were selected from a prospectively maintained database. Patients were assigned to 5 periods: 1993 to 1997, 1998 to 2002, 2003 to 2007, 2008 to 2012, and 2013 to 2017. The primary outcome was 5-year overall survival by using Kaplan-Meier log-rank tests for trends. RESULTS: A total of 1616 patients were analyzed. The median follow-up of surviving patients was 91.0 months (interquartile range [IQR], 62.6-127.5 months).The 5-year overall survival improved gradually from 32.8% to 48.2% over 25 years (P < .001). Hospital length of stay decreased from 16 days (median IQR, 14-24 days) in 1993 to 1997 to 11 days (IQR, 8-18 days) in 2013 to 2017 (P < .001). No decrease in mortality was encountered over 25 years, although over the last 5 years, in-hospital and 90-day mortality dropped from 4.2% and 8.3% in 2013 to 0% in 2017 (P < .05). Anastomotic leakages decreased from 26.4% to 9.7% between 2013 and 2017 (P < .001). CONCLUSIONS: Over the last 25 years, clinical outcomes and 5-year overall survival significantly improved in patients who underwent esophagectomy for cancer at this tertiary referral center.

Incidence and Treatment of Symptomatic Diaphragmatic Hernia After Esophagectomy for Cancer.

BACKGROUND: Diaphragmatic hernias after esophagectomy are mostly asymptomatic. However, they can also manifest with severe complications and be associated with high morbidity and mortality rates. The aims of this study were to assess the incidence, predictive factors, and preferred treatment of symptomatic diaphragmatic hernias and to evaluate the role of prophylactic cruroplasty in patients after esophagectomy for carcinomas of the esophagus or gastroesophageal junction. METHODS: A prospective database was used to retrospectively analyze consecutive patients who underwent esophagectomy between January 2005 and December 2015. RESULTS: A symptomatic diaphragmatic hernia was diagnosed in 21 (2.5%) of 851 included patients; 15 (4.3%) after 345 minimally invasive esophagectomies and 6 (1.2%) after 506 open esophagectomies (p = 0.004). Minimally invasive Ivor Lewis procedures had the highest incidence (9.4%; p = 0.002) as compared with all other procedures. Prophylactic cruroplasty did not decrease the incidence of symptomatic diaphragmatic hernias (2.1% vs 2.7%; p = 0.608). Surgical treatment consisted of cruroplasty, with reinforcement of Prolene pledgets (Ethicon, Somerville, NJ) in 11 patients. Major complications (Clavien-Dindo grade >IIIb) occurred in 3 patients, all after open repair (n = 9). Recurrences were found in 4 patients (19.0%), three after laparoscopic repair and one after open repair. CONCLUSIONS: The incidence of symptomatic diaphragmatic hernia after esophagectomy was 2.5%, with the highest incidence after minimally invasive Ivor Lewis esophagectomy (9.4%) as compared with other procedures. Although prophylactic cruroplasty is now the standard of care in patients undergoing minimally invasive esophagectomy, a significant lower hernia rate was not found in this study.