The Neck is the best location for an Anatomosis Claude Deschamps, MD Fletcher Allen Health Care University of Vermont Burlington, VT AATS Postgraduate Course April 27, 2014 Toronto, CA GERD1 Methods • Evidence Based (Boston strong) • Confidence Based (Vegas strong) • Convenience Based (strong) No disclosure GERD2 Evidence Based GERD3 Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC ©2005 MAYO CLINIC Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC ©2005 MAYO CLINIC Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC ©2005 MAYO CLINIC Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC ©2005 MAYO CLINIC Stapled vs. Hand-Sewn Anastomosis Cervical Linear Stapled ©2005 MAYO CLINIC ©2005 MAYO CLINIC GERD11 ICACT2009. 12 Stapled vs. Hand‐Sewn Anastomosis Leak Comparison Leak rate overall Hand‐sewn Stapled 26 (12.7%) 4 (5.3%) Adjusted p‐value * 0.008 * logistic regression analysis Stapled vs. Hand‐Sewn Anastomosis Dilatation Comparison Dilatations Hand‐sewn Stapled p‐value 70 (34%) 11 (14%) 0.001 80 patients 50 Neck 30 Chest GERD15 FUP at 3 months GERD16 FUP at one year GERD17 84 patients 36 chest 48 neck GERD18 GERD19 GERD20 GERD21 GERD22 GERD23 “When a gastric transplant is used after esophagectomy, a high prevalence of mucosal damage is observed in the esophageal remnant independently of the level of reconstruction. A left cervical anastomosis favors less reflux symptoms, less visualized damage, and delays the development of mucosal damage over time.” GERD24 Esophageal Resection: Long-Term Function and Quality of Life Allison J. McLarty, M.D., Claude Deschamps, M.D., Victor F. Trastek, M.D., Mark S. Allen, M.D., William S. Harmsen, M.S. and Peter C. Pairolero, M.D. Section of General Thoracic Surgery Mayo Clinic, Rochester, MN STSA96-F.1 Esophageal Resection: Long-Term Function & Quality of Life 107 patients survived > 5 years 77 Chest 30 neck Esophageal Resection: Long-Term Function & Quality of Life Quality of Life After Resection for Esophageal carcinoma Survey Ann Thorac Surg 1997 Jun; 63(6) Esophageal Resection: Long-Term Function & Quality of Life Factors Affecting Functional Outcome Cervical anastomosis had less reflux than an intrathoracic anastomosis (p<0.05) Selective Management of Intrathoracic Anastomotic Leak after Esophagectomy Juan Crestanello, Claude Deschamps Stephen Cassivi, Francis Nichols III, Mark Allen, Cathy Schleck, Peter Pairolero Divisions of General Thoracic Surgery and Biostatistics Mayo Clinic College of Medicine Rochester, MN Selective Management of Anastomotic Leaks GTS Operations in CT Screening WTSA 2003. 30 Selective Management of Anastomotic Leaks Material and Methods 761 Esophagectomies with Intrathoracic anastomosis Anastomotic leak 48 patients 6.3 % GTS Operations in CT Screening WTSA 2003. 31 Selective Management of Anastomotic Leaks Non-Operative Management Outcome 27 Patients • • • • # of Patients (%) Hospital Mortality Oral intake at dismissal Time to oral intake 1 (3.7) 25 (93) 13 days Hospitalization 20 days GTS Operations in CT Screening WTSA 2003. 32 Selective Management of Anastomotic Leaks Operative Management Outcome 20 Patients • • • • Hospital Mortality Oral intake at DC Time to oral intake Hospitalization GTS Operations in CT Screening WTSA 2003. 33 # of Patients (%) 3 (15) 12 (70) 21 days 31 days Selective Management of Anastomotic Leaks Survival (Contained vs. Non-Contained) S u r v i v a l (%) 100 p=0.04 80 60 Contained 33% 40 20 NonContained 15% 0 0 1 2 3 4 Years Operation GTS Operations in CT Screening WTSA 2003. Since 34 5 “It appears that a key technical component in avoiding anastomotic leaks seems to be achieving mucosal incorporation/apposition” GERD35 Morbidity In a meta-analysis comparing THE and TTE, nearly 5500 patients, comprising 44 series, were analyzed. Pulmonary complications were similar between the two groups, noted in 24% of patients after THE and in 25% of patients after TTE. The operative mortality was 6.3% after THE and 9.5% after Ivor Lewis Esophagogastrectomy (ILE) Aust N Z J Surg 1999;69(3):187– 94. Taipei2009. 36 Morbidity Esophagectomies with thoracic incisions carry increased pulmonary morbidity. Swanstrom et al. JAMA Surg. 2013 Aug;148(8):733‐8. doi: 10.1001/jamasurg.2013.2356. NSQIP database 1568 esophagectomies More pneumonia, vent dependance and septic shock Taipei2009. 37 7995 esophagectomies Neck 12.3% leak rate Chest 9.3% leak rate No difference in leakage associated mortality GERD38 Confidence based GERD39 GERD40 9 ILE vs 5 THE Taipei2009. 41 Locally Recurrent Esophageal Carcinoma: When is Re-resection Indicated? PH Schipper, SD Cassivi, C Deschamps, FC Nichols, MS Allen, DC Rice, and PC Pairolero Division of General Thoracic Surgery Mayo Clinic College of Medicine Rochester, Minnesota Recurrent Esophageal Carcinoma Overall Survival 100 90 80 70 60 % Alive 50 40 30 20 10 0 46% 19% 0 1 2 3 Years 4 5 All neck anastomosis GERD44 Esophagectomy for chalasia 101 Neck The longer the follow up, the higher the incidence of Barrett’s GERD46 Easier to supercharge GERD47 Convenience Based GERD48 Other reasons to go to the neck • Outside prior radiation ports • Proximal tumors • Long Barrett’s • Squamous/Multifocal Carcinoma • Huge hernia/Shortened esophagus • Emergency esophagectomy • Infected/Hostile pleural space • Teaching • General surgery • OR time GERD49 OR time • THE: • TTE: • EBE: • MIE: 2-4 hrs 3-6 hrs 5-7 hrs 6-8 Location Location Location Location Location Location Location GERD51 U of M GERD52 ICACT2009. 53 Esophagogastrectomy Ivor Lewis Esophagogastrectomy 5FrEsoph 2002. 55 Esophagogastrectomy ? 5FrEsoph 2002. 56 UAB GERD57 Summary Neck • Less esophagus at risk • Easier on the patient • Easier on you • More versatility Thank You! [email protected] Fletcher Allen Health Care/University of Vermont GERD60
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