Predictive factors for anastomotic leakage in the neck after retrosternal reconstruction for esophageal cancer

BACKGROUND/AIMS: Anastomotic leakage after transthoracic esophagectomy for esophageal cancer can induce life-threatening morbidity. This study investigated the predictive factors for anastomotic leakage in the neck after retrosternal reconstruction. METHODOLOGY: A total of 129 esophageal carcinoma patients undergoing transthoracic esophagectomy and esophagogastric anastomosis in the neck via a retrosternal approach were enrolled between April 1985 and March 2002. Predictive factors for anastomotic leakage were statistically evaluated. In a preliminary study using 18 cases, thoracic inlet space (TIS) was recommended to be extended more than 700 mm2. RESULTS: Partial resection of the bony structures was performed in 32 patients. The method of anastomosis and partial resection of bony structures according to the TIS independently influenced the likelihood of anastomotic leakage, with hand-sewn anastomosis and an absence of partial resection increasing its occurrence. CONCLUSIONS: Stapled anastomosis following the partial resection of the sternum and the left clavicle is recommended to avoid anastomotic leakage. These findings should be clarified by a randomized controlled study in a high-volume hospital.     

Conservative reconstruction using stents as salvage therapy for disruption of esophago-gastric anastomosis

Esophagectomy with extended lymphadenectomy and gastric conduit reconstruction is a radical procedure for the treatment of esophageal cancer that is associated with a high morbidity rate. Gastric conduit necrosis is a fatal complication that occurs in 2% of patients. Conventionally, two-stage salvage surgery consisting of removal of the necrotic gastric conduit followed by reconstruction has been performed; however, this procedure has a high morbidity rate. We describe a 61-year-old man who underwent minimally invasive esophagectomy complicated by slowly progressive gastric conduit necrosis associated with complete neck drainage and a stable overall condition. There was a 2 cm gap in the anastomosis. Because there was no evidence of residual gastric conduit necrosis, a removable, covered self-expanding metal stent (SEMS) was inserted to bridge the anastomosis. The stent was fixed to the patient’s ear with silk thread through the lasso on its proximal end to prevent migration. Eight weeks after insertion, the stent was removed easily without any associated complications. The anastomotic defect was completely bridged with granulation tissue, showing progressive epithelialization without leakage or stenosis. The patient was discharged home in good general health. This is the first report of the successful conservative management of esophago-gastric conduit anastomosis disruption with SEMS placement.     

Surgical repair of refractory strictures of esophagogastric anastomoses caused by leakage following esophagectomy

Refractory strictures of esophagogastric anastomosis caused by leakage following an esophagectomy are a severe complication, for which either repeated balloon dilations or bougies are not necessarily effective. In such a case, surgical repair is quite difficult because the esophageal substitute such as the stomach or colon is usually located in the mediastinum and severely adhesive to the neighboring organs. Furthermore, in case the resected stricture is too long for direct re‐anastomosis to be performed, a free jejunal graft or a new esophageal substitute should be prepared. This paper proposes a procedure for the re‐reconstruction of refractory stricture in the case of a retrosternal reconstruction with a gastric conduit, which frequently employs pull‐up route. The anterior plate of the manubrium was divided medially from the notch to the symphysis with the sternal saw. The manubrium is then removed, bite by bite, like breaking up rocks, with a bone rongeur forceps, starting with the anterior plate, then the posterior plate, from upper median part to the lower and lateral part of the sternum until it reaches the symphysis and the sternoclavicular and the sternocostal joints. It is safer to destroy the manubrium little by little from the anterior side so that the posterior periosteum, which is likely to adhere tightly to the gastric conduit, can be preserved. After the manubrium is almost completely resected and the posterior periosteum of the manubrium is preserved, a median longitudinal incision is carefully made on the periosteum so as not to damage the gastric conduit that may be adhesive to the periosteum. The periosteum was gradually opened bilaterally separating the periostium and the gastric conduit. Although gastroenterological surgeons may hesitate to remove the manubrium, removing the manubrium and preserving the posterior periosteum make it possible to avoid injuring the gastric conduit and to provide a wide view around the stenosis for safely resecting the anastomotic stricture. Furthermore, this procedure allows direct re‐anastomosis between the cervical esophagus and the gastric conduit without a complicated reconstruction such as a free jejunal graft. This procedure is strongly recommended as an alternative option so that a second reconstruction can be performed both safely and steadily.     

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

Several complications after esophagectomy with gastric pull‐up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull‐up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I–III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4–10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty‐three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1–24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.     

Angleplasty in gastric tube reconstruction after esophagectomy

Anastomotic leakage after radical esophagectomy is mostly caused by the hypoxia and high tension at the esophagogastric anastomotic site. Here, we introduce a new surgical technique, 'Angleplasty,' to enable the tensionless anastomosis at a highly oxygenic site of gastric conduit. In short, the seromuscular layer is cut for a perpendicular direction against a lesser curvature at a gastric angle and the gastric wall is carefully divided between the muscular and submucosal layers for longitudinal direction for 4–5 cm in length. Then, the wound is closed with seromuscular sutures for longitudinal direction. With this maneuver, the lesser curvature of the gastric roll is significantly elongated and the anastomosis site of the gastric conduit can be moved more distal on the greater curvature of the stomach where it is expected to receive more oxygen supply. This technique takes only several minutes, but provides highly favorable conditions for esophagogastric anastomosis and thus is clinically useful to reduce the risk of anastomotic leakage after esophagectomy.     

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.     

Vascular conditioning of the stomach before esophageal reconstruction by gastric interposition

Gastric interposition with intrathoracic or cervical esophagogastrostomy is currently the preferred operation for reconstruction after esophagectomy. Anastomotic leaks however result from poor vascular supply to the proximal stomach. They are responsible for significant morbidity and mortality. ‘Ischemic conditioning’ of the interposed stomach has been proposed as a technique where the ‘delay phenomenon’ aims at improving the microcirculation of the gastric conduit and preventing anastomotic leakage. Experimental observations and clinical studies have been conducted to document the immediate effects and results of this approach. The aim of this work is to review the principles, pathophysiology, experimental, and clinical evidence related to vascular conditioning of the stomach prior to esophagectomy with gastric interposition and esophagogastric anastomosis. MEDLINE and PubMed were searched to identify articles related to vascular conditioning of the stomach. Cross references were added and reviewed to complete the reference list. The anatomic basis of ischemic conditioning, the prevalence of ischemic events on the gastric conduit, the methodology to assess the microcirculation before and after gastric devascularization, animal experiments, and clinical studies reported on this approach were reviewed. Ten experimental works, eleven clinical observations, four reviews, and two editorial commentaries addressing ischemic conditioning of the stomach were identified and reviewed. Experimental observations document improved microcirculation to the proximal stomach following partial gastric devascularization. Clinical reports show the feasibility and relative safety of gastric ischemic conditioning. Preliminary observations suggest potential improvements to the gastric microcirculation resulting from gastric ischemic conditioning. This approach may help prevent complications at the esophagogastric anastomosis. The actual level of evidence however cannot promote its use outside of clinical research protocols.     

Gastroventricular fistula: severe complication of posterior mediastinal gastric tube reconstruction after esophagectomy

A case of gastroventricular fistula following resection of cancer of the midesophagus and reconstruction using a gastric tube via the retromediastinal route is presented. Given that a peptic ulcer occurring in the gastric tube can perforate into any adjacent structures, gastroventricular fistula is one of the most lethal complications after esophagectomy.     

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.     

Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer

Anastomotic leakage is a serious complication in colorectal surgery, especially in the treatment of adenocarcinoma located in the left-sided colon and rectum. It is controversial whether anastomotic leakage is a prognostic factor for local recurrence and/or survival in this disease. To evaluate the impact of anastomotic dehiscence on the outcome of surgery we reviewed data on 467 consecutive patients with adenocarcinoma of the left colon and rectum treated between 1985 and 1995 in our Department. Of these, 41 (8.8%) developed anastomotic leakage. The overall-survival differed nonsignificantly (P=0.57) between leakage and nonleakage groups. Of 331 patients with curative resection 29 showed an anastomotic leakage. There were 46 R0-resected patients who died under disease-related conditions: 7 patients in the leakage group (24.1%) and 39 in the nonleakage group (12.9%; P=0.045). In the curatively resected group 5 of 29 patients developed local recurrence in the leakage group (17.2%) but only 26 of 302 patients in the nonleakage group (8.6%; P = 0.0357). Multivariate analysis showed only the factors of age, stage of resection, staging of lymph nodes, and tumor staging as independent prognostic factors for overall survival. For local recurrence the multivariate analysis revealed tumor staging and anastomotic leakage as independently significant. Anastomotic leakage thus appears to be a prognostic factor for local tumor recurrence of colorectal cancer. In addition, disease-related survival is considerably decreased under leakage conditions. Anastomotic leakage was not shown in this study to be an independent prognostic factor for overall survival due to the lack of statistical significance. Accepted: 20 July 1998     

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.     

The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% ( n  = 90) in the cervical region and 4.2% ( n  = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.     

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.     

腹腔镜直肠前切除术后吻合口漏发生的危险因素及其防治措施

目的通过对结直肠漏评分（CLS）系统在腹腔镜直肠前切除术中的运用来探讨发生吻合口漏（AL）的相关因素及吻合口漏防治的经验分享。 方法纳入2014年1月至2017年6月期间于四川省肿瘤医院行腹腔镜直肠前切除术的患者,采用CLS评分系统来分析术后发生吻合口漏的危险因素,总结腹腔镜直肠前切除术并发AL的防治经验。 结果共582例患者纳入本研究,术后发生吻合口漏43例（7.3%）,其中有症状吻合口漏29例（4.9%）。单因素分析显示：性别、ASA麻醉分级、不健康个人史、新辅助治疗、吻合口距肛缘距离、附加的手术程序、术中失血与输血及手术时间与腹腔镜直肠前切除术后吻合口漏的发生相关(均P<0.05)。多因素回归分析显示：术前麻醉分级ASA（OR 3.173,95%CI：1.848~5.448）、不健康生活行为（OR 3.898,95%CI：2.144~7.085）、吻合口与肛缘的距离（OR 1.718,95%CI：1.3605~2.262）、附加的手术程序（OR 11.353,95%CI：3.387~38.058）、手术时间（OR 1.622,95%CI：1.144~2.301）、术中保护性造口（OR 0.024,95%CI：0.005~0.123）、改良技术的运用与否（OR 0.271,95%CI：0.091~0.803）是影响术后吻合口漏发生的独立危险因素(均P<0.05)。CLS评分系统对腹腔镜直肠前切除术后吻合口漏的发生有良好的预测作用,CLS 12分可以作为腹腔镜直肠前切除术后吻合口漏发生的高风险临界预测值。 结论对于腹腔镜直肠前切除术后CLS评分>12分,应警惕术后吻合口漏的发生,运用相关腹腔镜改良技术可以有效防治AL的发生。     

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction

Background and aims Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. Materials and methods Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3–4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. Results/findings No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). Interpretation/conclusion Patient’s safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.     

Fundus rotation gastroplasty: rationale, technique and results.

Anastomotic leakage is the main factor (up to 30%) for postoperative morbidity and mortality after esophageal resection. Compromised anastomotic perfusion after dissection of supplying vessels for gastric tube formation and tension on the suture line are the two main reasons for anastomotic insufficiency. To prevent anastomotic leakage, a new technique for gastric tube formation after esophageal resection has been developed and introduced into surgical practice: the fundus rotation gastroplasty (FRG). The following paper summarizes rationale, technique and early results of this new technique. It is shown that the FRG is a safe and effective technique for esophageal reconstruction and offers important advantages over conventional gastroplasties: (i). the improved perfusion of the oral part of the tube; (ii). the gain of tube length allowing for a safer performance of even pharyngeal anastomosis as shown by the low insufficiency rate of 9%; and (iii). the increase of remaining gastric reservoir supporting physiologic stomach and gut function. Therefore, the FRG seems to be an alternative and safe method for esophageal reconstruction, especially for high anastomotic locations.     

Omentoplasty versus no omentoplasty for cervical esophagogastrostomy following radical esophagectomy

BACKGROUND/AIMS: Omentoplasty--wrapping the omentum around the alimentary tract anastomosis is thought to lower the rate of anastomotic leakage. We evaluated the role of omentoplasty to reinforce cervical esophagogastrostomy after radical esophagectomy. METHODOLOGY: We compared anastomotic leakage, stricture formation, and related deaths in 63 patients who underwent radical esophagectomy and cervical esophagogastrostomy, with (n = 48) or without (n = 15) omentoplasty, between 1995 and 1999. RESULTS: An esophageal anastomotic leakage was diagnosed in 1 of the 48 patients (2.1%) with omentoplasty versus 3 of the 15 patients (20.0%) without omentoplasty (P < 0.01). Anastomotic stricture occurred in 2 (4.2%) of the omentoplasty group and 1 (6.7%) of the no omentoplasty group (P < 0.01). Death within 1 month was zero in the omentoplasty group and one (6.7%) in the no-omentoplasty group, despite no differences in lethal anastomotic leakage. CONCLUSIONS: Omentoplasty of cervical esophagogastrostomy reduced anastomotic leakage. Although promising, these observations require confirmation with a randomized prospective study.     

Long-term and short-term evaluation of esophageal reconstruction using the colon or the jejunum in esophageal cancer patients after gastrectomy

SUMMARY.  For esophageal cancer patients, the gastric tube is the first choice as an esophageal substitute, with the colon or the jejunum being used when the stomach cannot be used. We retrospectively compared these two methods from the viewpoint of peri-operative complications and long-term bodyweight alteration. From 1998 to 2005 53 patients who had undergone subtotal esophagectomy due to thoracic esophageal cancers were given reconstruction with the colon (28 cases) or the jejunum (25 cases). Both intestines were reconstructed via the subcutaneous route and were anastomosed to the internal mammalian artery and vein for a supercharged blood supply. There was no difference in operating time and blood loss. Compared with the colon reconstruction group, the hospital stay of the jejunum reconstruction group was significantly shorter (65 days vs 45 days, P  = 0.0120) and the incidence of anastomotic leakage tended to be less (13 cases, 46% vs 6 cases, 24%, P  = 0.1507), while other operative morbidity did not differ between the two groups. Bodyweight loss, which is a serious postoperative sequela after esophagectomy, was less in the jejunum group than in the colon group, showing a significant difference at 12 months after surgery. Our retrospective study revealed the jejunum to be superior to the colon for the reconstruction after esophagectomy along with gastrectomy, with respect to anastomotic leakage and bodyweight loss. The next step will be to conduct a prospective large cohort study.     

Modification of the procedure for esophageal reconstruction after resection of esophageal cancer

BACKGROUND/AIMS: Reconstruction after esophagectomy is still associated with the highest risk of anastomotic leakage among all of the gastrointestinal anastomoses. In 1994, the reconstruction phase of our procedure was modified aiming to reduce the risk of anastomotic leakage. We evaluated usefulness of our modified procedure. METHODOLOGY: 32 patients before the modification of reconstruction were included in Group A, whereas Group B included 80 patients after the modification. In Group A, a thin gastric tube was constructed along the greater curvature. In Group B, the gastric tube was made thinner and longer. We were able to preserve a vessel feeding the terminal segment of the gastric tube that secured ample blood supply to this segment. The cut end of the cervical esophagus was anastomosed to the posterior wall of the gastric tube near the greater curvature, where adequate blood supply is available, and the anastomotic line was covered with omentum. RESULTS: In Group A, anastomotic leakage occurred in 15.6%. In Group B, minor leaks occurred 2.5%, indicating a marked decrease. CONCLUSIONS: The method of esophageal reconstruction currently performed at our department does not require special techniques, but the occurrence of anastomotic leakage is very low.     

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.