Esophageal reconstruction is a crucial step during esophagectomy. Anastomotic leakage is a common complication after reconstruction and will result in great morbidity. Choices for reconstruction include the stomach, small intestine, and colon. The gastric conduit compared with the jejunum flap or colon interposition, has lower leakage rate because of less surgical complexity and fewer number of anastomosis and therefore are more widely used.1 Some studies have shown fewer postoperative digestive tract complications, earlier recovery, and a better quality of life when patients received gastric conduit reconstruction.2 The right gastric and gastroepiploic arteries are generally preserved for the gastric conduit.3,4 Creating an ideal gastric conduit is crucial because the blood supply may not be able to reach the anastomotic site, thus resulting in leakage, fistula, and even graft necrosis. Anastomotic leakage results in a longer hospital stay and potential tumor metastasis which leads to a decreased overall survival and disease-free survival rate.5 An ideal gastric conduit should have an adequate lumen diameter for a tension-free anastomosis without compromising blood supply. The more staples we used, the longer the gastric conduit and a more tension-free status we can achieve. However, the blood supply was more compromised at the cervical anastomosis, and the diameter also became narrow as the gastric conduit became longer. In addition, the number of staples we use to create the gastric conduit plays an important role. To lengthen the gastric conduit, we developed a stapling technique to create narrow gastric conduit for reconstruction. In the present study, we compared the 10-year outcomes of the narrow gastric conduit with a wide gastric conduit.

We retrospectively reviewed all patients in Taichung Veterans General Hospital who underwent esophagectomy with a cervical anastomosis from 2010 to 2019 (the study was approved by the institute review board of TCVGH, CE21162B-1). Patients with the history of gastric surgery, reconstruction with ileo-colon, esophagojejunostomy, or combination with total laryngectomy surgery were excluded (Fig. 1). A total of 493 patients were enrolled in this study. The clinicopathological characteristics of gender, clinical staging, tumor location, histology, and neoadjuvant therapy were documented. The methods of gastric conduit creation were divided into two groups. The creation of wide gastric conduit required fewer staples (two or three with endoscopic gastrointestinal anastomosis [Endo-GIA] 80-4.8 mm staples or endo-GIA 60-4.8 mm, respectively, Figs. 2A and 3A), which went linearly and obliquely from right to left and ended at fundus. The average width of wide gastric conduit was above 5 cm. On the other hand, the narrow gastric conduit was created with multiple staples (more than four staples, mostly used with endo-GIA 45-4.1 × 5, Figs. 2B and 3B), which ran along the great curvature to fundus and resected half to two third of stomach. The average width of narrow gastric conduit was 2.85 cm. There were two kinds of reconstruction route, retrosternal or posterior mediastinal route. In our study, the definition of anastomotic leakage included cervical wound with discharge, radiological diagnosis or fever with leukocytosis, sepsis combined with intrathoracic leakage requiring decortication. Chest radiograph with water-soluble oral contrast was not routinely performed. Most patients suffered from dysphagia after operation and asked for dilatation. Postoperation dilatation for anastomotic stenosis was defined as first time dilatation with <40 French. Patient characteristics and outcomes were documented using a standardized data collection form.

Flowchart describing the study population selection. PSM = propensity score matching.

Different types of gastric conduit. A, Wide gastric conduit. The wide gastric conduit creation with fewer staples (two staples with endo-GIA 80-4.8 mm or three staples with endo-GIA 60-4.8 mm). B, Narrow gastric conduit. The narrow gastric conduit with more staples (more than four staples, most used with endo-GIA 45-4.1 × 5). Endo-GIA = endoscopic gastrointestinal anastomosis.

Different types of gastric conduit. A, Wide gastric conduit. B, Narrow gastric conduit. The narrow gastric conduit can achieve more tension-free. Illustration by Yu-Sin Huang, ©2022 Yu-Sin Huang.

MedCalc version 20.110 (Mariakerke, Belgium) was used to conduct statistical analysis. For the significance of the study, Fisher exact test and Chi-square test for categorical variables, and the independent t test and Mann-Whitney test for continuous variables. Variables with p < 0.01 on univariate analysis were included in a multivariate logistic regression analysis. To minimize the difference between wide and narrow gastric conduit, a retrospective propensity score matching (PSM) analysis was performed to control the confounding factors. SPSS software (v.25.0 for Windows; SPSS Inc., Chicago, IL) was used to calculate the propensity score with a multivariable logistic regression model. Continuous variables were expressed as mean value ± SD, whereas categorical variables were expressed as number and percentages. A comparison between the two groups was performed, in which Fisher exact test and Chi-square test were used for categorical variables, and t test for continuous variables. The statistical significance was defined as p < 0.05.

Among the 493 patients, 170 patients underwent wide gastric conduit formation and 323 patients underwent narrow gastric conduit. Patient characteristics are demonstrated in Tables 1 and 2. Not much difference was observed in patients’ underlying comorbidities, such as diabetes, coronary artery disease, liver disease, hypertension, and cerebral vascular accident and clinical staging between wide and narrow gastric conduit groups. The histology was mostly composed of squamous cell carcinoma and adenocarcinoma in the wide gastric conduit group, whereas the narrow gastric conduit group was mostly composed of squamous cell carcinoma. Rare histologies, such as neuroendocrine and adenosquamous, in wide gastric conduit group, sarcoma, and melanoma in narrow gastric conduit group were found. However, more patients in the narrow group received neoadjuvant therapy (71.21% vs 51.76%, p < 0.001). Neoadjuvant therapy gave rise to the down-staging of esophageal cancer. As a result, pathology T staging was more advanced in the wide gastric conduit group than in the narrow gastric conduit group, mostly the T3 stage (41.18% vs 24.77%, p = 0.004). More patients received retrosternal route for reconstruction in wide gastric conduit group (91.76% vs 81.73%, p < 0.001), whereas video-assisted thoracic surgery (VATS) and laparoscopic surgery were performed more in narrow gastric conduit group. We calculated the propensity score with a multivariable logistic regression model including all the significant factors; however, only 63 patients from each group were matched. The sample size was small. As a result, we chose histology, neoadjuvant therapy, pathological T stage, pathological N stage, and pathological M stage for matching. After PSM with fiver significant factors, 140 patients from each group were matched by 1:1. Further data for PSM including all the significant factors are provided in Supplementary Data 1, https://links.lww.com/JCMA/A213 and 2, https://links.lww.com/JCMA/A214.

Table 3 reveals the outcomes between the two groups before and after PSM. The length of the gastric conduit was longer in the narrow gastric conduit group (28.53 ± 5.42 cm vs 19.38 ± 3.64 cm, p < 0.001). The width of the gastric conduit was greater in wide gastric conduit group (5.64 ± 0.48 cm vs 2.82 ± 0.22 cm, p < 0.0001). The leakage rate was significantly higher in the wide gastric conduit group (n = 41, 24.12%) than in the narrow gastric conduit group (n = 39, 12.07%, p < 0.001). However, the result in Supplementary Data 2, https://links.lww.com/JCMA/A214 revealed the trend of decreased leakage rate in narrow gastric conduit group without significance (23.81% vs 11.11%, p = 0.061). The 90-day mortality was twice more in narrow gastric conduit group without significance (2.35% vs 4.64%, p = 0.324). The cause of 90-day mortality in narrow gastric conduit group included six patients with anastomotic leakage with tracheal fistula, vessels bleeding, or severe sepsis, four patients with postoperation pneumonia, two patients with distant metastasis, and three patients with other underlying disease. In wide gastric conduit group, three patients died of anastomotic leakage with tracheal fistula or vessels bleeding, one patient died of distant metastasis, and one patient died of chronic obstructive pulmonary disease (COPD) with acute exacerbation. The length of stay was shorter in the narrow gastric conduit group (p < 0.001) than in the wide gastric conduit. In general, patients routinely admitted to the intensive care unit (ICU) for precise management of fluid status and vital sign monitoring, including artery blood gas test, urine specific gravity, and central venous pressure measurement. However, total 22 (4.46%) patients in both groups were not admitted to ICU after operation in Table 3. Our alternative policy for ICU admission is that patients will stay in recovery room overnight and are transferred to general ward on the next day under stable condition. ICU patients will be transferred out after endotracheal tube and nasogastric tube removal and adequate enteral nutrition via jejunostomy. ICU admission and stay were less in the narrow gastric conduit group (ICU admission, 93.50% vs 99.41%, p = 0.002; ICU stay, 4.62 ± 3.57 vs 6.88 ± 8.91 days, p = 0.002). The need for postoperation dilatation was higher in the wide gastric conduit group (n = 33, 19.41% vs n = 38, 11.76%, p = 0.0217). The duration from the operation to the first dilatation was no significant difference in both groups (2 month vs 2 months, p = 0.9808). In Table 3, the result of leakage rate, conduit length, conduit width, length of stay, ICU admission, ICU stay, and duration to first dilatation were still similar even after PSM.