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

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