Background
Esophageal cancer is the sixth most common cause of cancer-related death worldwide [
1]. The highest risk area for this cancer is often referred to as the “esophageal cancer belt,” stretching from northern Iran through the central Asian republics to North-Central China, and 90% of cases are squamous cell carcinomas [
2,
3]. Minimally invasive esophagectomy (MIE) has the potential to reduce the morbidity and mortality of esophageal cancer surgery. Open surgery is the current standard treatment; however, it is a complex procedure with high morbidity and mortality. To overcome this problem, MIE was introduced in the early 1990s and has yielded good postoperative results (morbidity 4%; mortality 1%) [
4]. In addition, a previous study reported that the tubular stomach reconstruction approach prevents postoperative recurrence and metastasis of esophageal cancer. Therefore, we adopted the thoracoscopic and laparoscopic cervical esophagogastric anastomosis technique in esophageal carcinoma patients to reconstruct the tubular stomach [
5].
However, most of the conclusions in literatures are based on data collected by different surgeons, which increased influences induced by subjective factors. Therefore, in order to reduce the impact of surgeon-subjective factors on these results, it may be valuable that these data be collected from the same surgeon in order to analyze the influences of retrosternal and prevertebral lifting paths of the tubular stomach on operative complications of patients with esophageal cancer. In this study, the clinical data of 63 patients who underwent thoracoscopic and laparoscopic esophagectomy and anastomosis of the esophagus and stomach were retrospectively analyzed. All operations were conducted by the same surgeon in the method of gastric tube reconstruction in the Thoracic Surgery Department of our hospital from January 2013 to December 2015, and our experience and outcomes were presented.
Discussion
Esophageal carcinoma is a common malignant tumor of the digestive tract in China, and surgical resection is known to be curative for locoregional disease in the case of esophageal cancer [
6]. Three-incision subtotal esophagectomy was recommended for esophageal cancer surgery especially for squamous cell carcinoma of the thoracic esophagus [
7]. Nevertheless, the conventional open esophagectomy has the disadvantages of extensive trauma, intense pain, and slow recovery. Video-assisted thoracoscopic surgery (VATS) shows an overall benefit on short-term quality of life (QOL) for the patients with esophageal cancer during the follow-up of 6 months after esophagectomy, compared with open surgery [
8]. The basis of minimally invasive techniques in esophageal surgery is to maintain the therapy effectiveness and quality of traditional operations, while reducing perioperative injury. It also can provide superior visualization and magnified view than open esophagectomy to perform thoracoabdominal esophagectomy with three-field lymphadenectomy to prevent lymph node metastasis [
9]. With the continuous improvement of minimally invasive endoscopic techniques, thoracoscopic and laparoscopic esophagectomies are not only suitable for patients with early esophageal cancer but are also suitable for parts of T3 patients [
10]. The study conducted by Zingg et al. [
11] has also shown that minimally invasive esophagectomy could reduce the incidence of pulmonary complications and respiratory failure in patients undergoing esophageal carcinoma surgery. Currently, the postoperative outcomes of retrosternal or prevertebral lifting paths of tubular stomach were controversial [
12,
13]. In our study, the different paths of stomach lifting in these two kinds of cervical esophagogastric anastomosis were completed by the same surgeon. This research method may be more valuable for the evaluation of the prognosis and reduce human disturbances in aspects of operation style, method of anesthesia, position, and whether artificial pneumothorax and other aspects as far as possible during surgery.
The surgical effect of the retrosternal and prevertebral paths in the recession of esophageal carcinoma is one of the subjects in a clinical study [
14]. Both the retrosternal and prevertebral paths are commonly used paths for tubular stomach upward lifting at present. Some scholars believe that the use of the prevertebral path has advantages of short anastomosis distance and operating convenience [
15]. Furthermore, as this operation can be completed without separating the gap, intraoperative bleeding risk is small and incidence rates of postoperative anastomosis fistula, anastomotic stenosis, and other complications are low. However, other scholars believe that the isolation of the retrosternal gap is safe, fast, and very convenient for stomach lifting. In addition, the retrosternal path in conventional three-incision surgery can be quickly and easily operated, operation time is not significantly different from the prevertebral path, the separation of the retrosternal gap does not significantly increase the amount of bleeding, and the postoperative radiotherapy does not influence the reconstruction of the digestive tract [
16‐
18]. In this study, operation time, bleeding volume, the number of dissected lymph nodes, and length of hospital stay between the two groups did not show significant differences. These findings revealed that the procedure of separating the gap was not a determinant factor for operation time and bleeding losses.
It was also observed that the volume of gastric juice drainage was significantly less in the retrosternal path group than in the prevertebral path group, and this result is consistent with a previous study [
19]. Previous studies have indicated that the incidence rates of duodenal reflux in patients who were operated through the retrosternal path were significantly lower than patients who were operated through the prevertebral path [
20,
21]. The reason for this may be because the sternum and pericardium provide continuous pressure on the tubular stomach of patients in the retrosternal path group, reducing gastric and duodenal reflux. We also believed that there were certain angles between the tubular stomach and thoracic outlet, as well as in the abdominal cavity, in patients from Shantou Hospital affiliated to Shantou University in the retrosternal path group, which could reduce gastric reflux and drainage [
22]. In addition, respiratory movement and the heart beat may promote peristalsis of the tubular stomach to a certain extent, which is beneficial to the gastric emptying. Therefore, postoperative reflux symptoms were lighter in patients operated through the retrosternal path than in patients operated through the prevertebral path; this presented with lower postoperative gastric drainage volume compared to patients in the prevertebral path group. Furthermore, this might be related to the preservation of the azygos vein arch during operation through the retrosternal path.
Anastomotic leakage, anastomotic stenosis, pulmonary infection, respiratory failure, arrhythmia, and thoracic infection are common complications after resection of esophageal carcinoma [
23]. Anastomotic leakage and anastomotic tension are closely associated with blood transport function. Some scholars found that the incidence rate of postoperative anastomotic leakage was higher in patients who were operated through the retrosternal path than in patients who were operated through the prevertebral path [
24]. It was reported that the retrosternal path was slightly longer than the prevertebral path. Furthermore, the tension of the anastomosis was larger, and both oxygen and blood supply to the anastomotic stoma were more insufficient compared to the prevertebral path. Moreover, the incidence rate of anastomotic leakage was higher. However, in this study, postoperative anastomotic leakage rate was low in these two groups and the difference was not significant. We speculate that this may be related to the following factors: (1) both groups with a tubular stomach diameter of 4 cm resulted in the effective increasing length of the residual stomach, and no obvious tension at the anastomotic stoma was found during the operation; (2) attention should be given in reducing the compression of the sternum outlet in the stomach. We expanded the width of the upper thoracic opening to 6–8 cm, and the gastric remnant was in a hypotonic state that made the blood vessels more smooth and reduced the incidence of anastomotic fistula; (3) a 2-mm negative pressure suction tube was placed at the cervical incision after operation, which kept the surrounding of the anastomosis clean and promoted the healing of the anastomotic stoma; and (4) the thin gastric tube was used before the operation, and indwelling time of the gastrointestinal decompression tube was extended, which kept the stomach in the empty state and reduced the impact of the anterior mediastinum in the stomach and anastomotic stoma, thereby effectively reducing the occurrence of fistula. In this study, the time of gastrointestinal decompression in most patients was more than 6 days, and the negative pressure drainage at the neck incision was helpful in reducing the incidence of anastomotic leakage. In addition, preoperative parenteral nutrition was given to patients in both groups to maintain normal levels of plasma protein; postoperative enteral nutrition support treatment was strengthened via jejunostomy fistulas to promote postoperative anastomotic stoma healing. Those factors might contribute to the absence of significant differences in anastomotic leakage between the two groups.
Pulmonary and thoracic infections are common complications after resection of esophageal cancer, and these are also the main causes of the reduced effect of surgery and length of stay. In recent years, studies have shown that thoracoscopic esophageal cancer resection can shorten recovery time, reduce lung function damage, reduce the incidence rate of postoperative pulmonary complications, and achieve the same effect as open chest surgery [
25]. The study conducted by Taguchi et al. [
26] revealed that thoracoscopic and laparoscopic esophageal cancer resection could better protect lung function and improve the quality of life of patients. In this study, postoperative pulmonary complications were significantly less in patients in the retrosternal path group than in patients in the prevertebral group, which is consistent with previous studies [
23]. The reason for it might be when the routine retrosternal tunnel was separated, the surgeon expanded the superior thoracic aperture and the tubular stomach was sent to the neck position on the left when the routine retrosternal tunnel was separated in the retrosternal path group, providing maximum maintenance in thoracic cavity volume and lung function [
20]. In addition, thoracoscopic incision was small with light pain and the integrity of the thorax was retained; therefore, there was little impact on the respiratory function of patients. In addition, this is conducive to early postoperative sputum drainage, thereby reducing the incidence of pulmonary infection. Therefore, the incidence rates of postoperative pulmonary infection were low in patients who underwent these two kinds of paths.
In summary, cervical esophagogastric anastomoses performed through different stomach lifting paths (retrosternal and prevertebral paths) are both feasible for digestive tract reconstruction. Postoperative gastric drainage volume and the incidence rate of pulmonary infection were less in patients in the retrosternal path group compared to patients in the prevertebral path group. Gastroesophageal anastomosis via the retrosternal path can be considered as a priority. However, further studies on surgical complications, long-term follow-ups, and survival rate are needed.