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Arm A consists of the concurrent application of Porcine Fibrin Sealant (PFS) on the gastroesophageal anastomosis during McKeown esophagectomy.

Arm B underwent conventional anastomosis during McKeown esophagectomy.

McKeown esophagectomy will be performed for patients with resectable thoracic esophageal carcinoma or gastroesophageal junction cancer. At last, 2.5ml Porcine Fibrin Sealant will be instilled over the cervical anastomose line.

Porcine Fibrin Sealant (PFS)

McKeown esophagectomy including open or minimally invasive esophagectomy will be performed for patients with resectable thoracic esophageal carcinoma or gastroesophageal junction cancer. Two-field lymphadenectomy with total mediastinal lymph node dissection is performed during surgery.

McKeown esophagectomy

Hong Yang, Ph.D.,M.D.

The primary objective is to evaluate the efficacy and assess the role of Porcine Fibrin Sealant (Bioseal®) in preventing cervical anastomotic leakage after esophagectomy in the patients with resectable thoracic esophageal cancer and gastroesophageal junction cancer.

Esophageal cancer (EC) is the most common cancers in the world, with more than 16,910 new cases and 15,690 deaths annually worldwide. Every year in China, no matter new cases or deaths account for more than half of the world. Currently, surgery is the most important and effective treatment for esophageal cancer. According to the recommendation in Chinese Experts' Consensus on Esophageal Cancer Radical Surgery (year 2017), the rightapproach esophagectomy should be adopted, in order to achieve radical lymph nodes dissection and improve the surgical outcomes. So Mckeown procedure is recommended preferentially. However, esophageal resection for cancer has been associated perioperative mortality. One of the major perioperative complications that affect morbidity and mortality in these patients is esophageal anastomotic leakage. Moreover, it was reported that the leakage incidence of cervical anastomosis after esophageal cancer resection was significantly higher than that of intrathoracic anastomosis. Therefore, how to minimize the incidence of esophageal anastomotic leaks in esophagectomy is particularly important, especially for Mckeown surgery.

In recent years, the prognostic outcome of esophageal cancer has been improved due to advances in surgical technique. However, esophageal anastomotic leakage is still one of the most serious complications following esophagectomy, with an incidence around 5% to 40%. For example, a research based on Japanese national database showed that the rate of anastomotic leakage after esophagectomy was 13.3%. A recent phase 3 clinical trial, the ChemoRadiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) reported an anastomotic leak rate of 26.1% after esophagectomy. Meanwhile, data from the investigator's center indicated that the leakage rate after esophagectomy was around 21.0%. Furthermore, anastomotic leakage following esophagectomy could seriously increase early mortality. According to the previous study, the risk of perioperative 90-day death was three times in patients with anastomotic leakage after esophagectomy than those without leaks (18.2% vs. 6.2%, P=0.003), and hospitalization was significantly increased.

Bioseal® (Guangzhou Bioseal Biotech Co., Ltd., China) is a porcine-derived fibrin sealant that has been widely used in various surgical procedures to assist in hemostasis for more than a decade. This type of fibrin sealant is made from biologically porcine-derived thrombin and fibrinogen, and is designed to form a stable fibrin clot by simulating the final pathway of the coagulation cascade. The fibrin clot will form a gel-like material on the surface of the surgical wound, which can not only directly block the tissue defect, but also promote the healing of the wound by using the fibrin network as the matrix where the fibroblasts and capillary endothelial cells can proliferate to form granulation. Therefore, Bioseal® have been reported to be used as sealing agent as well as wound healing agent during surgery in some studies.

In the recent years, some investigators have attempted to use the fibrin sealant to treat or prevent gastrointestinal leakage after enterectomy, gastrectomy, esophagectomy, or pancreaticoduodenectomy. The preliminary results show application of fibrin sealant may lower the chances of anastomotic leakage. Hence, it can diminish the mortality and morbidity of those patients with gastrointestinal reconstructions.

In 2004, a study conducted by Nguyen both in vitro and in vivo, found that application of fibrin sealant over gastric bypass could reduce the postoperative anastomotic leakage. Among the 16 animals (pigs) undergoing laparoscopic gastric bypass, 10 cases were applied with fibrin sealant on their primary anastomosis, and no anastomotic leakage or related complications was found. Five of the other 6 cases in control group had fistula or intra-abdominal abscess. Moreover#the follow-up study in humans showed that 66 patients in whom fibrin sealant was used as reinforcement on a primary anastomosis were all free of anastomotic leakage. In China, some studies also reported fibrin sealant could prevent anastomotic leakage for patients undergoing resection of rectal carcinoma or pancreato-biliary tumors.

As to esophagectomy, only few pilot studies have reported the similar attempts to prevent anastomotic leakage by using fibrin sealant. In 2007, Ling reported that application of fibrin sealant while implanting an esophageal stent under endoscopy was an effective approach for treating the postoperative esophageal anastomotic leakage. The studies conducted by Celal also showed that endoscopic treatment combined with fibrin sealant could be considered as a valuable option for the management of postoperative esophageal anastomotic leakage with a high degree of technical feasibility and safety. However, studies focusing on the role of fibrin sealant in the prevention of cervical leakage after esophagectomy are few.

In 2007, a prospective clinical trial conducted by Upadhyaya enrolled 45 infant patients who underwent esophagectomy for congenital esophageal atresia (EA) with tracheoesophageal fistula (TEF). In that study, a total of 52 patients were divided into two groups. In Group A, patients received fibrin sealant as reinforcement on a primary end-to-end esophageal anastomosis. In group B, fibrin glue was not used. In the final analysis, the overall rate of postoperative leakage is 26.9% (12/45), including 9.1% (2/22) in group A and 43% (10/23) in group B (p=0.017). In 2009, Saldaña-Cortés conducted a similar research but on puerile esophagectomy for caustic injury. Results showed that the postoperative cervical anastomotic dehiscence and leakage were observed in 28.5% of patients who received fibrin sealant in the study group and 50% of those in the control group. Both of those two studies indicated that fibrin glue, when used as a sealant for cervical esophageal anastomosis, could reduce the risk of leakage.

However, there is still no large-scale clinical trial investigating the use of fibrin sealant to prevent cervical anastomotic leakage after esophagectomy for esophageal cancer all over the world. The purpose of this study is to assess the role of fibrin glue (Bioseal®) in the prevention of leakage at the cervical esophageal anastomosis for esophageal cancer patients undergoing Mckeown surgery.

A(Surgery+PFS) Arm A consists of the concurrent application of Porcine Fibrin Sealant (PFS) on the gastroesophageal anastomosis during Mckeown surgery . Biological/Vaccine: Porcine Fibrin Sealant (PFS) 2.5ml Porcine Fibrin Sealant will be instilled over the cervical anastomose line.

B(Surgery)Arm B for conventional anastomosis

Study of Porcine Fibrin Sealant in Preventing Cervical Anastomotic Leakage (PLACE030)

A Multicenter Prospective Randomized Controlled Study of Porcine Fibrin Sealant in Preventing Cervical Anastomotic Leakage for Esophageal or Junctional Carcinoma. (PLACE030)

Incidence of postoperative cervical anastomotic leakage Cervical anastomotic leakage will be diagnosed based on a combination of clinical presentation, radiological findings, and/or endoscopic findings within the first 3 months after the operation.

Overall survival Overall survival (OS) is defined as the time period from the date of enrollment to the date of death or the last follow up

Disease Free Survival Disease-free survival (DFS) is defined as the time period from the date of R0 resection to the date of disease recurrence or death.

Postoperative complications will be recorded after each esophagectomy

Sun Yat-sen University

Associate Professor

Ischemia

Gastrointestinal Neoplasms

Digestive System Neoplasms

Head and Neck Neoplasms

Gastrointestinal Diseases

Esophageal Diseases

Preoperative artery embolization prior to esophagectomy

Tissue pressure of oxygen measurement in both arms by Licox system. The probe is inserted directly through the skin as a cervical drainage and it is fixed by Witzel technique in the gastric conduit. It is removed after the three measurements (intraoperatively, 24h and 48h after surgery) of the PtiO2 as a normal drainage.

Surgery without previous ischemic conditioning of the gastric conduit

Tissue pressure of oxygen measurement in both arms by Licox system. The probe is inserted directly through the skin as a cervical drainage and it is fixed by Witzel technique in the gastric conduit. It is removed after the three measurements (intraoperatively, 24h and 48h after surgery) of the PtiO2 as a normal drainage.

PAE will be performed by arteriographic procedure before esophageal resection surgery minimum 14 days before surgery.

An angiogram of the celiac trunk is performed through a femoral access before and after the embolization. Embolization by coils of the left gastric artery, splenic artery and the right gastric artery is realized.

Preoperative Arterial Embolization

This study is a randomized clinical trial to clarify if preoperative embolization of gastric arteries can reduce the incidence of oesophagogastric leakage after an esophagectomy for esophageal cancer comparing an experimental group vs control group.

In patients with infracarinal esophageal carcinoma, the surgery is a complex procedure and with a high morbidity. It consists of a subtotal esophagectomy with tubular gastroplasty and cervical esophagogastric anastomosis. The most important complication is the anastomotic leakage with a high mortality. Among the possible causes of anastomotic leakage an important factor is the impaired microcirculation in the anastomotic region after the partial devascularization of the stomach during the surgery. There are several experimental studies about the different techniques to improve this vascularization and their effects on mucosal oxygenation. There are several methods currently used for assessing tissue oxygenation. The polarographic partial pressure of oxygen (pO2) electrode has been considered as the 'gold standard' for measuring oxygen tension. This is the reason why tissue pressure of oxygen (PtiO2) will be measured by Licox® (Integra Neuroscience) system in two groups. There aren't prospective randomized controlled trials to answer these questions. For this reason the investigators propose to perform a prospective randomized controlled trial in patients underwent on this surgery, comparing two groups: one of them will be carried out a preoperative arterial embolization (PAE), and the other one will be operated directly, to demonstrate if the ischemic conditioning by PAE can reduce the incidence of anastomotic esophagogastric leakage and improve the gastric conduit oxygenation.

Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer.

Trial on Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer. Effects on Oxygenation and Anastomotic Leakage.

Clinic, endoscopy or computed tomography with oral contrast of dehiscence of oesophagogastric anastomosis.

Licox oxygen monitoring system placed during the surgery in the gastric conduit. Measurements: intraoperatively and 24 hours and 48 hours after surgery.

We will analyse the correlation between the measurement of tissue pressure oxygen and the prevention of anastomotic leakage.

Plasty ischemia when one or more of the following criteria is present:

* Endoscopic evidence of gastric mucosa ischemia
* Evidence in a thoracoabdominal CT with endovenous contrast

Investigator will analyse the morbidity between the two groups with the common postoperative complications: - Anastomotic leakage

* Wound infection
* Pulmonary complications
* Complications related to PAE
* Cardiologic complications

Postoperative mortality has been defined as any death, regardless of cause, occurring within 30 days after surgery in or out of the hospital.

investigators will consider since the day of the surgery until the day the patient will be discharged from the hospital

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Study of Porcine Fibrin Sealant in Preventing Cervical Anastomotic Leakage (PLACE030)	NCT03847857	Esophageal Anas...	Porcine Fibrin ... McKeown esophag...	18 Years - 75 Years	Sun Yat-sen University
Study of Porcine Fibrin Sealant in Preventing Cervical Anastomotic Leakage (PLACE030)	NCT03847857	Esophageal Anas...	Porcine Fibrin ... McKeown esophag...	18 Years - 75 Years	Sun Yat-sen University
Ischemic Conditioning of the Gastric Conduit in Esophageal Cancer.	NCT04268654	Esophageal Anas... Tissue Pressure...	Preoperative Ar...	18 Years - 80 Years	Fundación para la Investigación del Hospital Clínico de Valencia

Spots Global Cancer Trial Database for esophageal anastomotic leak