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.     

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.     

Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage

Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty‐one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3‐year and 5‐year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.     

Appropriate routes of reconstruction following transthoracic esophagectomy

BACKGROUND/AIMS: The effectiveness of reconstructive methods after esophagectomy remains controversial. METHODOLOGY: A total of 211 patients who underwent transthoracic esophagectomy and esophagogastric anastomosis using the gastric conduit were enrolled in this study. A retromediastinal approach was used in 79 patients and a retrosternal approach in 132. The surgical outcomes were compared between the two groups. RESULTS: In the retrosternal group, anastomotic leakage (26.5%), stenosis of the anastomosis (13.6%), and respiratory complications (18.2%) were frequently observed. Five patients died of aspiration pneumonia probably due to stenosis of the anastomotic site in the retrosternal group. In the retromediastinal group, two patients died from bleeding of a peptic ulcer in the gastric conduit. Partial resection of the manubrium significantly reduced the incidence of leakage in the retrosternal group (4/29 vs. 31/68, p=0.0305). Retrosternal approach and stage were independent prognostic factors for overall survival whereas only stage was an independent prognostic factor for disease-specific survival. CONCLUSIONS: Retrosternal reconstruction is suggested as the unwillingly adopted method of choice after palliative esophagectomy (R2) for the following radiotherapy. Partial resection of the bony structures can be used to prevent postoperative morbidity in this operative procedure. Retromediastinal reconstruction is the possible method of choice in patients receiving curative esophagectomy.     

A comparative study of the lengths of different reconstruction routes used after thoracic esophagectomy

Background

A challenge in esophageal reconstruction after esophagectomy is that the distance from the neck to the abdomen must be replaced with a long segment obtained from the gastrointestinal tract. The success or failure of the reconstruction depends on the blood flow to the reconstructed organ and the tension on the anastomotic site, both of which depend on the reconstruction distance. There are three possible esophageal reconstruction routes: posterior mediastinal, retrosternal, and subcutaneous. However, there is still no consensus as to which route is the shortest.

Methods

The length of each reconstruction route was retrospectively compared using measurements obtained during surgery, where the strategy was to pull up the gastric conduit through the shortest route. The proximal reference point was defined as the left inferior border of the cricoid cartilage and the distal reference point was defined as the superior border of the duodenum arising from the head of the pancreas.

Results

This study involved 112 Japanese patients with esophageal cancer (102 men, 10 women). The mean distances of the posterior mediastinal, retrosternal, and subcutaneous routes were 34.7?±?2.37 cm, 32.4?±?2.24 cm, and 36.3?±?2.27 cm, respectively. The retrosternal route was significantly shorter than the other two routes (both p?<?0.0001) and shorter by 2.31 cm on average than the posterior mediastinal route. The retrosternal route was longer than the posterior mediastinal route in only 5 patients, with a difference of less than 1 cm.

Conclusion

The retrosternal route was the shortest for esophageal reconstruction in living Japanese patients.

     

Comprehensive investigations of quality of life after esophagectomy with special reference to the route of reconstruction

BACKGROUND/AIMS: Esophagectomy is a very invasive operation, therefore, it is important to improve the postoperative quality of life (QOL) of the patients. The aim of this study was to evaluate the QOL of patients who had undergone esophagectomy for thoracic esophageal cancer. METHODOLOGY: We investigated 37 patients who had undergone esophagectomy. The anastomosis was made at the cervical location by the retrosternal route in 12 patients (RS group), at the high thoracic location by the posterior mediastinal route in 18 patients (HT group), and at the cervical location by the posterior mediastinal route in seven patients (PM group). QOL was evaluated by patient questionnaires concerning reflux esophagitis using QUEST and dumping syndrome, body weight, ambulatory pH monitoring, and immunostaining for iNOS and COX-2 as markers of inflammation. RESULTS: The QUEST score revealed that the findings suggesting reflux were few in the HT group. Patients suffered from dumping syndrome were significantly few in the HT group (p = 0.0399). The percentage time of pH < or =4.0 was shortest in the HT group at the position of the esophagogastric anastomosis (p < 0.0281). Body weight recovery was best in HT group (p < 0.0001). There was a tendency that iNOS and COX-2 immunoreactivity were weaker in HT group than other two groups. CONCLUSIONS: Our results suggest that QOL after esophageal reconstruction using a gastric tube is good in patients with the anastomosis at the high thoracic location by the posterior mediastinal route.     

Prevention and management of complications after colon interposition for corrosive esophageal burns

SUMMARY. We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric‐esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow‐up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re‐operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co‐ordination needs attention. Peri‐operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.     

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

SUMMARY.  Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86% vs 25%, P  = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI ( P <  0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II ( P <  0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1β and tumor necrosis factor-α were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1β of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.     

Feeding catheter gastrostomy at esophagectomy with gastric tube reconstruction through posterior mediastinal route

We introduce our novel and original idea of placing a feeding catheter gastrostomy (FCG) at esophagectomy with gastric tube reconstruction through the posterior mediastinal route. The 9-Fr catheter was inserted into the jejunum through the gastric tube by the creation of submucosal and Witzel tunnels on the gastric antrum. Among the 45 patients who underwent FCG, the catheter was guided to the anterior abdominal wall through the sub-diaphragm route in 25 patients (group A) or the extra-peritoneal route with the overlapping of catheter entry by the omentum in 20 patients (group B). There were no cases of spontaneous catheter prolapse or bowel obstruction. Five out of 45 patients (11.1%), including 4 (16%) in group A and 1 (5%) in group B, showed mild and transient localized peritonitis after catheter removal. The extra-peritoneal route with omental cover is recommended for safe indwelling catheterization. FCG is useful for avoiding jejunostomy-related bowel obstruction.     

Comparison between different reconstruction routes in esophageal squamous cell carcinoma

AIM:To compare postoperative complications and prognosis of esophageal squamous cell carcinoma patients treated with different routes of reconstruction. METHODS:After obtaining approval from the Medical Ethics Committee of the Sun Yat-Sen University Cancer Center, we retrospectively reviewed data from 306 consecutive patients with histologically diagnosed esophageal squamous cell carcinoma who were treated between 2001 and 2011. All patients underwent radical McKeown-type esophagectomy with at least two-field lymphadenectomy. Regular follow-up was performed in our outpatient department. Postoperative complica-tions and long-term survival were analyzed by treatment modality, baseline patient characteristics, and operative procedure. Data from patients treated via the retrosternal and posterior mediastinal routes were compared. RESULTS:The posterior mediastinal and retrosternal reconstruction routes were employed in 120 and 186 patients, respectively. Pulmonary complications were the most common complications experienced during the postoperative period (46.1% of all patients; 141/306). Compared to the retrosternal route, the posterior mediastinal reconstruction route was associated with a lower incidence of anastomotic stricture (15.8% vs 27.4%, P = 0.018) and less surgical bleeding (242.8 ± 114.2 mL vs 308.2 ± 168.4 mL, P 0.001). The median survival time was 26.8 mo (range:1.6-116.1 mo). Upon uni/multivariate analysis, a lower preoperative albumin level (P = 0.009) and a more advanced pathological stage (pT; P = 0.006; pN; P 0.001) were identified as independent factors predicting poor prognosis. The reconstruction route did not influence prognosis (P = 0.477). CONCLUSION:The posterior mediastinal route of reconstruction reduces incidence of postoperative complications but does not affect survival. This route is recommended for resectable esophageal squamous cell carcinoma.     

Treatment of dysphagia in esophageal carcinoma: Transthoracic En-Bloc esophagectomy and reconstruction 48 hours later

In 82 consecutive patients with esophageal cancer (90% squamous cell carcinoma, 10% adenocarcinoma) transthoracic “en bloc” esophagotomy with regional lymphadenectomy was performed. The reconstruction with gastric interposition was carried out with delayed urgency in a second operation 48–72 h after the initial procedure. The results of this group were compared to a group of 65 patients who had transmediastinal esophagectomy without thoractotomy and mediastinal as well as suprapancreatic lymphadenectomy and immediate reconstruction by gastric interposition. The number of postoperative risk situations concerning cardiopulmonary features were comparable in both groups. The 30-day mortality rate and postoperative morbidity was not significantly different between both patient groups (mortality rate: transthoracic: 6.6%, transmediastinal: 7.7%). The advantages of a 2-stage procedure are that esophagectomy and especially mediastinal lymphadenectomy can be performed precisely without time pressure. After 2 days the stomach is hypotonic and dilated as a result of truncal vagotomy and can easily be elevated to the neck. The interval of 48–72 hours was chosen because the postoperative right-to-left shunt has nearly normalized after this time period. En bloc esophagectomy and reconstruction with delayed urgency can be performed without disadvantages compared to a 1-stage procedure. It can especially be recommended for operations in which esophagectomy and mediastinal lymphadenectomy are difficult and wearisome.     

Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.     

Reflux esophagitis and columnar‐lined esophagus after cervical esophagogastrostomy (following esophagectomy)

Reflux esophagitis (RE) and columnar‐lined esophagus (CLE) are frequently observed after esophagectomy. The incidence of these conditions according to time and to the route of esophageal reconstruction after esophagectomy remains unknown. The aim of this study was to clarify any changes and differences of the incidence of RE and CLE in patients who underwent gastric tube reconstruction after esophagectomy. A hundred patients who underwent cervical esophagogastrostomy after resection of the thoracic esophagus were included in this study. We reviewed their endoscopic findings at 1 month, at 1 year and at 2 years after surgery, and compared the incidence rates of RE and CLE with the passage of time and among the three reconstruction routes; a subcutaneous route, a retrosternal route, and a posterior mediastinal route. The incidence rate of RE was 42%, 37% and 38%, at 1 month, 1 year and at 2 years after surgery, respectively. There was no significant difference in the incidence of RE according to the time after surgery. The incidence rate of severe RE (Grade C and D in the Los Angeles Classification) was 9% percent at 1 month after surgery, 18% at 1 year after surgery and 22% at 2 years after surgery, significantly increasing with passage of time. The incidence rate of CLE was 0% at 1 month after surgery, 14% at 1 year after surgery and 40% at 2 years after surgery, significantly increasing with passage of time. No difference was observed in the incidence of RE and that of CLE among the three routes of esophageal reconstruction. Severe RE and CLE increase with passage of time after cervical esophagogastrostomy. Therefore, careful endoscopic follow‐up is necessary for such patients irrespective of the route of esophageal reconstruction.     

Motility of the transverse colon used for esophageal replacement

The authors studied the motility of transverse colon used for reconstruction of the pharyngogastric transit after esophagectomy. The study included 10 patients who underwent esophagectomy 15 to 201 months (median, 48.5 months) before motility evaluation. Nine patients underwent operation because of caustic injury and one, because of esophageal cancer. The age of the patients ranged from 19 to 54 years (median, 36 years). A manometric esophageal catheter with five side holes spaced 5 cm apart (using the continuous perfusion method) was used to record motility. In three patients, it was not possible to introduce the manometric catheter inside the colon interposition. In the other seven, most of the time there was no contraction when motility was recorded. In four, there was contraction only in the segment 2 to 5 cm below the upper esophageal sphincter. In three, there were peristaltic or simultaneous contractions of long duration, sometimes associated with dry or wet swallows. The motility of colon interposition used to restore transit after esophagectomy is similar to that described for the colon. The contractions may be the consequence of graft distention after successive swallows.     

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.     

How important is the route of reconstruction after esophagectomy: a prospective randomized study

OBJECTIVE: A prospective randomized trial was performed to compare retrosternal and posterior mediastinal gastric tube reconstruction with regard to postoperative function and quality of life. METHODS: Twenty-six patients were randomly allocated to either retrosternal (n = 14) or posterior mediastinal (n = 12) reconstruction after gastric tube formation. Radionuclide transit studies were applied to obtain objective functional data and a standardized quality-of-life assessment was performed. RESULTS: Retrosternal reconstruction showed an increased morbidity (15 vs 13 major complications) and mortality (14.2 vs 8.3%). Radionuclide clearance in the supine position was delayed in the gastric tube in general, compared with normal controls (retention index > 40% vs < 10%). There was a significantly higher retention (p < 0.005) in the retrosternal group in the middle third of the tube and the whole tube after intake of the liquid tracer. The retention of the first solid tracer was also higher in the retrosternal group in the middle third of the tube (p = n.s.) and was significantly higher in the whole tube after 30 (p < 0.05) and 60 (p < 0.01) s. This had no significant impact on the patients' quality of life. CONCLUSIONS: The posterior mediastinal route of reconstruction is recommended but curative resection (R0) is mandatory to avoid possible complications due to local tumor relapse. After incomplete resection (R1 or R2) we recommend retrosternal reconstruction for better palliation.     

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     

Risk factors for complications after pharyngolaryngectomy with total esophagectomy

Background

Pharyngolaryngectomy with total esophagectomy (PLTE) is an effective surgical treatment for synchronous or metachronous hypopharyngeal or laryngeal cancer and thoracic esophageal cancer, although it is more invasive than esophagectomy and total pharyngolaryngectomy. The aim of this study was to identify risk factors for complications after PLTE.

Methods

From November 2002 to December 2014, a total of 8 patients underwent PLTE at the Shizuoka Cancer Center Hospital, Shizuoka, Japan. We investigated the clinicopathological characteristics, surgical procedures, and postoperative complications of these patients.

Results

Of the 8 patients, 5 underwent one-stage PLTE and 3 underwent staged PLTE. There was no mortality in this study. Two cases of tracheal necrosis, two of anastomotic leakage, and one of ileus were observed as postoperative complications. Two patients who underwent one-stage PLTE with standard mediastinal lymph node dissection developed tracheal necrosis and severe anastomotic leakage.

Conclusion

One-stage PLTE and standard mediastinal lymph node dissection were identified as the risk factors for severe postoperative complications. Staged PLTE or transhiatal esophagectomy should be considered when PLTE is performed and standard mediastinal lymph node dissection should be avoided when one-stage PLTE is performed with transthoracic esophagectomy.

     

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.     

Does the interponat affect outcome after esophagectomy for cancer?*

Clinical decision-making in esophageal cancer surgery is a process of balancing the risks of treatment against potential benefits, such as survival and quality of life. Various options are available for esophageal reconstruction. While these reconstructive options do not directly have an impact on cancer survival, they do affect operative morbidity and long-term quality of life. The affect of various interponats (reconstructive conduits) and routes of reconstruction on operative morbidity and foregut function is reviewed. Gastric interponats are preferred for esophageal reconstruction because of their reliable vascularity and the relative simplicity of the reconstructive operation. Colon interponats supposedly provide better long-term function as an esophageal substitute (unproven), but at the cost of increased operative complexity and morbidity. Colon interposition is therefore reserved for situations in which gastric transposition is not feasible. Both posterior and anterior mediastinal routes of gastric interponat reconstruction are acceptable (meta-analysis of randomized controlled trials). Posterior mediastinal reconstruction is usually preferred when a complete (R0) resection has been accomplished. Anterior mediastinal reconstruction may prevent secondary dysphagia after incomplete (R1, R2) resections.