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For McKeown esophagectomy, hand-sewn and mechanical esophagogastric anastomosis techniques have been improved for constructing esophagogastrostomy. However, postoperative anastomosis-related complication rates remain high in patients undergoing cervical anastomosis. Here, we report an original and reliable hand-sewn cervical tunnel esophagogastric anastomosis technique to maximally reduce cervical anastomotic leakage and stricture rates after McKeown esophagectomy. The key features and innovations of cervical tunnel esophagogastric anastomosis are the right gastroepiploic artery as the center for the esophagogastric anastomosis to reduce ischemia, sufficient width of the anastomotic site for anastomosis without stricture, enfolding of the anastomotic site by the tunnel, and tension- and rotation-free anastomosis.

BACKGROUND One cause of anastomotic leakage after radical esophagectomy is blood flow insufficiency at the cervical anastomosis site. . METHODS Eighteen patients, who underwent radical esophagectomy with gastric tube reconstruction, were studied. The regional tissue oxygen saturation (rSO2) was measured at the tip (point pre 0) and 2, 4, and 6 cm on the distal side of the tip (point pre 1, pre 2, and pre 3, respectively) before the gastric tube was raised to the cervical site through the retrosternal route. After that, rSO2 was measured at the tip, 2 and 4 cm on the distal side of the tip (points post 0, post 1, and post 2), the actual anastomotic site (point AN), and the chest skin as an indicator of whole-body oxygenation. The relationship between rSO2 scores and the rate of anastomotic leakage was determined. RESULTS The mean rSO2 at pre 0, pre 1, pre 2, and pre 3 were 48.9%, 52.3%, 54.8%, and 56.9%, respectively (p

Cervical anastomotic leakages may manifest either cervically or intrathoracically. We retrospectively investigated the management strategies and clinical outcomes of patients who developed anastomotic leakages after McKeown esophagectomy and the spectrum of its clinical manifestations.Patients with esophageal cancer who underwent McKeown esophagectomy with cervical anastomosis (n = 749) between January 2015 and December 2018 were included.Cervical anastomosis leakage was diagnosed in 53/749 (7.3%) patients. The leakage was primarily limited to cervical region in 16 (30.2%) patients, whereas intrathoracic spread was present in 37 (69.8%) patients. Intrathoracic manifestations were more commonly accompanied by fever (75.7% vs. 18.8%, P 0.001) and leukocytosis than cervical manifestations (81.1% vs. 25.0%, P 0.001). Compared to patients with cervical manifestations, those with intrathoracic manifestations had a longer duration of hospital stay (median; 58 vs. 40 days, P = 0.006) and higher incidence of tracheal fistula (21.6% vs. 0%, P = 0.045). Drainage through the neck wound was effective in all patients with cervical manifestations. Patients with intrathoracic manifestations who had transnasal inner drain or mediastinal drain placed intraoperatively achieved satisfactory drainage (27/37, 73.0%). Subsequent healing of anastomotic leaks was observed in 50 (94.3%) patients. There was no mortality associated with complications related to anastomotic leakage.Intrathoracic manifestations of cervical anastomotic leakage are common in patients after McKeown esophagectomy. However, they are diagnosed later and are associated with more severe clinical consequences than cervical manifestations. Thus, a high index of suspicion and an early intervention policy for such anastomotic leaks should be adopted and strengthened to decrease the incidence of adverse clinical outcomes.

Background Cervical anastomotic leakage remains a great challenge for thoracic surgeons in the surgical treatment of esophageal cancer. Among the factors affecting cervical anastomosis healing, the surgical technique is the key controllable element. This study aimed to identify the risk factors of cervical anastomotic leakage after McKeown esophagectomy, especially those controllable surgical factors. Methods A retrospective review of patients who underwent McKeown esophagectomy in the past eight years in West China Hospital was performed. Patients with cervical anastomotic leakage were assigned to leakage group (LG) while the left was enrolled in the none-leakage group (NLG). Multivariate logistic regression analysis was used to identify independent risk factors of anastomotic leakage. Results A total of 518 patients were enrolled in the final analysis. In the baseline comparison, the difference in fixation of anastomosis in the neck, anastomosis mode, diabetes, and hypertension between the LG and NLG reached statistically significant. Moreover, the statistical difference of cervical fixation, anastomosis mode, and hypertension remained significant in the multivariate logistic regression analysis. Conclusions The cervical anastomosis fixation, anastomosis mode, and hypertension are independent risk factors of gastroesophageal cervical anastomotic leakage.

Background Mechanical anastomosis is now widely used in surgery for esophageal cancer. An anastomotic fistula is still the most dangerous complication in mechanical anastomosis, especially for patients who undergo cervical anastomosis. However, due to the high anastomosis position and limited space, conventional embedding and suspension are rarely performed. This study aimed to introduce the steps of an improved embedded method in cervical circular stapled anastomosis and evaluate its efficacy in reducing complications. Methods In total, 31 patients who underwent minimally invasive esophagectomy were enrolled into the study. Pre-embedded cervical esophagogastrostomy with a circular stapler was adopted after thoracoscopic and laparoscopic esophagectomy for esophageal cancer. Results The results of surgical duration, blood loss, mean duration of hospitalization and operation complications such as anastomotic fistula, anastomotic stenosis and gastroesophageal reflux were recorded. The operative procedure lasted between 205-300 minutes with an average of 260.3 minutes. The postoperative recovery was good, with no complications such as anastomotic fistula, anastomotic stricture and pulmonary complication, except for two cases of gastroesophageal reflux. The postoperative hospital stay was 8-14 days with an average of 10.3 days. Conclusion Our data revealed that pre-embedded cervical circular stapled anastomosis is an alternative for patients with good stomach length, which can decrease the occurrence rate of anastomotic fistula by full peripheral embedding of anastomotic stoma. Key points This new technique can significantly reduce the risk of anastomotic leakage. This study adds further details enabling a smooth pre-embedded procedure to be performed.

Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer. Methods In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality. Results A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (RR 0.39, 95%CI 0.22–0.65). Severe complications (Clavien-Dindo ≥3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE (RR 0.49, 95%CI 0.25–0.88). Conclusion This study provides evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer.

Esophagectomy still represents a challenge surgical procedure. Anastomotic leakage is the most feared complication and is likely related to diminished anastomotic perfusion. ‘Supercharged’ microvascular anastomosis has been performed in select patients to supplement the blood supply to the graft and anastomosis, after esophagectomy. This study aimed to evaluate results after performing the supercharged cervical anastomosis for esophagectomy procedure. Methods This prospective cohort study evaluated patients who underwent esophagectomy with gastric reconstruction and cervical anastomosis for locally advanced esophageal carcinoma. Patients were selected in which cervical anastomosis using the supercharged cervical anastomosis for esophagectomy procedure was performed. The anastomotic perfusion areas were evaluated using indocyanine and SPY before and after supercharged cervical anastomosis for esophagectomy. Post esophagectomy complications were also recorded. Results The study enrolled 61 patients, which included 47 (77.0%) men, with a mean age of 67.3 years. Median additional surgical time was 112 min (IQ 90–180), Leakage occurred in 1.6% of the patients (microanastomosis thrombosis), whereas the corresponding anastomotic stricture rates were 3.2% (mean follow-up was 25 mounths). Perfusion analyses showed a 28% improvement in the anastomotic area after venous anastomosis and a 37% improvement after arterial and venous anastomosis. Conclusion The supercharged cervical anastomosis for esophagectomy procedure may be related to low occurrence of anastomotic leakage and improve perfusion in the anastomotic area via vein and arterial microanastomoses.

In early 2000s, cervical anastomosis after esophagectomy was associated with a higher rate of recurrent nerve trauma than thoracic anastomosis. Recently, new technologies have been developed that reduce surgical complications. Mediastinoscopic esophagectomy is reportedly less invasive and allows faster recovery than thoracoscopic esophagectomy. Intraoperative nerve monitoring (IONM) prevents recurrent laryngeal nerve (RNL) palsy. We present the case of minimally invasive mediastinoscopic Ivor-Lewis Esophagectomy (MMIE) under IONM performed on an elderly esophagogastric junction (EGJ) adenocarcinoma patient. Methods An 84-year old man was consulted for adenocarcinoma of GEJ without lymphnode metastasis. Despite his advanced age, he had no comorbidities. We planned to perform MMIE under IONM. The procedure started with a patient lithotomy, and three trocars plus small incision were made in the upper abdomen. Celiac lymphadenectomy was performed. Subsequently, a 35 mm incision was made in the left side of the neck and a monitor was attached to left vagus nerve. Three trocars were placed with single incision surgical devices and pneumomediastinum was noticed. Mediastinoscopic esophagectomy was performed. Gastric tube reconstruction via mediastinum with cervical anastomosis was performed. Results The operation was successful. Total operation time was 393 minutes, with an estimated blood loss of 5 mL. There were no intraoperative and postoperative complications, and no RLN palsy occurred. Conclusion MMIE with cervical anastomosis under IONM is safe and less invasive especially for the respiratory system as a thoracotomy is unnecessary. Video https://www.dropbox.com/s/9yqkzg3pm619pf6/%E7%B8%A6%E9%9A%94%E9%8F%A12%E5%88%8656%E7%A7%92.mp4?dl=0.

A esofagectomia é o tratamento curativo do câncer de esôfago não metastático atualmente. Contudo ainda há falta de evidências fiéis que mostrem uma diferença significativa entre as técnicas cirúrgicas e permanece a controvérsia sobre a localização anatômica ideal da anastomose esofagogástrica, intratorácica ou cervical. O objetivo desse estudo foi avaliar a influência do local da anastomose, cervical ou torácica, nas complicações operatórias e mortalidade da esofagogastrectomia com linfadenectomia em dois campos.

Esophagectomies are a notoriously difficult procedure that have undergone drastic changes over the last decade. In particular, the adoption of minimally invasive esophagectomies (MIEs) as the gold standard.We examine the evolution of the MIE, the support for this method, and our preferred methods for the creation of anastomoses following the resection.The submission of techniques that, after many years of practice, have become our standard methods for anastomosing the Neo-esophagus to the remnant esophagus both at the neck, and within the thorax.No matter which MIE technique is chosen, these anastomotic methods are readily available. Each is provided with step-by-step instructions, performed with standard laparoscopic instruments, and in a safe and reproducible manner.

Aims: This study aimed to determine the degree of reflux esophagitis after either intrathoracic or cervical esophagogastrostomy in patients with esophagogastric junction carcinoma. Patients and Methods: The study population consisted of 10 and 15 consecutive patients who underwent esophagectomy with gastric conduit reconstruction via intrathoracic (Ivor Lewis) or cervical (McKeown) esophagogastrostomy, respectively. Reflux esophagitis was evaluated annually after surgery and scored on a 0- to 4-point scale corresponding to grades N/M, A, B, C, and D, respectively. The reflux esophagitis score of each patient, defined as the average of scores at 1, 2, and 3 years after surgery, was compared between the groups. Results: Of the 30 planned annual endoscopic follow-ups (3 years in 10 patients) in the Ivor Lewis group and 45 planned follow-ups (3 years in 15 patients) in the McKeown group, 24 and 29 such follow-ups were performed in the Ivor Lewis and McKeown groups, respectively. The reflux esophagitis score was significantly better in the McKeown group than in the Ivor Lewis group (0.51 ± 0.24 versus 1.46 ± 0.29, P = 0.019). Overall survival did not significantly differ between the Ivor Lewis and McKeown groups (respective 5-year survival rates, 64% versus 57%, P = 0.75). Conclusions: The degree of reflux esophagitis may be greater in patients with esophagogastric junction cancer treated by Ivor Lewis esophagectomy than in those treated by McKeown esophagectomy. McKeown esophagectomy might be a more suitable method for the treatment of esophagogastric junction cancer with extended esophageal invasion.

The question about what type of cervical esophagogastric anastomosis after esophageal resection is better, hand-sewn or stapled, remains controversial in spite of many studies, some of them randomized.

Background To identify the association between the width of the gastric conduit and the benign anastomotic stricture (BAS) after esophagectomy with end-to-side cervical anastomosis for esophageal cancer. Methods Patients with esophageal cancer who underwent esophagectomy between July 2013 and July 2014 were included in this study. The gastric conduit was used for reconstruction in all patients and end-to-side cervical anastomosis were performed using a circular stapler. The patients were divided into a narrow group (3-5 cm) and a wide group (>5 cm) based on the gastric conduit width. Univariate and multivariate logistic regressions were used to analyze the possible factors (patients’ age, gender, preoperative comorbidities, neoadjuvant chemotherapy, gastric conduit width, anastomotic leakage) that could affect the incidence of BAS. Results Two-hundred and one patients were included in this study. The median follow-up period was 29 months (17-58 months). Seven cases (3.5%) showed anastomotic leakage in the postoperative period and 38 patients (18.9%) developed BAS; all within the first year of follow-up. In univariate analysis, the width of the gastric conduit was the only risk factor for the development of BAS (odds ratio [OR] = 3.36, P = .005). In multivariate logistic regression analysis, the wide group was an independent significant risk factor for the development of BAS developing compared with the narrow group (OR = 2.84, P = .02). Conclusions A wide gastric conduit width (>5 cm) is an independent risk factor for the development of BAS after esophagectomy and stapled cervical end-to-side anastomosis for esophageal cancer.

Background As an extensive surgery, minimally invasive esophagectomy (MIE) has advantages in reducing morbidity and improving quality of life for patients suffering from esophageal cancer. This study aims to investigate differences between MIE and open esophagectomy (OE) for considerations of the safety of procedures, rate of tumor resection, postoperative complications, and quality of life. This paper also tends to provide some references for MIE on esophageal cancer therapy. Methods A retrospective data analysis was undertaken on 140 patients who either underwent MIE or OE for esophageal cancer with cervical anastomosis from March 2013 to May 2014 by our surgical team. Preoperative characteristics were analyzed for both groups. Differences in perioperative and oncologic outcomes were compared in operation time, intraoperative blood loss, lymph nodes retrieved, and R0-resection rate. Accordingly, a comparative analysis was conducted on complications namely anastomotic leakage, pulmonary infection, in-hospital mortality, and short-term (3 months) postoperative EORTC C30 Global health as well. Results A total of 140 patients (87 with MIE and 53 with OE) were enrolled and the two groups were homogeneous in terms of patient- and tumor-related data. There was no difference on postoperative ICU stay (21.15 ± 1.54 h vs 21.75 ± 1.68 h, p = 0.07) and R0-resection rate (100% vs 100%, p = 1.00). The operation time for MIE was significantly shorter (146.08 ± 17.35 min vs 200.34 ± 14.51 min, p P P P = 0.24). Complications such as in-hospital mortality and short-term (3 months) postoperative EORTC C30 Global health displayed no difference between both groups as well. Conclusions The number of lymph nodes and intraoperative blood loss were significantly ameliorated in MIE. A 4–5 cm longitudinal incision below the xiphoid process was made to create the gastric conduit under direct vision assisting in shortening the total operation time significantly.

Surgical site infection (SSI) surveillance has become increasingly important during the peri-operative period of esophagectomy with cervical anastomosis (McKeown esophagectomy). This study sought to clarify the risk factors for SSI and to develop a stratification scoring system to predict SSI after esophagectomy with cervical anastomosis.All patients who underwent elective esophagectomy with cervical anastomosis were studied between January 2010 and December 2016 in the Chinese Academy of Medical Sciences Cancer Hospital (CAMS). Univariable analysis and multivariable logistic regression were used to screen the independent risk factors. A risk stratification scoring system was developed based on multivariable logistic regression parameters. The model derivation set involved 711 consecutive cases, and the validation set involved 168 consecutive cases.In the model derivation set, there were 711 patients, of whom 146 were found to have SSI and the incidence rate was 20.53%. Multivariable analysis found that SSI was associated independently with the following adverse risk factors: peripheral vascular disease, prior chest surgery, no pre-operative surgical antibiotic prophylaxis (SAP) administration within 120 minutes prior to incision, low serum albumin, and low pre-albumin at post-operative day zero to three, respectively. Each of these factors contributed one point to the risk score and a risk stratification scoring system was established. The SSI rates were increased gradually in the low, intermediate, high, and extremely high-risk groups (p 0.001). The area under the receiver operating characteristic (AUROC) curve was 0.706 for the logistic regression model and 0.704 for the scoring system. In the validation set, the model performed equivalently (AUC = 0.824).The validated stratification scoring system could predict accurately the risk of SSI after esophagectomy with cervical anastomosis. This could be helpful in the selection of high-risk patients requiring frequent monitoring and more aggressive interventions to decrease the incidence of SSI.

Purpose Minimally invasive esophagectomy is increasingly performed for esophageal or gastroesophageal junctional cancer, with advantages of improved perioperative outcomes in comparison with open esophagectomy. McKeown and Ivor Lewis are widely used procedures of minimally invasive esophagectomy, and there have been controversies on which one is preferred for patients with resectable esophageal or junctional cancer. Patients and methods This review was registered at the International Prospective Register of Systematic Reviews (number CRD42017075989). Studies in PubMed, Embase, Web of Science, the Cochrane Library, and ClinicalTrials.gov were thoroughly investigated. Eligible studies included prospective and retrospective studies evaluating short-term outcomes of minimally invasive McKeown esophagectomy (MIME) vs minimally invasive Ivor Lewis esophagectomy (MILE) in patients with resectable esophageal or junctional tumors. Main parameters included anastomotic leak and 30-day/in-hospital mortality. Overall incidence rates (ORs)/weighted mean difference (WMD) with 95% confidence intervals (CIs) were calculated by employing random-effects models. Results Fourteen studies containing 3,468 cases were included in this meta-analysis. Age, male sex, and American Joint Committee on Cancer (AJCC) stage between the 2 groups were not statistically different. MIME led to more blood loss, longer operating time, and longer hospital stay than MILE. MIME was associated with higher incidence of pulmonary complications (OR =1.96, 95% CI =1.28-3.00) as well as total anastomotic leak (OR =2.55, 95% CI =1.40-4.63), stricture (OR =2.07, 95% CI =1.05-4.07), and vocal cord injury/palsy (OR =5.62, 95% CI =3.46-9.14). In addition, the differences of R0 resection rate, number of lymph modes retrieved, blood transfusion rate, length of intensive care unit stay, incidence of cardiac arrhythmia, and Chyle leak between MIME and MILE were not statistically significant. Notably, incidence of severe anastomotic leak (OR =1.28, 95% CI =0.73-2.24) and 30-day/in-hospital mortality (OR =1.76, 95% CI =0.92-3.36) as well as 90-day mortality (OR =2.22, 95% CI =0.71-6.98) between the 2 procedures were also not significantly different. Conclusion This study suggests that MIME and MILE are comparable with respect to clinical safety. MILE may be a better option when oncologically and clinically suitable. MIME is still a safe alternative procedure when clinically indicated. However, this evidence is at risk for bias; randomized controlled trials are needed to validate or correct our results.

Anastomotic leakage, fibrous stricture and gastro-oesophageal reflux are three major complications of gastro-oesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to traditional side-to-side anastomosis (SS) and end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux.A total of 390 patients with thoracic oesophageal cancer underwent minimally invasive oesophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. A detailed description of the surgical procedure is provided, and the major postoperative complications, including postoperative leakage, stricture and reflux, were compared using a three-armed controlled study.The anastomotic method was an independent risk factor for anastomotic leakage, as well as stricture and reflux. The rate of anastomotic leakage of the NA group (1.0%) was significantly lower than that in the SS group (8.8%, P = 0.025) and in the CS group (8.5%, P = 0.001). The rate of anastomotic stricture in the NA group was not significantly different than that in the SS group (1.5% vs. 2.9%, P = 0.368) but was significantly lower than that in the CS group (1.5% vs. 18.9%, P 0.001). The incidence of gastro-oesophageal reflux in the NA group was significantly lower than that in the SS group and the CS group (5.7% vs. 23.5% and 18.3%, P = 0.003 and 0.001, respectively).Jiang's anastomosis technique remarkably reduces the incidence of gastro-oesophageal anastomotic leakage, stricture and reflux, and it is a safe and effective technique for minimally invasive oesophagectomy.

Objective Esophagectomy has high rates of morbidity and mortality. Anastomotic leakage is the most frequent complication and is likely caused by diminished anastomotic perfusion. Supercharged microvascular anastomosis has previously been performed in select patients to supplement the blood supply to the graft and anastomosis after esophagectomy. This study aimed to evaluate complications that may arise after performing the supercharged cervical anastomosis for esophagectomy procedure. Methods This prospective comparative study evaluated patients who underwent esophagectomy with gastric reconstruction and cervical anastomosis for locally advanced esophageal carcinoma. Patients were divided into group 1, in which conventional cervical anastomosis was performed, and group 2, in which cervical anastomosis using the supercharged cervical anastomosis for esophagectomy procedure was performed. The anastomotic perfusion areas in group 2 patients were evaluated using indocyanine and the SPY device (Novadaq Technologies, Inc, Toronto, Ontario, Canada) before and after supercharged cervical anastomosis for esophagectomy. Postesophagectomy complications were also recorded. Results The study enrolled 80 patients, which included 62 (77.5%) men, mean age 64.3 years. Groups 1 and 2 comprised 55 patients and 25 patients, respectively. Leakage occurred in 10.5% and 0% of patients in groups 1 and 2, respectively (P = .169), whereas the corresponding anastomotic stricture rates were 14.5% and 4%, respectively (P = .260). Perfusion analyses showed a 26.5% improvement in the anastomotic area after venous anastomosis and a 34.6% improvement after arterial and venous anastomosis. Conclusions The supercharged cervical anastomosis for esophagectomy procedure may reduce the occurrence of anastomotic leakage and improve perfusion in the anastomotic area via vein and arterial microanastomoses.

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.

Background: The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer. Methods: Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage. Results: The operative duration was 60–90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5–8 days (median, 6 days) after the BPP repair operation without any discomfort. Conclusions: The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.

4509 Background: Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer. Methods: In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality. Results: A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded from the trial due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (relative risk 0.39, 95% CI 0.22-0.65; risk difference 19.4%, 95% CI 7.9%-31.8%). Overall AL rate was 12.3% after Ivor Lewis MIE and 34.1% after McKeown MIE. Severe complications (Clavien-Dindo ≥ 3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE. Pleural effusion requiring drainage occurred in 9.8% of patients after Ivor Lewis MIE and 21.1% of patients after McKeown MIE. RLN palsy rate was 0% after Ivor Lewis MIE and 7.3% after McKeown MIE. Median length of hospital stay was 10 days (IQR 8 – 15 days) after Ivor Lewis MIE and 12 days (IQR 9 – 18 days) after McKeown MIE. ICU length of stay and mortality rates were comparable between groups. Conclusions: These findings provide evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer. Clinical trial information: NTR4333 .

Minimally invasive esophagectomy is increasing performed for cancers of the esophagus and gastroesophageal junction. This video demonstrates the setup and key steps for a robotic transhiatal esophagectomy with a cervical anastomosis.

Summary The diagnosis and the treatment of anastomotic leak after esophagectomy are the keys to reduce the morbidity and mortality after this surgery. The stent plays an important role in the treatment of the leakage and in the prevention of reoperation. We have analyzed the database of the section of the esophagogastric surgery of Donostia University Hospital from June 2003 to May 2012. It is a retrospective study of 113 patients with esophagectomy resulting from tumor, and 24 (21.13%) of these patients developed anastomotic leak. Of these 24 patients, 13 (54.16%) have been treated with a metallic stent and 11 (45.84%) without a stent. The average age of the patients was 55.69 and 62.45 years, respectively. All patients treated with and without a stent have been males. Eight (61.5%) stents were placed in the neck and five (38.5%) in the chest. However, among the 11 fistulas treated without a stent, 9 patients had cervical anastomosis (81.81%) and 2 patients (18.18%) had anastomosis in the chest. Twelve patients (92.30%) with a stent preserve digestive continuity, and 10 patients (90.90%) were treated without a stent. One patient died in the stent group and one in the nonstent group. The treatment with metallic stent of the anastomotic leak after esophagectomy is an option that can prevent reoperation in these patients, but it does not decrease the average of the hospital stay. The stent may be more useful in thoracic anastomotic leaks.

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

The short-term advantages of minimally invasive esophagectomy (MIE) in terms of less morbidity and better Quality of Life (QoL) in comparison with open esophagectomy (OE) became visible in the last few years. There are two main MIE approaches: a transthoracic resection (TTE; either accompanied by an intrathoracic or cervical anastomosis) or a transhiatal resection (THE; accompanied by a cervical anastomosis). However, controversy about what approach is best for gastro-esophageal junction tumors (GEJ) still exists and the choice of the approach is currently based on the surgeons’ discretion. In this chapter, we describe the indications for each minimally invasive approach for GEJ tumors, the surgical technique, the most common complications and their treatment, our own experiences, patient-survival rates, current developments and problems regarding surgical treatment for patients with cancer of the GEJ.

A transthoracic approach (Ivor Lewis and McKeown) allows dissection of the difficult esophagus under direct vision and may improve extent of lymphadenectomy and radial margin for midesophageal tumors. Cervical anastomosis in the McKeown esophagectomy allows for a greater length of the proximal esophagus to be resected. Thus many surgeons prefer this approach for middle and upper esophageal tumors. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure.

BACKGROUND: Currently, a cervical esophagogastric anastomosis (CEA) is often performed after minimally invasive esophagectomy (MIE). However, the CEA is associated with a considerable incidence of anastomotic leakage requiring reintervention or reoperation and moderate functional results. An intrathoracic esophagogastric anastomosis (IEA) might reduce the incidence of anastomotic leakage, improve functional results and reduce costs. The objective of the ICAN trial is to compare anastomotic leakage and postoperative morbidity, mortality, quality of life and cost-effectiveness between CEA and IEA after MIE.METHODS/DESIGN: The ICAN trial is an open randomized controlled multicentre superiority trial, comparing CEA (control group) with IEA (intervention group) after MIE. All patients with esophageal cancer planning to undergo curative MIE are considered for inclusion. A total of 200 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is anastomotic leakage requiring reintervention or reoperation, and secondary outcomes are (amongst others) other postoperative complications, new onset of organ failure, length of stay, mortality, benign strictures requiring dilatation, quality of life and cost-effectiveness.DISCUSSION: We hypothesize that an IEA after MIE is associated with a lower incidence of anastomotic leakage requiring reintervention or reoperation than a CEA. The trial is also designed to give answers to additional research questions regarding a possible difference in functional outcome, quality of life and cost-effectiveness.TRIAL REGISTRATION: Netherlands Trial Register: NTR4333 . Registered on 23 December 2013.

to present treatment of patients with gastroesophageal cancer.41 cases of esophagogastrectomy with simultaneous intestinal repair were analyzed. There were 37 operations for malignancies and 4 operations for benign diseases. Indications for surgery were defined. Abdominocervical access was predominantly used. In 6 patients esophageal repair was finished by high intrapleural anastomosis due to insufficient length of the graft for cervical anastomosis. Surgical technique of esophagogastrectomy was described in detail at all stages.Better functional results were achieved in isoperistaltic esophagocoloplasty when graft's aboral end was anastomosed with Roux-segment of jejunum or with vertical bend of duodenum in end-to-side fashion. Mortality rate was 12.2%.We consider that isoperistaltic repair on left colonic vessels has better functional results.Введение. Лечение больных гастроэзофагеальным раком является сложной задачей. Материал и методы. Представлен анализ результатов 41 эзофагогастрэктомии (ЭГЭ) с одномоментной интестинальной эзофагопластикой. При онкологических заболеваниях сделано 37 операций, при доброкачественных заболеваниях - 4. Дано обоснование показаний к столь объемному вмешательству. Превалировал абдоминоцервикальный доступ. У 6 больных пластику пищевода закончили наложением высокого внутриплеврального анастомоза при недостаточной длине трансплантата для анастомоза на шее. Подробно описана хирургическая техника на всех этапах ЭГЭ. Результаты и обсуждение. Лучшие функциональные результаты получены при изоперистальтической эзофагоколопластике, когда аборальный конец трансплантата соединяли конец в бок с Ру-сегментом тощей кишки или с вертикальным коленом двенадцатиперстной кишки. Летальность составила 12,2%. Вывод. В функциональном отношении считаем лучшей изоперистальтическую пластику на левых ободочных сосудах.

Objective The aim of our study was to evaluate the clinical effect and the prospect of the three-incision (right thoracotomy, midline laparotomy and left cervical incisions) esophagectomy for the treatment of esophageal carcinoma.

Objective: To identify independent risk factors for development of benign cervical anastomotic strictures in general and specifically for refractory strictures after esophagectomy in a large series of patients. Summary Background Data: Benign strictures develop frequently when a cervical anastomosis is performed after esophagectomy, causing burdensome symptoms and poor quality of life. Methods: From 1996 to 2006, all patients in the Academic Medical Center prospective database undergoing esophagectomy with a cervical anastomosis were included. Stricture was defined as dysphagia requiring endoscopic dilation of the anastomosis. Prediction of stricture was assessed using uni- and multivariate logistic regression analysis. Evaluation of risk factors was also performed for refractory strictures (>2 times the median number of dilations in all patients with stricture) in a similar fashion. Results: A total of 607 patients underwent potentially curative esophagectomy, with an in-hospital mortality of 2.5%. During follow-up, 253 (41.7%) patients developed a stricture after a median time of 74 days, requiring a median number of 5 dilations. Cardiovascular disease (P = 0.002), gastric tube compared with colonic interposition (P = 0.03), and anastomotic leakage (P = 0.002) were predictive for development of stricture in multivariate analysis. Development of stricture within 90 days after surgery (P = 0.001), chemoradiotherapy (P = 0.02), and anastomotic leakage (P = 0.03) were independent predictors for refractory strictures requiring over 10 dilations. Conclusions: The benign cervical stricture rate after esophagectomy was relatively high. Cardiovascular disease, gastric tube compared with colonic interposition and postoperative anastomotic leakage were independent predictors for development of benign anastomotic stricture. Anastomotic leakage, chemoradiotherapy and early development of stricture were independently associated with the development of refractory strictures, requiring a higher number of dilations. Prevention of anastomotic stricture formation should be focused on prevention of anastomotic leakage.

INTRODUCTION: Minimally invasive oesophageal resections are being increasingly propagated. However, a leakage of the cervical anastomosis, occurring in up to 30 % of the cases, remains a severe disadvantage. By means of a case report, a new alternative technique of intrathoracic thoracoscopic anastomosis is described. PATIENT AND METHOD: After the customary laparoscopic abdominal performance of lymph-node dissection, a gastric conduit was performed in a 73-year-old patient with an adenocarcinoma of the gastro-oesophageal junction. After that the oesophagus had been resected thoracoscopically and an intrathoracic side-to-side/functional end-to-end anastomosis between the gastric conduit and oesophagus was performed with linear staplers. RESULTS: There were no postoperative complications. CONCLUSION: The intrathoracic thoracoscopic oesophagogastrostomy seems to be an oncologically adequate procedure that has less complications than the other laparoscopic-thoracoscopic techniques described so far. However, further studies are necessary to prove this conclusively.

Background Minimally invasive oesophagectomy (MIO; thoracoscopy, laparoscopy, cervical anastomosis) is a complex procedure and few substantial series have been published. This study documented the morbidity, mortality and challenges of adopting MIO in a specialist unit in the UK. Methods A prospective group of 77 patients was listed consecutively with the intention of performing MIO. Three other patients underwent open oesophagectomy during the study period. Results MIO was attempted in 77 patients, completed successfully in 70, abandoned in six patients (8 per cent) with unsuspected metastatic disease, and converted to a thoracoscopic anastomosis in one patient. There was one in-hospital death (1 per cent). Complications occurred in 33 patients (47 per cent), including nine gastric conduit-related complications (13 per cent). Median lymph node harvest was 21 (range 7–48) nodes. Mean overall and disease-free survival times were 35 and 33 months respectively. Median disease-free survival for patients with stage III disease was 26 months. Conclusion MIO can be performed with acceptable mortality and morbidity rates in an unselected series of patients. There was more morbidity related to gastric tube ischaemia than was expected.

Unilateral vocal-cord paralysis after esophagectomy involving a cervical anastomosis is uncommon in experienced hands but can cause marked morbidity because of pulmonary complications. It is important for the surgeon to understand the anatomy of the recurrent laryngeal nerve to avoid this complication. The diagnosis is usually easily made at the bedside and can be confirmed by visualization of the glottis. Early treatment may include supportive care with a speech pathologist or injection of the vocal-cord with temporary material to improve glottic closure. Definitive treatment can best be performed by medialization thyroplasty.

The aim of this study was to the determine impact of severe esophageal anastomotic leak (SEAL) upon long-term survival and locoregional cancer recurrence.The impact of SEAL upon long-term survival after esophageal resection remains inconclusive with a number of studies demonstrating conflicting results.A multicenter database for the surgical treatment of esophageal cancer collected data from 30 university hospitals (2000-2010). SEAL was defined as a Clavien-Dindo III or IV leak. Patients with SEAL were compared with those without in terms of demographics, tumor characteristics, surgical technique, morbidity, survival, and recurrence.From a database of 2944 operated on for esophageal cancer between 2000 and 2010, 209 patients who died within 90 days of surgery and 296 patients with a R1/R2 resection were excluded, leaving 2439 included in the final analysis; 208 (8.5%) developed a SEAL and significant independent association was observed with low hospital procedural volume, cervical anastomosis, tumoral stage III/IV, and pulmonary and cardiovascular complications. SEAL was associated with a significant reduction in median overall (35.8 vs 54.8 months; P = 0.002) and disease-free (34 vs 47.9 months; P = 0.005) survivals. After adjustment of confounding factors, SEAL was associated with a 28% greater likelihood of death [hazard ratio = 1.28; 95% confidence interval (CI): 1.04-1.59; P = 0.022], as well as greater overall (OR = 1.35; 95% CI: 1.15-1.73; P = 0.011), locoregional (OR = 1.56; 95% CI: 1.05-2.24; P = 0.030), and mixed (OR = 1.81; 95% CI: 1.20-2.71; P = 0.014) recurrences.This large multicenter study provides strong evidence that SEAL adversely impacts cancer prognosis. The mechanism through which SEAL increases local recurrence is an important area for future research.

We have utilized a circular stapler for intra-thoracic anastomosis (ITA) after radical esophagectomy since July 1999, and moreover, for cervical anastomosis (CA) since July 2001. In this study，we evaluate the usefulness of esophagogastric anastomosis with a circular stapler. Subjects were 28 esophageal patients who underwent esophagectomy followed by esophagogastric anastomosis with a circular stapler in the period from July 1999 to February 2003. Esophagogastric anastomosis with a circular stapler was performed by end to side anastomosis. Subjects consisted of 20 cases undergoing ITA and 8 cases undergolng CA. The incidences of anastomotic leakage were 15.0％ and 12.5％, respectively. The cases with anastomotic leakage were treated with a conservative therapy and cured. The incidences of anastomotic stenosis in ITA and CA were 15.0％ and 12.5％, respectively. Anastomotic stenosis occurred from one to six months after operation in the cases without anastomotic leakage. One or two balloon dilatation could not relieved in 3 of the 4 cases with anastomotic stenosis. Anastomotic bleeding was not found. There was only one case with severe reflex esophagitis in ITA. We are almost satisfied with these results. Therefore, it was thought that esophagogastric anastomosis with a circular stapler isuseful.

Background: A choice of retrosternal or orthotopic route for reconstruction exists after three-phase esophagectomy with cervical anastomosis. Whether the route of reconstruction affects postoperative morbidity, mortality and recurrence patterns remains controversial. Study Design: Patients with cancer of the thoracic esophagus who underwent three-phase esophagectomy between 1990 and 1999 were studied. Postoperative outcome, recurrence patterns and survival were analyzed from a prospectively collected database. Results: Seventy-five patients underwent three-phase esophagectomy. There were 46 patients in the retrosternal group and 29 in the orthotopic group. The mean age of the retrosternal group was younger than the orthotopic group, 60 and 66 years, respectively (p = 0.004). The retrosternal group also had more advanced disease; 24% of patients had curative resection compared with 59% in the orthotopic group (p = 0.003). There was no significant difference in postoperative complications except that the retrosternal group had more blood loss, median 800 ml compared with 700 ml (p = 0.04). Hospital mortality was 13% in the retrosternal group and 3.4% in the orthotopic group (p = 0.24). Multivariate analysis showed that age (odds ratio 1.16, p = 0.035) and pulmonary risk (odds ratio 10, p = 0.01) were predictive of hospital mortality, but not the route of reconstruction. No patient in the retrosternal group developed recurrence in the gastric conduit compared to 4 of 28 patients (14%) in the orthotopic group (p = 0.03). Two of these patients were symptomatic with bleeding from the intragastric recurrence. Survival was worse in the retrosternal group, 5-year survival was 29.8 vs. 8.2% (p < 0.01), reflecting the more advanced disease and higher prevalence of palliative resections. Conclusions: Cardiopulmonary complications and hospital mortality were not significantly different in the two groups. Recurrent tumor infiltration of the gastric conduit occurred in 14% of patients when the orthotopic route was used.

Gastric pull-up is the most commonly used procedure for esophageal replacement in both malignant and benign conditions. In our article we compare the differences in mortality and morbidity between thoracic anastomosis and cervical anastomosis during gastric pull-up. The study group comprised of 126 patients - 58 patients (56%) with cervical anastomosis and 68 patients (64%) with thoracic anastomosis. The overall mortality in the study group was 5.55% (7 patients), while the overall morbidity was higher at 28%. There were no significant differences between the two subgroups regarding mortality and morbidity, although the rate of anastomotic leakage was higher in the cervical subgroup (13.8% vs 1.5%). We recommend performing thoracic anastomosis during gastric pull-up whenever the location of the lesion allows it, since the procedure is safe, relatively easy to master and it shortens operating time by excluding the cervical approach.

Background: Recurrence at the cervical anastomosis of a tumour of the oesophagogastric junction after resection of the oesophagus with gastric tube reconstruction is a peculiar phenomenon in view of the distance of the primary tumour from the proximal anastomosis. It is hypothesised that contamination with tumour cells from the nasogastric tube or the gastric reconstruction tube could be responsible for this phenomenon. Method: Fifteen patients with a tumour of the oesophagus or gastric cardia were included. During the operation the nasogastric tube was left in the resected specimen. Debris from the tube was washed out for cytological examination. Also the gastric reconstruction tube was washed out and the debris examined for malignant cells. Results: In all of the patients with a tumour extending intraluminally malignant cells were found in the nasogastric tube or the gastric reconstruction tube or both. In 92% of these patients malignant cells were found in the nasogastric tube, while 60% of the gastric reconstruction tubes were contaminated with tumour cells. Conclusion: The presence of intraluminal malignant cells during oesophageal resection and gastric tube reconstruction is very high, possibly leading to anastomotic recurrence. Measures should be taken to minimise local contamination with tumour cells.

In this chapter, we will outline our technique for laparoscopic and thoracoscopic transhiatal esophagectomy with cervical anastomosis. We utilize this technique routinely in patients with esophageal and Siewert’s types 1 and 2 gastroesophageal junction cancer. This technique has been shown to be safe in the setting of neoadjuvant chemoradiation since most patients in the western world present with locally advanced carcinoma and receive multimodality treatment. This technique is best reserved for those patients who have no history of previous gastric surgery such as a Nissen fundoplication. In such patients, the amount of gastric conduit available to reach the neck may be limited and an intrathoracic esophagogastric anastomosis may be preferable as described in other portions of this book.

Rates of anastomotic leak in patients who undergo oesophagectomy with cervical anastomosis formation are reported within the literature to surpass those of patients undergoing thoracic anastomosis formation. Though preferred by a number of surgeons, cervical anastomosis is associated with higher rates of anastomotic leak, the consequences of which can be severe. Routine contrast oesophagograms are therefore utilised in a number of institutions as a means of recognising leaks early. They are not without potential complications, however, and the predictive value of contrast imaging has previously been debated. This best evidence topic reviews the use of contrast oesophagograms in screening for cervical anastamotic leak, concluding that their inherent risk of aspiration combined with poor sensitivity should preclude their use as a screening tool. High rates of specificity nevertheless indicate the potential utility of these studies in patients for whom there is clinical suspicion of a leak.

A 56-year-old female was evaluated for dysphagia, revealing an adenocarcinoma of the distal esophagus. The patient received neoadjuvant chemoradiotherapy and after a period of 6 weeks he underwent a three stage open transthoracic esophagectomy with a cervical anastomosis. Progressively, the patient developed an important pleura effusion of the left hemithorax on the chest radiography.

A 64-year-old female was evaluated for dysphagia, revealing a squamous cell carcinoma of the mid-esophagus. Tumor was staged as T3-4N2M0. She was treated by neoadjuvant chemoradiotherapy and after an interval of six weeks she underwent a three stage thoraco-laparoscopic esophageal resection with a cervical anastomosis. On the 8th postoperative day patient developed an infection of the cervical wound.

A 63-year-old female was diagnosed with a squamous cell carcinoma of the mid esophagus, staged as T3N1M0. She was treated by chemoradiotherapy and after a period of 6 weeks she underwent a three stage esophageal resection with a cervical anastomosis. Postoperatively the patient developed a high volume chylothorax.

World journal of surgical oncology 10, 159 (2012). doi:10.1186/1477-7819-10-159, Published by Biomed Central, London

Modified transhiatal oesophagectomy is described for the resection of tumours affecting the distal third of the oesophagus. The operation confers the advantages of radical resection and the ability to undertake the procedure under direct vision. Forty patients with a median age of 67 years underwent this operation during a 36-month period and were followed for up to 42 months after surgery. The hospital mortality rate was one of 40 patients and the median postoperative stay 10 days. All but four patients left hospital within 2 weeks of operation. Eighteen of 30 patients were alive at 12 months and seven of 18 at 24 months after operation. Only two patients are known to have developed local recurrence in the tumour bed. This procedure confers the advantages of a radical approach under direct vision and incorporates the principles of near-total oesophagectomy and cervical anastomosis in the treatment of oesophageal cancer.

Background: When forming an esophageal substitute with an ileocolon in esophageal reconstruction with cervical anastomosis, the ileocolic vessels should be divided in many cases and this may be followed by the occurrence of poor blood circulation in the pulled-up substitute. Methods: Twenty-two consecutive esophageal reconstructions using an all-main-vessel-preserving ileocolon had been performed in the past 4 years and we evaluated the usefulness of this surgical modality. Results: In every case, the extension length of the ileocolon was sufficient for esophageal reconstruction. There were no serious surgical complications concerning the esophageal substitutes such as necrosis of the pulled-up ileocolon. Conclusions: Although it was thought that the surgical techniques shown here were possible only in selected patients, successful esophageal reconstructions were achieved with this new concept in 22 consecutive patients with various backgrounds. The procedures shown here are not new; however, the concept of using the all-main-vessel-preserving ileocolon as an esophageal substitute for every patient requiring esophageal reconstruction is new.