Resection of midesophageal carcinoma with esophagogastric anastomosis

This report is based on 432 cases of cancer of the oesophagus, 154 of which involved the middle third. There were 82 men and 72 women, ranging in age from 42 to 81, average 62. Operative mortality was 15.7%. The philosophic objectives were to restore promptly the ability to swallow, to obtain a worthwhile survival period, and to avoid the miseries associated with oesophageal carcinoma. Preoperative preparation, operative techniques including errors and safeguards, postoperative management, and overall results are specified. The stomach is preferred to jejunum or colon as a means of restoring continuity of the alimentary tract following resection of oesophageal carcinoma.     

Cervical esophagogastric anastomosis for benign disease. Functional results

Ninety-one adult patients (average age 49 years) with various benign esophageal disorders treated by total thoracic esophagectomy and a cervical esophagogastric anastomosis have been followed up with personal interviews and examinations from 6 to 104 months (average 34 months). Outpatient esophageal dilation has been used liberally for any degree of postoperative cervical dysphagia. At their latest follow-up, 39 patients (43%) eat without dysphagia; four patients (4%) have mild dysphagia necessitating no treatment; 34 patients (37%) have undergone one to three dilations during the first 6 to 12 postoperative months for intermittent dysphagia; and 14 patients (16%) have more severe dysphagia necessitating regular anastomotic dilations (two thirds of these perform home self-dilations). Mild regurgitation of gastric contents has been experienced by 27 (30%), particularly when recumbent after eating, but only four patients sleep with the head of the bed elevated to prevent nocturnal regurgitation. No patient has had pulmonary complications resulting from aspiration. Twenty patients (22%) have had varying degrees of "dumping syndrome," generally transient and well controlled with medication. Two patients have required an additional gastric drainage operation 16 months and 82 months, respectively, after the esophagectomy. At their latest evaluation, 33% of the patients weigh 3 to 83 (average 19) pounds more than they weighed preoperatively, 38% weigh 5 to 40 (average 12) pounds less, and 29% have had no change in their weight. The stomach functions well as a visceral esophageal substitute and, like the esophagus, is more thick-walled and resilient than colon. Significant gastroesophageal reflux is uncommon after a properly performed cervical esophagogastric anastomosis. Postoperative dysphagia can be minimized by attention to technique in constructing the anastomosis. These data support our belief that the stomach is the preferred organ for esophageal replacement, not only for carcinoma, but also for benign diseases as well.     

Cervical esophago-visceral anastomosis with an endoscopic linear stapler. Note on a surgical technique

The incidence of anastomotic fistula in the neck after esophagectomy and esophagogastroplasty may be as high as 30%; the incidence of anastomotic stenosis may be as high as 10%. To avoid these potential and sometimes serious complications, the authors describe a partially mechanical esophago-visceral anastomosis. The esophageal stump is brought near the anterior wall of the transposed stomach. A small gastrotomy is performed. An endoscopic linear stapler is then inserted in the esophageal and gastric lumen, and fired. The anterior wall of the anastomosis is fashioned with a running suture.     

Esophagogastrectomy for benign esophageal stricture. Fate of the esophagogastric anastomosis.

Eighty-nine patients who had resection of benign esophageal stricture with esophagogastrostomy were reviewed through medical records and by mailed questionnaire. The 30-day mortality rate was 8.9%. Seventy-six patients were available for follow-up for an average of 66.4 months (Group 1). Forty-three of these patients were followed up for longer than 5 years (Group 2). The incidence of postoperative heartburn in Groups 1 and 2 was 7.9% and 7.0%, respectively. The incidence of postoperative dysphagia in Groups 1 and 2 was 39.4% and 30.2%, respectively, with most episodes occurring within 2 years of operation. The vast majority of these patients required multiple esophageal dilatations over a long time. The high rate of restricture precludes support for the routine use of an esophagogastric anastomosis after resection of benign esophageal stricture.     

A new technique for intestinal isoperistaltic anastomosis utilizing a linear stapler for enlargement after anastomosis performed with a circular stapler

Background The high incidence of anastomotic stenosis after gastrointestinal surgery using circular staplers is a major problem. In response, we have developed a new technique that uses a linear stapler to enlarge an anastomotic opening made using a circular stapler. Methods Anastomoses were created by the new technique or by the conventional approach using a circular stapler in pig small intestine. The method was also applied in treatment of a colon cancer patient. Results The area of the anastomotic opening obtained with the new technique was more than 3 times that in the control (p < 0.001), with no significant difference between the methods in a leak test. Follow-up of the patient undergoing surgery with this approach revealed an uneventful course with a widely patent anastomosis confirmed after 3 months. Conclusions This procedure provides a larger anastomotic opening than conventional anastomosis with circular staplers, without impairing the integrity of the anastomosis.     

Latero-terminal anastomosis in colorectal surgery using a mechanical stapler. Technical note]

Following a discussion of the various methods of colorectal anastomosis in cancer surgery, the Authors describe a technical variant using a mechanical stapler in a high rectal location. The rapidity of anastomosis as well as the decreased risk of dehiscence, fistula and stenosis are underlined.     

Usefulness of automatic triangular anastomosis for esophageal cancer surgery using a linear stapler (TA-30).

In a clinical evaluation, thirty-one patients with thoracic esophageal cancer who were treated from 1997 to 2000 were selected as subjects including those who underwent hand sewn anastomosis method, circular stapler method and triangular anastomosis method. Incidence of anastomosis failure was 27.3%, 25.0% and 8.3% for the hand sewn anastomosis method, circular stapler method and triangular anastomosis method, respectively. Anastomosis stenosis was found in 32.4%, 45.6% and 8.3% for the hand sewn anastomosis method, circular stapler method and triangular anastomosis method, respectively. In the basic examination, reduction rate of anastomosis caliber was 22.1+/-4.8%, 14.9+/-1.4% and 7.37+/-0.9%, for the hand sewn anastomosis method, circular stapler method and triangular anastomosis method. Microscopic evaluation revealed serious problems with the circular stapler method. The cause of anastomotic stenosis may include the fact that if anastomosis is performed by a circular stapler method, all the layers of gastrointestinal tract are punched out at the anastomosis portion, and mucosal conjugation is not observed and the muscular layer is exposed in the inner lumen of the gastrointestinal tract. Taking that the ulcer is formed circularly at the anastomotic portion into account, it is easily understood that this circular ulcer develops into stenosis in the healing process. The advantage of triangular anastomosis for esophago-gastric anastomosis is less suture failure, and is extremely advantageous for prevention of stenosis at the anastomotic portion when compared with other anastomosis methods. However, with regard to the healing process of eversion anastomosis in gastrointestinal tract instrumental anastomosis, detailed examination is expected hereafter.     

Cervical esophageal anastomosis following cervical esophageal diversion: a new use for an old instrument

Proximal cervical esophageal diversion is occasionally employed in the management of distal esophageal perforation. However, subsequent esophageal reconstruction can pose a formidable surgical challenge. The DeBakey femoral tunneling device has proven helpful in identifying the distal defunctionalized segment of esophagus during certain types of reconstruction. We describe the use of this instrument to reestablish esophageal continuity in two instances.     

手工与吻合器行食管胃吻合术后胃食管反流症状的临床观察

目的 通过临床观察应用手工和吻合器行主动脉弓下食管胃吻合术后的胃食管反流症状的发生率和程度,以指导选择一种合理的吻合方法.方法 全组30例,分成手工组(17例)和吻合器组(13例),观察从开始进食到进食后1个月胃食管反流的发生率和程度.结果 手工组有4例术后出现胃食管反流(23.5%),无严重反流病例;吻合器组11例(84.6%)术后出现胃食管反流,重度反流4例.全组无吻合口瘘、狭窄,无术后死亡.结论 食管胃黏膜管套叠吻合比吻合器吻合在术后抗反流上有优势,在进行主动脉弓下食管胃吻合时应尽量选择具有良好抗反流效果的吻合方法.     

Peroral and transgastric esophageal anastomosis with flexible shaft remote-control stapler (SurgASSIST)

Stapled cervical esophageal anastomoses are technically challenging and are associated with relatively high complication rates, particularly in leaks and anastomotic strictures. We describe the use of a flexible shaft, remote-control, circular stapling device in forming high esophageal anastomoses in 2 patients. Retrograde transgastric and prograde peroral approaches are evaluated comparing ease of technical application and outcomes. Both procedures were performed after total esophagectomy for cancer in a 72-year-old male patient with preoperative down-staging and a 78-year-old female who proceeded directly to surgery. The introduction of rigid staplers in the esophagus by either route can be difficult and technical pointers and the potential applications of the flexible SurgASSIST device are discussed. Potential benefits include shorter time for constructing the anastomosis and a wider lumen resulting in possible cost benefit. Both patients had uneventful technical construction of stapled anastomoses, and the only complication in the female was a leak in the gastric close-off at the site of introduction of the flexshaft. Both are alive and well without recurrence at 2 years and 22 months.     

Simple pyloroplasty using a linear stapler in surgery for esophageal cancer

This article describes a simple pyloroplasty procedure using a linear stapler in surgery for esophageal cancer. Simple pyloroplasty was carried out using a linear stapler in a total of 22 patients, whose stomachs were used as esophageal substitutes in the surgery for esophageal cancer. Endoscopy was performed and the pyloric diameter was measured perioperatively. A barium meal study was conducted 1 month after the surgery. Stapling enlarged the diameter of the pylorus by nearly 10 %. Endoscopy revealed a smooth inner surface of the pylorus, enlargement of pyloric channel, and fewer spasms of the pylorus at the 1-month follow-up. Postoperative barium meal studies showed good patency of all of the patients’ gastric outlets. Simple pyloroplasty is a time-saving and non-soiling technique used to perform the drainage of the gastric conduit for resection of esophageal cancer.     

Four hundred esophageal anastomoses with a stapler

Four-hundred esophageal anastomoses were performed with a stapler in the Department of Digestive Surgery, Hospital Beaujon in Paris, in a six year period. The experience of the 14 different surgeons in esophageal surgery was very uneven (zero to 25 years). Two-hundred and sixty-eight esophagogastrostomies (220 in the chest and 48 in the neck), 83 esophagojejunostomies and 49 esophagocolostomies were done. The overall mortality rate was 9.2%, three per cent owing to leaks. The average incidence of leakage was 7% falling to 5.5% if cervical anastomoses were excluded. The incidence of stenoses was 8%. Several points which might account for problems are discussed. Stapled anastomoses seem to reduce the mortality and the morbidity rates of esophageal anastomoses, especially for surgeons with no experience in esophageal surgery.     

食管胃颈部器械吻合在食管癌切除术中的应用

目的 探讨食管癌切除后使用消化道圆型吻合器行食管胃颈部吻合的安全性和可行性。方法回顾性分析2009年8月至2011年4月间河南省人民医院采用一次性圆形吻合器行食管癌切除后食管胃颈部吻合病例的临床资料。结果202例患者中除1例因吻合时部分食管撕裂而需手工缝合修补外,其余均一次吻合成功。无手术死亡病例。术后出现颈部吻合口瘘6例（3．0％）,经保守处理后均在短期内愈合;无胸内吻合口瘘或其他吻合器械相关并发症发生;有2例患者在进食后出现较明显的胃食管反流。经10．2个月的中位随访,全组患者均未发现吻合口狭窄。结论食管癌切除后使用吻合器行食管胃颈部吻合安全、可行。