Omentoplasty for cervical esophagogastrostomy following radical esophagectomy with three-field dissection

BACKGROUND/AIMS: Anastomotic leakage is the main cause of postoperative mortality and incidence of which, following three-field lymph node dissection, is around 30%. The study was undertaken to investigate the role of omentoplasty to reinforce cervical esophagogastrostomy with the expectation of lowering the rate of anastomotic leakage after radical esophagectomy with three-field lymph node dissection. METHODOLOGY: Between July 1995 and Dec 1997, a total of 32 patients underwent total thoracic esophagectomy with three-field lymph node dissection and cervical esophagogastrostomy. Eleven patients were stage IIA, 3 stage IIB, 5 stage III and 13 stage IV. After radical esophagectomy and lymph node dissection, several omental branches of the gastroepiploic vessels remained to supply a gastric tube. An end-to-side cervical esophagogastrostomy was performed on the posterior wall of the gastric tube using a circular stapler. The omentoplasty--wrapping the esophagogastrostomy--was performed. A retrosternal route for reconstruction was used in 23 patients and a posterior mediastinal route in 9 patients. RESULTS: Esophageal anastomotic leakage occurred in only 1 patient, 3.1% overall. There was neither pyothorax nor mediastinitis. There was no lethal anastomotic leakage. Later, 2 patients (6.2%) developed an anastomotic stricture that required balloon dilatation. CONCLUSIONS: Omentoplasty to reinforce cervical esophagogastrostomy decreases anastomotic failure following radical esophagectomy with three-field lymph node dissection.     

Albert-Lembert versus hybrid-layered suture in hand sewn end-to-end cervical esophagogastric anastomosis after esophageal squamous cell carcinoma resection

Background

Hand sewn cervical esophagogastric anastomosis (CEGA) is regarded as preferred technique by surgeons after esophagectomy. However, considering the anastomotic leakage and stricture, the optimal technique for performing this anastomosis is still under debate.

Methods

Between November 2010 and September 2012, 230 patients who underwent esophagectomy with hand sewn end-to-end (ETE) CEGA for esophageal squamous cell carcinoma (ESCC) were analyzed retrospectively, including 111 patients underwent Albert-Lembert suture anastomosis and 119 patients underwent hybrid-layered suture anastomosis. Anastomosis construction time was recorded during operation. Anastomotic leakage was recorded through upper gastrointestinal water-soluble contrast examination. Anastomotic stricture was recorded during follow up.

Results

The hybrid-layered suture was faster than Albert-Lembert suture (29.40±1.24 min vs. 33.83±1.41 min, P=0.02). The overall anastomotic leak rate was 7.82%, the leak rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (3.36% vs. 12.61%, P=0.01). The overall anastomotic stricture rate was 9.13%, the stricture rate in hybrid-layered suture group was significantly lower than that in Albert-Lembert suture group (5.04% vs. 13.51%, P=0.04).

Conclusions

Hand sewn ETE CEGA with hybrid-layered suture is associated with lower anastomotic leakage and stricture rate compared to hand sewn ETE CEGA with Albert-Lembert suture.     

Does celiac trunk stenosis correlate with anastomotic leakage of esophagogastrostomy after esophagectomy?

The formation of a gastric tube for esophageal replacement requires partial devascularization of the stomach and induces microcirculatory changes in the anastomotic region of the gastric fundus. The additional influence of celiac trunk stenosis on anastomotic healing has not been investigated. In total, 23 patients with an esophageal carcinoma underwent transthoracic esophagectomy. Reconstruction was performed by a gastric tube (x22) with cervical or thoracic esophagogastrostomy or colon interposition (x1). All patients had a selective mesenterico-celiacography preoperatively via puncture of the right femoral artery. Preoperative cardiovascular and pulmonary risk factors were assessed. Angiographic findings were correlated to postoperative anastomotic leakage of esophagogastrostomy (x22). In seven out of 23 patients (30.4%), a stenosis of the celiac trunk could be demonstrated (x3 stenosis of 50%, x4 stenosis > 80%). Except for one patient with an additional stenosis of the superior mesenteric artery of > 80%, none of the patients with celiac trunk stenosis developed a postoperative anastomotic leakage of the esophagogastrostomy. Coronary artery disease was the only preoperative risk factor to predict a stenosis of the celiac trunk. Isolated stenosis of the celiac trunk does not seem to impair circulation of the gastric tube.     

Prospective evaluation of omentoplasty in preventing leakage of colorectal anastomosis

PURPOSE: The aim of this study was to investigate the role of omentoplasty, by means of intact omentum, in preventing anastomotic leakages after rectal resection. METHODS: Between 1992 and 1997 a total of 112 patients (64 males) with a mean age of 64.7 (range, 39–83) years were randomly assigned to undergo omentoplasty (Group A) or not (Group B) to reinforce the colorectal anastomosis after anterior resection for rectal cancer. The primary end point was anastomotic leakage; the secondary end point included morbility and mortality related to omentoplasty. RESULTS: The two groups were comparable in terms of preoperative and intraoperative characteristics. Staple-ring disruption at plain abdominal radiographs was detected in seven instances in Group A and in ten in Group B patients (P = not significant). Two leakages were evident clinically in Group A and seven in Group B (P<0.05). Three leaks were documented radiologically in Group A and eight in Group B (P = not significant). No complications related to omentoplasty were observed in Group A. There were two repeat operations for anastomotic leakage in Group B. At follow-up, one stricture developed in Group A and three in Group B (P = not significant) CONCLUSIONS: Despite a similar incidence of staple-ring defects, a strikingly lower rate of clinically and radiologically detected leaks developed in patients submitted to omentoplasty. Although not affecting the incidence of anastomotic disruption, omentoplasty seems to contain the severity of anastomotic leakage.     

The value of omentoplasty in protecting colorectal anastomosis from leakage. A prospective randomized study in 126 patients

BACKGROUND/AIMS: Anastomotic leakage is a major cause of mortality in colorectal surgery. Several methods have been evaluated in order to prevent anastomotic leakage. To decrease the rate and severity of anastomotic leakage, omentoplasty (OP) has been proposed by several authors on the basis of experimental and clinical studies. A prospective, randomized trial was designed to study the influence of omentoplasty on anastomotic leakage after colorectal resection. METHODOLOGY: One hundred and twenty-six patients undergoing elective or emergency surgery for malignancy, benign tumor, diverticular disease and other were randomly assigned to omentoplasty (OP group) or not (NO group). The primary end point was the rate of clinical and radiological anastomotic leakage. Both groups were comparable in terms of demographic data, preoperative characteristics and intraoperative findings. RESULTS: Eighteen patients (14.3%) had anastomotic leakage, 4 (6.4%) in the OP group and 14 (21.9%) in the NO group. Significant differences (P<0.05) between the two groups were also found in terms of repeat operation (3.2% vs. 14.1%) and deaths (3.2 vs. 7.8%). Other factors associated with anastomotic leakage were the distal site of anastomosis (<5 cm from anal verge) and the emergency. CONCLUSIONS: Omental wrap, with its mechanical and biological properties, seems to be effective in lowering the rate and the severity of anastomotic leakage after colorectal surgery.     

Evolution and critical appraisal of anastomotic technique following resection of esophageal adenocarcinoma

The aim of this study was to critically evaluate acute and long-term complications of hand-sewn and semimechanical cervical esophagogastric anastomosis following resection of primary esophageal adenocarcinoma. Between February 1991 and 2001, 91 consecutive patients underwent subtotal esophagectomy (transthoracic, n=49; transhiatal, n=42), transposing a gastric tube based on the right gastroepiploic artery. All esophagogastric anastomoses were performed in the left neck using a hand-sewn technique (n=53) and, from September 1997, a side-to-side semimechanical technique (n=38). Outcomes evaluated were anastomotic leak rates, length of stay, and development of strictures. Postoperative mortality was 4.4% (all cardiopulmonary causes). Fifty-eight patients (63.7%) had an uncomplicated postoperative course, with a median postoperative length of stay of 10 days (vs. 20 days with associated morbidity; P 相似文献   

The vascularization of a gastric tube as a substitute for the esophagus is affected by its diameter.

The stomach is used for reconstruction of the upper gastrointestinal tract after esophageal resection for cancer. The whole stomach can be used, but also a wide or narrow gastric tube can be constructed. Short-term functional results are superior after use of a narrow tube. Healing of the cervical esophagogastrostomy can be impaired, leading to leakage and stricture. The decreased vascularization at the site of the anastomosis may be one reason. It was hypothesized that the quality of the vascularization of the gastric tube, used as a substitute for the oesophagus after esophagectomy, depends on its diameter. The vascularization of postmortem specimens was studied using angiography. Whole stomachs (3), wide (3) and narrow gastric tubes (3) were constructed. In a patient with an anastomotic stricture of a narrow tube with a cervical esophagogastrostomy vascularisation was evaluated by angiography. After infusion of contrast through the supplying arteries, the whole stomachs and wide gastric tubes showed adequate vascularization, whereas the narrow gastric tube showed poor vascularization especially at the site of the anastomosis. In narrow gastric tubes, the right gastroepiploic artery was the only feeding artery. In the patient's angiography, a limited contrast visualization of the proximal end of the gastric tube could be demonstrated. Although a narrow gastric tube is favoured by some surgeons, the use of whole stomach or a type of gastric tube with preservation of the right gastric artery may lead to a better anastomotic healing.     

Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique

BACKGROUND/AIMS: During the past 4 years, we have experienced a marked reduction in the incidence of esophageal anastomotic leakage and/or stricture coinciding with the use of a mechanical circular stapler for gastric cancer patients. METHODOLOGY: We reviewed medical records of gastric cancer patients who underwent a total or proximal gastrectomy, and compared the leakage or stricture of stapled anastomosis with the hand-sewn anastomosis technique. A total of 390 esophageal anastomosis were performed between January 1978 and August 1997. Two types of mechanical circular staplers were used (EEA and CDH). RESULTS: Anastomotic leakage occurred in 13 (3.3%) of 390 cases; three (4.5%) of 66 cases with hand-sewn anastomosis, and 10 (3.1%) of 324 cases with stapled anastomosis (EEA: 4.5%, CDH: 0%). The anastomotic leakage rate was significantly lower in the CDH stapler group than in the EEA stapler group. Anastomotic stricture occurred in one (1.5%) of 66 cases of hand-sewn anastomosis, and 16 (4.9%) of 324 cases of stapled anastomosis (EEA: 5.9%, CDH: 2.9%). There were no significant differences in the stricture rate between the hand-sewn group and the stapler group. CONCLUSIONS: Stapling anastomosis using a CDH stapler led to a reduction in the incidence of anastomotic leakage. Surgeons must, however, continue to be aware of anastomotic stricture.     

食管癌食管胃颈部吻合术59例报导

目的：评价食管癌患者行胸腹段食管切除食管胃颈部吻合术疗效。方法：回顾59例应用此法手术的食管癌病例．总结手术体会、并发症的处理及病人术后生活质量。结果：本组无手术死亡．围手术期吻合口瘘2例伴颈部切口感染．无肺部感染及严重心律失常病例。术后随访6个月．5例有返流症状。结论：食管癌患者行胸腹段食管切除食管胃颈部吻合术疗效满意．并发症少，术后生活质量高．值得提倡。     

Omentoplasty in the prevention of anastomotic leakage after colorectal resection: a meta-analysis

Purpose  Whether omentoplasty after colorectal anastomosis can reduce anastomotic leakage is controversial. Our aim was to do a meta-analysis of randomized controlled trials to compare anastomotic leakage rates between an omentoplasty group and a no omentoplasty group after colorectal anastomosis. Materials and methods  We searched the Cochrane Center Register of Controlled Trials, PubMed, EMBASE, and Chinese Biomedical Literature Database up to June 2008 in any language. Reference lists from all selected articles were also examined. Randomized controlled trials of omentoplasty in the prevention of anastomotic leakage after colorectal resection were selected and evaluated by two investigators. Analyses were performed using Review Manager 4.2. Results  Three randomized controlled trials totaling 943 participants were included. Meta-analysis results showed that no statistically significant difference was found between the omentoplasty group and the no omentoplasty group in radiological anastomotic leakage (RR 0.76, 95% CI 0.41 to 1.40), death (RR 1.01, 95% CI 0.55 to 1.86), and repeat operation (RR 0.60, 95% CI 0.35 to 1.05), except for clinical anastomotic leakage (RR 0.36, 95% CI 0.16 to 0.78). Conclusion  Based on available data from a small number of trials, there is not enough evidence to say whether or not omentoplasty should be used to reduce anastomotic leakage after colorectal resection. The decision as to whether we should continue to use this technique might remain a matter of surgical judgment. Therefore, the results still need to be confirmed by future multicenter, well-designed trials. Specific author contributions: Tian-Kang Guo, Xiang-Yong Hao and Hong-Ling Li drafted the review and performed the statistical analyses. Ke-Hu Yang and Jin-Hui Tian wrote the search strategy and performed the electronic searches. Ke-Hu Yang and Bin Ma extracted data. All authors participated in the interpretation of the statistical analyses, revision of this article, and approval of the final version submitted.     

Anterior vs. Posterior Mediastinal Routes in Colon Interposition after Esophagectomy

Background/Aims: Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. Methodology: We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Results: Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Conclusions: Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.     

The use of circular stapler for cervical esophagogastric anastomosis after esophagectomy: surgical technique and early postoperative outcome

Stapled esophagogastric anastomosis after esophagectomy is considered to be superior to traditional handsewn techniques. Linear staplers are usually used. The aim of this study is to evaluate early postoperative results of circular stapler in cervical esophagogastric anastomosis. Records of all patients who underwent esophagectomy during the years 2003–2008 were reviewed. Patients that underwent transthoracic esophagectomy, colon transposition, or linear stapler anastomosis were excluded. Esophagogastric anastomosis was done either handsewn or using circular stapler. Patients underwent either pyloromyotomy, pyloroplasty, or no pyloric intervention. Postoperative leakage was diagnosed either clinically or radiologically. The end-point of this study was the incidence of anastomotic leak in the immediate postoperative period. Eighty-two patients (average age 66 years, male/female, 52/30) met the inclusion criteria. In 30 patients, the anastomosis was handsewn, and in 52 patients, it was done using a circular stapler. Overall operative mortality rate was 4.8% (four patients because of pulmonary or cardiac complications). Anastomotic leak occurred in five ( n  = 5, 16.6%) patients in the handsewn group and eight ( n  = 7, 13.4%) patients in the circular stapler group. Pyloric manipulation had no significant effect over the leakage rate. Routine upper-gastrointestinal (GI) series done on the fifth or sixth postoperative day did not reveal any of the leaks. Cervical esophagogastric anastomosis using an end-to-side circular stapler is feasible and safe, and has comparable outcomes to handsewn anastomosis in regard of leakage rates or other major surgical or general complications. Postoperative GI series seems to be a poor diagnostic tool for anastomotic leakage and could be omitted as a routine study for occult anastomotic leak.     

Massive distension of the esophageal stump after cervical esophagogastrostomy in psychiatric patients

We present two similar cases of huge distension of the esophageal stump after cervical esophagogastrostomy in two psychotic patients. Chronic use of anti-psychotic drugs, in combination with prolonged mild anastomotic stricture, may have contributed to this situation.     

Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation

BACKGROUND: A benign gastroesophageal anastomotic stricture occurs in up to 42% of patients after transhiatal esophagectomy for esophageal cancer. Management of anastomotic strictures may require extended periods of serial endoscopic dilation, with significant risk, cost, and inconvenience for the patient. OBJECTIVE: To determine if placement of removable self-expandable polyester silicon-covered (Polyflex) stents (SEPSs) prolonged the interval between endoscopic interventions in the management of persistent anastomotic stricture. DESIGN: Retrospective cohort study. SETTING: National Cancer Institute designated comprehensive cancer center. PATIENTS: Eight patients after a transhiatal esophagectomy referred for management of benign persistent anastomotic strictures. INTERVENTIONS: Serial balloon and bougie dilations and SEPS placement. MAIN OUTCOME MEASUREMENT: The interval between endoscopic interventions and the number of endoscopic interventions before and after SEPS placement. RESULTS: Over a 365-day period, 13 SEPS were placed in 8 patients with benign persistent anastomotic strictures after a transhiatal esophagectomy. A SEPS placement delayed the interval between endoscopic interventions from a mean of 7 days before stent insertion to 62 days after insertion (P < .008). The median number of preinsertion interventions was 4 and was reduced to 1 after insertion (P < .005). LIMITATION: The small number of patients. CONCLUSIONS: A SEPS placement did not result in stricture resolution or stabilization after SEPS removal. The SEPS migration rate was much higher in our patients with postesophagectomy anastomotic strictures than previously reported for other types of strictures. However, a SEPS placement did significantly delay the interval between endoscopic interventions in patients with persistent gastroesophageal anastomotic strictures after transhiatal esophagectomy. SEPS placement should be considered as an alternative to continued serial dilation in patients with persistent anastomotic strictures after transhiatal esophagectomy.     

Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis

SUMMARY.   Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5–28), and the median length of stay in hospital was 9 days (range 6–45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers.     

改良式左胸腹联合左颈二切口在食管癌根治术中的应用(附21例临床分析)

目的探讨改良式左胸腹联合左颈二切口在食管下段癌根治术中的应用. 方法对2002年2月至2003年6月采用了改良式左胸腹联合左颈二切口根治术的21例食管下段癌患者的手术时间、手术并发症、上腹部淋巴结清扫范围进行回顾性分析. 结果改良式左胸腹联合左颈二切口根治术能有效的简化了手术操作步骤,减少了手术创伤及并发症,扩大了腹内淋巴结清扫范围. 结论改良式左胸腹联合左颈二切口根治术是食管下段癌患者的较理想的术式.     

Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia

STUDY OBJECTIVES: Anastomotic leakage after esophagectomy is associated with high postoperative morbidity and mortality. The most important predisposing factors for anastomotic leaks are ischemia of the gastric conduit and low blood oxygen content. The aim of this study was to evaluate the influence of thoracic epidural analgesia (TEA) on the incidence of anastomotic leakage after esophagectomy. DESIGN: Retrospective study. SETTING: A thoracic surgery and anesthesia department in a teaching hospital. PATIENTS: Two hundred seven patients who underwent one-stage esophagectomy between 1998 and 2003. INTERVENTIONS: The effects of perioperative factors and postoperative complications on the incidence of anastomotic leakage were analyzed. Leakage was defined as an anastomotic disruption detected by an ionic x-ray contrast study and confirmed by upper endoscopy in the postoperative period. Analyzed factors included effective TEA placed before the surgical procedure. MEASUREMENTS AND RESULTS: Anastomotic leakage occurred in 23 patients (11%). This complication was associated with a significant increase in length of stay in the ICU and in the hospital (mean, 19 +/- 16 days vs 9 +/- 7 days [+/- SD], p = 0.008; and 43 +/- 27 days vs 23 +/- 11 days, respectively; p < 0.001). Mortality in patients presenting anastomotic leakage was 26%, compared with 5.4% in the remainder (p = 0.002). Factors independently associated with the incidence of leakage included estimated blood loss per milliliter during the surgical procedure (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.001 to 1.007), the cervical location for anastomosis (OR, 5.4; 95% CI, 1.3 to 22.9), and the development of an ARDS in the postoperative period (OR, 4.1; 95% CI, 2.6 to 176.5). Ninety-three patients benefited from an effective TEA for 4.4 +/- 0.8 days. The use of TEA was independently associated with a decrease in the incidence of anastomotic leakage (OR, 0.13; 95% CI, 0.02 to 0.71). CONCLUSIONS: The results of this retrospective study suggest that TEA is associated with a decrease in occurrence of anastomotic leakage.     

Esophagogastrectomy without pyloroplasty

There is no consensus on the need for pyloroplasty after esophagectomy or proximal gastrectomy with an esophagogastrostomy and vagotomy. Arguments for routine pyloroplasty include prevention of postoperative delayed gastric emptying. Arguments against include prevention of postoperative dumping syndrome and bile reflux esophagitis. The purpose of this study was to assess clinical outcomes of patients undergoing esophagogastrectomy without routine pyloroplasty. All patients undergoing esophagogastrectomy or proximal gastrectomy with esophagogastrostomy from October 1996 to September 2002, inclusive were reviewed for age, gender, diagnosis, type of resection, pathology, short-term complications, long-term complications, remedial procedures performed, and postoperative gastric emptying scintigraphy. 58 patients were studied. Postoperative mortality was 6.9%, and anastomotic leak rate 12.1%. Eleven patients (19%) had symptomatic gastroparesis, two required pyloric balloon dilation and one a pyloroplasty. No patients complained of dumping symptoms; reflux requiring medical intervention occurred in seven (12.1%), and anastomotic stricture requiring dilation occurred in five (8.6%). Omitting a pyloroplasty does not lead to a high frequency of symptomatic delayed gastric emptying. Maintaining the pylorus may protect patients from dumping syndrome, and bile reflux esophagitis with its potential noxious effects on the remaining esophageal mucosa.     

Two-field radical lymphadenectomy in the treatment of esophageal carcinoma

This paper retrospectively compares post-operative complications, mortality and long-term survival of patients with esophageal carcinoma who were treated with standard esophagectomy or with extended two-field lymph node clearance. Fifty-seven patients with resectable esophageal carcinoma were included in the study. Twenty-eight patients were submitted to a radical two-field esophagectomy and lymphadenectomy, while the remaining 29 were submitted to a standard, more conservative, esophagectomy performed mostly through a transhiatal route. The two groups of patients were similar in all clinical, laboratory and pathologic features. There was a significant lower anastomotic leakage rate in the group of patients submitted to a radical lymph node resection; post-operative respiratory complication rate and mortality were similar in both groups. The overall 5-year survival was 20%. When lymph node resection was performed, the 5-year survival rate rose to 36%; it was 44% when nodal involvement was negative and 19% for N1 patients; when standard esophagectomy was the procedure, these figures were 9% (p < 0.05), and 6% respectively.     

Surgical attempts to avoid anastomotic leaks and reduce reflux esophagitis following esophagectomy for cancer

Background  We analyzed the results of our surgical attempts to establish a safe reconstruction after esophagectomy for cancer that withstands both early and subsequent complications. Methods  Patients who underwent an intrathoracic or cervical esophagogastrostomy were selected. We preserved the esophagus keeping an oral margin of at least 3 cm and made an anastomosis with the gastric wall as low as possible to avoid an anastomotic leak. We included an antireflux procedure in the intrathoracic anastomosis. We examined the effect of these surgical approaches in three patient groups: one group with cervical anastomosis (CA group, n = 21), and the other two groups with intrathoracic anastomosis after resection of cancer in the upper or middle thoracic esophagus (UM group, n = 104) or in the lower thoracic or abdominal esophagus (LA group, n = 30). Results  No leak was found in the esophagogastric anastomosis in any group. A gastric suture line dehiscence developed in two cases in the UM group. Postoperative endoscopy revealed that mean anastomotic height in the UM group was 4.1 cm lower than in the CA group (P < 0.0001) and 2.1 cm higher than in the LA group (P = 0.0006). The incidence of reflux esophagitis was 0% in the CA group, 43% in the UM group, and 37% in the LA group, with significant differences between the CA group and the other groups. Conclusions  Our surgical attempts to avoid leaks of esophagogastrostomy were entirely successful. An intrathoracic anastomosis combined with an antireflux procedure was not advantageous for the incidence of reflux esophagitis compared to cervical anastomosis, but it minimized the effects of anastomotic height on the development of reflux esophagitis.