gms | German Medical Science

Background: Ivor-Lewis esophagectomy and intrathoracic anastomosis is a standard treatment for esophageal cancer. For reconstruction after esophageal resection an improved tube length was observed using a fundus rotation gastroplasty (FRG) in comparison to the conventional Kirschner-Akiyama gastric tube (GT). Previously a comparable oncologic outcome was reported even though the lesser curvature with the adjacent lymph nodes remains in situ when performing a FRG. This study aims to elucidate if there are differences in the amount of resected lymph nodes and if this influences recurrence and long term prognosis.

Materials and methods: This is a retrospective analysis of 367 patients (pts) with esophageal cancer (AEG or SCC) who underwent curative surgery with an Ivor-Lewis esophagectomy and intrathoracic anastomosis with either primary GT or FRG reconstruction at Heidelberg University from 01/2001-06/2015. Qualitative parameters were compared by χ2-, quantitative by Mann-Whitney-U-, and survival data by log-rank-test according to Kaplan-Meier.

Results: Of the 367 patients 259 (70.5%) patients received a Kirschner-Akiyama gastric tube reconstruction and 108 patients (29.5%) a FRG. Preoperatively these groups did not differ in gender, ASA score, cT category and co-morbidities. Patients with a FRG had more frequently an AEG (51.4% vs 29.7%) while patients with GT had more frequently a SCC (70.3% vs 48.6%) (p<0.001). And patients with FRG had more frequently a cN0 staging (50.5% vs 32.1%)(p=0.007) and received less frequently neoadjuvant therapy (p<0.05).

During the perioperative period there were no difference in surgical complications, including major (Clavian-Dindo >2) complications and anastomotic leakages. However medical complications were more frequent in the FRG group (p=0.029). The median operative time with 315 min (192-490) vs 290 min (200-389) (p<0.001) and the median in hospital time with 21 days (14-64) vs 19.5 (13-49.9) (p=0.036) were longer in the FRG group while the ICU time did not differ.

In patients with a FRG reconstruction fewer lymph nodes (median 15 (6,8-32.4)) were harvested while a median of 21 (9-36) LNs were resected during GT reconstruction (p<0.001). The number of positive lymph nodes and the mean lymph node ratio was with 0.11±0.19 for FRG and 0.13±0.22 for GT reconstruction not different (p=0.8 and p=0.2).

Patients in both groups did not differ in pT (p=0.31) and pM (p=0.65) category or R status (ap=0.75), but patients with GT reconstruction had a tendency to a higher pN category with 48.5% with positive LN vs 38.5% (p=0.07).

The fewer number of resected lymph nodes did not influence the median survival with 30.2 months (20.2-40.2 95% CI) for GT and 38.2 months (28.9-47.4 95% CI) for FRG (p=0.371). However the long term survival favored the GT group. While the 3 year survival rate was comparable with 47% for GT and 52% for FRG, the 5-year survival was 41% TG and 35% FRG and the 8 year survival 38% GT and 26% FRG. The recurrence pattern did not differ between the two groups.

Conclusion: While both FRG and GT reconstructions are feasible and comparable after Ivor-Lewis esophagectomy, GT reconstruction leads to a higher number of resected lymph nodes. Even though the patients have a less favourable tumor stage in the GT reconstruction group the median survival is equal and the long term survival seems to favour patients receiving GT reconstruction Further long term survival data should be analyzed.