title: Modifications in retrosternal reconstruction after oesophagogastrectomy may reduce the incidence of anastomotic leakage.
abstract: OBJECTIVE
  The retrosternal route has been an alternative for oesophageal reconstruction after oesophagectomy. But the longer route and the higher incidence for cervical anastomotic leakage compared with the posterior mediastinal approach have always hampered its wider use. However, with the recent work reported by Chen and colleagues, the anterior route has been confirmed to provide the shortest physiological distance for oesophageal reconstruction using the stomach. Furthermore, improving the original surgical procedures seemed to improve outcomes. This research aims to evaluate whether modification of the original surgical standard of alimentary tract reconstruction after oesophagectomy can reduce the incidence of anastomotic leakage.
  
  
  METHODS
  One hundred and two patients were divided into the research group and the control group. Subjects in the research group received the improved three-incision oesophagectomy (right chest/belly/left neck) after which the alimentary tract reconstruction was achieved by using a gastric conduit positioned through the retrosternal route. Patients in the control group received the original surgical procedures. Parameters such as the incidence of anastomotic leakage, pneumonia, length of hospital stay, ICU stay and pathological staging were compared between the two groups.
  
  
  RESULTS
  No significant statistical differences were found in parameters such as age, gender, height, weight, comorbidities, location and length of the tumour and final pathological staging of the patients between the two groups. Similarly, intraoperative and postoperative information such as operating time, hospital stay, pneumonia and volume of blood loss are comparable between the two groups. The incidence of anastomotic leakage was, respectively, 4.84% (3/62) in the research group and 20% (8/40) in the control group. The incidence of anastomotic leakage in the research group was lower than the one in the control group, and the difference was statistically significant (P = 0.037).
  
  
  CONCLUSIONS
  Modifications of the original surgical standard including expanding the retrosternal tunnel, widening the gastric tube, resection of the sternothyroid muscle and fixation of the gastric tube, contribute to decreasing the incidence of cervical anastomotic leakage.
authors.affiliation: Department of Thoracic Surgery,  Fudan University Shanghai Cancer Center, Shanghai,  China.
authors.forename: Hong
authors.initials: H
authors.lastname: Hu
authors.forename: Ting
authors.initials: T
authors.lastname: Ye
authors.forename: Yawei
authors.initials: Y
authors.lastname: Zhang
authors.forename: Jie
authors.initials: J
authors.lastname: Zhang
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.forename: Haiquan
authors.initials: H
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D057868:Anastomotic Leak / Q000517:prevention & control*; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D016022:Case-Control Studies; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061646:Operative Time