Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device

Abstract

BACKGROUNDBenign oesophageal strictures carry a significant level of morbidity, causing burdensome symptoms impacting on quality of life. Post-oesophagectomy anastomotic stricture rates as high as 41% have been reported in the literature. These can require endoscopic dilatation, often multiple times to relieve dysphagia. The aim of the present study was to determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.AIMTo determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.METHODSWe performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesophagectomy performed from 2004-2018 to determine the stricture rate. The database comprised a single-surgeon series of open, two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis. Tumour location, histology, neoadjuvant chemotherapy, stapler size, T-stage and R-status were analysed to see if they could predict stricture formation. Stricture was defined as dysphagia requiring endoscopic dilatation. Patients with anastomotic leaks were excluded on the basis they would develop an anastomotic stricture.RESULTSOne hundred and seventy patients were collected in the database. Nineteen were excluded on the basis of anastomotic leak, perioperative death and early recurrence. One hundred and fifty-four patients (119 males, 35 females) with a mean age of 64 ± 10 years were eligible for analysis. A total of 15 patients developed strictures a median of 99 d (interquartile range: 84-133) after surgery, giving a Kaplan-Meier estimated stricture rate of 10% at one year. None of the factors considered were found to be significantly associated with strictures.CONCLUSIONIn this study the stricture rate was 10%, with the majority occurring in the first 100 d after surgery. No significant independent factors were found in the development of strictures.

Comparison of Postoperative Outcomes of Hand-Sewn Versus Stapled Esophago-jejunal Anastomosis During Total Gastrectomy for Gastric Cancer in 72 Patients: A Retrospective, Single-Center Study in Poland

“…The surprisingly higher rate of stenosis in the hand-sewn group may be due to the fact that follow-up time was significantly longer in the hand-sewn group (median 2.1 years vs 1.1 years, respectively), as the stapled anastomosis was used more frequently over time. However, most strictures tend to occur during the first 3 months after surgery, which was observed both in the present study and in previous studies [ 39 , 43 ], and most of our patients had follow-up time longer than 4 months (there was only 1 case with 2-month follow-up), suggesting that this between-group difference did not affect the analysis. Nevertheless, follow-up duration should always be taken into account, as it may be one of factors responsible for disparity in stenosis rates across studies.…”

“…Among the long-term complications associated with EJA, anastomotic stricture is one of the most important, as it affects patient's quality of life and often requires invasive treatment by endoscopic dilation. The frequency of anastomotic strictures in the literature varies from 4.1 to 38% [38][39][40][41][42][43][44][45] APPROVED GALLEY PROOF circular stapler [38], the overall stricture rate was 38%, with differences reported for the various stapler sizes. A higher stricture risk was observed when a 25-mm stapler was used compared with a 28-or 29-mm device (53% vs 23%, respectively).…”

“…Moreover, the occurrence of anastomotic leakage was an independent risk factor for stenosis. In a recent analysis, Tyler et al [ 39 ] excluded patients with anastomotic leakage as a known risk factor for stenosis, and they observed a 10% stenosis rate (most occurring during the first 100 days after surgery). In our study, symptomatic anastomotic strictures mostly occurred 3.5 months after surgery, in a total of 13 cases (18.1%).…”

“…The decision about stapler size was made intraoperatively, based on the inner diameter of the patient’s esophagus. In some studies there was no difference in strictures rates, comparing 21-mm and 25-mm [ 40 ] or 23–25-mm and 28–33-mm circular staplers [ 39 , 41 , 42 ]. However, a large Japanese cohort [ 43 ], as well as a randomized trial by Fisher et al [ 44 ], reported the use of smaller stapler as a risk factor for stenosis.…”