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The ‘cocoon’ effect of an omental wrap in maturing gastro-oesophageal anastomosis: Comparative case-series Lap-assisted Vs Open Oesophagectomy for Oesophageal Cancers.

Nehemiah Samuel, Mr, Maria Tsachiridi, Miss, Jordan Fletcher, Mr, Anand Tamhankar, Mr, Clive Kelty, Mr. Northern General Hospital

Background: The two-stage oesophagectomy (Ivor-Lewis procedure) remains the mainstay of curative surgery for oesophageal cancers in the UK. Gastro-oesophageal anastomotic leak is a potentially devastating complication of this procedure affecting perioperative morbidity and mortality. Although the leak rates have improved over the years, it still remains widely variable.

Intraoperative reinforcement of gastro-oesophageal anastomosis with an ‘omental wrap’ has been proposed as a measure to reduce anastomotic leak rates. There is some data to suggest that this additional technique reduces anastomotic leak. We reviewed our single institution data to assess if the omental wrap indeed had a ‘cocoon’ effect in maturing the anastomosis and reducing leak rates.

Methods: Data for all cancer oesophagectomies (ILOG) performed in our institute since April 2013-17 was retrospectively analysed from a prospectively maintained database. The patients were categorised into two groups. Group A: those who underwent conventional open ILOG and Group B: those who had a laparoscopically assisted (abdominal phase) ILOG with an omental wrap reinforcement of the anastomosis during the thoracic phase.

The primary outcome was the anastomotic leak rates. Secondary outcomes included perioperative complications, 30-day mortality, post-op recovery and length of hospital stay.

Results: Both Group A (n=113) and Group B (n=52) were identical with regards to age at surgery (median 65 vs 68, p=0.080); Sex (% male 85 vs 77, p=0.208); history of smoking (p=0.521), and preoperative co-morbidities, fitness state (p>0.05). The BMI (median 27.9 vs 24.9, p=0.004) and ASA physical status Grade-3 (46.6% vs 28.8%, p=0.035) for Group A was significantly higher than Group B.

The anastomotic leak rate was significantly higher in Group A in comparison to Group B in which no patient developed anastomotic leak (17/113 vs 0/52, p=0.003). Similarly chest infections were also higher (47.8% vs 28.8%, p=0.027). Other morbidity such as reoperation, chyle leak, pulmonary embolism and 30-day mortality rate were similar in both groups. The median (IQR) length of stay was significantly higher for Group A 11 (9-19) vs Group B 9 (9-14) days p=0.038.

Conclusions: Our results have demonstrated significant improvement in the anastomotic leak rates, chest infections and hence faster post-op recovery for patients, with the addition of an omental wrap to reinforce the anastomosis. Shorter hospital stay in turn has cost-benefit implications to health care providers. A formal RCT to prove or disprove potential benefits of the wrap technique may be worth pursuing to inform current surgical practice.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 87701

Program Number: P452

Presentation Session: iPoster Session (Non CME)

Presentation Type: Poster

30

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