Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis

Abstract

Background: Leakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery. Method: Embase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A "random-effects model" was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I 2-test. Results: From the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7e24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42e3.34)), celiac axis (OR 1.62(CI 1.15e2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27e5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I 2 ¼ 71% and 59%, respectively) but not for the right branches of the celiac axis (I 2 ¼ 0%). Conclusion: This meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.

The ISCON-trial protocol: laparoscopic ischemic conditioning prior to esophagectomy in patients with esophageal cancer and arterial calcifications

“…One of these factors includes hypovascularization of the gastric conduit which opposes healing of the anastomosis and consequently contributes to leakages. In retrospective analyses of both participating centres of the current study, major calcifications of the aorta and celiac axis have been shown to be an independent risk factor for anastomotic leakage [20,21]. The preoperative identification of patients at risk for anastomotic leakage allows for personalized treatment programs.…”

Role of Radiology in the Preoperative Detection of Arterial Calcification and Celiac Trunk Stenosis and Its Association with Anastomotic Leakage Post Esophagectomy, an Up-to-Date Review of the Literature

“…This up-to-date literature review adds value to the previously published reviews by Knight et al [ 28 ] and Hoek et al [ 29 ] concerning the impact of arterial calcification in AL after esophagectomy, by including studies evaluating another radiological risk factor for AL, namely celiac trunk stenosis. Given the fact that the arterial supply of the reconstructed GC which will be anastomosed to the esophageal remnant derives invariably from the right gastroepiploic artery [ 25 ], a branch of the celiac trunk, it is rational to assume that stenosis in the celiac trunk may lead to increased rates of GC necrosis and anastomotic leakage following esophagectomy.…”

“…A total of 68 potentially relevant articles were identified through an electronic search of bibliographic databases and a manual search of reference lists, of which 34 were directly excluded as duplicates. Of the remaining 34 articles that underwent full-text evaluation, 25 were excluded for the following reasons: 1 case report of 2 patients [ 33 ], 1 systematic review [ 28 ], 1 systematic review and meta-analysis [ 29 ], and 22 articles which were assessed as irrelevant. Finally, 9 original studies fulfilled the inclusion criteria and were further scrutinized [ 30 , 31 , 34 , 35 , 36 , 37 , 38 , 39 , 40 ].…”

“…The aforementioned reasons are also possible factors in the wide variation in the reported incidence of AL. Due to the discrepancies in the above-mentioned results, Hoek et al [ 29 ] conducted a meta-analysis pooling data from all studies investigating the relation between arterial calcification and AL after esophagectomy with GC reconstruction [ 29 ]. The meta-analysis showed a significant association between high calcium score and AL for the thoracic aorta, celiac trunk, and right post-celiac axis, confirming the hypothesis that atherosclerotic disease can lead to AL.…”

“…Since, routinely, a full-body CT scan is available for each patient undergoing esophagectomy, the evaluation of radiological risk factors predicting poor outcomes, and in particular AL, can be easily incorporated into everyday practice Figure 2 . A recent review by Knight et al [ 28 ] and a meta-analysis by Hoek et al [ 29 ] examined the association between AL and arterial calcification following esophagectomy. Both studies concluded that there is significant evidence pointing to the contribution of calcification in the thoracic aorta, the celiac axis, and the right post-celiac arteries in the development of postoperative AL for patients undergoing esophagectomy with GC reconstruction.…”