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Ann Thorac Surg 2000;70:999-1000
© 2000 The Society of Thoracic Surgeons
a Division of General Thoracic Surgery, USA
Address reprint requests to Dr Heitmiller, Division of General Thoracic Surgery, Department of Surgery, Osler 624, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287
e-mail: rheitmil{at}jhmi.edu
Simplified, Standardized Technique for Cervical Esophagogastric Anastomosis: As Originally Published in 1994
Christopher D. Stone, MD, and Richard F. Heitmiller, MD
Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Using transhiatal esophagectomy, the ease of performing the cervical esophagogastric anastomosis varies greatly depending on neck size, length of mobilized stomach, and adhesions from previous neck operations. We therefore have developed a technique, used in 45 consecutive patients undergoing transhiatal esophagectomy, that has simplified the technical performance of cervical esophagogastric anastomosis. (Ann Thorac Surg 1994;58:259–61)
Updated in 2000 by Richard F. Heitmiller, MD
Regardless of surgical esophagectomy technique, postoperative morbidity, mortality, and functional results are closely linked to healing of the esophagogastric anastomosis. As Stone and I [1] wrote in 1994, when using the transhiatal esophagectomy approach, "the ease of performing the cervical esophageal anastomosis may vary considerably depending primarily on the patient’s neck size and the length of the mobilized stomach. In addition, the anastomotic exposure often diminishes as the anastomosis is completed and falls away into the neck and upper chest." Therefore, we developed a technique designed to improve exposure and to facilitate reproducibility of a safe cervical esophagogastric anastomosis during transhiatal esophagectomy. With this technique, the cervical esophagus and the gastric fundus are held in apposition and at skin level to optimize anastomotic exposure. In other words, it is an anastomotic setup technique and does not mandate use of a specific anastomotic method. It is my practice to use a two-layered, hand-sewn anastomotic approach, which has been shown to be safe for both cervical and intrathoracic esophageal anastomoses. At this institution, my colleagues and I continue to use both the set-up technique and the two-layered, hand-sewn anastomosis without modification from its earlier description.
The anastomotic setup technique is illustrated in Figure 1. The traction stitches are not designed to pull the stomach into the neck. Attempting to do so could cause a tear in the fundal tip. Rather the stomach is pushed up to the neck from below. The traction stitches are designed to prevent twisting of the stomach tube and also to hold the stomach in position once it is in place in the neck. When the anastomosis has been completed, the two traction stitches are cut, and both stitch sites are reinforced with Lembert sutures. Failure to do this might result in leakage from these sites. Before the cervical incision is closed, the stomach is gently pulled down to straighten the esophagogastric axis. Anastomotic strictures are more easily dilated if this maneuver is performed.
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We believe that the anastomotic exposure provided by this setup technique optimizes the results and facilitates the teaching of the skills needed to perform a safe esophageal anastomosis.
References
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