Preemptive Endoluminal Negative Pressure in Minimally Invasive Transthoracic Esophagectomy

University of Zurich (UZH)

Status: Unknown

Conditions: Esophageal Cancer; Surgery--Complications; Leak, Anastomotic

Treatments: Device: Eso-SPONGE® device

Study type: Interventional

Funder types: Other

Identifiers

NCT04162860

2019-00562

Details and patient eligibility

About

The primary objective of the preSponge randomized controlled trial (RCT) will be to assess the potential protective effects of preemptive endoscopic negative pressure therapy (ENP) on postoperative morbidity in high-risk patients undergoing total minimally invasive transthoracic esophagectomy with gastric pull-up reconstruction and high intrathoracic anastomosis (thoracoscopic and laparoscopic Ivor Lewis esophagectomy).

Enrollment: 100 estimated patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

We will include adult patients (≥18 years of age) with resectable esophageal cancer (adenocarcinoma or squamous cell carcinoma) with high risk for anastomotic leakage (AL) who provided informed consent and are scheduled for minimally invasive transthoracic Ivor Lewis esophagectomy. Robotic-assisted procedures will also be included.

Patients considered at high risk for AL must have at least one of the following risk factors:

• American Society of Anesthesiologists Classification (ASA) score >2
• Diabetes (insulin dependent or HbA1c ≥ 6.5%)
• Chronic pulmonary disease (first second of forced expiration (FEV1)/Forced volume vital capacity (FVC) ratio ≤ 70%)
• Heart failure (left ventricular ejection fraction (LVEF) <55%)
• Preexisting cardiac arrhythmia (pacemaker or paroxysmal supraventricular tachyarrhythmia)
• Chronic kidney disease stage 4-5 (glomerular filtration rate (GFR) < 30ml/min/1.73 m2)
• Chronic liver disease with treated portal hypertension (porto-caval pressure gradient ≥5-≤10mmHg, including patients with transjugular intrahepatic portosystemic shunt (TIPS))
• Previous radiotherapy or chemo-radiation ≥50Gray (Gy) (salvage esophagectomy)

Alternatively, patients must have at least two of the following risk factors:

• Arteriosclerosis score 2 according to van Rossum et al.13 (aorta and coeliac axis)
• Malnutrition (Body mass index (BMI) ≤ 18.5kg/m2)
• Obesity (BMI ≥ 35kg/m2)
• Heart failure with preserved ejection fraction (LVEF >55%)
• Active or former smoking
• Age > 65 years
• World health Organisation (WHO)/Zubrodt score > 1
• chronic kidney disease stage 2-3 (GFR 30-89 ml/min/1.73 m2)
• chronic liver disease without portal hypertension (porto-caval pressure gradient ≤5mmHg)

Exclusion criteria

• Inability to follow the procedures of the study, e.g. due to language problems, psychological disorders, or dementia.
• Patients younger than 18 years
• Patients undergoing esophagectomy for benign disease or for malignancy other than adenocarcinoma or squamous cell carcinoma
• Patients scheduled for other technical variants of esophagectomy, such as open, hybrid, or transhiatal procedures (intraoperative conversions to open access surgery will not be excluded)
• Chronic liver disease with portal hypertension (porto-caval pressure gradient >10mmHg)
• Distant organ metastasis (cM+)

Trial design

Primary purpose: Prevention

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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100 participants in 2 patient groups

minimally invasive esophagectomy with preemptive ENP

Experimental group

Description:

Patients will undergo a standard total minimally invasive transthoracic Ivor Lewis esophagectomy with preemptive ENP. After completion of the esophago-gastric anastomosis, an Eso-SPONGE® system will be inserted via an intraoperative gastroscopy. ENP will be carried out upon completion of the esophago-gastrostomy, but no later than 12 hours after the surgical intervention. Postoperatively, secretions are then continuously evacuated using a suction pump generating a negative pressure between 75 and 100 mmHg. ENP will remain for 4 days and will be monitored with clinical parameters.

Treatment:

Device: Eso-SPONGE® device

Standard minimally invasive esophagectomy

No Intervention group

Description:

Patients in the control group will undergo a standard minimally invasive transthoracic Ivor Lewis esophagectomy without preemptive ENP.