Efficacy and Postoperative Outcomes of Laparoscopic Retrosternal Route Creation for the Gastric Conduit: Propensity Score–Matched Comparison to Posterior Mediastinal Reconstruction

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Figure legends

Figure 1.

Patient flow chart. Propensity score matching using logistic regression with

the simple nearest neighbor method was performed. Each group had 62

patients.

Figure 2.

Postoperative anastomotic complications. Anastomotic stenosis, defined as

symptoms requiring endoscopic dilatation within 4 months after surgery,

10

occurred in 16% (n = 10) of patients in the LR group and 27% of patients (n

11

= 17) in the PM group.

12

13

Figure 3.

14

Route-specific complications. Gastro-tracheal fistula and hiatal hernia only

15

occurred in the PM group (2%, n = 1 and 3%, n = 2), respectively). Pulmonary

16

embolism occurred at the same rate in both groups (5%, n = 3 in each group).

17

18

Figure 4.

19

Reflux esophagitis at the gastric conduit anastomosis. One patient in the LR

20

group had mucosal damage (Grade B). In the PM group, three patients had

21

esophageal mucosal damage (Grade A, B, and C, respectively), and six

22

patients had minimal esophageal mucosal changes (Grade M). Patients with

28

Grade N status in each group (42 in the LR group and 32 in the PM group)

were not shown. Grades are based on the modified Los Angeles classification

system for gastroesophageal reflux disease.

Fisher’s exact test.

29

Table 1. Demographic and clinicopathological characteristics of patients

Whole cohort

Laparoscopic retrosternal

Matched cohort

Posterior mediastinal

Laparoscopic retrosternal

Posterior mediastinal

group

group

(n = 62)

(n = 312)

68 (45-83)

67 (27-84)

group

group

(n = 62)

(n = 62)

68 (45-83)

68 (42-80)

0.152

Age

0.726

a)

a)

0.021

0.348

b)

b)

Gender

Male / Female

43 (69%) / 19 (31%)

259 (83%) / 53 (17%)

21.7 (15.8–33.0)

21.30 (13.7- 31.3)

43 (69%) / 19 (31%)

37 (60%) / 25 (40%)

21.7 (15.8–33.0)

21.2 (15.4–31.3)

0.398

Body mass index (kg/m 2 )

0.481

a)

a)

0.295

0.634

b)

b)

ASA PS classification

4 (6%)

24 (8%)

4 (6%)

7 (11%)

30

50 (81%)

266 (85%)

50 (81%)

47 (76%)

8 (13%)

22 (7%)

8 (13%)

8 (13%)

0.058

0.856

b)

b)

Preoperative therapy

NAC / None

Conventional

34 (55%) / 28 (45%)

213 (68%) / 99 (32%)

19 (31%) / 43 (69%)

296 (95%) / 16 (5%)

Robot-

34 (55%) / 28 (45%)

36 (58%) / 26 (42%)

19 (31%) / 43 (69%)

59 (95%) / 3 (5%)

<0.001

assisted MIE

<0.001

b)

b)

0.411

0.835

c)

c)

cT stage (UICC 7th edition)

cT1

19 (31%)

128 (40%)

19 (31%)

19 (31%)

cT2

12 (19%)

49 (16%)

12 (19%)

10 (16%)

cT3

30 (48%)

130 (42%)

30 (48%)

33 (53%)

cT4

1 (2%)

1 (2%)

5 (2%)

0.575

0.863

c)

c)

Tumor location

31

Ce

1 (2%)

1 (0.3%)

1 (2%)

Ut

12 (19%)

63 (20%)

12 (19%)

11 (18%)

Mt

27 (44%)

135 (43%)

27 (44%)

31 (50%)

Lt

22 (35%)

113 (36%)

22 (35%)

20 (32%)

0.857

0.61

cLymph node metastasis

b)

b)

160 (51%) / 152

Yes / No

29 (47%) / 33 (53%)

29 (47%) / 33 (53%)

31 (50%) / 31 (50%)

(49%)

<0.001

<0.001

b)

b)

Lymph node dissection

103 (33%) / 209

Three-field / two-field

5 (8%) / 57 (92%)

5 (8%) / 57 (92%)

22 (35%) / 40 (65%)

(67%)

<0.001

0.003

b)

b)

Anastomotic method

Circular stapler

0 (0%)

18 (6%)

0 (0%)

6 (10%)

32

Hand-sewn (Gambee stich)

Triangulating

4 (7%)

83 (27%)

4 (7%)

12 (19%)

58 (93%)

211 (67%)

58 (93%)

44 (71%)

stapling

technique

0.552

0.322

b)

b)

Histology

SCC / Other

55 (89%) / 7 (11%)

287 (92%) / 25 (8%)

55 (89%) / 7 (11%)

a)

Wilcoxon rank-sum test

b)

χ 2 test

c)

Fisher ’s exact test

ASA PS American Society of Anesthesiologist Physical Status; NAC neoadjuvant chemotherapy;

MIE minimally invasive esophagectomy; UICC Union for International Cancer Control; SCC squamous cell carcinoma.

Data are expressed as medians (range).

59 (95%) / 3 (5%)

33

Table 2. Operative outcomes

Laparoscopic retrosternal group

Posterior mediastinal group

(n = 62)

Operative time (min)

Thoracic portion (min)

Total blood loss (ml)

(n = 62)

755 (521–1327)

657 (443–1061)

<0.001

c)

379 (170–625)

303 (185–582)

<0.001

c)

20 (0–300)

143 (0–670)

<0.001

c)

p-Stage (UICC 7th edition)

0.48

2 (3.2%)

1 (1.6%)

IA

15 (24.2%)

20 (32.3%)

IB

5 (8.1%)

1 (1.6%)

IIA

6 (9.7%)

10 (16.1%)

IIB

11 (17.7%)

7 (11.3%)

IIIA

9 (14.5%)

5 (8.1%)

IIIB

7 (11.3%)

7 (11.3%)

IIIC

3 (4.8%)

4 (6.5%)

e)

34

IV

4 (6.5%)

7 (11.3%)

Anastomotic leakage - All grades

Yes

15 (24%)

12 (19%)

No

47 (76%)

50 (81%)

Anastomotic leakage > Grade III

a)

Yes

15 (24%)

8 (13%)

No

47 (76%)

54 (87%)

Pneumonia > Grade II

Yes

13 (21%)

12 (19%)

No

49 (79%)

50 (81%)

0.166

d)

0.508

a)

Yes

15 (24%)

11 (18%)

No

47 (76%)

51 (82%)

Gastro-tracheal fistula > Grade II

Yes

d)

1.00

a)

Other complications > Grade II

0.663

1.00

a)

1 (2%)

d)

d)

e)

35

No

62 (100%)

Hiatal hernia > Grade II

61 (98%)

0.496

a)

Yes

2 (3%)

No

62 (100%)

60 (97%)

Pulmonary embolism > Grade II

a)

Yes

3 (5%)

3 (5%)

No

59 (95%)

59 (95%)

24 (16–84)

30 (9–583)

Postoperative hospital stay (days)

Anastomotic stenosis

Yes

10 (16%)

17 (27%)

No

52 (84%)

45 (73%)

e)

1.00

e)

0.05

c)

0.192

d)

0.037

e)

Grade of reflux esophagitis in the

conduit

b)

42 (68%)

32 (51%)

6 (9%)

36

1 (2%)

1 (2%)

1 (2%)

1 (2%)

19 (30%)

21 (34%)

Not available

a)

Grades are based on the Clavien–Dindo classification of surgical complications

b)

Grades are based on the modified Los Angeles classification system of gastroesophageal reflux disease

c)

Wilcoxon rank-sum test

d)

χ 2 test

e)

Fisher ’s exact test

UICC Union for International Cancer Control

Data are expressed as medians (range).

62 patients who underwent

laparoscopic retrosternal route creation

(September 2019 – July 2021)

312 patients who underwent

posterior mediastinal reconstruction

(April 2010 – July 2021)

Propensity score matching

(Covariates; Age, Gender, cT, cN, Tumor location, Neoadjuvant chemotherapy, Histology)

Unmatched (n=250)

Matched (n=124)

Laparoscopic retrosternal

(LR) group

(n=62)

VS

Posterior mediastinal

(PM) group

(n=62)

Anastomotic

leakage

Col: LeakAll

(All grades)

Anastomotic leakage

Col: LeakGrade3Higher

> Grade III

30

30

24

30

(%)

20

20

16

13

(%)

(%)

10

10

10

L-RS

Laparoscopic

retrosternal

27

24

19

20

Col:

Stenosis

Anastomotic

stenosis

PM

Posterior

mediastinal

L-RS

Laparoscopic

retrosternal

PM

Posterior

mediastinal

L-RS

Laparoscopic

retrosternal

PM

Posterior

mediastinal

Gastro-tracheal fistula

Hiatal hernia

Pulmonary embolism

20

20

20

15

15

15

(%) 10

(%) 10

(%) 10

L-RS

Laparoscopic

retrosternal

PM

Posterior

mediastinal

L-RS

Laparoscopic

retrosternal

PM

Posterior

mediastinal

L-RS

Laparoscopic

retrosternal

PM

Posterior

mediastinal

Reflux esophagitis at the gastric conduit anastomosis

Contingency:

EGD1yr

4factor

p = 0.037

Numberofofpatients

Cases

Number

Laparoscopic

retrosternal

n=43

Posterior

mediastinal

n=41

L-RS

PM

...