Anastomotic Complications after Esophagectomy. Bryan Meyers, MD MPH Thoracic Surgery Washington University School of Medicine
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1 Anastomotic Complications after Esophagectomy Bryan Meyers, MD MPH Thoracic Surgery Washington University School of Medicine
2 Use of Stomach as Conduit Simplest choice after esophagectomy Single anastomosis Apparently redundant blood supply Reaches into the neck if needed
3
4 EG Anastomosis Complications Stenosis requiring dilation Leak Gastric tip necrosis Late functional problems
5 What are Current Anastomotic Leak Rates? Do we really need to keep talking about this?
6 Frequency of Ischemic Complications Routine endoscopy after esophagectomy and reconstruction blue to black discoloration of the mucosa, adherence of a green or silver-metallic mucus to the mucosa that could not be removed by irrigation, or a clearly demarcated nonedematous mucosa with ulceration. Prevalance was 9.2% of nearly 400 patients Briel JW, et al. J Am Coll Surgeons 2004;198:536
7 To Staple or Sew? Does it Matter? Liu Q-X, et al. Eur J Cardiothorac Surg. 2015;47:118
8 Results Hand-sewn (n=232) Stapled (n=235) P-value Operative time 226 ± ± 16 < Anastomotic Leaks Anastomotic Strictures 17 (7.3) 7 (3.0) (7.5) 31 (14.2) Department of Surgery Division of Cardiothoracic Surgery
9 MIE vs. Open: Impact on leaks Result: No impact of MIE vs open on leaks Odds ratio 0.97 World J Surg Oncol. 2015; 13: 269
10 "Staple Line on Staple Line" EG Anastomosis: A Novel Technique Mankins,Kesler
11 The Specific Problem: Gastric Tip Necrosis Results in mediastinitis and empyema Requires at least 2 additional operations if managed successfully Much higher mortality associated with development of this complication
12 Local Experience: Conduit Ischemia 484 patients WUSM with esophagectomy from described as gastric tip necrosis Hospital mortality 4/17 Median hospital stay 35 days Median delay to repair: 7 days All surgeons represented in proportion to esophagectomy volume
13 Surrogate Measures of Ischemia Can we quantify looks dusky? Direct oximetry of the stomach Clark electrode Laser Doppler flowmetry Tonometry (intramucosal ph) H2 gas clearance Thermal scanning Near Infrared Spectroscopy (NIRS) Indocyanine Green (SPY system)
14 Results of Surrogate Measures Demonstrate reproducible decreases in blood flow at various stages of mobilization and transposition Imperfect ability to predict leaks or ischemia Some ability to demonstrate relative impact of techniques and physiology of patient on stomach perfusion
15 Factors Influencing Gastric Blood Flow Intrinsic blood supply to the stomach. Compression of the gastric tube just distal to the anastomosis. (e.g.: azygous) Narrow tubularization of the gastric conduit. Degree of trauma or struggle with mobilization or transposition of the tube. Systemic hypotension. Venous congestion or kinking of venous drainage
16 Possible Practical Solutions Invoked for Prevention Maintain ideal blood flow via optimization of BP through volume administration Dopamine? Neosynephrine? Avoid epidural induced hypotension Handle the gastric tube gently Make a wider gastric tube Leave right gastric & left gastric artery intact Avoid gastric distention Avoid PEEP
17 Less Practical, but Novel Solutions Surgical Ischemic Preconditioning Various degrees of starting the mobilization of the stomach in advance of resection Perhaps paired with node assessment Non-surgical Ischemic Preconditioning Interventional radiology procedure Injection of microspheres into LGA Delay of anastomosis when subjective ischemia is detected
18 Gastric Preconditioning A, Divided omentum preserving the right gastroepiploic. B, Left gastroepiploic artery cut. C, Kocher maneuver. D, Common hepatic and splenic artery cleared. E, Left gastric artery and vein cut. F, 60-mm endostapling between the distal and middle third of the lesser curvature. G, Introduction site of the circular stapler in the chest. H, Future esophagogastrostomy. I, Linear stapling for completion of the conduit in the chest. Ann Surg February; 245(2): 241
19 Summary Huge topic, hard to capture in 10 minutes Careful handling and meticulous technique will improve outcomes Gastric conduit ischemia is always present to varying degrees Be nimble and open to minor alterations in technique
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