Preemptive Endoluminal Negative Pressure in Minimally Invasive Transthoracic Esophagectomy

Study Overview
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Brief Summary
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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).

Official Title
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Preemptive Endoluminal Negative Pressure Therapy at the Anastomotic Site in Minimally Invasive Transthoracic Esophagectomy - An International Multicenter Randomized Controlled Trial

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

Intervention / Treatment
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* Device: Eso-SPONGE® device


Participation Criteria
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Eligibility Criteria
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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+)

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: minimally invasive esophagectomy with preemptive ENP<br>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. | Device: Eso-SPONGE® device<br>* Preemptive ENP therapy will be carried out with either an Eso-SPONGE® device system (Eso-SPONGE®, B. Braun Melsungen AG, Melsungen, Germany). Eso-SPONGE® consists of an open-pored polyurethane foam fitted to a gastric tube. Secretions are then continuously evacuated using a suction pump generating a negative pressure between 75 and 100 mmHg.<br>|
| No Intervention: Standard minimally invasive esophagectomy<br>Patients in the control group will undergo a standard minimally invasive transthoracic Ivor Lewis esophagectomy without preemptive ENP. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Length of hospital stay until fit-for-discharge criteria are reached | The patients' oral/enteral nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus. The patient does not require oxygen during mobilisation (short walk or climbing stairs) or at rest. Central venous catheters should be removed before discharge (unless present preoperatively). Adequate analgesia at rest and during mobilisation (pain score <4 on a scale from 0 to 10) is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters (white cell count, C-reactive protein) should be trending down and close to normal. There should be adequate support after discharge (assistance by family, ambulatory nursing, or rehabilitation facility). | 90-days postoperatively | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative Complications | Assessment of postoperative complications according to Clavien-Dindo | 90-days postoperatively | 
| Postoperative Complications | Hospital readmissions | 90-days postoperatively | 
| Postoperative Complications | Anastomotic stricture | 90-days postoperatively |