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Ann Thorac Surg 2001;71:419-424
© 2001 The Society of Thoracic Surgeons
a Division of General Thoracic Surgery, Allegheny General Hospital and Dental Public Health Department, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
Accepted for publication August 21, 2000.
Address reprint requests to Dr Landreneau, Allegheny General Hospital, Lung Center, 02 level, South Tower, 320 E North Ave, Pittsburgh, PA 15212-4772
e-mail: rlandren{at}wpahs.org
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
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Methods. During a 42-month period, 93 patients undergoing either transhiatal esophagectomy or a three-incisional approach to esophagectomy underwent either hand-sewn (n = 43), partial mechanical (n = 16), or totally mechanical (n = 34) cervical esophagogastric anastomoses. The occurrence of postoperative anastomotic leak and the development of postoperative anastomotic stricturing requiring dilation therapy were analyzed between these groups using 
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Results. All patients survived esophagectomy and were available for postoperative follow-up. Anastomotic leak developed in 10 patients (23%) with hand-sewn, 1 patient (6%) with partial mechanical, and 1 patient (3%) with total mechanical anastomoses (p < 0.05). Anastomotic stricture development paralleled the occurrence of anastomotic leak rate with 25 patients (58%) with hand-sewn, 3 patients (19%) with partial mechanical, and 6 patients (18%) with total mechanical anastomoses experiencing strictures requiring dilation therapy (p < 0.05).
Conclusions. These results suggest that partial or mechanical cervical esophagogastric anastomoses created with the endoscopic stapling device may be superior to hand-sewn anastomotic techniques.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Etiologic factors leading to anastomotic failure range from poor surgical anastomotic technique, imprecise dissection and mobilization of the stomach leading to gastric ischemia, and variable intragastric collateral circulation, which can also lead to gastric fundic tip ischemia.
Thoracic surgeons continue to explore operative methods for esophagectomy that can reduce these cervical esophagogastric anastomotic failures. Recently, we and others have reported our experiences with the creation of the cervical esophagogastric anastomosis using the endoscopic linear cutting and stapling devices [2–4]. The technical efficiency of this approach to cervical esophagogastric anastomoses is intriguing. We describe the mechanical anastomotic technique accomplished with the endoscopic stapler and compare our results with this methodology to that of our results with hand-sewn cervical esophagogastric anastomoses after esophagectomy.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Our cervical esophagogastric anastomotic technique has evolved over the last few years from a totally hand-sewn single-layer technique to an anastomosis partially or completely established with endosurgical mechanical stapling devices (EndoGIA, USSC, Norwalk, CT; Endoscopic linear cutter, Ethicon Endosurgical, Cincinnati, OH). Forty-three of these patient underwent traditional single-layer hand-sewn cervical esophagogastric anastomoses. Fifty patients had their cervical anastomosis created partially (n = 16) or totally (n = 34) with an endoscopic mechanical stapling device.
The anastomotic failure rate and the need for postoperative dilation therapy among these patients undergoing the various anastomotic techniques described were evaluated.
Hand-sewn cervical anastomotic patient group
There were a total of 43 patients in the hand-sewn group. These patients represent the first 23 months of this esophagectomy experience. Thirty-two patients (74%) underwent THE. The three-incisional approach to esophagectomy (laparotomy, thoracotomy with cervical anastomosis) was used in the remaining 11 (26%) patients. Thirty-four of these patients (79%) underwent esophagectomy for carcinoma of the esophagus or gastroesophageal junction (GEJ). Twenty-four patients were diagnosed with adenocarcinoma of the lower esophagus or GEJ (71%); 9 patients had squamous cell carcinoma of the mid or lower esophagus (26%); 1 patient had a distal esophageal leiomyosarcoma resected.
The remaining 9 patients underwent esophagectomy for benign disease.
Partial mechanical cervical anastomotic patient group
Sixteen patients underwent esophagectomy with a cervical anastomosis partially created with the endoscopic stapling device. This approach is similar to that recently described by Collard [2] and Orringer and associates [3]. These patients represented our later esophagectomy experience from December 5, 1997, to July 29, 1998. Eleven (69%) of these patients underwent THE, whereas 5 had three-incisional esophagectomies. Fifteen patients (94%) underwent esophagectomy for esophageal carcinoma (14 adenocarcinoma of the distal esophagus or GEJ, 1 squamous cell carcinoma of the distal esophagus). Only 1 patient in this group underwent esophagectomy for benign disease.
Total mechanical cervical anastomotic patient group
Our most recently operated on patients in this series have all undergone a totally mechanical cervical esophagogastric anastomosis after esophagectomy. This represent our most recent experience from August 31, 1998, to July 29, 1999. Twenty-four (71%) underwent THE, whereas 10 patients had a three-incisional esophagectomy performed. Twenty-eight of the esophagectomies were performed for carcinoma (82%). Twenty-five patients had adenocarcinoma of the distal esophagus or GEJ, and 3 patients had distal esophageal squamous cell cancer. Six patients in this most recently operated on group underwent esophagectomy for benign disease.
Operative technique for esophagectomy
When a three-incisional esophagectomy is performed, a standard right lateral thoracotomy through the sixth intercostal space is used. Double-lumen endotracheal intubation is used in these cases to obtain selective ventilation of the left lung and collapse of the ipsilateral right lung. This approach is primarily chosen to resect mid esophageal lesions where injury to the distal trachea or azygos vein is greater when THE is used [7]. Standard intrathoracic dissection of the esophagus and periesophageal lymphatics are undertaken. Closure of the thoracotomy is accomplished, and the patient is then positioned for the laparotomy and cervical aspects of the esophagectomy.
The laparotomy aspect of the esophagectomy is standardized. A midline upper abdominal incision is created. The liver is retracted and dissection about the stomach begun. The stomach is completely mobilized by ligation and division of the left gastric artery at its origin from the celiac axis and ligation of all short gastric vessels distal to their communication with the right gastroepiploic arcade (Fig 1). The posterior gastric vessels originating directly from the splenic artery in the bare area of the upper posterior gastric fundus are also carefully ligated and divided. A generous Kocher maneuver is performed to further enhance the mobility of the gastric graft. A pyloromyotomy is accomplished. Vascular integrity of the transposed stomach was maintained through preservation of the right gastroepiploic and right gastric vascular pedicles.
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A left cervical incision is made, and dissection of the cervical esophagus is accomplished taking care to avoid injury to the recurrent laryngeal nerve [5]. Direct dissection is carried down through the thoracic inlet to near the level of the tracheal carina. A sponge stick is then used through the cervical incision to pass along the anterior and posterior aspects of the esophagus to create a communication between the lower neck and posterior mediastinum.
After the esophagus has been completely mobilized, transection of the esophagus is accomplished with a standard gastrointestinal anastomosis (GIA) instrument at the cervical incision. The mobilized and transected esophagus is brought through the mediastinum, and the proximal gastric division is accomplished through the abdominal incision. Tubularization of the gastric graft was avoided during the resection of the esophagus and proximal stomach so as to preserve the submucosal (collateral) circulation extending to the gastric fundic tip from the lesser curvature vasculature [2]. The gastric graft is placed within a sterile laparoscopic cover bag and connected to a large Penrose drain traversing the posterior mediastinum. The gastric graft is then brought into the cervical incision by gently pulling the Penrose drain attached to the covered stomach graft. This latter technique avoids unnecessary handling of the stomach and potential cardiovascular compromise by the surgeon’s hand during manual delivery of the gastric graft into the neck. Potential torsion of the gastric graft’s vascular pedicle is also reduced by this no touch approach to gastric transposition through the posterior mediastinum (Fig 2).
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Partial mechanical cervical esophagogastric anastomotic technique
The partial mechanical technique involves application of the endoscopic stapling device to create the posterolateral aspect of the esophagogastric anastomosis. Two firings of an endoscopic stapling device are performed through the gastrotomy and the approximated cervical esophagus to create an anastomosis that is 4 to 5cm long (Figs 4 and 5). The anterior aspect of the anastomosis is accomplished with a standard interrupted suture technique. The nasogastric tube and Jackson-Pratt drain is positioned as described above.
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Patients are seen 2 weeks after discharge and then at regular intervals as needed with a usual frequency of every 3 to 6 months. Inquiry into postoperative dysphagia is made. If dysphagia is present, a barium esophagram is obtained to assess the integrity of the cervical anastomosis. Subsequent dilations are performed if the patient’s dysphagia persists or returns after the initial dilation therapy.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Hand-sewn anastomotic patient group
Ten patients had an anastomotic leak (23%). Eight of these patients with leaks experienced postoperative dysphagia requiring dilation therapy. The number of dilations required per patient ranged from 1 to 38.
Among all patients undergoing a hand-sewn anastomosis, 25 (58%) experienced postoperative dysphagia requiring subsequent dilation therapy. Five patients required a single dilation, whereas the remaining 20 patients required multiple dilations ranging from 2 to 38 dilations (mean, 5 postoperative dilations).
Partial mechanical anastomosis patient group
Only 1 patient (6%) in the partial mechanical anastomosis group had an anastomotic leak. This leak was minor in nature, and the patient did not have any postoperative dysphagia. Three other patients experienced postoperative dysphagia (19%) requiring dilation. These patients underwent between 2 and 11 postoperative dilations (mean, 3 dilations).
Total mechanical anastomosis patient group
Only 1 patient (3%) in the total mechanical anastomosis group had an anastomotic leak. This patient has experienced postoperative dysphagia requiring 5 dilations to overcome dysphagia. Six patients (18%) have experienced postoperative dysphagia requiring dilation. Three patients required a single dilation and have had no subsequent dysphagia. The remaining 3 patients have required 2 to 6 dilations (mean, 3 dilations) to control their postoperative dysphagia symptoms.
Statistical analysis of our leak rate and overall complication rate (leak or dilation) was performed using a Fischer’s exact test. Comparing the leak rate of the suture anastomotic group to the partial and total mechanical anastomotic groups yields a statistically significant difference (p = 0.01) with fewer leaks in the mechanical anastomotic groups. Looking at the differences in the total complication rate, which includes either leak or stricture requiring dilation, we noted a significantly lower total complication rate among the mechanical anastomotic groups (p = 0.0003).
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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Traditionally, cervical esophagogastric anastomoses after esophagectomy have been accomplished using a variety of manual suturing techniques. Various methods have been explored in an effort to reduce the anastomotic complication rate. Single-layer and double-layer interrupted suturing have been advocated by various investigators [11, 12]. Others have used a running sutured anastomotic technique. Nonabsorbable and absorbable suture material has also been explored in an effort to reduce the anastomotic failure rate. Finally, the intraoperative use of a transoral bougie crossing the anastomosis has been explored in an effort to reduce postoperative anastomotic narrowing (R.I. Whyte, personal communication). No particular suture approach has been found to be generally superior to any other when a careful anastomotic technique is used. Remarkably the anastomotic failure rate is similar irrespective of the manual suturing technique used.
The equivalent results with these hand-sewn anastomotic approaches primarily reflects on the importance of ischemia of the transposed stomach leading to anastomotic failure rather than any major fault in the hand-sewn anastomotic techniques.
In an effort to overcome the limitations of hand-sewn anastomoses, mechanical stapled anastomotic techniques have been explored. A more uniform distribution of forces across the anastomosis and an increased width of the primary anastomosis has been suggested as central advantages of stapled anastomotic techniques. Reduced manipulation and trauma to the gastric fundus during the creation of the anastomosis with a mechanical stapled technique may also be an advantage over hand-sewn anastomoses. These technical factors may be particularly important when the vascular integrity of the transposed gastric fundus is marginal.
Early attempts at stapled cervical esophagogastric anastomoses have been met with limited success and subsequent appeal by the majority of surgeons performing cervical esophagogastric anastomoses after esophagectomy [13]. These approaches have not caught on because of the cumbersome problems of manipulation of standard GIA noted as an increased stricture rate when compared with hand-sewn anastomotic techniques. Difficulties in the transoral introduction of the working end of the end-to-end mechanical stapling device for cervical anastomosis has reduced enthusiasm for this alternative mechanical anastomotic technique [14].
The introduction of the smaller and easier to use endoscopic linear cutting and stapling devices has been associated with renewed interest in stapled anastomotic approaches to the cervical esophagogastric anastomosis. Collard [2] and Orringer and associates [3] have reported on the use of staplers to fashion a partially mechanical anastomosis. This approach is quite feasible. We have taken the next logical step to the use of this instrumentation toward the performance of a totally mechanical cervical esophagogastric anastomosis.
The use of these mechanical anastomotic approaches has resulted in a significant reduction in the anastomotic leak rate and the postoperative development of dysphagia among our esophagectomy patients. Our specific findings regarding the results with these mechanical anastomotic techniques have also been reported in a general sense by others [2, 3].
Technical issues in creating the anastomosis are at play, but also local ischemia of the gastric graft is made worse by imprecise positioning of sutures or excessive tension on the tissues [15]. The esophagus is rarely the problem, but the gastric graft fundic tip is usually the culprit made worse by imprecisely sutured anastomotic techniques.
The evidence at hand regarding these mechanical anastomotic techniques is gratifying. Our results and those of others lead us to recommend a partial or total mechanical anastomotic technique preferentially over hand-sewn suturing methods for the creation of cervical esophagogastric anastomoses.
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References |
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TopAbstractIntroductionPatients and methodsResultsCommentReferences |
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