The sterno-tracheal distance is an important factor of anastomotic leakage of retrosternal gastric tube reconstruction after esophagectomy

Inoue, Seiya; Yoshida, Takahiro; Nishino, Takeshi; Goto, Masakazu; Furukita, Yoshihito; Yamamoto, Yota; Fujiwara, Satoshi; Minato, Takuya; Sumitomo, Hiroyuki; Yuasa, Yasuhiro; Takizawa, Hiromitsu; Tangoku, Akira

doi:10.1007/s10388-019-00705-9

Cited by 6 publications

(7 citation statements)

References 13 publications

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“…[28][29][30][31] Furthermore, the size of the thoracic inlet (superior thoracic aperture) is reportedly associated with cervical anastomotic leak, both in the PM and RS reconstructions, suggesting that compression of the clavicular head and the sternoclavicular joint may impair blood flow of the gastric conduit. [32][33][34] However, it is unclear which route is more significantly affected by a narrow thoracic inlet, and whether this may lead to different risks of anastomotic leak between the two groups. The effect of the gastric conduit width (wide vs narrow) on anastomotic leak is another topic of clinical interest; however, there is currently no consensus on the superiority of either method.…”

Section: Discussionmentioning

confidence: 99%

“…Although the length of reconstruction route may explain the risk of anastomotic leak, there are controversies surrounding the required conduit length between the PM and RS routes 28‐31 . Furthermore, the size of the thoracic inlet (superior thoracic aperture) is reportedly associated with cervical anastomotic leak, both in the PM and RS reconstructions, suggesting that compression of the clavicular head and the sternoclavicular joint may impair blood flow of the gastric conduit 32‐34 . However, it is unclear which route is more significantly affected by a narrow thoracic inlet, and whether this may lead to different risks of anastomotic leak between the two groups.…”

Section: Discussionmentioning

confidence: 99%

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Impact of Reconstruction Route on Postoperative Morbidity After Esophagectomy: Analysis of Esophagectomies in the Japanese National Clinical Database

Kikuchi

Endo

Yamamoto

et al. 2021

Annals of Gastroent Surgery

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Background: Esophagectomy followed by gastric conduit reconstruction is a standard surgical procedure for esophageal cancer. However, there is no evidence of the superiority or inferiority of the posterior mediastinal (PM) versus the retrosternal (RS) reconstruction route with regard to short-term outcomes after esophagectomy.We aimed to elucidate whether the reconstruction route can affect the short-term outcomes after esophagectomy followed by gastric conduit reconstruction. Methods:We reviewed the clinical data of patients who underwent esophagectomy between 2016 and 2018 from the Japanese National Clinical Database. This study included 9786 patients who underwent gastric conduit reconstruction through the PM or RS route with cervical anastomosis. Results:Of the 9786 patients analyzed, 3478 and 6308 underwent gastric conduit reconstruction thorough the PM and RS routes, respectively. The incidence of anastomotic leak and surgical site infection (SSI) was significantly lower in the PM group than in the RS group (11.7% vs 13.8%, P = .005 and 8.4% vs 14.9%, P < .001, respectively), while the incidence of pneumonia was higher in the PM group (13.7% vs 12.2%, P = .040). Generalized estimating equation logistic regression analysis revealed a higher risk of anastomotic leak and SSI (odds ratio [OR], 1.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Impact of Reconstruction Route on Postoperative Morbidity After Esophagectomy: Analysis of Esophagectomies in the Japanese National Clinical Database

Kikuchi

Endo

Yamamoto

et al. 2021

Annals of Gastroent Surgery

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“…Preoperative evaluation of the narrowness of the inlet space is important to reduce the complications arising from compression by the SCJ. Several studies have evaluated the size of the thoracic inlet space [2][3][4]. Kunisaki et al recommended a thoracic inlet space (TIS) of > 700 mm 2 and resection of bony structures to avoid anastomotic leakage when the space is narrow [2].…”

Section: Discussionmentioning

confidence: 99%

“…Kunisaki et al recommended a thoracic inlet space (TIS) of > 700 mm 2 and resection of bony structures to avoid anastomotic leakage when the space is narrow [ 2 ]. Inoue et al concluded that the sterno-tracheal distance (STD) was an independent risk factor for anastomotic leakage in the retrosternal route and that this route should be avoided in patients with an STD < 13 mm [ 3 ]. In all three cases in the present study, the TIS was < 700 mm 2 , meaning that the inlet space was narrower than that recommended by Kunisaki et al However, the STD was > 13 mm in all three cases, meaning that the STD was of sufficient width to perform retrosternal reconstruction (Figs.…”

Section: Discussionmentioning

confidence: 99%

“…Three reconstruction routes possible after esophagectomy are posterior mediastinal, retrosternal and percutaneous. Although the retrosternal route is often chosen for safety in the event of postoperative complications, it has a drawback in terms of higher incidence of anastomotic leakage and stenosis [1][2][3][4]. One of the reasons for this problem is that the reconstructed organ which passes through the narrow thoracic inlet with abrupt flexion around the trachea is compressed by the sternoclavicular joint (SCJ).…”

Section: Introductionmentioning

confidence: 99%

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Anastomotic leakage after esophagectomy possibly caused by compression of the gastric conduit behind the sternoclavicular joint: a report of three cases

et al. 2021

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Background The narrowness of the thoracic inlet is often a problem in retrosternal reconstruction after esophagectomy. We report here three cases in which compression of the gastric conduit behind the sternoclavicular joint possibly caused anastomotic leakage. Case presentations The first case was a 71-year-old man who underwent subtotal esophagectomy for upper esophageal cancer followed by retrosternal reconstruction. On postoperative day 2, he developed septic shock and underwent reoperation because of a necrotic gastric conduit. The tip of the conduit above the manubrium was necrotic due to strangulation as a result of compression by the sternoclavicular joint. The second and third cases were a 50-year-old woman and a 71-year-old man who underwent subtotal esophagectomy for middle and lower esophageal cancer, respectively, followed by retrosternal reconstruction. Despite indocyanine green fluorescence imaging indicating adequate blood flow in both cases, the tip of the conduit appeared pale and congested because of compression by the sternoclavicular joint after anastomosis. Postoperatively, these two patients developed anastomotic leakage that was confirmed endoscopically on the ventral side of the gastric wall that had been pale intraoperatively. Conclusions When performing reconstruction using the retrosternal route after esophagectomy, it is important to ensure that compression by the sternoclavicular joint does not have an adverse impact on blood flow at the tip of the gastric conduit.

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What is the best reconstruction procedure after esophagectomy? A meta‐analysis comparing posterior mediastinal and retrosternal approaches

Booka

Takeuchi

Morita

et al. 2023

Annals of Gastroent Surgery

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Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta‐analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70–0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58–1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56–1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid‐ to long‐term quality of life.

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The sterno-tracheal distance is an important factor of anastomotic leakage of retrosternal gastric tube reconstruction after esophagectomy

Cited by 6 publications

References 13 publications

Impact of Reconstruction Route on Postoperative Morbidity After Esophagectomy: Analysis of Esophagectomies in the Japanese National Clinical Database

Impact of Reconstruction Route on Postoperative Morbidity After Esophagectomy: Analysis of Esophagectomies in the Japanese National Clinical Database

Anastomotic leakage after esophagectomy possibly caused by compression of the gastric conduit behind the sternoclavicular joint: a report of three cases

What is the best reconstruction procedure after esophagectomy? A meta‐analysis comparing posterior mediastinal and retrosternal approaches

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