Why is there a high incidence of of esophageal anastomosis?

Answer 1

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.

The organ most used for reconstruction after esophagectomy is the stomach.[1,2] Advantages include ease of construction and the prospect to achieve a substitute of sufficient length. Proximal gastric necrosis, with subsequent gastroduodenal content contaminating the anastomotic area, is a disastrous complication, however, and bears a high mortality rate irrespective of whether the anastomosis is in the neck or in the thorax.[3,4] The ideal anastomotic localization has been the subject of several clinical investigations[1,3-5] but has not been adequately evaluated. Some authors favor cervical esophagogastric anastomoses despite an increased incidence of leakage,[5]stricture formation,[6] and damage to the recurrent laryngeal nerve[7] because of better tumor eradication[5] and reduced mortality and morbidity associated with an anastomotic breakdown.[1,2,4] Others deny a difference in leakage rates,[3] stricture frequency,[3,5] and the innocence of dehiscence in cervical anastomoses[3,5,8] or a better long-term survival.[5] The variation in the results might be explained by different methods of preparing, localizing, and anastomosing the esophageal substitute.

The quality of an anastomosis is infrequently expressed as anastomotic diameter but more often is judged by the frequency of stricture during follow-up. This may be misleading because there is no accepted definition of a stricture. Nor is dysphagia a good marker because it is well known that patients can experience dysphagia with a wide anastomosis and, vice versa, patients may not seek medical attention because of dysphagia until the anastomosis is only a couple of millimeters wide.[9] Moreover, it is not reported the length of the additional esophageal resection necessary for a neck anastomosis. The consequence of this on anastomotic width and postoperative weight development has not been studied.

This trial was designed to compare in a prospective randomized fashion two methods of esophagogastric anastomosis, one in the neck and the other in the apex of the right chest, in a group of patients not affected by perioperative radiochemotherapy. The number of patients required in the study to reach 80% power was based on the high radiologic leakage frequency of about 20% for neck anastomoses reported at study start[5] and the hope to improve it to the more acceptable level of 2% for intrathoracic anastomoses.[10] Hospital mortality and morbidity, anastomotic level and diameter, body weight development, and long-term survival were the endpoints.