Skip to main content

Advertisement

SpringerLink
Log in

Additional Microvascular Anastomosis to Gastric Conduit During Esophagectomy Reduces Anastomotic Leaks: Propensity Score Weighting Study

  • Thoracic Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Impaired gastric conduit perfusion during esophagectomy and reconstruction is considered a key risk factor of anastomotic leaks. The aim of this study is to evaluate the indication and feasibility of additional microvascular anastomosis (AMA) to the gastric conduit in esophageal cancer surgery.

Patients and Methods

Patients who received an esophagectomy with gastric conduit reconstruction between July 2008 and July 2021 at a single center were reviewed. Patient characteristics, anastomotic viability index (AVI) of the gastric conduit measured with thermal imaging, and operative outcomes were analyzed using Fisher’s exact test and Mann–Whitney U test. Two propensity score weighting methods (inverse probability of treatment weighting and overlap weighting) were applied to investigate whether AMA reduces anastomotic leaks.

Results

Of the 293 patients who underwent an esophagectomy over the study period, 26 received AMA. AVI in the AMA group was significantly lower than that in the control group (0.64 vs. 0.74, p = 0.026). Overall anastomotic leak rates were 3.8% in the AMA group and 12.4% in the control group. Using two different propensity score weighting methods, the same conclusion was obtained that AMA significantly reduced anastomotic leaks after esophagectomy (both p < 0.001). The logistic regression model for estimating probability of anastomotic leaks provided AVI criteria for AMA application and revealed that AMA significantly reduced the estimated leak rates by a maximum of 49%.

Conclusions

Additional microvascular anastomosis significantly reduced anastomotic leaks after esophagectomy. The proposed AVI criteria for AMA application can help guide surgeons as to when AMA is needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1.
Fig. 2.
Fig. 3.

Similar content being viewed by others

Data availability

The data underlying this article will be shared upon reasonable request to the corresponding author.

References

  1. Raymond DP, Seder CW, Wright CD, et al. Predictors of major morbidity or mortality after resection for esophageal cancer: a society of thoracic surgeons general thoracic surgery database risk adjustment model. Ann Thorac Surg. 2016;102:207–14.

    Article  Google Scholar 

  2. Markar SR, Arya S, Karthikesalingam A, et al. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol. 2013;20:4274–81.

    Article  Google Scholar 

  3. Ishikawa Y, Breuler C, Chang AC, et al. Quantitative perfusion assessment of gastric conduit with indocyanine green dye to predict anastomotic leak after esophagectomy. Dis Esophagus. 2022;35(5):doab079. https://doi.org/10.1093/dote/doab079.

    Article  Google Scholar 

  4. Nishikawa K, Fujita T, Yuda M, et al. Quantitative assessment of blood flow in the gastric conduit with thermal imaging for esophageal reconstruction. Ann Surg. 2020;271:1087–94.

    Article  Google Scholar 

  5. Fujioka M, Hayashida K, Fukui K, et al. Venous superdrained gastric tube pull-up procedure for hypopharyngeal and cervical esophageal reconstruction reduces postoperative anastomotic leakage and stricture. Dis Esophagus. 2017;30:1–6.

    Article  CAS  Google Scholar 

  6. Takeda FR, Tutihashi R, Tustumi F, et al. Supercharged cervical anastomosis for esophagectomy and gastric pull-up. J Thorac Cardiovasc Surg. 2021;162:688–97.

    Article  Google Scholar 

  7. Coral RP, Constant-Neto M, Silva IS, et al. Comparative anatomical study of the anterior and posterior mediastinum as access routes after esophagectomy. Dis Esophagus. 2003;16(3):236–8. https://doi.org/10.1046/j.1442-2050.2003.00335.x.

    Article  CAS  Google Scholar 

  8. Rice TW, Kelsen DP, Blackstone EH, et al. Esophagus and esophagogastric junction. In: MB Amin, SB Edge, FL Greene, et al., editors. AJCC cancer staging manual. 8th edn. New York: Springer; 2017. p. 185–202.

    Chapter  Google Scholar 

  9. Low DE, Alderson D, Cecconello I, et al. International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann Surg. 2015;262:286–94.

    Article  Google Scholar 

  10. Li F, Thomas LE, Li F. Addressing extreme propensity scores via the overlap weights [published correction appears in Am J Epidemiol. 2021 Jan 4, 190(1), pp. 189–190]. Am J Epidemiol. 2019;188:250–7.

    Google Scholar 

  11. Kawai KI, Kakibuchi M, Sakagami M, et al. Supercharged gastric tube pull-up procedure for total esophageal reconstruction. Ann Plast Surg. 2001;47:390–3.

    Article  CAS  Google Scholar 

  12. Yoshimi F, Asato Y, Ikeda S, et al. Using the supercharge technique to additionally revascularize the gastric tube after a subtotal esophagectomy for esophageal cancer. Am J Surg. 2006;191:284–7.

    Article  Google Scholar 

  13. Mao H, Li L, Greene T. Propensity score weighting analysis and treatment effect discovery. Stat Methods Med Res. 2019;28:2439–54.

    Article  Google Scholar 

  14. Kono K, Sugai H, Omata H, et al. Transient bloodletting of the short gastric vein in the reconstructed gastric tube improves gastric microcirculation during esophagectomy. World J Surg. 2007;31(4):780–6.

    Article  Google Scholar 

  15. Yukaya T, Saeki H, Kasagi Y, et al. Indocyanine green fluorescence angiography for quantitative evaluation of gastric tube perfusion in patients undergoing esophagectomy. J Am Coll Surg. 2015;221:e37–42.

    Article  Google Scholar 

Download references

Acknowledgement

The authors would like to thank Lili Zhao, PhD, Department of Biostatistics, University of Michigan, for the statistics consultation.

Author information

Authors and Affiliations

  1. Department of Surgery, The Jikei University School of Medicine, Tokyo, Japan

    Yoshitaka Ishikawa MD, Katsunori Nishikawa MD, FACS, Keita Takahashi MD, Takanori Kurogochi MD, Masami Yuda MD, Yujiro Tanaka MD, Akira Matsumoto MD, Yuichiro Tanishima MD, PhD, Fumiaki Yano MD, FACS & Ken Eto MD, FACS

  2. Section of Thoracic Surgery, University of Michigan, Ann Arbor, MI, USA

    Yoshitaka Ishikawa MD & Rishindra M. Reddy MD, FACS

Authors
  1. Yoshitaka Ishikawa MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Katsunori Nishikawa MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Keita Takahashi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Takanori Kurogochi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Masami Yuda MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yujiro Tanaka MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Akira Matsumoto MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yuichiro Tanishima MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Fumiaki Yano MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Ken Eto MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Rishindra M. Reddy MD, FACS
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yoshitaka Ishikawa MD.

Ethics declarations

Disclosure

None of the authors has anything relevant to disclose. This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 59 KB)

Supplementary file2 (DOCX 12 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ishikawa, Y., Nishikawa, K., Takahashi, K. et al. Additional Microvascular Anastomosis to Gastric Conduit During Esophagectomy Reduces Anastomotic Leaks: Propensity Score Weighting Study. Ann Surg Oncol 30, 874–881 (2023). https://doi.org/10.1245/s10434-022-12737-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-022-12737-0

Search

Navigation