Search

Background:. The incidence of anastomotic leakage in gastrointestinal surgery is highest after esophagogastric anastomosis, with leakage rates of 10% to 38% still being reported, but little consensus as to cause or corrective. The role of anastomotic tension from a series of physiological forces acting on the anastomosis from the moment of recovery from anesthesia may be underestimated. It was hypothesized that anchoring the conduit in the mediastinum would provide the greatest protection during the vulnerable healing phase. Patients and Methods:. A prospectively maintained database was interrogated for anastomotic leakage following the introduction of an anastomotic technique employing anchoring sutures where the gastric conduit was secured to the mediastinal pleura with 3 obliquely inserted load-bearing sutures. A contrast study was performed between days 5 and 7 and all intrahospital mortalities underwent autopsy. Clinical, radiological, and autopsy leaks were recorded. Results:. Of 146 intrathoracic esophagogastric anastomoses in 144 patients, 81 (55%) of which were stapled, there was 1 clinical leak and 1 patient with an aortoenteric fistula, considered at autopsy to be possibly due to an anastomotic leak, to give an anastomotic leak rate of 2 in 146 (1.37%). Conclusion:. The low anastomotic leak rate in this series is potentially due to the protective effect of anchoring sutures, the chief difference from an otherwise standard anastomotic technique. These sutures protect the anastomosis from a series of distracting forces during the most vulnerable phase of healing. It is intuitive that the absence of tension would also reduce any risk posed by a minor impairment of blood supply or any imperfection of the technique.

Abstract Background An important parameter for survival in patients with esophageal carcinoma is lymph node status. The distribution of lymph node metastases depends on tumor characteristics such as tumor location, histology, invasion depth, and on neoadjuvant treatment. The exact distribution is unknown. Neoadjuvant treatment and surgical strategy depends on the distribution pattern of nodal metastases but consensus on the extent of lymphadenectomy has not been reached. The aim of this study is to determine the distribution of lymph node metastases in patients with resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed. This can be the foundation for a uniform worldwide staging system and establishment of the optimal surgical strategy for esophageal cancer patients. Methods The TIGER study is an international observational cohort study with 50 participating centers. Patients with a resectable esophageal or gastro-esophageal junction carcinoma in whom a transthoracic esophagectomy with a 2- or 3-field lymphadenectomy is performed in participating centers will be included. All lymph node stations will be excised and separately individually analyzed by pathological examination. The aim is to include 5000 patients. The primary endpoint is the distribution of lymph node metastases in esophageal and esophago-gastric junction carcinoma specimens following transthoracic esophagectomy with at least 2-field lymphadenectomy in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and (disease free) survival. Discussion The TIGER study will provide a roadmap of the location of lymph node metastases in relation to tumor histology, tumor location, invasion depth, number of lymph nodes and lymph node metastases, pre-operative diagnostics, neo-adjuvant therapy and survival. Patient-tailored treatment can be developed based on these results, such as the optimal radiation field and extent of lymphadenectomy based on the primary tumor characteristics. Trial registration NCT03222895, date of registration: July 19th, 2017.