食管癌贲门癌术后吻合口及胸胃瘘的临床分析

目的　探讨食管癌、贲门癌切除术后吻合口及胸胃瘘发生的高危因素及防治措施。方法　分析 1990年 1月～ 2 0 0 3年 12月间 136 9例行食管癌、贲门癌切除、食管重建术病人的临床资料。结果　本组颈部吻合口瘘的发生率为 16 .2 4 %。胸内吻合口及胃瘘发生率为 2 .0 % ,死亡率2 8.0 % ;前 6年和近 7年相比 ,胸内瘘的发生率为 3.33%对 1.4 6 % (P =0 .0 31)。胸内机械吻合瘘的发生率为 0 .5 1%。结论　吻合口瘘及胸胃瘘是食管重建术后严重的并发症 ,应用机械吻合、熟练掌握手术技巧和加强围术期管理是预防瘘发生的有效方法     

Surgical complications of esophageal resections: our experience with 168 operations

We performed 346 operations for oesophageal cancer between 1 June 1991 and 31 May 2001. 168 of them were resections. The resection rate was 48.5 percent. The most frequently performed operation was subtotal resection of the oesophagus with the removal of paraesophageal lymph nodes. Reconstruction was usually performed with gastric tube pulled up retrosternally according to Akiyama with cervical oesophago-gastrostomy (135/168). In 24 patients intrathoracic oesophago-gastrostomy and in 9 patients other type of reconstruction was performed. Considerable co-morbidity was present in 88 percent of our patients (148/168). Alcohol dependency was noted in 88 patients however we suspect there were patients who did not admit alcohol abuse. Extended resection i.e. other organs' resection together with the oesophagus was performed in 59 patients. Postoperative recovery was uneventful in 49.4 percent (83/168) of our patients. Surgical complications occurred in 28.6 percent. Anastomotic leak was observed in 21 cases (12.5 percent). The most severe complication was necrosis of an organ used in reconstruction (7 patients, 4.2 percent). 23 patients (13.7 percent) died in the postoperative period, 7 of them (4.2 percent) because of surgical complication. Statistical analysis proved that the R status and the extension of resection had no influence on the frequency of complications and mortality rate except for when the removal of the entire stomach or gastric stump was performed in one sitting with the oesophageal resection. The frequency of anastomotic leakage is grossly affected by the anastomosis technique and whether it was in cervical or in thoracic position.     

Collare Anastomosenstenosen nach Magenhochzug beim Ösophaguskarzinom

Common late complications after esophagectomy and gastric tube reconstruction for esophageal carcinoma are symptomatic, benign fibrotic stenoses of the cervical anastomosis, which require dilatation. Since the prognosis of esophageal carcinoma still remains poor, bad functional results such as dysphagia affect quality of life. In a retrospective analysis, our patients were evaluated with regard to the underlying effects of cervical anastomotic stenosis after esophagectomy and gastric tube reconstruction. From 1 January 1989 to 31 July 1995, 173 patients with carcinoma of the esophagus were operated in our institution. Transhiatal esophageal dissection was performed in 133 patients; 40 patients underwent transthoracic en bloc resection. The 30-day mortality rate was 7.5% (13 patients). Postoperative fibrotic stenosis of the cervical anastomosis requiring dilatation occurred in 36.4% (63 patients) 6–12 weeks after operation. Fibrotic stenosis of the cervical anastomosis did not develop in 97 patients. There was a significant difference concerning the incidence of anastomotic leaks within both groups: whereas in 23.8% of the 63 patients who developed a fibrotic stricture of the cervical anastomosis an anastomotic leak preceded this event (P<0.001), no anastomotic leak occurred in the group of 97 patients with normal healing of the cervical anastomosis. In addition, significantly (P<0.01) more patients (37.5%,n=23) with preexisting diabetes mellitus could be found among the 63 patients who developed a fibrotic stricture of the cervical anastomosis, in contrast to the 97 patients without anastomotic stenosis.     

Revascularization using the short gastric vessels of the gastric tube after subtotal esophagectomy for intrathoracic esophageal carcinoma

BACKGROUND: Maintaining sufficient blood flow to the substitutive organ after esophagectomy is essential to decrease the risk of anastomotic leakage. STUDY DESIGN: Forty-one patients underwent subtotal esophagectomy for intrathoracic esophageal carcinoma and reconstruction using the gastric tube. Additional vascular anastomosis between the short gastric vessels and the vessels in the neck was performed in 15 patients. Tissue blood flow was measured by laser Doppler flowmetry before and after vascular anastomosis. The incidence of anastomotic leakage in the revascularization group was compared with that in the remaining 26 patients. RESULTS: Venous anastomosis was performed in 14 patients and arterial anastomosis in 9. There was a significant increase in tissue blood flow after venous anastomosis alone (mean percent increase: 36%; p < 0.01), and after arterial and venous anastomoses (mean percent increase: 108%; p < 0.01). No anastomotic leakage was observed in the revascularization group; six patients (23.1%) in the control group had leakage (p < 0.05). Patients in the revascularization group started taking a meal 10.0 +/- 0.4 days postoperatively, compared with 15.1 +/- 1.8 days in the control group (p < 0.05). CONCLUSIONS: Additional vascular anastomosis in esophageal reconstruction after subtotal esophagectomy achieved good results. This procedure can reduce the risk of anastomotic leakage and may be useful for esophageal reconstruction.     

食管腐蚀性烧伤后严重狭窄的外科治疗

目的探讨食管腐蚀性烧伤后狭窄的外科治疗经验及胃或横结肠代食管重建手术的应用价值。方法对98例食管腐蚀性烧伤后狭窄的患者中72例广泛食管狭窄、病变超过食管中段以上者采用横结肠代食管、保留结肠左动脉升支、胸骨后顺蠕动吻合,其中横结肠咽腔吻合18例,横结肠食管颈部吻合54例,胸段食管旷置不切除;26例狭窄位于中下段,经胸切除瘢痕段食管用胃重建食管,胃食管胸内吻合。结果结肠食管重建72例中,术后死亡4例（5．56％）,发生颈部吻合口瘘14例（19．44％）,后期出现颈部吻合口狭窄7例,经治疗后均痊愈。胃重建食管26例无手术死亡,术后发生胸内吻合口狭窄3例,经扩张治愈。结论食管腐蚀性烧伤后狭窄在伤后20～24周可积极采取食管重建术,根据食管狭窄段严重程度及位置决定是否行狭窄段食管切除、选择食管重建替代物及吻合的位置。可采用横结肠食管颈部吻合或结肠咽腔吻合术,胸内胃食管吻合术。     

食管切除颈部消化道重建术后吻合口良性狭窄形成的影响因素

目的：探讨食管切除颈部消化道重建术后吻合口良性狭窄形成的影响因素。方法回顾性分析2003-2012年间在南京医科大学附属淮安医院接受食管癌切除术并行颈部消化道重建的946例食管癌患者的临床资料。吻合口良性狭窄定义：出现吞咽困难症状、经内镜证实需内镜扩张治疗,同时排除经病理证实的恶性病变。分别应用χ^2检验和Logistic回归分析来明确与吻合口良性狭窄形成相关的危险因素。结果156例（16．5％）患者术后出现颈部吻合口良性狭窄。单因素分析显示,心血管病史（P＝0．001）、糖尿病病史（P＝0．041）、管状胃重建（P＝0．050）、端端吻合（P＝0．013）及术后出现吻合口瘘（P＝0．008）与术后吻合口良性狭窄发生有关。多因素分析显示,心血管病史（P＝0．004）、管状胃重建（P＝0．026）、端端吻合（P＝0．043）及术后吻合口瘘（P＝0．001）为吻合口良性狭窄形成的独立影响因素。结论食管切除管状胃颈部重建具有较高的吻合口良性狭窄发生率。对于具有心血管病史者,应维持术后血压的稳定;尽量避免行端端吻合;对于术后吻合口瘘者,在瘘口愈合后可考虑尽早行内镜扩张以预防吻合口狭窄的形成。     

Using the supercharge technique to additionally revascularize the gastric tube after a subtotal esophagectomy for esophageal cancer

BACKGROUND: Maintaining sufficient blood flow to the gastric tube after a subtotal esophagectomy for esophageal cancer is crucial for decreasing esophagogastric anastomotic leakage. METHODS: After subtotal esophagectomy for esophageal cancer, the supercharge technique was performed in 21 esophageal reconstruction patients to additionally revascularize the gastric tube using the splenic artery and vein, external carotid artery, and internal jugular vein. Operative results of the supercharge group were retrospectively compared with those of the control group (patients not receiving the technique). RESULTS: Both operation time and operative blood loss in the supercharge group were significantly longer and larger than those of the control group. However, the incidence of anastomotic leakage was significantly lower in the supercharge group than in the control group. CONCLUSION: This practical supercharge technique reduces leakage during esophageal anastomosis.     

Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis

OBJECTIVE: The purpose of the study was to compare in prospective randomized fashion a manually sutured esophagogastric anastomosis in the neck and a stapled in the chest after esophageal resection and gastric tube reconstruction. SUMMARY BACKGROUND DATA: Despite the fact that all reconstructions after esophagectomy will result in a cervical or a thoracic anastomosis, controversy still exists as to the optimal site for the anastomosis. In uncontrolled studies, both neck and chest anastomoses have been advocated. The only reported randomized study is difficult to evaluate because of varying routes of the substitute and different anastomotic techniques within the groups. The reported high failure rate of stapled anastomoses in the neck and the fact that most surgeons prefer to suture cervical anastomoses made us choose this technique for anastomosis in the neck. Our routine and the preference of most surgeons to staple high thoracic anastomoses became decisive for type of thoracic anastomoses. METHODS: Between May 9, 1990 and February 5, 1996, 83 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (41 patients) or an esophagogastric anastomosis in the chest (42 patients). To evaluate selection bias, patients undergoing esophageal resection during the same period but not randomized (n = 29) were also followed and compared with those in the study (n = 83). Objective measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery. The long-term survival rates were compared with the log-rank test. RESULTS: Two patients (1.8%) died in hospital, and the remaining 110 patients were followed until death or for a minimum of 60 months. The genuine 5-year survival rate was 29% for chest anastomoses and 30% for neck anastomoses. The overall leakage rate was 1.8% (2 cases of 112) with no relation to mortality or anastomotic method. All patients in the randomized group had tumor-free proximal and distal resection lines, but 1 patient in the nonrandomized group had tumor infiltrates in the proximal resection margin. At 3, 6, and 12 months after operation, there was no difference in anastomotic diameter between the esophagogastric anastomosis in the neck and in the thorax (P = 0.771), and both increased with time (P = 0.004, ANOVA repeated measures). Body weight development was the same in the two groups. With similar results in randomized and nonrandomized patients, study bias was eliminated. CONCLUSIONS: When performed in a standardized way, neck and chest anastomoses after esophageal resection are equally safe. The additional esophageal resection of 5 cm in the neck group did not increase tumor removal and survival; on the other hand, it did not adversely influence morbidity, anastomotic diameter, or eating as reflected by body weight development.     

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??Application and study of the delta-shaped anastomosis technique in laparoscopic radical resection of gastric stump cancer LIU Hong-bin??XU Wei??YU Jian-ping??et al. Department of General Surgery, Lanzhou General Hospital of Lanzhou Military Command of PLA??Lanzhou 730050??China
Corresponding author??LIU Hong-bin??E-mail??Liuhongbin999@163.com
Abstract Objective To investigate the safety and efficacy of the delta-shaped esophageal and jejunum anastomosis technique in laparoscopic radical resection of gastric stump cancer. Methods The clinical data of 8 patients with gastric stump cancer admitted between June 2013 and April 2014 in Lanzhou General Hospital of Lanzhou Military Command of PLA were analyzed retrospectively. All the patients were performed laparoscopic radical resection of gastric stump cancer and reconstruction of digestive tract with delta-shaped anastomosis technique. The perioperative status??lymph node dissection and complications were analyzed and followed up. Results Eight patients were performed laparoscopic radical resection of gastric stump cancer successfully. The average operation time was (213.8±21.7) min??including the delta-shaped esophageal and jejunum anastomosis time (29.3±4.8) min. The average amount of bleeding was (105.6±23.4) mL and the average number of lymph node was 29.8±4.1. All the patients were extubated on the first days after operation with the average bed time after operation (0.8±0.3) d??semi liquid food time (1.8±0.3) d??the first ventilation time after operation (2.3±0.4) d??the average hospital stay time after operation (7.3±0.8) d. There was no case of postoperative anastomotic stricture??obstruction??hemorrhage and other complications related to operation??and no death during perioperative period. All the patients recovered and were discharged. The follow-up time was (2-12) months. All the patients were in good condition??can be fed normal diet. Conclusion The delta-shaped anastomosis technique in reconstruction of digestive tract is safe??feasible in laparoscopic radical resection of gastric stump cancer. It can obtain satisfactory short-term effect.     

Esophageal resection with fundus rotation gastroplasty

Esophageal resection with fundus rotation gastroplasty. Anastomotic failure after esophageal resection remains a surgical problem with high clinical relevance. Anastomotic failure can be attributed to tension at the anastomosis especially in cervical anastomoses, as well as a perfusion deficit due to resection of the arterial arcade along the gastric lesser curvature. We attributed the anatomical deficiencies of conventional gastroplasties by developing a technique, that utilizes the whole gastric fundus and maintains the arterial arcade along the gastric lesser curvature: fundus rotation gastroplasty. Experimentally those tubes are 20 % longer than conventional tubes according to Kirschner/Akiyama and twice as good perfused. Clinically low failure rates of 7 % for cervical and thoracic anastomoses are achieved.     

Video-assisted surgery for gastric carcinoma arising in a gastric tube reconstructed retrosternally

Advances in diagnostic and surgical techniques have improved the prognosis of esophageal cancer, but there is growing concern about gastric tube cancer after esophagectomy. Gastric carcinoma arising in tubes that were reconstructed retrosternally is usually resected through a median sternotomy; however, this is invasive and carries a risk of osteomyelitis after suture-line failure. We performed video-assisted gastric tube resection, eliminating the need for sternotomy by using a sternal lifting method, on a 71-year-old man who had previously undergone esophagectomy and reconstruction retrosternally. The tumor was a Borrmann type 1 advanced cancer located near the esophagogastric anastomosis. Neck collar and upper abdominal incisions were made, and the sternum was lifted using a Kent retractor to extend the retrosternal space. Under videoscope assistance, we stripped the adhesions around the gastric tube carefully and performed total gastric tube resection. For the reconstruction, the ileocolon was lifted through the retrosternal space, and an ileoesophagostomy and Roux-en-Y reconstruction were performed. Despite leakage from an esophago-ileoanastomosis on postoperative day 6, the patient recovered well without mediastinitis or osteomyelitis of the sternum. Thus, our surgical procedure provides a good surgical view, decreases surgical stress, and reduces the risk of fatal postoperative complications.     

Complete mechanical cervical anastomosis using a narrow gastric tube after esophagectomy for cancer.

OBJECTIVE: Fibrous stenosis of the esophagogastric cervical anastomosis remains a significant complication occurring in up to one-third of cases. Trying to reduce the incidence of this complication, we describe our technique of cervical esophagogastric anastomosis using endoscopic linear stapler which seems to reduce the incidence of fibrous stricture formation after resection of esophageal cancer. METHODS: Between March 2000 and June 2003, 26 patients (15 males and 11 females) underwent esophagectomy using tubulized stomach for reconstruction. Cervical esophagogastric anastomosis using linear endoscopic stapler was performed in all cases. The occurrence of post-operative anastomotic leak and development of anastomotic stricture were recorded and analyzed. RESULTS: All patients survived esophagectomy and were available for post-operative follow-up. Anastomotic leak developed in one case. No patient developed fibrous stenosis that required dilatation therapy. CONCLUSION: Complete mechanical esophagogastric anastomosis, using endoscopic linear stapler is effective and safe, even when a narrow gastric tube is used as esophageal substitute. This technique seems superior to other techniques to reduce the incidence of post-operative anastomotic complications.     

Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer

A 59-year-old man with a history of the thoraco-abdominal esophagus resection with retrosternal gastric tube reconstruction for esophageal cancer complicated by anastomosis leakage and purulent pericarditis was admitted for aortic regurgitation due to infective endocarditis. Floppy vegetation and worsening cardiac failure indicated aortic valve replacement. In a median sternotomy approach, the thickest adhesion between the cervical esophagus and posterior surface of the manubrium sternae was freed using an ultrasonic osteotome. Severe adhesions in the pericardium due to purulent pericarditis were found. Median sternotomy enabled minimal exposure of the aortic root, upper right atrium, and right superior pulmonary vein for instituting extracorporeal circulation and replacing the aortic valve. The patient’s postoperative course was uneventful. For cardiac surgery in patients with a retrosternal gastric tube, left anterior or right thoracotomy may be considered to avoid gastric tube injury. Median sternotomy, however, is an alternative enabling safe heart exposure, and the ultrasonic osteotome was very useful in incising the sternum without injuring the cervical esophagus, which had no serosa.     

Aortic valve replacement after retrosternal gastric tube reconstruction for esophageal cancer.

A 59-year-old man with a history of the thoraco-abdominal esophagus resection with retrosternal gastric tube reconstruction for esophageal cancer complicated by anastomosis leakage and purulent pericarditis was admitted for aortic regurgitation due to infective endocarditis. Floppy vegetation and worsening cardiac failure indicated aortic valve replacement. In a median sternotomy approach, the thickest adhesion between the cervical esophagus and posterior surface of the manubrium sternae was freed using an ultrasonic osteotome. Severe adhesions in the pericardium due to purulent pericarditis were found. Median sternotomy enabled minimal exposure of the aortic root, upper right atrium, and right superior pulmonary vein for instituting extracorporeal circulation and replacing the aortic valve. The patient's postoperative course was uneventful. For cardiac surgery in patients with a retrosternal gastric tube, left anterior or right thoracotomy may be considered to avoid gastric tube injury. Median sternotomy, however, is an alternative enabling safe heart exposure, and the ultrasonic osteotome was very useful in incising the sternum without injuring the cervical esophagus, which had no serosa.     

Does seeding of intraluminal tumour cells cause anastomotic recurrence after oesophageal resection?

BACKGROUND: Recurrence at the cervical anastomosis of a tumour of the oesophagogastric junction after resection of the oesophagus with gastric tube reconstruction is a peculiar phenomenon in view of the distance of the primary tumour from the proximal anastomosis. It is hypothesised that contamination with tumour cells from the nasogastric tube or the gastric reconstruction tube could be responsible for this phenomenon. METHOD: Fifteen patients with a tumour of the oesophagus or gastric cardia were included. During the operation the nasogastric tube was left in the resected specimen. Debris from the tube was washed out for cytological examination. Also the gastric reconstruction tube was washed out and the debris examined for malignant cells. RESULTS: In all of the patients with a tumour extending intraluminally malignant cells were found in the nasogastric tube or the gastric reconstruction tube or both. In 92% of these patients malignant cells were found in the nasogastric tube, while 60% of the gastric reconstruction tubes were contaminated with tumour cells. CONCLUSION: The presence of intraluminal malignant cells during oesophageal resection and gastric tube reconstruction is very high, possibly leading to anastomotic recurrence. Measures should be taken to minimise local contamination with tumour cells.     

腹腔镜残胃癌根治术中应用三角吻合技术研究（附8例报告）

目的 探讨腹腔镜残胃癌根治术运用食管空肠三角吻合的安全性及近期疗效。方法 回顾性分析2013年6月至2014年4月兰州军区兰州总医院收治的8例残胃癌病人的临床资料,均行腹腔镜残胃癌根治术,消化道重建采用食管空肠三角吻合,分析病人术中术后情况、淋巴结清扫、并发症等并随访观察。结果 8例病人均成功施行腹腔镜残胃癌根治术,平均手术时间（213.8±21.7）min,其中食管空肠三角吻合时间（29.3±4.8）min,术中出血量（105.6±23.4）mL,清扫淋巴结（29.8±4.1）枚。所有病人均于术后第1天拔除胃管,术后下床时间（0.8±0.3）d,进食半流质时间（1.8±0.3）d,术后首次通气时间（2.3±0.4）d,术后住院时间（7.3±0.8）d。所有病人术后均未出现吻合口狭窄、梗阻、出血等并发症,无围手术期死亡,均痊愈出院。随访时间为2～12个月,病人一般情况良好,均可正常饮食。结论 腹腔镜残胃癌根治术中采用食管空肠三角吻合技术进行消化道重建安全、可行,近期疗效较好。     

Metachronous gastric carcinoma from a gastric tube after radical surgery for esophageal carcinoma

BACKGROUND: Cases of metachronous gastric carcinoma arising from a gastric tube used for reconstruction have been increasing in long-term survivors of esophageal cancer in recent years. We investigated the characteristics of gastric tube carcinoma to determine the most appropriate approach to managing it. METHODS: Between 1980 and 1997, 508 patients underwent radical esophagectomy for esophageal carcinoma at Keio University Hospital. Reconstruction was performed with a gastric tube in 414 (81.5%) of them, and 8 of them developed a metachronous carcinoma in the gastric tube. The clinical and pathologic characteristics of the gastric tube carcinomas were evaluated in this study. RESULTS: Gastric cancer was detected during follow-up endoscopic examinations or in an upper gastrointestinal series in seven patients. All of the cancers were diagnosed as adenocarcinoma histopathologically. Endoscopic mucosal resection was performed in two patients, partial resection of the residual stomach was performed in three patients. One patient was treated by endoscopic mucosal resection as palliative therapy, since he had severe pulmonary emphysema. Total resection of the gastric tube was attempted in 2 advanced cases but was unsuccessful because of direct invasion of other organ by the cancer. The 5 patients who underwent curative resection are alive with no subsequent recurrence. CONCLUSIONS: Since early diagnosis permits less invasive treatment and curative treatment is difficult in advanced cases, strict postoperative examinations are important after radical esophagectomy to ensure early detection of metachronous gastric carcinoma arising from gastric tubes used for reconstruction.     

下咽及颈段食管癌的外科治疗

目的探讨下咽及颈段食管癌的外科治疗途径。方法分析１９８０年以来７６例下咽及颈段食管癌的外科治疗,其中位于下咽者３１例,颈段食管者４５例。结果下咽癌的切除率为９８６％（３０／３１）,食管重建包括口底食管吻合３例;咽、喉及颈段食管切除后用颈阔肌皮瓣重建１２例、游离空肠间插３例,全咽、全喉、全食管切除后用胃重建１２例。颈段食管癌的切除率为９１％（４１／４５）,除１例外均采用非开胸食管切除后用胃重建食管。术后并发症的发生率在用胃重建的５２例为３６５％（包括１例术后死于心力衰竭）,游离空肠者３３３％,颈阔肌皮瓣重建者为１６７％。随访２～１０８个月（平均５６５个月）,下咽癌的１、３、５年生存率分别为７９３％、６０％和３１６％,颈段食管分别为６８３％、９５％和０。结论下咽及颈段食管癌的切除率甚高,但下咽癌的远期疗效明显优于颈段食管癌。咽、喉及颈段食管切除后采用颈阔肌皮瓣重建是一种安全、有效的手术方法,并发症少,远期效果优良。     

A case of cardiac tamponade following esophageal resection

We report a rare case of cardiac tamponade after esophageal resection for esophageal cancer. A 69-year-old man underwent subtotal esophagectomy and reconstruction of the gastric tube with cervical anastomosis via the poststernal route and three-field lymphadectomy via a median sternotomy. On postoperative day 4, the patient developed dyspnea, chest oppression, and hemodynamic instability due to cardiac tamponade. Emergency percutaneous catheter drainage was performed to manage the cardiac tamponade. Acute pericarditis due to the original surgical procedure was suspected to be the cause of the tamponade. Although rare, cardiac tamponade should be considered as a cause of hemodynamic instability after esophageal resection.     

Additional microvascular anastomosis in reconstruction after total esophagectomy for cervical esophageal carcinoma.

BACKGROUND: Maintaining sufficient blood flow to the substitute organ after total esophagectomy is essential for decreasing the risk of anastomotic leakage. Additional venous, or arterial and venous, anastomoses between the vessels of the gastric tube and the vessels in the neck after total esophagectomy are described for 11 patients with cervical esophageal carcinoma. METHODS: The tissue blood flow was measured by laser Doppler flowmetry before and after anastomosis. Venous anastomosis was performed for all 11 patients, and arterial anastomosis was added for 7 patients. RESULTS: A significant increase in tissue blood flow was observed after venous anastomosis alone (mean, 19%; P < 0.05) and after arterial and venous anastomoses (mean 43%; P < 0.01). There was no anastomotic leakage or hospital death. CONCLUSIONS: This procedure may reduce the risk of anastomotic leakage especially in the case of pharyngogastrostomy following total esophagectomy.