nach oben

World Journal of Surgery

Erschienen in:

24.10.2016 | Original Scientific Report

Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis

verfasst von: Zuhair Ahmed, Jessie A. Elliott, Sinead King, Claire L. Donohoe, Narayanasamy Ravi, John V. Reynolds

Erschienen in: World Journal of Surgery | Ausgabe 2/2017

Einloggen, um Zugang zu erhalten

Abstract

Background

Benign anastomotic strictures occur frequently after esophagectomy, and impact on postoperative recovery, nutritional status, and quality of life. This large cohort study explored the incidence of stricture after transthoracic (2- and 3-stage) and transhiatal resections with uniform single-layer sutured anastomotic technique, and aimed to identify independent risk factors.

Methods

Patients undergoing esophagectomy with gastric conduit reconstruction between February 2001 and October 2014 were studied prospectively. Symptomatic anastomotic stricture was defined as dysphagia requiring endoscopic dilatation, and refractory strictures as those requiring >5 dilatations. Multivariable logistic regression was performed to determine factors independently associated with stricture development.

Results

Five-hundred and twenty-four patients, 77 % with adenocarcinoma, underwent esophagectomy [2-stage, n = 328 (62.6 %); 3-stage, n = 129 (23.3 %); transhiatal, n = 74 (14.1 %)], with an overall inhospital mortality rate of 2.7 %. 58.5 % of patients received neoadjuvant therapy [chemotherapy only, n = 119 (22.7 %); chemoradiation, n = 188 (35.9 %)]. Anastomotic stricture developed in 125 patients (24.5 %), was refractory in 20 (3.9 %) and required a median of 2 dilatations (range 1–18). On multivariable analysis, ASA grade (P < 0.05), cervical anastomosis (P < 0.001), and a significant postoperative cardiac event (P < 0.05) were independently associated with stricture risk. Refractory strictures were independently associated with anastomotic leak (P = 0.01) and transhiatal resections (P < 0.001).

Conclusion

Benign anastomotic strictures are common, particularly with cervical reconstruction, and after transhiatal resection. Refractory strictures are rare. Where fitness and oncologic equivalence apply, a thoracic anastomosis provides significant advantages compared with a cervical anastomosis in terms of anastomotic stricture risk.

Nur mit Berechtigung zugänglich

Reynolds JV, Donohoe CL, McGillycuddy E, Ravi N, O’Toole D, O’Byrne K, Hollywood D (2012) Evolving progress in oncologic and operative outcomes for esophageal and junctional cancer: lessons from the experience of a high-volume center. J Thorac Cardiovasc Surg 143(5):1130–1137.e1CrossRefPubMed

van Hagen P, Hulshof MC, van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijnhoven BP, Richel DJ, Nieuwenhuijzen GA, Hospers GA, Bonenkamp JJ, Cuesta MA, Blaisse RJ, Busch OR, ten Kate FJ, Creemers GJ, Punt CJ, Plukker JT, Verheul HM, Spillenaar Bilgen EJ, van Dekken H, van der Sangen MJ, Rozema T, Biermann K, Beukema JC, Piet AH, van Rij CM, Reinders JG, Tilanus HW, van der Gaast A (2012) Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 366(22):2074–2084CrossRefPubMed

Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL (2007) Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg 246(3):363–374CrossRefPubMedPubMedCentral

Brusselaers N, Mattsson F, Lagergren J (2014) Hospital and surgeon volume in relation to long-term survival after esophagectomy: systematic review and meta-analysis. Gut 63(9):1393–1400CrossRefPubMed

Klevebro F, Alexandersson von Dobeln G, Wang N, Johnsen G, Jacobsen AB, Friesland S, Hatlevoll I, Glenjen NI, Lind P, Tsai JA, Lundell L, Nilsson M (2016) A randomized clinical trial of neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy for cancer of the esophagus or gastro-esophageal junction. Ann Oncol 27(4):660–667. doi:10.1093/annonc/mdw010 CrossRefPubMed

Klevebro F, Johnsen G, Johnson E, Viste A, Myrnas T, Szabo E, Jacobsen AB, Friesland S, Tsai JA, Persson S, Lindblad M, Lundell L, Nilsson M (2015) Morbidity and mortality after surgery for cancer of the esophagus and gastro-esophageal junction: a randomized clinical trial of neoadjuvant chemotherapy vs. neoadjuvant chemoradiation. Eur J Surg Oncol 41(7):920–926CrossRefPubMed

Markar SR, Karthikesalingam A, Low DE (2015) Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis. Dis Esophagus 28(5):468–475CrossRefPubMed

Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE (2013) Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with esophageal cancer. Br J Surg 100(1):105–112CrossRefPubMed

Lagergren P, Avery KN, Hughes R, Barham CP, Alderson D, Falk SJ, Blazeby JM (2007) Health-related quality of life among patients cured by surgery for esophageal cancer. Cancer 110(3):686–693CrossRefPubMed

10.

Petrin G, Ruol A, Battaglia G, Buin F, Merigliano S, Constantini M, Pavei P, Cagol M, Scappin S, Ancona E (2000) Anastomotic stenoses occurring after circular stapling in esophageal cancer surgery. Surg Endosc 14(7):670–674CrossRefPubMed

11.

Rice TW (2006) Anastomotic stricture complicating esophagectomy. Thorac Surg Clin 16(1):63–73CrossRefPubMed

12.

Martin L, Jia C, Rouvelas I, Lagergren P (2008) Risk factors for malnutrition after esophageal and cardia cancer surgery. Br J Surg 95(11):1362–1368CrossRefPubMed

13.

Davis SJ, Zhao L, Chang AC, Orringer MB (2011) Refractory cervical esophagogastric anastomotic strictures: management and outcomes. J Thorac Cardiovasc Surg 141(2):444–448CrossRefPubMed

14.

Honkoop P, Siersema PD, Tilanus HW, Stassen LP, Hop WC, van Blankenstein M (1996) Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J Thorac Cardiovasc Surg 111(6):1141–1146 (discussion 1147–1148) CrossRefPubMed

15.

van Heijl M, Gooszen JA, Fockens P, Busch OR, van Lanschot JJ, van Berge Henegouwen MI (2010) Risk factors for development of benign cervical strictures after esophagectomy. Ann Surg 251(6):1064–1069CrossRefPubMed

16.

Dewar L, Gelfand G, Finley RJ, Evans K, Inculet R, Nelems B (1992) Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition. Am J Surg 163(5):484–489CrossRefPubMed

17.

Briel JW, Tamhankar AP, Hagen JA, DeMeester SR, Johansson J, Choustoulakis E, Peters JH, Bremner CG, DeMeester TR (2004) Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 198(4):536–541 (discussion 541–532) CrossRefPubMed

18.

Donohoe CL, O’Farrell NJ, Ravi N, Reynolds JV (2012) Evidence-based selective application of transhiatal esophagectomy in a high-volume esophageal center. World J Surg 36(1):98–103. doi:10.1007/s00268-011-1307-0 CrossRefPubMed

19.

Walsh TN, Noonan N, Hollywood D, Kelly A, Keeling N, Hennessy TP (1996) A comparison of multimodal therapy and surgery for esophageal adenocarcinoma. N Engl J Med 335(7):462–467CrossRefPubMed

20.

Cunningham D, Allum WH, Stenning SP, Thompson JN, Van de Velde CJ, Nicolson M, Scarffe JH, Lofts FJ, Falk SJ, Iveson TJ, Smith DB, Langley RE, Verma M, Weeden S, Chua YJ, Participants MT (2006) Perioperative chemotherapy versus surgery alone for resectable gastresophageal cancer. N Engl J Med 355(1):11–20CrossRefPubMed

21.

Keegan N, Keane F, Cuffe S, Cunningham M, Ravi N, Lee G, Kennedy M, Grogan W, O’Neill B, Power D, Leonard G, Keane M, Small C, Parker I, Moulton B, O’Reilly S, Reynolds J, Group I (2014) ICORG 10-14: Neo-AEGIS: a randomized clinical trial of neoadjuvant and adjuvant chemotherapy (modified MAGIC regimen) versus neoadjuvant chemoradiation (CROSS protocol) in adenocarcinoma of the esophagus and esophagogastric junction. J Clin Oncol 32(5s):TPS4145

22.

Reynolds JV, Muldoon C, Hollywood D, Ravi N, Rowley S, O’Byrne K, Kennedy J, Murphy TJ (2007) Long-term outcomes following neoadjuvant chemoradiotherapy for esophageal cancer. Ann Surg 245(5):707–716CrossRefPubMedPubMedCentral

23.

Sharma P, Kozarek R (2009) Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 105(2):258–273CrossRefPubMed

24.

Ripley RT, Sarkaria IS, Grosser R, Sima CS, Bains MS, Jones DR, Adusumilli PS, Huang J, Finley DJ, Rusch VW, Rizk NP (2016) Pretreatment dysphagia in esophageal cancer patients may eliminate the need for staging by endoscopic ultrasonography. Ann Thorac Surg 101(1):226–230CrossRefPubMed

25.

Mellow MH, Pinkas H (1985) Endoscopic laser therapy for malignancies affecting the esophagus and gastresophageal junction. Analysis of technical and functional efficacy. Arch Intern Med 145(8):1443–1446CrossRefPubMed

26.

Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Thygesen K, Alpert JS, White HD, Jaffe AS, Katus HA, Apple FS, Lindahl B, Morrow DA, Chaitman BA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasche P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S (2012) Third universal definition of myocardial infarction. Eur Heart J 33(20):2551–2567CrossRefPubMed

27.

Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentral

28.

Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA (2013) The comprehensive complication index: a novel continuous scale to measure surgical morbidity. Ann Surg 258(1):1–7CrossRefPubMed

29.

Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, van Raemdonck D (2002) Anastomotic complications after esophagectomy. Dig Surg 19(2):92–98CrossRefPubMed

30.

Suma H, Takanashi R (1990) Arteriosclerosis of the gastroepiploic and internal thoracic arteries. Ann Thorac Surg 50(3):413–416CrossRefPubMed

31.

Salo JA, Perhoniemi VJ, Heikkinen LO, Verkkala KA, Jarvinen AA (1992) Pulse oximetry for the assessment of gastric tube circulation in esophageal replacements. Am J Surg 163(4):446–447CrossRefPubMed

32.

Pierie JP, De Graaf PW, Poen H, Van der Tweel I, Obertop H (1994) Impaired healing of cervical esophagogastrostomies can be predicted by estimation of gastric serosal blood perfusion by laser Doppler flowmetry. Eur J Surg 160(11):599–603PubMed

33.

Kulik A, Ruel M (2011) Lipid-lowering therapy and coronary artery bypass graft surgery: what are the benefits? Curr Opin Cardiol 26(6):508–517CrossRefPubMed

34.

Deo SV, Dunlay SM, Shah IK, Altarabsheh SE, Erwin PJ, Boilson BA, Park SJ, Joyce LD (2013) Dual anti-platelet therapy after coronary artery bypass grafting: is there any benefit? A systematic review and meta-analysis. J Card Surg 28(2):109–116CrossRefPubMed

35.

Bedenis R, Lethaby A, Maxwell H, Acosta S, Prins MH (2015) Antiplatelet agents for preventing thrombosis after peripheral arterial bypass surgery. Cochrane Database Syst Rev 2:CD000535

36.

Antiplatelet Trialists’ Collaboration (1994) Collaborative overview of randomised trials of antiplatelet therapy–II: maintenance of vascular graft or arterial patency by antiplatelet therapy. BMJ 308(6922):159–168CrossRef

37.

Higgins DF, Kimura K, Iwano M, Haase VH (2008) Hypoxia-inducible factor signaling in the development of tissue fibrosis. Cell Cycle (Georgetown, Tex) 7(9):1128–1132CrossRef

38.

Scholz CC, Cavadas MA, Tambuwala MM, Hams E, Rodriguez J, von Kriegsheim A, Cotter P, Bruning U, Fallon PG, Cheong A, Cummins EP, Taylor CT (2013) Regulation of IL-1beta-induced NF-kappaB by hydroxylases links key hypoxic and inflammatory signaling pathways. Proc Natl Acad Sci USA 110(46):18490–18495CrossRefPubMedPubMedCentral

39.

Eltzschig HK, Carmeliet P (2011) Hypoxia and inflammation. N Engl J Med 364(7):656–665CrossRefPubMedPubMedCentral

40.

Han WQ, Zhu Q, Hu J, Li PL, Zhang F, Li N (2013) Hypoxia-inducible factor prolyl-hydroxylase-2 mediates transforming growth factor beta 1-induced epithelial-mesenchymal transition in renal tubular cells. Biochim Biophys Acta 1833(6):1454–1462CrossRefPubMedPubMedCentral

41.

Nolan KA, Brennan EP, Scholz CC, Cullen C, Ryan A, Taylor CT, Godson C (2015) Paricalcitol protects against TGF-beta1-induced fibrotic responses in hypoxia and stabilises HIF-alpha in renal epithelia. Exp Cell Res 330(2):371–381CrossRefPubMed

42.

Kelley ST, Coppola D, Karl RC (2004) Neoadjuvant chemoradiotherapy is not associated with a higher complication rate vs. surgery alone in patients undergoing esophagectomy. J Gastrointest Surg 8(3):227–231 (discussion 231–222) CrossRefPubMed

43.

Zhou D, Liu QX, Deng XF, Min JX, Dai JG (2015) Comparison of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis. J Cardiothorac Surg 10:67CrossRefPubMedPubMedCentral

44.

Honda M, Kuriyama A, Noma H, Nunobe S, Furukawa TA (2013) Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg 257(2):238–248CrossRefPubMed

45.

Deng XF, Liu QX, Zhou D, Min JX, Dai JG (2015) Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer: a meta-analysis. World J Gastroenterol 21(15):4757–4764PubMedPubMedCentral

46.

Ercan S, Rice TW, Murthy SC, Rybicki LA, Blackstone EH (2005) Does esophagogastric anastomotic technique influence the outcome of patients with esophageal cancer? J Thorac Cardiovasc Surg 129(3):623–631CrossRefPubMed

47.

Nederlof N, Tilanus HW, Tran TC, Hop WC, Wijnhoven BP, de Jonge J (2011) End-to-end versus end-to-side esophagogastrostomy after esophageal cancer resection: a prospective randomized study. Ann Surg 254(2):226–233CrossRefPubMed

48.

Yuan Y, Zeng X, Hu Y, Xie T, Zhao Y (2014) Omentoplasty for esophagogastrostomy after esophagectomy. Cochrane Database Syst Rev 10:CD008446

49.

Markar SR, Arya S, Karthikesalingam A, Hanna GB (2013) Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol 20(13):4274–4281CrossRefPubMed

50.

Page RD, Asmat A, McShane J, Russell GN, Pennefather SH (2013) Routine endoscopy to detect anastomotic leakage after esophagectomy. Ann Thorac Surg 95(1):292–298CrossRefPubMed

51.

Schaible A, Sauer P, Hartwig W, Hackert T, Hinz U, Radeleff B, Büchler MW, Werner J (2014) Radiologic versus endoscopic evaluation of the conduit after esophageal resection: a prospective, blinded, intraindividually controlled diagnostic study. Surg Endosc 28(7):2078–2085CrossRefPubMed

Titel: Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis
verfasst von: Zuhair Ahmed
Jessie A. Elliott
Sinead King
Claire L. Donohoe
Narayanasamy Ravi
John V. Reynolds
Publikationsdatum: 24.10.2016
Verlag: Springer International Publishing
Erschienen in: World Journal of Surgery / Ausgabe 2/2017
Print ISSN: 0364-2313
Elektronische ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-016-3746-0

Neu im Fachgebiet Chirurgie

Häusliche Gewalt in der orthopädischen Notaufnahme oft nicht erkannt

28.05.2024 Häusliche Gewalt Nachrichten

In der Notaufnahme wird die Chance, Opfer von häuslicher Gewalt zu identifizieren, von Orthopäden und Orthopädinnen offenbar zu wenig genutzt. Darauf deuten die Ergebnisse einer Fragebogenstudie an der Sahlgrenska-Universität in Schweden hin.

Fehlerkultur in der Medizin – Offenheit zählt!

28.05.2024 Fehlerkultur Podcast

Darüber reden und aus Fehlern lernen, sollte das Motto in der Medizin lauten. Und zwar nicht nur im Sinne der Patientensicherheit. Eine negative Fehlerkultur kann auch die Behandelnden ernsthaft krank machen, warnt Prof. Dr. Reinhard Strametz. Ein Plädoyer und ein Leitfaden für den offenen Umgang mit kritischen Ereignissen in Medizin und Pflege.

Mehr Frauen im OP – weniger postoperative Komplikationen

21.05.2024 Allgemeine Chirurgie Nachrichten

Ein Frauenanteil von mindestens einem Drittel im ärztlichen Op.-Team war in einer großen retrospektiven Studie aus Kanada mit einer signifikanten Reduktion der postoperativen Morbidität assoziiert.

TAVI versus Klappenchirurgie: Neue Vergleichsstudie sorgt für Erstaunen

21.05.2024 TAVI Nachrichten

Bei schwerer Aortenstenose und obstruktiver KHK empfehlen die Leitlinien derzeit eine chirurgische Kombi-Behandlung aus Klappenersatz plus Bypass-OP. Diese Empfehlung wird allerdings jetzt durch eine aktuelle Studie infrage gestellt – mit überraschender Deutlichkeit.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Aktuelle BDC Leitlinien-Webinare

S3-Leitlinie „Diagnostik und Therapie des Karpaltunnelsyndroms“

Karpaltunnelsyndrom BDC Leitlinien Webinare

CME: 2 Punkte

Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.

Prof. Dr. med. Gregor Antoniadis

S2e-Leitlinie „Distale Radiusfraktur“

Radiusfraktur BDC Leitlinien Webinare

CME: 2 Punkte

Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?

PD Dr. med. Oliver Pieske

Dr. med. Benjamin Meyknecht

S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“

Appendizitis BDC Leitlinien Webinare

CME: 2 Punkte

Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.

Dr. med. Mihailo Andric

Live-Webinar "Urologie und Sexualmedizin in der Praxis"

Springer Medizin

Risk Factors for Anastomotic Stricture Post-esophagectomy with a Standardized Sutured Anastomosis