REDUCING CONDUIT ISCHEMIA AND ANASTOMOTIC LEAKS IN TRANSHIATAL ESOPHAGECTOMY: SIX PRINCIPLES
Matias E. Czerwonko*, Farhood Farjah, Brant K. Oelschlager
University of Washington, Seattle, WA
Background: Transhiatal Esophagectomy (THE) is an accepted approach for distal esophageal and gastroesophageal junction (GEJ) cancers. Its reported weaknesses are limited loco-regional resection (radial margins and lymphadenectomy) and high anastomotic leak rates of 12.3%. We have used laparoscopic assistance to perform a THE (lapTHE) as our preferred method of resection for most GEJ cancer for over 20 years. Our unique approach and experience may provide superior outcomes.
Methods: We reviewed all patients who underwent LapTHE with extended lymph node dissection for distal esophageal and GEJ malignancy by a single surgeon over 10 years (2011-20). We included 6 principles in our approach destined to promote anastomotic healing: 1. minimize dissection trauma to the stomach; 2. routine Kocher maneuver; 3. detailed division of ubiquitous lesser sac adhesions and exposure of the gastroepiploic arcade; 4. resection of proximal 5 cm of the stomach and performing the anastomosis with a better perfused part; 5. stapled side to side anastomosis 6. routine feeding jejunostomy use. Pre-operative characteristics, operative details, postoperative complications, and short-term outcomes were tracked by review of our database and electronic medical record.
Results: One hundred and forty-seven patients underwent LapTHE during the study period (table 1). Most patients had adenocarcinoma (93%) and received neoadjuvant chemoradiation (84%). The median lymph nodes procured was 19 (range 5-49) and R0 resection was achieved in all cases (95% confidence interval [CI] 98-100%). Median hospital stay was 7 days and was 8 days or less in 127 patients (86%). Overall major complication rate was 24% (95%CI 17-32%), ninety-day mortality was 2.0% (95%CI 0.4-5.8%) and reoperation was 5.4% (95%CI 2.4-10%) (Table 2). Three patients (2.0%, 95%CI 0.4-5.8%) developed an anastomotic leak. No patient developed ischemia of the conduit (95%CI 0-2.5%). Median follow up was 901 days (range 52-5240). Nine patients (6.1%, 95%CI 2.8-11%) developed an anastomotic stricture.
Conclusions: Routine use of LapTHE for distal esophageal and GEJ cancers and inclusion of these six operative principles allow for radical oncologic resection and a low rate of anastomotic complications relative to national benchmarks.
Table 1. Demographic and preoperative characteristics of the cohort
Table 2 Operative variables and post-operative complications by type
Back to 2022 Abstracts