Skip to main content
NCBI home page
PLOS One logoLink to PLOS One
. 2023 Mar 31;18(3):e0283890. doi: 10.1371/journal.pone.0283890

An individual’s physique is associated with the length of the reconstruction route via the retrosternal approach

Kotaro Honda 1, Sang-Woong Lee 1,*, Masaru Kawai 2, Ryo Tanaka 1, Yoshiro Imai 1, Kentaro Matsuo 1, Kazuhisa Uchiyama 1
Editor: Mohamad Khair Abou Chaar3
PMCID: PMC10065263  PMID: 37000827

Abstract

We hypothesized that an individual’s physique is related to reconstruction length, as organs reconstructed via the retrosternal route are curved toward the ventral side. This study aimed to determine factors contributing to the reconstruction length of the retrosternal route. Fifty patients underwent subtotal esophagectomy with esophagogastric reconstruction via the posterior mediastinal route between 2010 and 2014; the esophagus–stomach and posterior mediastinal route lengths were measured to evaluate whether they could be approximated. Forty patients underwent reconstruction via the retrosternal route between 2015 and 2020; the esophagus–stomach and retrosternal route lengths were compared, and contributing factors were analyzed. Each length was measured perioperatively using three-dimensional enhanced computed tomography images. The associated factors obtained included age, sex, height, body weight, body mass index, thickness and height of the thorax, depth of the thoracic inlet space, thoracic curve, left hepatic lobe volume, and the thickness and height of the liver. The length of the esophagus–stomach could approximate that of the posterior mediastinal route [posterior mediastinal-esophagus–stomach; 0.04 (-0.5–0.6) cm, p = 0.77]. Using three-dimensional enhanced computed tomography images, the lengths of the esophagus–stomach and retrosternal routes were comparable, despite variability [retrosternal-esophagus–stomach; 0.72 (-0.1–1.8) cm, p = 0.095]. Analyzing factors associated with the length revealed a positive correlation of body weight, body mass index, and thickness of the thorax with the difference. A higher body mass index (OR = 1.7, 95% CI 1.1–2.8, p = 0.007) was associated with a longer retrosternal route in the multivariate analysis. An individual’s physique is associated with the reconstruction length; particularly, the length of the retrosternal route was longer in patients with a high body mass index.

Introduction

Subtotal esophagectomy, the typical treatment for esophageal cancer, remains a highly invasive surgical procedure with various complications, including anastomotic leakage or ischemia of the reconstructed organs, such as the stomach, jejunum, or ileocolon [1,2]. Specifically, anastomotic leakage caused by both surgical [3–8] and patient factors [9–12] increases mortality [13] and worsens patient prognosis [14]. Among surgical factors, a strain on the anastomotic site and low blood flow of the reconstructed organs are likely to cause anastomotic leakage and ischemia; therefore, the length of the reconstruction route is thought to be associated with an anastomosis-related complication. One strategy to prevent anastomosis-related complications can be to pull the reconstructed organ up via the shortest route. Especially in cases of low blood flow or when the reconstructed organ is too short, the decision on the shortest route should be made to avoid postoperative adverse events.

The posterior mediastinal (PM) and retrosternal (RS) routes are the standard reconstruction routes following radical esophagectomy for cancer in 40.2% and 40.1% of cases, respectively, as reported by the Comprehensive Registry of Esophageal Cancer in Japan in 2013 [15]. The reconstruction route and organs are selected after considering the safety issues and postoperative quality of life, and the preferred surgical procedure depends on the individual institute or surgeon. Although several studies have explored the shortest reconstruction route after subtotal esophagectomy, there remains a lack of consensus on the optimal route for the reconstruction [16–21].

We hypothesized that an individual’s physique is associated with the length of the reconstruction route via the RS route curved toward the ventral side, and the length of the reconstruction route varies with each case. Thus, this study aimed to analyze the factors that contribute to the reconstruction length of the RS route following subtotal esophagectomy.

Materials and methods

Ethical information

This study was approved by the Institutional Review Board of Osaka Medical and Pharmaceutical University and conformed to the provisions of the Declaration of Helsinki in 1995 (as revised in Edinburgh 2000). The requirement for informed consent from the patients was waived by the review board because of the retrospective study design.

Patients

At our department, thoracoscopic subtotal esophagectomy with three-field lymph node dissection in the prone position is the standard treatment approach for thoracic esophageal cancer. Reconstruction is performed following the modified Collard [22,23] or triangulating stapled cervical esophagogastric anastomosis [24], using the narrow gastric conduit constructed under laparoscopic assistance. The anastomosis is performed at the lesser curvature of the gastric conduit and as much on the anal side as possible, where the blood flow is optimal. The RS route is created by tunneling the dorsal sternum to the neck after a small laparotomy, and then pulling the gastric conduit up to the neck. The manubrium or clavicle is not resected.

Among consecutive patients who underwent the reconstruction via the PM route following subtotal esophagectomy between 2010 and 2014, the esophagus–stomach (ES) length was retrospectively compared with the length of the PM route to evaluate whether they were approximate in patients who underwent reconstruction via the PM route. The length of the ES compared with that of the PM route was defined as the length of the esophagus plus the distance from the esophageal hiatus to the origin of the gastroduodenal artery (GDA).

Subsequently, consecutive patients who underwent the reconstruction via the RS route following a subtotal esophagectomy between 2015 and 2020 were examined. From 2015 onwards, we used the RS route as the standard reconstruction route to avoid esophagobronchial fistula formation. The lengths of the ES and RS routes were measured as alternatives to the lengths of the PM and RS routes, and factors associated with the length of the reconstruction route were analyzed in all the patients.

Contrast-enhanced computed tomography (CT; slice thickness, ≤2.0 mm) was carried out before and after surgery in all patients. The Kocher maneuver was not performed routinely during the esophagectomy; however, the patients on whom this was performed were excluded, as the measurement points may have shifted. No patients had hiatal hernia of the esophagus.

Measurements

Reconstruction lengths were measured by three-dimensional contrast-enhanced CT (3D-CT) using the Volume Analyzer SYNAPSE VINCENT by Fujifilm (Japan). All scans were obtained in a neutral position during inspiration. Each length was measured by plotting the established reference points of the intestinal lumen from the lower border of the cricoid cartilage to the origin of the GDA. The lengths of the ES and PM routes were measured by plotting the reference points at the lower border of the cricoid cartilage, upper border of the jugular notch, lower border of the tracheal bifurcation, middle point between the lower border of the tracheal bifurcation and esophageal hiatus, esophageal hiatus, and origin of the GDA (Fig 1A). The reconstruction length of the RS route was measured by plotting reference points at the lower border of the cricoid cartilage, upper border of the jugular notch, lower border of the tracheal bifurcation, lower border of the body of the sternum, lower border of the left lobe of the liver, and origin of the GDA (Fig 1B).

Fig 1.

Fig 1

Open in a new tab

(a) Reference points for measuring the length of the esophagus and stomach and the posterior mediastinal route. ① Cricoid cartilage, ② jugular notch, ③ tracheal bifurcation, ④ middle point between ③ and ⑤, ⑤ esophageal hiatus, and ⑥ gastroduodenal artery. (b) Reference points for measuring the length of the retrosternal route. ① Cricoid cartilage, ② jugular notch, ③ tracheal bifurcation, ④ lower border of the body of sternum, ⑤ lower border of the left hepatic lobe, and ⑥ gastroduodenal artery.

To analyze the factors contributing to the reconstruction length of the RS route, factors related to an individual’s physique and the difference between the lengths of the ES and RS routes were investigated; patients with longer and shorter routes were divided into subgroups within the RS group and were compared by each parameter. All the following factors obtained through 3D-CT in the mid-sagittal central plane were measured: thickness and height of the thorax, depth of the thoracic inlet space, thoracic curve, left hepatic lobe volume, and thickness and height of the liver (Fig 2). The patients’ age, sex, height, body weight, and body mass index (BMI) were also obtained. The measurements were carried out in triplicate, and the mean was used as the measured value.

Fig 2. Measurement methods for factors contributing to the length of the reconstruction route.

Fig 2

Open in a new tab

(a) Thin thorax: BMI of 17.9 kg/m2, thoracic thickness of 9.7 cm, and RS–ES length of -0.7 cm. (b) Thick thorax: BMI of 26.3 kg/m2, thoracic thickness of 14.3 cm, and RS–ES length of 1.8 cm. Each point was measured in the mid-sagittal central plane. ① The thickness of the thorax was measured from the lower border of the body of the sternum to the vertebral body. ② The height of the thorax was measured from the upper border of the jugular notch to the lower border of the body of the sternum. ③ The depth of the thoracic inlet space was measured from the upper border of the jugular notch to the lower border of the cricoid cartilage. ④ The thoracic curve was measured at the angle of the extended intersection between Th1 upper and Th12 lower borders of the vertebral body. ⑤ The height of the liver was measured at the cranial–caudal distance. ⑥ The thickness of the liver was measured at the anterior–posterior distance.

Statistical analysis

Values are presented as medians (ranges). Continuous data were compared using the Wilcoxon rank-sum test, and the differences in each group were analyzed using Fisher’s exact probability test. The relationship between the length of the reconstruction route and the measured factors was tested using Spearman’s rank correlation coefficient. A multivariate logistic regression was performed to analyze the factors contributing to the reconstruction length. The receiver operating characteristic analysis was performed to calculate the area under the receiver operating characteristic curve and the cut-off value. All analyses were performed using JMP® 14 (SAS Institute Inc., Cary, NC, USA), yielding two-sided p-values; p<0.05 was considered significant.

Results

Table 1 shows the characteristics of the patients and tumors in each group by the reconstruction routes. A total of 50 consecutive patients underwent reconstruction via the PM route following subtotal esophagectomy between 2010 and 2014, and 40 consecutive patients underwent reconstruction via the RS route following subtotal esophagectomy between 2015 and 2020. No significant difference in anastomosis-related complications was found between the two groups.

Table 1. Characteristics of each reconstruction route group.

PMa (n = 50) RSb (n = 40) p-value
Age, years, median (range) 69 (64–73) 70.5 (65–75) 0.29
Sex
    Male/Female 46/4 29/11 0.02
Height, cm, median (range) 164.5 (161.8–169.0) 164.0 (159.5–168.8) 0.29
Body weight, cm, median (range) 58.0 (51.0–63.4) 54.6 (45.0–61.9) 0.05
BMI, kg/m2, median (range) 21.5 (19.2–23.3) 19.6 (17.6–22.7) 0.05
Histology
    Squamous cell carcinoma 47 (94) 39 (97.5) 0.49
    Adenocarcinoma 2 (4) 0 (0)
    Others 1 (2) 1 (2.5)
Tumor location
    Upper/middle/lower 5(10) / 32(64) / 13(26) 3(7.5) / 23(57.5) / 14(35) 0.81
pStagec
    I 25 (50) 7 (17.5) 0.01
    II 4 (8) 8 (20)
    III 16 (32) 17 (42.5)
    IV 5 (10) 8 (20)
Neoadjuvant therapy
    No 31 (62) 9 (22.5) 0.001
    Chemotherapy 17 (34) 27 (67.5)
    Chemoradiotherapy 2 (4) 4 (10)
Anastomotic complications
    Anastomotic leak 10 (20) 7 (17.5) 0.79
    Ischemia 1 (2) 2 (5) 0.58
Open in a new tab

Data are presented as n (%), unless otherwise indicated.

aPosterior mediastinal

bRetrosternal

cTNM classification (UICC 8th edition).

Table 2 shows the lengths of the routes; in PM reconstructions (n = 50), the median lengths of the ES and PM routes were 33.0 (32.0–34.2) and 33.1 (31.7–33.8) cm, respectively. The difference between the ES and PM routes (PM–ES) was 0.04 (-0.5–0.6) cm (p = 0.77). In the RS reconstructions (n = 40), the median lengths of the ES and RS routes were 33.3 (32.0–34.7) and 34.0 (33.2–35.3) cm, respectively. The median difference between the ES and RS route (RS–ES) was 0.72 (-0.1–1.8) cm; therefore, the RS route was slightly longer than the ES route, although no significant difference was noted (p = 0.095). The RS ≥ ES group included 30 cases, whereas the RS < ES group included 10 cases; meanwhile, the anastomosis-related complications in each group comprised six cases and one case, respectively, in which there was no significant difference (p = 0.66).

Table 2. Length of each route and difference between post- and preoperative lengths.

Preoperative length
(ESa)		 Postoperative length
(PMb/RSc)		 Difference
(Post-Pre)		 p-value
PM (n = 50) 33.0 (32.0–34.2) 33.1 (31.7–33.8) 0.04 (-0.5–0.6)d 0.77
RS (n = 40) 33.3 (32.0–34.7) 34.0 (33.2–35.3) 0.72 (-0.1–1.8)e 0.095
Open in a new tab

Values are expressed as median distance and range.

aEsophagus–stomach

bPosterior mediastinal

cRetrosternal.

dDifference between the lengths of the ES and PM routes (PM–ES). A smaller PM–ES value indicates that the lengths of the ES and PM routes are comparable.

eDifference between the lengths of the ES and RS routes (RS–ES). A positive RS–ES value indicates that the RS route is longer than the PM route, as the length of the ES can be approximated to that of the PM route.

In addition, the factors contributing to the length of the reconstruction route were investigated. Spearman’s rank correlation analysis showed that the difference between the lengths of the ES and RS routes was positively correlated with body weight (ρ = 0.42, p = 0.007), BMI (ρ = 0.52, p = 0.001), and thickness of the thorax (ρ = 0.39, p = 0.01), as shown in Fig 3. The univariate analysis indicated that the length of the RS route was significantly associated with BMI (p = 0.006) and the height of the liver (p = 0.04). Furthermore, in the multivariate analysis, only BMI (OR = 1.7, 95% CI 1.1–2.8, p = 0.007) was associated with the length of the RS route, as shown in Table 3. In this study, the cut-off value of BMI was 19.6 kg/m2 (area under curve 0.8). There were five obese cases with BMI >25 kg/m2, in which the RS route was longer than the ES route and no anastomosis-related complications were observed.

Fig 3. Relationships between the three factors and differences in reconstruction lengths.

Fig 3

Open in a new tab

The three factors associated with the difference between the length of the retrosternal route and that of the esophagus–stomach (RS–ES) were analyzed using Spearman’s rank correlation coefficient; positive correlations were observed with each factor. (a) Body weight: ρ = 0.42, p = 0.007; (b) BMI: ρ = 0.52, p = 0.001; (c) Thickness of the thorax: ρ = 0.39, p = 0.01.

Table 3. Relationship between factors and reconstruction routes.

Variables RSa ≧ESb (n = 30) RS<ES (n = 10) Univariate analysis
p-value		 Multivariate analysis
OR (95% CI) p-value
Age 70.5 (64.8–77.0) 69.5 (63.8–73.0) 0.38
Sex (male/female) 22 / 8 7 / 3 1.00
Height (cm) 163.5 (159.2–167.2) 165.5 (160.1–171.1) 0.37
Body weight (kg) 56.2 (49.4–63.6) 47.2 (39.9–56.4) 0.05
BMI (kg/m2) 21.0 (18.1–24.0) 17.4 (15.8–19.1) 0.006 1.7 (1.1–2.8) 0.007
Thickness of
the thorax (cm)		 11.3 (9.2–12.4) 10.4 (9.6–11.0) 0.25 0.6 (0.2–1.4) 0.24
Height of
the thorax (cm)		 13.9 (13.2–15.6) 14.9 (13.0–15.8) 0.84
Depth of thoracic
inlet space (cm)		 2.7 (1.6–3.1) 2.5 (1.1–3.4) 0.56
Thoracic curve (°) 25.0 (20.1–33.4) 27.5 (23.8–37.6) 0.27 1.0 (0.82–1.1) 0.6
Left hepatic lobe
volume (ml)		 198.8 (155.0–238.0) 231.3 (173.5–263.4) 0.30
Height of the liver
(cm)		 5.9 (4.6–7.8) 8.0 (6.2–8.6) 0.04 0.6 (0.2–1.0) 0.07
Thickness of the
liver (cm)		 7.5 (6.1–8.5) 6.3 (5.8–7.1) 0.13
Open in a new tab

aRetrosternal

bEsophagus–stomach, assumed to be the same length as the posterior mediastinal route.

Discussion

This study has some notable findings. First, comparison of the reconstruction lengths of the ES and PM routes revealed that the preoperative length of the PM route could approximate that of the ES route. Second, comparison of the lengths of the ES and RS routes in patients who underwent reconstruction via the RS route showed that the ES and RS reconstruction routes had similar lengths, though the difference between the ES and RS routes varied in each case (Table 2). Finally, analysis of the factors contributing to the length of the reconstruction route revealed that the RS route was longer in patients with a high BMI (Fig 3 and Table 3). Clinicians could consider using the Kocher maneuver and creating a long gastric conduit when treating obese patients. To the best of our knowledge, this study was the first report on the reconstruction length following subtotal esophagectomy measured by perioperative 3D-CT.

Table 4 lists seven studies comparing the differences between the PM and RS routes, including the present study. Of them, except for our study, four studies utilized cadaver’s body and the remaining two directly performed measurements during surgery. The proximal reference point was the lower border of the cricoid cartilage, similar to that reported in previous studies. In all cases, the level of the anastomosis was accurately determined via the CT images because a stapling device was used for cervical anastomosis. Additionally, the level of anastomosis in all cases was determined at the oral side rather than at the jugular notch. Although the proximal reference point for measurement was the lower border of the cricoid cartilage and not the level of anastomosis, the difference did not affect the measurement results. The distal reference points varied in each study, including the GDA, celiac axis, pyloric ring, and duodenum at the level of the pancreatic head. In our study, the origin of the GDA was measured, as the point fixed in the retroperitoneum was easily identified on CT images and did not shift during surgery. Some previous studies have reported that the PM route is the shortest [16–18], whereas others have reported that the RS route is the shortest [19–21]. Given these contrasting results, there remains a lack of consensus on the shortest route. Moreover, no studies have investigated the relation of the reconstructed length with patients’ characteristics. In our study, we found no differences in the length of the PM and RS routes, though the differences were significant in some cases. An analysis of some of the patient’s demographic characteristics revealed that the BMI contributed to the reconstruction length. To the best of our knowledge, no study has so far showed the positive correlation between the reconstruction length and an individual’s physique, including BMI, body weight, and thickness of the thorax (Fig 3). Previous studies analyzing actual lengths measured during surgery could reveal reliable findings; however, in a practical situation, surgeons often like to know the information preoperatively in each case. In the present study, the results based on measurements using 3D-CT images did not show any significant difference in length between the RS and PM routes; however, we found that the reconstruction length was related to physical factors. The variability of the results in previous reports may be attributed to the physique of the enrolled patients, which should be considered when comparing reconstruction lengths. The reconstructed organs were curved regardless of the reconstruction route; therefore, the 3D measurement method used in the present study was considered a novel approach that enabled preoperative measurement of the curved length, based on the individual’s physique, and helped predict a shorter reconstruction route.

Table 4. Studies on the differences between RSa and PMb.

Authors n Subjects Proximal
reference point		 Distal reference point and RS-PM value (cm)
Celiac axis GDAc Pyloric ring Duodenumd
Orringer and Sloan [16] 10 Cadaver Unknown Unknowne
Ngan and
Wong [17]		 20 Cadaver Cricoid cartilage 1.9
Coral et al.
[18]		 50 Cadaver Cricoid cartilage 5.3 2.5
Chen et al.
[19]		 60 Patient in surgery Cricoid cartilage -2.8
Hu et al. [20] 20 Cadaver Cricoid cartilage 2.5 -1.3 -1.5
Yasuda et al.
[21]		 112 Patient in surgery Cricoid cartilage -2.3
Current study 40 Patient Cricoid cartilage 0.7
Open in a new tab

aRetrosternal

bPosterior mediastinal

cGastroduodenal artery.

dSuperior border of the duodenum arising from the head of the pancreas.

eOrringer and Sloan reported that the RS route was longer than the PM route; however, data were not available.

Several studies have examined the relationship between the reconstruction routes and anastomotic leakage, where no significant difference was observed in the incidence of anastomotic leakage between the RS and PM routes [6,25–30]. The length is not the only cause of complications; anastomotic leakage is caused by a combination of several factors [3–12]. However, the reconstruction length is considered a critical factor related to anastomotic leakage due to an increase in the incidence of similar complications if the reconstructed organs are anastomosed at a site with poor blood flow. The anastomotic leakage in esophagectomy with cervical anastomosis in this study occurred in 17 (18.9%) of the 90 total cases, including 10 (20%) of the 50 cases wherein the PM route was employed and seven (17.5%) of the 40 cases wherein the RS route was used. Notably, the incidence of anastomotic leakage in our study was higher than that reported in other studies. While our results offer some insight on the subject, further study is needed to identify the optimal reconstructive route to reduce anastomotic leakage. Although our series did not reveal a relationship between the length of the reconstruction route and anastomotic leakage and did not reveal a relationship between the BMI and anastomotic leakage, a study reported that obesity is associated with anastomotic leakage in esophagectomy [31]. In Japan, the selection of the reconstruction route depends on the surgeon and institute, and the PM and RS routes are standard reconstruction routes employed after radical esophagectomy for cancer in 40.2% and 40.1% of cases, respectively, with no significant differences reported between the surgical outcomes of the two routes. At our institute, the RS route is the standard reconstruction route undertaken when serious complications, such as esophagobronchial fistula, are likely to develop after reconstruction using the PM route. Our study corroborates the results of previous studies in Japan by showing that the surgical outcomes of esophagectomy do not differ between both routes. The results of our study suggest that the PM route should be selected to avoid anastomosis-related complications when treating obese patients with a high perioperative risk. In this study, five overweight cases had BMIs >25 kg/m2, including one with BMI >30 kg/m2; in all these cases, the RS route was longer than the PM route. Thus, even if the standard route for reconstruction is RS, we recommend using the PM route when treating obese patients (BMI >25 kg/m2) to avoid anastomosis-related complications and potentially improve the surgical outcome of esophagectomy for esophageal cancer in such patients. To verify our results, it is necessary to further investigate the relationship in more obese patients with esophageal cancer.

This study has a few limitations. First, the study followed a retrospective design, and the results may have a patient selection bias. Second, the time point for surgeries varied owing to factors such as equipment and surgeon availability. This could also introduce variations in the outcomes of esophagectomies. Third, there may be a discrepancy between the actual length measured during the surgery and the length measured using CT. In this study, both these lengths were not compared. However, the study findings revealed that the reconstruction length was clearly related to the individual’s physique. Elucidation of the factors contributing to the reconstruction length and comparison of the differences in the length of the PM and RS routes before esophagectomy using the 3D measurement method can help clinicians select the optimal reconstruction route. Consequently, the outcome of esophagectomies for esophageal cancer may improve. Further studies exploring the relationships between reconstruction lengths, individual’s physique, and outcomes of esophagectomies are needed to confirm these findings.

Conclusion

The length of the reconstruction route was found to be dependent on an individual’s physique; in particular, the RS route was longer in patients with a high BMI. Thus, when treating obese patients with a high perioperative risk, clinicians could consider using the Kocher maneuver to create a long gastric conduit and employing the PM route to potentially reduce the incidence of anastomosis-related complications.

Supporting information

S1 Data

(XLSX)

Click here for additional data file. (19.7KB, xlsx)
S2 Data

(XLSX)

Click here for additional data file. (24.6KB, xlsx)

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author received no specific funding for this work.

References

  • 1.Kassis ES, Kosinski AS, Ross P Jr, Koppes KE, Donahue JM, Daniel VC. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg. 2013;96: 1919–1926. doi: 10.1016/j.athoracsur.2013.07.119 [DOI] [PubMed] [Google Scholar]
  • 2.Takeuchi H, Miyata H, Gotoh M, Kitagawa Y, Baba H, Kimura W, et al. A risk model for esophagectomy using data of 5354 patients included in a Japanese nationwide web-based database. Ann Surg. 2014;260: 259–266. doi: 10.1097/SLA.0000000000000644 [DOI] [PubMed] [Google Scholar]
  • 3.Honda M, Kuriyama A, Noma H, Nunobe S, Furukawa TA. Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg. 2013;257: 238–248. doi: 10.1097/SLA.0b013e31826d4723 [DOI] [PubMed] [Google Scholar]
  • 4.Yoshida N, Baba Y, Watanabe M, Hiyoshi Y, Ishimoto T, Iwagami S, et al. Triangulating stapling technique covered with the pedicled omental flap for esophagogastric anastomosis: a safe anastomosis with fewer complications. J Am Coll Surg. 2015;220: e13–e16. doi: 10.1016/j.jamcollsurg.2014.10.015 [DOI] [PubMed] [Google Scholar]
  • 5.Anegg U, Lindenmann J, Maier A, Smolle J, Smolle-Jüttner FM. Influence of route of gastric transposition on oxygen supply at cervical esophagogastric anastomoses. Br J Surg. 2008;95: 344–349. [DOI] [PubMed] [Google Scholar]
  • 6.Yamasaki M, Miyata H, Yasuda T, Shiraishi O, Takahashi T, Motoori M, et al. Impact of the route of reconstruction on post-operative morbidity and malnutrition after esophagectomy: a multicenter cohort study. World J Surg. 2015;39: 433–440. doi: 10.1007/s00268-014-2819-1 [DOI] [PubMed] [Google Scholar]
  • 7.Kechagias A, van Rossum PSN, Ruurda JP, van Hillegersberg R. Ischemic conditioning of the stomach in the prevention of esophagogastric anastomotic leakage after esophagectomy. Ann Thorac Surg. 2016;101: 1614–1623. doi: 10.1016/j.athoracsur.2015.10.034 [DOI] [PubMed] [Google Scholar]
  • 8.Zehetner J, DeMeester SR, Alicuben ET, Oh DS, Lipham JC, Hagen JA, et al. Intraoperative assessment of perfusion of the gastric graft and correlation with anastomotic leaks after esophagectomy. Ann Surg. 2015;262: 74–78. doi: 10.1097/SLA.0000000000000811 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Tsutsui S, Moriguchi S, Morita M, Kuwano H, Matsuda H, Mori M, et al. Multivariate analysis of postoperative complications after esophageal resection. Ann Thorac Surg. 1992;53: 1052–1056. doi: 10.1016/0003-4975(92)90388-k [DOI] [PubMed] [Google Scholar]
  • 10.Fischer C, Lingsma H, Hardwick DA, Cromwell DA, Steyerberg E, Groene O. Risk adjustment models for short-term outcomes after surgical resection for esophagogastric cancer. Br J Surg. 2016;103: 105–116. [DOI] [PubMed] [Google Scholar]
  • 11.Yamana I, Takeno S, Shibata R, Shiwaku H, Maki K, Hashimoto T, et al. Is the geriatric nutritional risk index a significant predictor of postoperative complications in patients with esophageal cancer undergoing esophagectomy? Eur Surg Res. 2015;55: 35–42. doi: 10.1159/000376610 [DOI] [PubMed] [Google Scholar]
  • 12.Vande Walle C, Ceelen WP, Boterberg T, Vande Putte D, Van Nieuwenhove Y, Varin O, et al. Anastomotic complications after Ivor Lewis esophagectomy in patients treated with neoadjuvant chemoradiation are related to radiation dose to the gastric fundus. Int J Radiat Oncol Biol Phys. 2012;82: e513–e519. doi: 10.1016/j.ijrobp.2011.05.071 [DOI] [PubMed] [Google Scholar]
  • 13.Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg. 2004;10: 71–75. [PubMed] [Google Scholar]
  • 14.Lagarde SM, de Boer JD, ten Kate FJ, Busch OR, Obertop H, van Lanschot JJ. Postoperative complications after esophagectomy for adenocarcinoma of the esophagus are related to timing of death due to recurrence. Ann Surg. 2008;247: 71–76. doi: 10.1097/SLA.0b013e31815b695e [DOI] [PubMed] [Google Scholar]
  • 15.Watanabe M, Tachimori Y, Oyama T, Toh Y, Matsubara H, Ueno M, et al. Comprehensive Registry of Esophageal Cancer in Japan, 2013. Esophagus. 2021;18: 1–24. doi: 10.1007/s10388-020-00785-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Orringer MB, Sloan H. Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J Thorac Cardiovasc Surg. 1975;70: 836–851. [PubMed] [Google Scholar]
  • 17.Ngan SY, Wong J. Lengths of different routes for esophageal replacement. J Thorac Cardiovasc Surg. 1986;91: 790–792. [PubMed] [Google Scholar]
  • 18.Coral RP, Constant-Neto M, Silva IS, Kalil AN, Boose R, Beduschi T, et al. Comparative anatomical study of the anterior and posterior mediastinum as access routes after esophagectomy. Dis Esophagus. 2003;16: 236–238. doi: 10.1046/j.1442-2050.2003.00335.x [DOI] [PubMed] [Google Scholar]
  • 19.Chen H, Lu JJ, Zhou J, Zhou X, Luo X, Liu Q, et al. Anterior versus posterior routes of reconstruction after esophagectomy: a comparative anatomic study. Ann Thorac Surg. 2009;87: 400–404. doi: 10.1016/j.athoracsur.2008.11.016 [DOI] [PubMed] [Google Scholar]
  • 20.Hu H, Ye T, Tan D, Li H, Chen H. Is anterior mediastinum route a shorter choice for esophageal reconstruction? A comparative anatomic study. Eur J Cardio Thorac Surg. 2011;40: 1466–1469. doi: 10.1016/j.ejcts.2011.03.038 [DOI] [PubMed] [Google Scholar]
  • 21.Yasuda T, Shiraishi O, Kato H, Hiraki Y, Momose K, Yasuda A, et al. A comparative study of the lengths of different reconstruction routes used after thoracic esophagectomy. Esophagus. 2012;18: 468–474. [DOI] [PubMed] [Google Scholar]
  • 22.Collard JM, Romagnoli R, Goncette L, Otte JB, Kestens PJ. Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy. Ann Thorac Surg. 1998;65: 814–817. doi: 10.1016/s0003-4975(97)01384-2 [DOI] [PubMed] [Google Scholar]
  • 23.Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119: 277–288. doi: 10.1016/S0022-5223(00)70183-8 [DOI] [PubMed] [Google Scholar]
  • 24.Furukawa Y, Hanyu N, Hirai K, Ushigome T, Kawasaki N, Toyama Y, et al. Usefulness of automatic triangular anastomosis for esophageal cancer surgery using a linear stapler (TA-30). Ann Thorac Cardiovasc Surg. 2005;11: 80–86. [PubMed] [Google Scholar]
  • 25.van Lanschot JJ, van Blankenstein M, Oei HY, Tilanus HW. Randomized comparison of prevertebral and retrosternal gastric tube reconstruction after resection of esophageal carcinoma. Br J Surg. 1999;86: 102–108. [DOI] [PubMed] [Google Scholar]
  • 26.Wong AC, Law S, Wong J. Influence of the route of reconstruction on morbidity, mortality and local recurrence after esophagectomy for cancer. Dig Surg. 2003;20: 209–214. doi: 10.1159/000070387 [DOI] [PubMed] [Google Scholar]
  • 27.Wang H, Feng M, Tan L, Wang Q. Comparison of the short-term quality of life in patients with esophageal cancer after subtotal esophagectomy via video-assisted thoracoscopic or open surgery. Dis Esophagus. 2010;23: 408–414. doi: 10.1111/j.1442-2050.2009.01025.x [DOI] [PubMed] [Google Scholar]
  • 28.Chan ML, Hsieh CC, Wang CW, Huang MH, Hsu WH, Hsu HS. Reconstruction after esophagectomy for esophageal cancer: retrosternal or posterior mediastinal route? J Chi Med Assoc. 2011;74:505–510. doi: 10.1016/j.jcma.2011.09.006 [DOI] [PubMed] [Google Scholar]
  • 29.Zheng YZ, Dai SQ, Li W, Cao X, Wang X, Fu JH, et al. Comparison between different reconstruction routes in esophageal squamous cell carcinoma. World J Gastroenterol. 2012;18: 5616–5621. doi: 10.3748/wjg.v18.i39.5616 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Markar SR, Arya S, Karthikesalingam A, Hanna GB. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol. 2013;20: 4274–4281. doi: 10.1245/s10434-013-3189-x [DOI] [PubMed] [Google Scholar]
  • 31.Mengardo V, Pucetti F, Mc Cormack O, Chaudry A, Allum WH. The impact of obesity on esophagectomy: a meta-analysis. Dis Esophagus. 2017;31: 1–9. [DOI] [PubMed] [Google Scholar]

Decision Letter 0

Eric D Roessner

11 Feb 2022

PONE-D-21-33230An individual’s physique affects the length of the reconstruction route via the retrosternal approachPLOS ONE

Dear Dr. Lee,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please bare in mind that substantial issues have been raised by the reviewers. Therefore a major revision of the article is mandatory before resubmitting, addressing all issues raised. 

Please submit your revised manuscript by Mar 28 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Eric D. Roessner, Prof.

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf  and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2.  In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I congratulate Dr. Sang-Woong Lee and his colleagues on a clear and well-written manuscript.

I have several comments and questions:

1) The findings from this article are not new, although the method is more applicable to clinical practice.

2) Please specify if you included patients with hiatal hernia. My assumption is that you had no patients with hiatal hernia based on pathology and BMI, but it is important to specify this.

3) Presumably, your practice changed in 2015; it would appear that you switched to performing mainly RS reconstructions. Otherwise, why the 2 different time periods? Why did you switch?

4) The leak rate is high when compared to other reports in the literature; please explain how your leak rate compared with that of other series of esophagectomy with cervical anastomosis.

5) Your study would carry much more weight and validation to your measurement method if you would also provide a measurement of the anastomosis from the teeth as determined by endoscopy. How do we know the level of the anastomosis is the same? That also significantly affects how we interpret these data.

6) Your technique for retrosternal reconstruction should be explained in the methods. Where exactly do you perform the anastomosis? Do you remove a portion of the manubrium or the sterno-clavicular joint?

7) Conclusion: What should a practicing esophageal surgeon do with this information? Outcomes were the same. What is the practical relevance of this study?

8) As a North American surgeon, I have learned from your article that primary reconstruction via the retrosternal route is a feasible approach. In North America, we reserve the retrosternal rout mainly for delayed reconstruction.

Reviewer #2: Overall, the aim of the study is clear, the results are as well. Nevertheless, a few things remain unclear:

A. The results state, that retrosternal approach might be associated to higher anastomotic leakage in higher BMI patients due to a longer conduit.

B. Clavicular or sternal resection is often needed to avoid postoperative dysphagia in patients with retrosternal approach. This is congruent to our experience. Therefore our clinic has set the posterior mediastinal approach as the standard procedure.

--> In which case would you still recommend retrosternal approach and therefore prove relevance of these findings?

In your manuscript you mentioned that higher BMI is associated to longer routes for RS routes. Fig 3 shows some kind of visualization. Nevertheless, for clinical use, a consequence of these findings could be stated. Is there possibly a cut-off value for significant lengthening of the route? Is there a recommendation for which approach to prioritize or avoid with a certain BMI?

The discussion lacks a conclusion for clinicians towards which consequence your findings might have (literature states that anastomotic leakage rates overall are not higher in the retrosternal approach than in the posterior mediastinal approach, as you stated earlier in your manuscript).

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 Mar 31;18(3):e0283890. doi: 10.1371/journal.pone.0283890.r002

Author response to Decision Letter 0

25 Mar 2022

Responses to Editor’s and Reviewers’ Comments

To Reviewer #1

Reviewer’s comment 1

The findings from this article are not new, although the method is more applicable to clinical practice.

Response to comment 1

Thank you for your comment. We believe that the 3D measurement method used in the present study was a novel approach to enable preoperative measurement of the curved length, based on the individual’s physique, and predict a shorter reconstruction route. We found that the retrosternal route (RS) was longer in patients with a high BMI, and thus suggest practicing esophageal surgeons to consider using the Kocher maneuver for creating a long gastric conduit when treating obese patients. It is necessary to further investigate the relationship between reconstruction length and surgical outcomes of esophagectomy in patients with a high BMI. We have added the following sentence to the Discussion section: “...therefore, the 3D measurement method used in the present study was considered a novel approach that enabled preoperative measurement of the curved length, based on the individual’s physique, and helped predict a shorter reconstruction route.” (Page 14, lines 256–258)

Reviewer’s comment 2

Please specify if you included patients with hiatal hernia. My assumption is that you had no patients with hiatal hernia based on pathology and BMI, but it is important to specify this.

Response to comment 2

Thank you for your comment. In this study, each length was measured by plotting the established reference points from the lower border of the cricoid cartilage to the origin of the GDA, including the esophageal hiatus. Therefore, we believe that the presence of a hiatal hernia of the esophagus did not affect reconstruction length. Nonetheless, we have added the following sentence to the Materials and Methods section: “No patients had hiatal hernia of the esophagus.” (Page 5, lines 100).

Reviewer’s comment 3

Presumably, your practice changed in 2015; it would appear that you switched to performing mainly RS reconstructions. Otherwise, why the 2 different time periods? Why did you switch?

Response to comment 3

Thank you for your comment. At our department, the RS route has been used as the standard reconstruction route since 2015 for cases wherein serious complications, such as esophagobronchial fistula, may develop after reconstruction using the posterior mediastinal (PM) route. According to your suggestion, we have added the following sentence to the Patients section: “From 2015 onwards, we used the RS route as the standard reconstruction route to avoid esophagobronchial fistula formation.” (Page 5, lines 92–94)

Reviewer’s comment 4

The leak rate is high when compared to other reports in the literature; please explain how your leak rate compared with that of other series of esophagectomy with cervical anastomosis.

Response to comment 4

Thank you for your pertinent comment. The anastomotic leakage in esophagectomy with cervical anastomosis in this study occurred in 17 (18.9%) of the 90 total cases, including in 10 (20%) of 50 cases wherein the PM route was used and seven (17.5%) of the 40 cases wherein the RS route was used. The reported leak rates of esophagectomy with cervical anastomosis are 12.3 % [1] and 13.6 % [27], and as you pointed out, the leak rate in our study is higher than these reported values. In our department, thoracoscopic subtotal esophagectomy was considered the standard treatment approach for thoracic esophageal cancer since 2010, but the standard reconstruction route was changed from the PM route to the RS route from 2015 onwards. Both routes (PM and RS) result in a high incidence of anastomotic leakage during the induction phase. Thus, the search is ongoing for optimal reconstructive routes that reduce anastomotic leakage, and the present study is one of the attempts to address this knowledge gap. In response to your suggestion, we have added the following text to the Discussion section: “The anastomotic leakage in esophagectomy with cervical anastomosis in this study occurred in 17 (18.9%) of the 90 total cases, including 10 (20%) of the 50 cases wherein the PM route was employed and seven (17.5%) of the 40 cases wherein the RS route was used. Notably, the incidence of anastomotic leakage in our study was higher than that reported in other studies. While our results offer some insight on the subject, further study is needed to identify the optimal reconstructive route to reduce anastomotic leakage.” (Pages 15 & 16, lines 272–277)

Reviewer’s comment 5

Your study would carry much more weight and validation to your measurement method if you would also provide a measurement of the anastomosis from the teeth as determined by endoscopy. How do we know the level of the anastomosis is the same? That also significantly affects how we interpret these data.

Response to comment 5

Thank you for your comment. In this study, we could not measure the anastomosis with reference to the teeth using endoscopy. However, in response to your suggestion, we have added the following sentence to the Discussion section: “The proximal reference point was the lower border of the cricoid cartilage, similar to that reported in previous studies. In all cases, the level of the anastomosis was accurately determined via the CT images because a stapling device was used for cervical anastomosis. Additionally, the level of anastomosis in all cases was determined at the oral side rather than at the jugular notch. Although the proximal reference point for measurement was the lower border of the cricoid cartilage and not the level of anastomosis, the difference did not affect the measurement results.” (Page 13, lines 228–234)

Reviewer’s comment 6

Your technique for retrosternal reconstruction should be explained in the methods. Where exactly do you perform the anastomosis? Do you remove a portion of the manubrium or the sterno-clavicular joint?

Response to comment 6

Thank you for your comment. According to your suggestion, we have added the following sentence to the Material and Methods section: “The anastomosis is performed at the lesser curvature of the gastric conduit and as much on the anal side as possible, where the blood flow is optimal. The RS route is created by tunneling the dorsal sternum to the neck after a small laparotomy, and then pulling the gastric conduit up to the neck. The manubrium or clavicle is not resected.” (Page 4, lines 81–84)

Reviewer’s comment 7

Conclusion: What should a practicing esophageal surgeon do with this information? Outcomes were the same. What is the practical relevance of this study?

Response to comment 7

Thank you for your suggestion. This study found that the RS route was longer in patients with a high BMI. It is necessary to further investigate the relationship between reconstruction length and surgical outcomes of esophagectomy in patients with a high BMI. However, the results of this study indicate that practicing esophageal surgeons could consider using the Kocher maneuver to create a long gastric conduit when treating obese patients. According to your suggestion, we have added the following sentence to the Conclusion: “Thus, when treating obese patients with a high perioperative risk, clinicians could consider using the Kocher maneuver to create a long gastric conduit and employing the PM route to potentially reduce the incidence of anastomosis-related complications.” (Page 17, lines 312–313).

Reviewer’s comment 8

As a North American surgeon, I have learned from your article that primary reconstruction via the retrosternal route is a feasible approach. In North America, we reserve the retrosternal rout mainly for delayed reconstruction.

Response to comment 8

Thank you for your advice. In Japan, the PM and RS routes are the standard reconstruction routes following radical esophagectomy for cancer in 40.2% and 40.1% of cases, respectively. Further, the selection of the reconstruction route depends on the surgeon and institute. Existing literature shows no significant difference in the surgical outcomes of esophagectomy between both routes. According to your suggestion, we have added the following sentence to the Discussion section: “In Japan, the selection of the reconstruction route depends on the surgeon and institute, and the PM and RS routes are standard reconstruction routes employed after radical esophagectomy for cancer in 40.2% and 40.1% of cases, respectively, with no significant differences reported between the surgical outcomes of the two routes. At our institute, the RS route is the standard reconstruction route undertaken when serious complications, such as esophagobronchial fistula, are likely to develop after reconstruction using the PM route. Our study corroborates the results of previous studies in Japan by showing that the surgical outcomes of esophagectomy do not differ between both routes. The results of our study suggest that the PM route should be selected to avoid anastomosis-related complications when treating obese patients with a high perioperative risk. In this study, five overweight cases had BMIs >25 kg/m2, including one with BMI >30 kg/m2; in all these cases, the RS route was longer than the PM route. Thus, even if the standard route for reconstruction is RS, we recommend using the PM route when treating obese patients (BMI >25 kg/m2) to avoid anastomosis-related complications and potentially improve the surgical outcome of esophagectomy for esophageal cancer in such patients.” (Page 16 & 17, lines 279–293)

 

To Reviewer #2

Reviewer’s comment 1

A. The results state, that retrosternal approach might be associated to higher anastomotic leakage in higher BMI patients due to a longer conduit.

B. Clavicular or sternal resection is often needed to avoid postoperative dysphagia in patients with retrosternal approach. This is congruent to our experience. Therefore our clinic has set the posterior mediastinal approach as the standard procedure.

--> In which case would you still recommend retrosternal approach and therefore prove relevance of these findings?

Response to comment 1

In Japan, the PM and RS routes are the standard reconstruction routes following radical esophagectomy for cancer in 40.2% and 40.1% of cases, respectively. The selection of the reconstruction route depends on the surgeon and institute, and the surgical outcomes of esophagectomy do not significantly differ between both routes. In our department, the RS route is the standard reconstruction route employed in cases where reconstruction using the PM route may result in serious complications, such as esophagobronchial fistula, and the manubrium or clavicular resection is not performed. The present study corroborated the results of previous studies in Japan by showing that surgical outcomes of esophagectomy do not differ between both routes. The results of our study suggest that the PM route should be selected to avoid anastomosis-related complications when treating obese patients with a high perioperative risk. According to your suggestion, we have added the following sentence to the Discussion: “Thus, even if the standard route for reconstruction is RS, we recommend using the PM route when treating obese patients (BMI >25 kg/m2) to avoid anastomosis-related complications and potentially improve the surgical outcome of esophagectomy for esophageal cancer in such patients.” (Pages 16 & 17, lines 290–293).

Reviewer’s comment 2

In your manuscript you mentioned that higher BMI is associated to longer routes for RS routes. Fig 3 shows some kind of visualization. Nevertheless, for clinical use, a consequence of these findings could be stated. Is there possibly a cut-off value for significant lengthening of the route? Is there a recommendation for which approach to prioritize or avoid with a certain BMI?

Response to comment 2

Thank you for your pertinent comment. In this study, longer RS routes were observed in patients with a BMI of 19.6 kg/m2 or above (area under the curve, 0.8). This cut-off value is described in the Results section (Page 10, line 186). According to your suggestion, we have added the following sentence to the Discussion section: “In this study, five overweight cases had BMIs >25 kg/m2, including one with BMI >30 kg/m2; in all these cases, the RS route was longer than the PM route. Thus, even if the standard route for reconstruction is RS, we recommend using the PM route when treating obese patients (BMI >25 kg/m2) to avoid anastomosis-related complications and potentially improve the surgical outcome of esophagectomy for esophageal cancer in such patients.” (Pages 16 & 17, lines 288–293).

Reviewer’s comment 3

The discussion lacks a conclusion for clinicians towards which consequence your findings might have (literature states that anastomotic leakage rates overall are not higher in the retrosternal approach than in the posterior mediastinal approach, as you stated earlier in your manuscript).

Response to comment 3

Thank you for your suggestion. This study found that the RS route was longer in patients with a high BMI but did not determine the relationships between reconstruction length and surgical outcomes of esophagectomy in obese patients. Although no significant difference is observed between surgical outcomes of esophagectomy using the two routes, there is room to further investigate how reconstruction length is associated with surgical outcome of esophagectomy in patients with a high BMI. The results of this study indicate that practicing esophageal surgeons could consider adding the Kocher maneuver and creating a long gastric conduit when treating obese patients. Furthermore, employing the PM instead of the RS route may improve the outcomes of esophagectomy for esophageal cancer in such patients. According to your suggestion, we have added the following sentence to the Discussion section: “Clinicians could consider using the Kocher maneuver and creating a long gastric conduit when treating obese patients.” (Page 13, lines 222–223)

Attachment

Submitted filename: Response_to_Reviewers.docx

Click here for additional data file. (27.7KB, docx)

Decision Letter 1

Callam Davidson

5 Dec 2022

PONE-D-21-33230R1An individual’s physique affects the length of the reconstruction route via the retrosternal approachPLOS ONE

Dear Dr. Lee,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 19 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Callam Davidson

Editorial Office

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Your study is observational and therefore causality cannot be inferred. Please update your title to reflect this (replace ‘affects’ with ‘is associated with’) and check throughout the manuscript for similar instances (I found examples in both the abstract and conclusions).

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you very much for addressing all comments and adding details to the discussion. Congratulations on your acceptance!

Reviewer #3: Honda et al. used 3DCT to measure the distance between the posterior mediastinal route and the retrosternal route during esophagectomy, and reported that high BMI was associated with the distance in the retrosternal route. Your manuscript is well written and methodology is adequate. Reviewer has a few questions and comments.

1. The authors concluded that choosing the posterior mediastinum route reduces anastomosis-related complications in obese patients with long distance of the retrosternal reconstruction route. However, the relationship between the length of the reconstruction route and the incidence of anastomotic leakage was not shown in this paper.

2. As for the similar question, is there a difference in the incidence of suture failure between the RS ≥ ES group and the RS < ES group?

3. Please add the references of Collard and triangulating stapled anastomosis. (line 79-80)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2023 Mar 31;18(3):e0283890. doi: 10.1371/journal.pone.0283890.r004

Author response to Decision Letter 1

30 Dec 2022

Responses to Editor’s and Reviewers’ Comments

To Editor

Editor’s comment

Your study is observational and therefore causality cannot be inferred. Please update your title to reflect this (replace ‘affects’ with ‘is associated with’) and check throughout the manuscript for similar instances (I found examples in both the abstract and conclusions).

Response to comment

Thank you for your kind suggestion. We have checked throughout the manuscript for similar instances. We have replaced “affect” with “is associated with” in the title and body of the manuscript according to your suggestion (Page 1, lines 1 & Page 1, lines 15 & Page 2, lines 18 & Page 2, lines 21 & Page 3, lines 21 & Page 5, lines 5).

To Reviewer #3

Reviewer’s comment 1

The authors concluded that choosing the posterior mediastinum route reduces anastomosis-related complications in obese patients with long distance of the retrosternal reconstruction route. However, the relationship between the length of the reconstruction route and the incidence of anastomotic leakage was not shown in this paper.

Response to comment 1

Thank you for your pertinent comment. In the RS reconstructions (n=40), the RS ≥ ES group had 30 cases and the RS < ES group had 10 cases; anastomosis-related complications occurred in six cases and one case in the two groups, respectively, which were not significantly different (p=0.66). Our series did not reveal a relationship between the length of the reconstruction route and anastomotic leakage because of the small number of cases. Furthermore, five overweight cases had BMIs >25 kg/m2; in all these cases, the RS route was longer than the PM route, and no anastomosis-related complications were observed. Our study revealed no relationship between BMI and anastomotic leakage; however, the study findings revealed that the reconstruction length was related to the individual’s physique. Further studies exploring the relationships between reconstruction lengths, individual’s physique, and outcomes of esophagectomies are needed to confirm these findings. According to your suggestion, we have added the following sentence to the Results and Discussion sections: “The RS ≥ ES group included 30 cases, whereas the RS < ES group included 10 cases; meanwhile, the anastomosis-related complications in each group comprised six cases and one case, respectively, in which there was no significant difference (p=0.66)” (Page 10, lines 7-10). “Although our series did not reveal a relationship between the length of the reconstruction route and anastomotic leakage and did not reveal a relationship between the BMI and anastomotic leakage” (Page 16, lines 6-7).

Reviewer’s comment 2

As for the similar question, is there a difference in the incidence of suture failure between the RS ≥ ES group and the RS < ES group?

Response to comment 2

Thank you for your comment. As noted in the response to comment 1, there was no difference in the incidence of suture failure between the RS ≥ ES and RS < ES groups. According to your suggestion, we have added the following sentence to the Results section: “The RS ≥ ES group included 30 cases, whereas the RS < ES group included 10 cases; meanwhile, the anastomosis-related complications in each group comprised six cases and one case, respectively, in which there was no significant difference (p=0.66)” (Page 10, lines 7-10).

Reviewer’s comment 3

Please add the references of Collard and triangulating stapled anastomosis. (line 79-80)

Response to comment 3

Thank you for your advice. We have added the following references for Collard and triangulating stapled anastomosis according to your suggestion:

22. Collard JM, Romagnoli R, Goncette L, Otte JB, Kestens PJ. Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy. Ann Thorac Surg. 1998;65: 814-817.

23. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side‐to‐side stapled anastomosis. J Thorac Cardiovasc Surg. 2000;119: 277-288.

24. Furukawa Y, Hanyu N, Hirai K, Ushigome T, Kawasaki N, Toyama Y, et al. Usefulness of automatic triangular anastomosis for esophageal cancer surgery using a linear stapler (TA-30). Ann Thorac Cardiovasc Surg. 2005;11: 80-86.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (22.3KB, docx)

Decision Letter 2

Mohamad Khair Abou Chaar

20 Mar 2023

An individual’s physique is associated with the length of the reconstruction route via the retrosternal approach

PONE-D-21-33230R2

Dear Dr. Lee,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Mohamad Khair Abou Chaar

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear authors,

I want to congratulate you on the work you presented and thank you for making the modifications requested by our reviewers. I have no further comments and I believe that the manuscript is fit for publication.

Thank you,

Mohamad Khair Abou Chaar, MD

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

**********

Acceptance letter

Mohamad Khair Abou Chaar

23 Mar 2023

PONE-D-21-33230R2

An individual’s physique is associated with the length of the reconstruction route via the retrosternal approach

Dear Dr. Lee:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Mohamad Khair Abou Chaar

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Data

    (XLSX)

    Click here for additional data file. (19.7KB, xlsx)
    S2 Data

    (XLSX)

    Click here for additional data file. (24.6KB, xlsx)
    Attachment

    Submitted filename: Response_to_Reviewers.docx

    Click here for additional data file. (27.7KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (22.3KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

    Articles from PLOS ONE are provided here courtesy of PLOS

    RESOURCES