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Endoscopic mucosal ischemic index for predicting anastomotic complications after esophagectomy: a prospective cohort study

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A Correction to this article was published on 16 February 2023

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Abstract

Background

Postoperative complications related to gastric conduit reconstruction are still common issues after McKeown esophagectomy. A novel endoscopic mucosal ischemic index is desired to predict anastomotic complications after McKeown esophagectomy.

Aims and methods

The purpose of this study was to prospectively evaluate the safety and efficacy of endoscopic examinations of the anastomotic region in the acute period after esophagectomy.

Endoscopic examinations were performed on postoperative days (PODs) 1 and 8. The severity of ischemia was prospectively validated according to the endoscopic mucosal ischemic index (EMII).

Results

A total of 58 patients were included after evaluating the safety and feasibility of the endoscopic examination on POD 1 in 10 patients. Anastomotic leakage occurred in 6 patients. Stricture occurred in 13 patients. A greater than 67% circumference and lesion length greater than 20 mm of anastomotic ischemic area (AIA) on POD 1 were associated with develo** anastomotic leakage after esophagectomy (OR: 14.5; 95% CI: 1.8–306.5; P = 0.03, OR: 19.4; 95% CI: 1.7–536.8; P = 0.03). More than 67% circumferential ischemic mucosa and ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were associated with develo** anastomotic strictures after esophagectomy (OR: 6.4; 95% CI: 1.4–31.7; P = 0.02, OR: 5.9; 95% CI: 1.2–33.1; P = 0.03). Patients with either more than 67% circumferential ischemic mucosa or ischemic mucosal lengths greater than 20 mm of AIA on POD 1 were defined as EMII-positive patients. The sensitivity, specificity, and positive and negative predictive values of EMII positivity on POD 1 for leakage were 100%, 78.8%, 35.3%, and 100%, respectively. The sensitivity, specificity, and positive and negative predictive values of the EMII positivity on POD 1 for strictures were 69.2%, 82.2%, 52.9%, and 90.2%, respectively.

Conclusions

The application of an endoscopic classification system to mucosal ischemia after McKeown esophagectomy is both appropriate and satisfactory in predicting anastomotic complications.

Trial registration

Clinical Trial.gov Registry, ID: NCT02937389, Registration date: Oct 17, 2015.

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Data availability

Raw data were generated at Nagasaki University. Derived data supporting the findings of this study are available from the corresponding author SK on request.

Change history

Abbreviations

MIE:

Minimally invasive esophagectomy

CPK:

Creatine phosphokinase

CRP:

C-reactive protein

POD:

Postoperative day

SD:

Standard deviation

IQR:

Interquartile range

ROC:

Receiver operating characteristic

AUC:

Area under the ROC curve

OR:

Odds ratio

CI:

Confidence interval

inf:

Infinity

OE:

Open esophagectomy

WBC:

White blood cells

CD:

Clavien‒Dindo

ICU:

Intensive care unit

PPV:

Positive predictive value

NPV:

Negative predictive value

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Acknowledgements

The authors thank Shuntaro Sato, who helped with the statistical analysis.

Funding

Funding was received for writing the manuscript. This study was supported by Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (17K16569 Shinichiro Kobayashi, and 21K16400 Shinichiro Kobayashi) and Takeda Science Foundation.

Author information

Authors and Affiliations

  1. Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, 8528102, Japan

    Shinichiro Kobayashi, Kazuma Kobayashi, Yasuhiro Nagata, Shun Yamaguchi, Masaaki Hidaka & Susumu Eguchi

  2. Department of Tissue Engineering and Regenerative Therapeutics in Gastrointestinal Surgery, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan

    Kengo Kanetaka & Yasuhiro Maruya

  3. Department of Surgery, National Hospital Organization Nagasaki Medical Center, Kubara 2-1001-1, Ohmura, Nagasaki, Japan

    Akira Yoneda

  4. Department of Endoscopy, Nagasaki University Hospital, Sakamoto 1-7-1, Nagasaki, Japan

    Naoyuki Yamaguchi

  5. Center for Comprehensive Community Care Education, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan

    Yasuhiro Nagata

Authors
  1. Shinichiro Kobayashi
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  2. Kengo Kanetaka
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  6. Yasuhiro Nagata
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  10. Susumu Eguchi
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Contributions

S.K. designed the study, analyzed the data, and wrote the initial draft of the manuscript. Kengo Kanetaka, Kazuma Kobayashi, and Naoyuki Yamaguchi contributed substantially to the interpretation of data and supervised patient treatment. A.Y., Y.N., S.Y., Y.M., and H.M. substantially participated in the discussion and assisted in the preparation of the manuscript. S.E. supervised the patient treatment and assisted substantially in editing the manuscript. All other authors contributed to the data collection and interpretation and critically reviewed the manuscript. All authors have approved the final version of the manuscript and agree to be accountable for all aspects of the work and ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Correspondence to Shinichiro Kobayashi.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Nagasaki University Hospital (16082215). The data of this study were prospectively analyzed. Written informed consent was obtained from the patients before esophagectomy.

Competing interests

The authors declare no competing interests.

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Kobayashi, S., Kanetaka, K., Yoneda, A. et al. Endoscopic mucosal ischemic index for predicting anastomotic complications after esophagectomy: a prospective cohort study. Langenbecks Arch Surg 408, 37 (2023). https://doi.org/10.1007/s00423-023-02783-x

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