Effect of severed right gastric artery on postoperative anastomosis after Mckeown surgery for esophageal carcinoma: A Randomized controlled trial

doi:10.21203/rs.3.rs-4907093/v1

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Effect of severed right gastric artery on postoperative anastomosis after Mckeown surgery for esophageal carcinoma: A Randomized controlled trial

https://doi.org/10.21203/rs.3.rs-4907093/v1

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Objective

To evaluate the effect of right gastric artery on anastomotic fistula and anastomotic stenosis after Mckeown surgery for esophageal carcinoma.

Methods

Prospective analysis of 120 esophageal cancer resection from July 2018 to July 2020 In all cases, esophagogastric and neck anastomosis was performed and randomly divided into 60 cases in the right gastric artery sparing group (Group A) and 60 cases in the right gastric artery disconnection group (Group B), and the occurrence of anastomotic fistula and stenosis in different surgical groups were analyzed.

Results

Postoperative anastomosis in 120 patients: there was no significant difference in the incidence of postoperative anastomotic fistula (10% / 16.7%) (P > 0.05). There were differences between the two groups in groups A and B 2 months after surgery(P < 0.05); no significant difference between the two groups 4 months after surgery (P > 0.05).

Conclusion

Separation of right gastric artery has no effect on anastomotic fistula after esophageal cancer and may cause postoperative anastomotic stenosis in patients.

right gastric artery

esophageal cancer

tube stomach

anastomosis

Esophageal cancer is a malignant tumor originating from the esophageal mucosal epithelium, ranking ninth and sixth in incidence and mortality worldwide. In the field of thoracic surgery, the surgical treatment of esophageal cancer has a hundred years of history [1], but its minimally invasive surgery (minimally invasive esophagectomy, MIE) has only been widely used for more than 10 years. The reason is that esophageal cancer surgery not only involves esophageal resection but also requires digestive tract reconstruction, which has a wide anatomical area and complex operation. At present, the main surgical methods of minimally invasive surgery for esophageal cancer include 3: thoracic laparoscopy and esophageal resection (gastroesophageal neck anastomosis, McKeown MIE), thoracic laparoscopy and esophageal resection (gastroesophageal intrathoracic anastomosis, Ivor-Lewis MIE), minimally invasive resection of transperforated esophageal cancer, etc. As a substitute for the esophagus after esophagectomy, gastric [1,2] is favored by surgeons because of its rich blood supply and elasticity, and it is more consistent with the physiological state (compared to empty and colon). Studies have shown that the width of the gastric tube has no effect on the local blood supply of the anastomosis and anastomotic fistula, but the whole stomach and subwhole stomach will increase the postoperative gastric emptying disorder and pulmonary complications [3,4]. In clinical work, in order to promote gastric emptying and reduce postoperative pulmonary complications, [5]gastric tube is usually made 30-40cm along and 3cm wide along the large curved side. This structure retained the right branch of the omentum and part of the right gastric artery; but there was no literature on the influence of the right gastric artery on the gastric blood supply and anastomotic fistula. The purpose of this study evaluated the effect of the right gastric artery on cervical anastomotic fistula and anastomotic stenosis after esophageal cancer.

1.1 General information

One hundred and twenty patients admitted between July 2018 and July 2020 were included in this study. Inclusion criteria were histopathologically confirmed carcinoma of the middle upper esophagus and patients meeting enrollment criteria. Exclusion criteria were patients with stage IIIB or IV, history of previous abdominal surgery, previous chemoradiotherapy, history of previous disease (severe diabetes, cardiopulmonary insufficiency, cirrhosis, etc.), unresectable esophageal tumors, and patients who were lost to follow-up and refused follow-up. The study group consisted of 74 men and 46 women, randomly divided into two groups A and B with 60 cases; there were no statistical differences in gender, age, tumor length, pathological stage, tumor staging, and number of dissected lymph nodes (see Table 1, 2); Group B fully exposed the right arteriovenous root (variation in some vessels). Pathological TNM staging was based on the 2018 edition of UICC / AJCC TNM staging.

Table 1

Patient case characteristics
characteristics	A group	B group	P price
Tumor length	1.9 ± 0.80	2.1 ± 0.75	0.163
age/year	55 ± 7	55 ± 5	0.868
Male: female / Example number	34/26	40/20	0.260
Operation time	251 ± 21.8	263 ± 18	0.003
Clean lymph nodes / piece	26 ± 3.3	25.9 ± 2.3	0.608

Table 2

Patient case characteristics
characteristics		A group	B group	P price
Pathological stage	I stage	12	8	0.607
	IIA stage	24	22
	IIB stage	16	22
	IIIA stage	8	8
Tumor segmentation / number of cases	epimere	14	18	0.409
Tumor segmentation / number of cases	middle piece	46	42	0.409

1.2 Surgical method

The same surgeon performed Mckeown surgery for thoracic and laparoscopic esophageal cancer under the same conditions.

Group A (60 patients) retained the right gastric artery, Thoracoscopic free oesophagus, anatomically related regional lymph nodes; Laparoscopic free gastric body, 3cm from the gastric omental distal end of the vascular arch, Right blood vessel preservation of the gastric omentum, From the left, short, and left side of gastric omentum, The lymph nodes such as the left gastric artery, the common hepatic artery and the celiac artery were dissected; Shaborite descending 5cm auxiliary small incision, As the starting point after issuing two branches in the right gastric artery, With GCFLGB (Johnson & Johnson) along the stomach bend length about 30-40cm, 3cm wide (Figure B), None of the patients underwent pyloric formation, Tube and gastric lift through the esophageal bed to the left neck, Oesophagogastric left cervical anastomosis was performed with IIIROWS-24-C and GCFLFB (Johnson & Johnson).

Group B (60 cases) left the right gastric artery group (Figure A), the same method as the previous, the difference is between the root of the right gastric artery and the vessel.

Both groups were successfully extubated, anti-infection, sputum reduction, atomization, acid suppression, nutrition and other symptomatic treatment, postoperative nasogastric tube preservation, continuous gastrointestinal decompression, and removal after gastrointestinal exhaust; intensive care for 2 days, chest film, blood and biochemistry review on the 2nd day after surgery; esophagography (universal meglumine) was reviewed on the 5th day after surgery, and discharged on the 10th day after surgery. Gastroscopy and upper gastrointestinal angiography were performed to observe postoperative anastomotic stenosis.

1.3 Diagnosis of anastomotic fistula and anastomotic stenosis after esophageal cancer

Anastomotic fistula: The main clinical manifestations of cervical anastomotic fistula are cervical skin swelling, tenderness, subcutaneous emphysema and fluctuation. When the suture is opened, there can be food residue, rancid pus outflow, accompanied by or without fever. Its position is shallow and easy to find, and can be clearly diagnosed combined with clinical symptoms and signs. The clinical manifestations of intrathoracic anastomotic fistula are mainly systemic poisoning symptoms, including persistent high fever, massive cough of purulent sputum, severe chest pain, dyspnea, and intraoperative liquid pneumothorax. Some patients have toxic shock without timely diagnosis and treatment. Auxiliary examination: package effusion or liquid pneumothorax. Upper gastrointestinal angiography (generalized glutamine) was this. If the non-invasive examination fails to find the small posterior wall fistula or localized fistula is feasible chest puncture, cloudy fluid or containing food residue and gastroscopy for clear diagnosis.

Astomotic stenosis: record the occurrence of anastomotic stenosis at 2 and 4 months after surgery in groups A and B. Grade I: general feeding has obstruction, but semi-liquid diet, 8-10mm wide, observation; grade: semi-liquid food has obstruction, 5-8mm wide, grade, 3-5mm wide, wide, 3mm wide or even blind for treatment.

Table 3

Astomotic fistula and stenosis in two groups
Example number		A group	B group	P price
Anastomotic narrow	Two months after surgery	18	36	0.001
Anastomotic narrow	Four months after surgery	6	11	0.152
Anastomotic fistula		6	10	0.283

1.4 Statistical treatment

Data were analyzed using SPSS16.0 statistical software, data were expressed as x ± s using independent sample t-test, and count data by chi-square test where P < 0.05 was considered statistically significant.

Subject characteristics in both groups are shown in Table 1, 2. There was no significant difference in gender, age, tumor length, pathological stage, tumor stage and number of dissected lymph nodes between the two groups; because group B required full exposure to the right gastric arteriovenous root (variation), the operation time between the two groups was different (P = 0.003). The anastomotic fistula and anastomotic stenosis in both groups are shown in Table 3. Group A: 6 cervical anastomotic fistula (10.0%); Group B: 10 (16.7%); there was no significant difference between the two groups (P > 0.05). The patients with anastomotic fistula in both groups recovered smoothly after symptomatic treatment including anti-infection, phlegm resolving, drainage and nutritional support. Gastroscopy and upper gastrointestinal angiography performed 2 months after surgery, group A cervical anastomotic stenosis (30%), group B 36 (60%), showed a difference between the two groups (P < 0.05); gastroscopy and upper gastrointestinal angiography, 6 (20%) in group A, and 11 (36.7%), showing no significant difference in anastomotic stenosis in the two groups (P > 0.05).

For the middle and upper esophageal cancer, McKeown surgery was adopted, which achieved the complete resection of esophageal tumor, standardized regional lymph node dissection and appropriate digestive tract reconstruction. The endoscopic esophageal cancer surgery has the advantages of less trauma, less bleeding, quick postoperative recovery and less postoperative complications. The causes of anastomotic fistula include: (1) anastomotic technical problems: for example, when beginners perform surgery, the chance of anastomotic fistula may increase due to unskilled technology.(2) Device problems: if the stapler nail problems may also cause anastomotic fistula.(3) Local infection: there may be contamination around the anastomosis, and localized infection foci appear after surgery. The infection focus tends to the weak side, and sometimes it can be penetrated into the gastric cavity through the anastomosis, leading to anastomotic fistula.(4) Anchotic tension: some patients' stomach is relatively small, tension when anastomosis, tension is too large, it is difficult to heal.(5) Poor blood transport: when the stomach is lifted, most of the stomach needs to be ligated to supply blood vessels, resulting in insufficient blood transport, and the anastomosis is not easy to heal in the condition of ischemia and hypoxia.(6) Patient's own factors: such as older age, preoperative malnutrition, hypoproteinemia, diabetes, etc., are the causes of poor healing. Astomotic fistula is one of the fatal complications after esophageal cancer, and once it occurs, its mortality is high. The fistula may lead to leakage of digestive fluid, causing thoracic or abdominal infection, which can be life-threatening when severe. In addition, anastomotic fistula can also affect the postoperative recovery and increase the hospital stay and treatment costs.

The causes of anastomotic stenosis after esophageal cancer include: (1) uneven alignment of anastomotic mucosa: poor occlusion of mucosal layer during anastomosis, which may lead to the formation of scar after healing and cause stenosis.(2) Hypergrowth of granulation: hyperplasia of granulation tissue at the anastomosis may also lead to stenosis.(3) Postoperative infection: Postoperative infection may lead to inflammation and edema of the tissue surrounding the anastomosis, and then form a scar and cause stenosis.(4) Thick tissue layer in the anastomotic area: the tissue layer is too thick in the anastomosis, and the scar is large after healing, which may also lead to stenosis.(5) Tumor recurrence: some patients may have tumor recurrence after surgery, and the tumor tissue may grow at the anastomosis site, leading to stenosis.

Anstomotic stenosis can seriously affect the patient's feeding function, leading to dysphagia, eating disorders, and even inability to eat. Long-term eating difficulties will lead to malnutrition, wasting, weight loss, seriously affecting the quality of life and survival of patients. In addition, anastomotic stenosis may cause other complications, such as reflux esophagitis and pulmonary infection.

Breaking the right gastric artery has a specific implementation value in certain medical procedures, including: (1) reducing intraoperative bleeding. In some procedures, such as laparoscopic pancreaticoduodenectomy, first separating the right gastric artery can reduce the arterial blood supply to the pancreatic head and neck, thus reducing the risk of bleeding during the procedure. This is because the right gastric artery is one of the important blood feeding arteries of the head and neck of the pancreas, and it can significantly reduce the blood flow in this area after disconnection, making the surgical operation more clear and safe. By reducing intraoperative bleeding, the amount of blood transfusion can be further reduced, thus reducing the risk of infection, allergies and other blood transfusion, and helping the patient recover after surgery.(2) Optimize the surgical visual field. After leaving the right gastric artery is severed, the blood supply to the pancreatic head and neck is reduced, making the surgical vision clearer and facilitating the doctor to perform more refined operations. This is essential for the success of complex surgical procedures. A clear surgical field helps doctors to locate and handle the lesion site faster, thus shortening the operation time and reducing the surgical risk.(3) Improve the surgical success rate and patient prognosis. The surgical method of preferential arterial resection helps to achieve total pancreatic mesangial resection, which can significantly improve the R0 resection rate (i. e., complete tumor resection rate). This is important for improving patient outcomes. With a more thorough lymph node dissection and more precise surgical resection, the risk of postoperative local recurrence can be reduced, thus improving long-term patient survival. Due to the low intraoperative blood loss, short operation time and small surgical trauma, the postoperative recovery time is usually relatively short.

In recent years, we routinely used Mckeown surgery for middle and upper esophageal cancer. This operation can clean the lymph nodes of two or three fields, and it is faster and less traumatic than the traditional thoracotomy surgery, which has become the standard operation method. This operation often produces tube stomach and left neck anastomosis, which is bound to have neck anastomosis related problems (anastomosis method, large tension, blood deviation, etc.), resulting to anastomotic fistula and anastomotic stenosis; how to minimize the above complications has become a problem for thoracic surgeons. This prospective randomized study showed that the analysis of postoperative anastomosis in 120 patients: no significant difference in the incidence of postoperative anastomotic fistula (10% / 16.7%) between groups A and B (P > 0.05). There were differences between the two groups in anastomotic stenosis in groups A and B (P < 0.05); no significant difference between the two groups 4 months after surgery (P > 0.05). Pieri, et al. [6] injected contrast agent into the feeding artery to detect the vascularization of the three esophageal substitutes (whole stomach, subtotal stomach, narrow tube stomach); according to its study, the right artery of gastric omenum was the only feeding artery, and the narrow tube stomach was poorly vascularized at the anastomosis. However, PanH, Zhang R, LiA et al [3,4] studied 30 cadavers and showed that the right gastroomental artery was the main donor of the large curved lateral gastric tube, and the contribution of the right gastric artery was negligible. Yoichi Tabira et al [5] showed that the subwhole stomach has the right gastroomental vessel and the right gastric vessel, but the tissue blood flow at the anatomical site is equal to the narrow tube stomach, and only the right gastroomental artery provides blood supply. This contrasts with the Patel P H^[6]The results are consistent with those of et al. Janssen H J B et al [7,8] measured the blood flow of the gastric tissue and reported leakage in 100 patients with less than 10 mL/min. These results suggest that blood flow at the anastomotic site may be the main predictor of leakage. However, they did not describe the diameter of the tube stomach and chose three different co-reconstruction routes (posterior mediastinum, retrosternal, and subcutaneous), and these factors may have influenced their results. Charalabopoulos A^[9]The results showed that the right gastric artery had no effect on the blood flow in the gastric tube, while the right gastric mesh artery was an important source. As reported by [10], the BMI decreased at 6 months, remained at the same level for 12 months after surgery, decreased food intake at 6 months, and increased slightly in 12 months after surgery, and the postoperative nutritional status was no different. And Hosogi H et al^[11,12]The tube stomach was compared to the whole stomach and concluded that the whole stomach was superior to the narrow gastric tube due to the slightly increased capacity and maintenance of the gastric submucosal vascular network. This finding differs from our results due to the type of replacement (whole stomach or subwhole, gastric tube or elongated gastric tube) and the path of reconstruction. In addition, the application of total gastric esophagus has a high probability of gastric emptying disorder after surgery, and the paragastric lymph nodes should be dissected along the small bend side during the operation, so we do not use the whole stomach as an esophageal substitute^[13,14]. On the other hand, an intraoperative vagal denervation was observed. Gaic outlet obstruction after gastric replacement, due to the effect of delayed gastric emptying on postoperative nutritional status Kubo N et al [15] study showed that preoperative embolization of the right gastric artery, gastric short and left artery of gastric membrane, left gastric neck anastomosis will reduce the incidence of anastomotic fistula; however, this study will extend the perioperative period.

Based on the above analysis, the blood supply to the right half of the stomach and the vicinity of the right gastric artery. This may lead to blood transport disorders in the anastomotic region and thus affect the healing of the anastomosis. Anastomotic ischemia is one of the main causes of anastomotic fistula after esophageal cancer^[16]. When the right gastric artery is severed, if the other collateral circulation is not fully established, the anastomotic area may heal poorly by ischemia, leading to the anastomotic fistula^[17]. In some cases, doctors may need to reconstruct the digestive tract and reduce the tension of the anastomosis. However, when the right gastric artery is severed, the blood supply to this part of the gastric tissue may be affected, thus reducing its compliance during the anastomosis and then increasing the tension of the anastomosis^[18]. Astomotic ischemia not only affects the healing process but may also increase the risk of infection. Because ischemic tissue is more susceptible to pathogens such as bacteria, which triggers infection around the anastomosis^[19]。

This study is a single-center trial, and the number of patients included is small, so the statistical analysis may not be sufficient to give differential results, which requires further demonstration by a multi-center large sample study.

Separation of right gastric artery has no effect on anastomotic fistula after esophageal cancer, which may cause postoperative anastomotic stenosis in patients.

Acknowledgements

Thanks to Professor Yongbin Song and Professor Huien Wang for their careful and delicate surgical operation, the clinical trial can be carried out. Thank the thoracic surgery colleagues for their support.

Author contributions

Yongbin Song conceived the study. QIfan Yin collected the data, Shuhui Gao analysed the data and performed statistical analyses. Guibin Zhang drafted the manuscript. Huien WANG and Peng Qie gave important intellectual contribution and critically revised the manuscript. All authors read and approved the fnal manuscript.

Funding

Scientific Research Fund Project of Hebei Provincial Health Department.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study conforms to the ethical guidelines in a priori approval by the local Ethical Committee of the Hebei General Hospital. Our research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki and approved by Ethical Committee of the Hebei General Hospital with approval number (20200507). All enrolled patients signed informed consent.

Consent for publication

Our research obtained the consent of patients or patients’ carer for publication.

Competing interests

The authors declare no competing interests.

Author details

1 Thoracic Surgery, Hebei General Hospital, No 348,West He-Ping Road, Xinhua District, Shijiazhuang 050000, Hebei Province, China.

2. Department of Respiratory Medicine, Hebei General Hospital, No 348,West He-Ping Road, Xinhua District, Shijiazhuang 050000, Hebei Province, China.

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No competing interests reported.

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Effect of severed right gastric artery on postoperative anastomosis after Mckeown surgery for esophageal carcinoma: A Randomized controlled trial

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Abstract

Figures

Introduction

Data and methods

1.1 General information

1.2 Surgical method

1.3 Diagnosis of anastomotic fistula and anastomotic stenosis after esophageal cancer

1.4 Statistical treatment

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

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