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Ann Thorac Surg 1998;65:814-817
© 1998 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Terminalized Semimechanical Side-to-Side Suture Technique for Cervical Esophagogastrostomy

Jean-Marie Collard, MD, Renato Romagnoli, MD, Louis Goncette, MD, Jean-Bernard Otte, MD, Paul-Jacques Kestens, MD

Department of Surgery, Louvain Medical School, Brussels, Belgium
Department of Radiology, Louvain Medical School, Brussels, Belgium

Accepted for publication September 23, 1997.

Dr Collard, Digestive Surgery Unit, Saint-Luc Academic Hospital, Hippocrate Ave, 10, B-1200 Brussels, Belgium.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background. The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture.

Methods. A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GIA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies.

Results. The cross-sectional area was 225 ± 15.7 mm2 (mean ± standard error of the mean) for the 16 semimechanical anastomoses versus 136 ± 15 mm2 for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 ± 13.5 mm2 in 29 patients without dysphagia to 107.5 ± 4.7 mm2 in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 ± 16 mm2 in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 ± 5.5 mm2 to 174.6 ± 8.1 mm2, with concomitant symptomatic relief (p = 0.0277).

Conclusions. The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. Inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
The classic end-to-side manual technique of esophagogastrostomy after gastric pull-up to the neck carries a high risk of technical complications such as fistulas and strictures [1][2][3][4][5][6][7][8]. There are three main conditions that can jeopardize the healing process of such an anastomosis: (1) undue tension on the gastric wall, (2) relative ischemia at the anastomotic site in the fundus [9], and (3) narrowness of the cervical esophageal lumen, especially in nonobstructive esophageal diseases. Undue tension on the gastric wall can be prevented by proper elongation and mobilization of the gastric pouch, so as to obtain a long gastric transplant [1]. Maintenance of all the intramural vascular pathways when elevating the whole stomach up to the neck rather than their partial removal after resection of the lesser curvature for gastric tubulization provides the anastomotic site in the fundus with a better blood supply, so that technical complications at the cervical anastomosis are less likely [10][11][12]. From the idea that construction of a large-bore anastomosis should reduce the risk of stricture formation, we developed a terminalized semimechanical side-to-side suture technique from a technique of endoscopic stapling division of Zenker’s diverticulum that had been described previously [13].

This report evaluates the gain in surface area that can be obtained with the terminalized semimechanical side-to-side suture technique compared with the classic end-to-side manual suture technique. It also correlates the ease with which a patient can swallow solid food with the cross-sectional area of the cervical anastomosis at early follow-up barium swallow study.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
Manual End-to-Side Suture Technique
In the manual end-to-side suture technique, two hemicircumferential single-layer running sutures are made using 4/0 Vicryl (polyglactin 910; Johnson & Johnson, Somerville, NJ) and taking full thickness of the esophageal wall and the extramucosal layers of the stomach. This suture technique was used in more than 250 patients who were operated on at our institution. Twenty-four of these patients in whom the whole stomach was used as an esophageal substitute were selected randomly as a reference group for the present study. There were 19 men and 5 women ranging in age from 40 to 73 years.

Terminalized Semimechanical Side-to-Side Suture Technique
In the terminalized semimechanical side-to-side suture technique, once the cervical esophagus has been transected and the stomach pulled up to the neck, a small incision is made at the top of the gastric transplant. The posterior wall of the esophageal stump and that of the fundus are placed side by side (Fig 1). The two forks of an Endo-GIA stapler (US Surgical Corp, Norwalk, CT) are placed across the two opposing walls with the anvil in the gastric lumen and the cartridge of staples in the esophageal lumen. After approximation of the two forks, the trigger of the stapler is squeezed to allow forward displacement of the knife and the delivery of three rows of staples on each side. After the two forks have been separated, the stapler is removed and the two stapled wound edges retract laterally on the action of the intramural musculature. The medial slit thus becomes a V-shaped opening between the two lumina. The two posterior walls realign themselves by exerting gentle downward traction on the transplant. The anterior walls are sutured to each other using a single-layer running suture technique similar to that used in manual anastomoses. This kind of anastomosis was performed in 16 patients with esophageal cancer, 14 of whom had their whole stomach used as an esophageal substitute and 2 of whom had a greater curvature tube placed. There were 13 men and 3 women ranging in age from 43 to 80 years.



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  		Terminalized semimechanical side-to-side anastomosis between the whole stomach and the cervical esophageal stump with the Endo-GIA 30 stapler. Note the V-shaped opening between the two lumina. The cardiac staple line is located far from the anastomotic site at the top of the fundus.

 
Assessment of the Cervical Anastomosis
The integrity of the cervical anastomosis was checked routinely by having the patients drink methylene blue–stained water on the seventh postoperative day rather than by performing a contrast medium swallow study. The latter procedure performed immediately after operation exposes the patient to the risk of aspiration pneumonia. A barium swallow study was performed 4 to 6 weeks after hospital discharge.

The cross-sectional area of the cervical esophagogastrostomy was evaluated according to the mode of suturing (ie, semimechanical versus manual) in the 40 study patients (38 of whom had their whole stomach used as an esophageal substitute and 2 of whom had a greater curvature tube placed). This area was estimated by measuring the width of the anastomotic lumen on contrast medium radiographs taken from two viewpoints perpendicular to one another. The anastomotic area was likened to an ellipse ) (Fig 2), and a correction factor equal to 0.8 was applied to each measurement to make up for radiologic magnification. The 40 study patients were classified into three subcategories according to whether they had no difficulty swallowing (no dysphagia), they had to cut solid food such as bread and meat into small pieces to prevent cervical hold-up at swallowing (moderate dysphagia), or they could eat only semisolid or liquid food and required endoscopic dilation (severe dysphagia).



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  		Method of assessing the cross-sectional area of anastomosis at postoperative barium swallow study. A factor equal to 0.8 was applied to each measurement to make up for radiologic magnification.

 
A fistula of the cervical anastomosis was defined as any weeping of saliva or methylene blue–stained water through the Penrose drain that was left in the area of the suture line. A stricture of the cervical anastomosis was defined as any narrowing of the suture line at early follow-up barium swallow study that prevented the patient from swallowing solid food, even cut into small pieces, and required endoscopic dilation.

Statistics
The Fisher’s exact, Mann-Whitney, and Kruskal-Wallis statistical tests were used appropriately.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
All the 40 study patients had negative methylene blue test results 7 days after operation. No patient had the development of a deep cervical abscess at clinical examination of the neck, but 1 patient with a semimechanical anastomosis had a minute, blind fistula into the immediate paraesophageal soft tissues at barium swallow study 2 months after operation.

Twenty-nine patients, 15 (93.7%) of the 16 who had a semimechanical anastomosis and 14 (58.3%) of the 24 who had a manual anastomosis had no significant dysphagia 2 months after operation (p = 0.0274). Seven patients who had a manual anastomosis had to chew solid food well to prevent dysphagia, and 3 patients who had a manual anastomosis had severe dysphagia for solids that required endoscopic dilation. The patient who had a blind cervical fistula after a semimechanical anastomosis also had the development of a tight stricture that was dilated endoscopically.

The cross-sectional area of the semimechanical anastomosis in 16 patients was 225 ± 15.7 mm2 (mean ± standard error of the mean), whereas that of the manual anastomosis in 24 patients was 136.8 ± 15 mm2 (p = 0.0001) (Fig 3). The anastomotic area was 206.6 ± 13.5 mm2 in the patients without dysphagia, 107.5 ± 4.7 mm2 in the patients with moderate dysphagia for solids, and 55.7 ± 16 mm2 in the patients who required endoscopic dilation for severe dysphagia for solids (p = 0) (Fig 4). Six of the 7 patients who had experienced moderate dysphagia for solids at the 2-month follow-up examination underwent radiologic reevaluation of their cervical anastomosis a few months later, after their swallowing difficulties had disappeared. The cross-sectional area of the anastomosis in these 6 patients had increased from 107.3 ± 5.5 mm2 at the time of hospital discharge to 174.6 ± 8.1 mm2 at follow-up (p = 0.0277).



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  		Cross-sectional area of the cervical esophagogastrostomy expressed in square millimeters (mm). The left side shows the results for 24 manual end-to-side anastomoses, and the right side shows the results for 16 terminalized semimechanical side-to-side anastomoses.

 


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  		Cross-sectional area of the cervical esophagogastrostomy expressed in square millimeters (mm) in three subgroups of patients categorized according to their ability to swallow solid food at early follow-up.

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
The terminalized semimechanical side-to-side suture technique allows the construction of a much larger anastomosis than the classic single-layer running manual suture technique. A similar phenomenon was observed by Welter and Turbelin [14] with mechanical anastomoses in other segments of the gut. Although it is limited to a small number of patients, our early experience with the semimechanical suture technique indicates that it improves the ease with which the patient can ingest solid food after gastric pull-up to the neck. This is evidenced by the absence of difficulty in swallowing large pieces of solid food in all our study patients, with the exception of the 1 in whom a blind fistula and then a tight stricture developed.

Performance of the semimechanical suturing technique when the whole stomach is used is facilitated greatly by the fact that the cardiac staple line is located far from the anastomotic site in the fundus. When the greater curvature tube is used, the staple line along the lesser curvature terminates at the highest point of the transplant, so that there is no longer any staple-free fundic cuff [10]. Therefore, stapling division of the top of such a gastric tube for semimechanical anastomosis leaves a narrow band of gastric tissue between the two staple lines (ie, the one that results from the tubulization and the one that is related to the anastomosis), with the potential for subsequent ischemic problems (Fig 5). This is attested to by the fact that the only patient in whom a blind cervical fistula developed with subsequent stenosis of the semimechanical cervical anastomosis had undergone resection of the subcardiac area of the stomach with the application of three cartridges of staples on the gastric wall.



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  		Terminalized semimechanical side-to-side anastomosis between the cervical esophageal stump and a greater curvature tube. The upper end of the staple line related to gastric tubulization (S) is incorporated into the cervical anastomosis, so that a narrow band of gastric tissue between this staple line and the right margin of the V-shaped posterior opening may be poorly vascularized and may become necrotic (N). Compare this with Fig 1.

 
A contraindication to the use of the semimechanical suturing technique is the existence of a primary tumor arising in the cervical esophageal segment. In such a situation, division of the cervical esophagus just distal to the cricopharyngeus muscle makes application of the stapler impossible. Likewise, the semimechanical suture technique, because it requires a longer available esophageal stump than the end-to-side manual suture technique for introduction of the stapler, is not recommended after esophagectomy performed for a tumor located at the level of the thoracic inlet.

On the other hand, our radiologic studies show that a cervical anastomosis with a surface area of more than 125 mm2 is required for easy swallowing of solid food after operation. Moderate narrowing of the anastomosis just after operation may result from some degree of local edema. Spontaneous disappearance of the operation-related inflammatory changes at the suture line with time results in substantial enlargement of the anastomosis with concomitant symptomatic relief. As a practical consequence, dysphagia for solids in relation to moderate narrowing of the cervical anastomosis does not require endoscopic dilation unless the patient has been operated on with a palliative intent and has a short life expectancy.

The present study, together with a previously published study [10] that reported a lower risk of cervical fistula and stenosis when the whole stomach was used as an esophageal substitute than when a greater curvature tube was used, indicates that a terminalized semimechanical side-to-side anastomosis between the cervical esophageal stump and the whole stomach pulled up to the neck is an excellent technique that allows easy ingestion of large pieces of solid food soon after subtotal esophagectomy and esophageal replacement with the stomach. This observation is of major clinical significance not only for patients who have anticipated long-term survival after radical esophageal resection [15][16][17], but also for patients who undergo palliative procedures and in whom alimentary comfort is of utmost importance over the short term.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
We thank Mrs Bernadette Jacqmain and Mrs Nadine Thiebaut for their kind assistance.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Collard JM, Otte JB, Kestens PJ Reconstruction after esophagectomy. In: Steichen FM, Welter R, eds. Minimally invasive surgery and new technology. St. Louis: Quality Medical Publishing, 1994:629-636.
  2. Dewar L, Gelfand G, Finley RJ, Evans K, Inculet R, Nelems B Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition. Am J Surg 1992;163:484-489.[Medline]
  3. Siersema PD, Honkoop P, Tilanus HW Risk factors for benign stricture after oesophagectomy and gastric tube reconstruction with cervical anastomosis. In: Peracchia A, Bonavina L, Fumagalli U, Bona S, Chella B, eds. Recent advances in diseases of the esophagus. Bologna: Monduzzi, 1996:261-266.
  4. Orringer MB, Marshall B, Stirling M Transhiatal esophagectomy for benign and malignant disease. J Thorac Cardiovasc Surg 1993;105:265-277.[Abstract]
  5. Lam TCF, Fok M, Cheng SWK, Wong J Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomosis. J Thorac Cardiovasc Surg 1992;104:395-400.[Abstract]
  6. Zieren HU, Müller JM, Pichlmaier H Prospective randomized study of one- or two-layer anastomosis following oesophageal resection and cervical oesophagogastrostomy. Br J Surg 1993;80:608-611.[Medline]
  7. Bardini R, Bonavina L, Asolati M, Ruol A, Castoro C, Peracchia A Single-layered cervical esophageal anastomoses: a prospective study of two suturing techniques. Ann Thorac Surg 1994;58:1087-1090.[Abstract]
  8. Chasseray VM, Kiroff GK, Buard JL, Launois B Cervical or thoracic anastomosis for esophagectomy for carcinoma. Surg Gynecol Obstet 1989;169:55-62.[Medline]
  9. Liebermann-Meffert D, Meier R, Siewert JR Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992;54:1110-1115.[Abstract]
  10. Collard JM, Tinton N, Malaise J, Romagnoli R, Otte JB, Kestens PJ Esophageal replacement: gastric tube or whole stomach?. Ann Thorac Surg 1995;60:261-267.[Abstract/Free Full Text]
  11. Kudo T, Abo S, Itabashi T Prognosis of esophageal substitute in tissue viability and anastomotic leakage. In: Siewert JR, Hölscher AH, eds. Diseases of the esophagus. Pathophysiology, diagnosis, conservative and surgical treatment. Berlin: Springer-Verlag, 1988:522-525.
  12. Collard JM, Otte JB, Jamart J, Reynaert M, Kestens PJ An original technique for lengthening the stomach as an oesophageal substitute after oesophagectomy. Preliminary results. Dis Esoph 1989;2:171-174.
  13. Collard JM, Otte JB, Kestens PJ Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Surg 1993;56:573-576.[Abstract]
  14. Welter R, Turbelin JM The geometry of functional end-to-end anastomosis and a comparative study of anastomotic surfaces using mechanical sutures in gastrointestinal surgery. In: Ravitch MM, Steichen FM, eds. Principles and practice of surgical stapling. Chicago: Year Book Medical Publishers, 1987:16-28.
  15. Collard JM, Romagnoli R, Otte JB, Kestens PJ. The denervated stomach as an esophageal substitute is a contractile organ. Ann Surg (in press).
  16. Collard JM, Otte JB, Reynaert M, Kestens PJ Quality of life three or more years following esophagectomy for cancer. J Thorac Cardiovasc Surg 1992;104:391-394.[Abstract]
  17. Collard JM, Otte JB, Reynaert M, et al. Extensive lymph node clearance for cancer of the esophagus or cardia: merits and limits in reference to 5-year absolute survival. Hepatogastroenterology 1995;42:619-627.[Medline]



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