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Kolokotronis et al. Mini-invasive Surg 2021;5:19 https://dx.doi.org/10.20517/2574-1225.2021.07 Page 3 of 11

Both groups were compared regarding anastomotic leaks and strictures, postoperative morbidity, 90-day
mortality and survival.

[22]
To assess the severity of perioperative morbidity, the Clavien-Dindo classification was used ; the overall
postoperative morbidity during first hospital stay (surgical and respiratory complications included) was
divided into minor morbidity, corresponding to Clavien-Dindo Grades I-II, and major/lethal postoperative
morbidity corresponding to Clavien-Dindo Grades III-V. The group of minor postoperative morbidity
consisted of complications treated conservatively. The group of major postoperative morbidity consisted of
complications requiring surgical, endoscopic or radiological intervention (Clavien-Dindo Grade III); life-
threatening complications requiring ICU management (Grade IV); and lethal complications (Grade V). The
mortality during the first hospital stay was divided into 30-, 60- and 90-day mortality.

The disruption of the anastomosis leading to extravasation of intraluminal content was defined as
anastomotic leak. The definite diagnosis of anastomotic leak was confirmed endoscopically. Data collection
and analysis were performed only on patients who underwent an intrathoracic anastomosis.

Anastomotic stricture was defined as dysphagia in the 6-month endoscopic control requiring intervention
(endoscopic dilatation). Patients with anastomotic stricture suffered from Clavien-Dindo Grade III
complication.

Tumor management
Endoscopy was performed preoperatively as well as 6 months postoperatively to exclude tumor recurrence.
In the preoperative work-up, a computed tomography was performed to detect further organ metastases.
Neoadjuvant therapy was carried out preoperatively according to the international guidelines . Surgical
[23]
resection followed 4-6 weeks after the end of the neoadjuvant therapy. Until 2012, we used the PLF scheme,
based on cisplatin, folic acid, 5-fluoruracil and simultaneous irradiation [45 Gy (1.5 Gy per day)] in cases of
squamous-cell esophageal carcinoma. Since 2012, we have performed neoadjuvant chemoradiation, as
proposed by the Dutch CROSS trial, consisting of weekly administration of carboplatin und paclitaxel for 5
weeks and concurrent radiotherapy (41.4 Gy in 23 fractions) followed by surgery 4-6 weeks later.
Cardiopulmonary examinations (electrocardiogram, echocardiogram and lung function test) were
performed preoperatively.

Perioperative treatment
Patients received single-shot antibiotics intraoperatively. This included metronidazole 500 mg i.v. and
ceftriaxone 2 g i.v. In the case of penicillin allergy, clindamycin 600 mg i.v. was injected. After confirmation
of a patent anastomosis-using radiographic control-on Postoperative Day 5, the nasogastric tube was
routinely removed. Then, enteral feeding including liquids was started.

Statistical analysis
Statistical analysis was performed using χ² test (chi square test), binary logistic regression and Mann-
Whitney U test. Survival data were recorded contacting either the Cancer Registry of Saarland or the house
physicians. A 6-month follow-up was routinely performed including endoscopy. Log rank test and Cox
regression were performed for survival analysis. Statistical analysis was conducted using IBM SPSS Statistics
V22.0 (SPSS, Inc., Chicago, IL, USA).