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Esophageal Anastomosis
Techniques Raphael Bueno, MD
Associate Chief, Division of Thoracic Surgery
Brigham and Women’s Hospital
Professor of Surgery
Harvard Medical School
2013 AATS/STS General Thoracic Surgery Symposium
Disclosures
• See booklet
• No relevant disclosures
Why Does it Matter?
• Outcome
– Quality of swallowing
• Complications
– Strictures (early and late)
– Leak (escalating categories of severity) • even minor ones increase the late risk of strictures
– Dehiscence (caused by a significant leak or conduit necrosis)
– TEF (misadventure, infection, dilatation)
Price et al. Ann thorac Surg 2013;95:1154-61)
Paper Surgery Technique Procedure Type Locaion Total Cases Leak Number
Luketich et al. Minimally Invasive 3-hole neck 481 26
Minimally Invasive Ivor-Lewis chest 530 23
Sihag et al. Minimally Invasive Ivor-Lewis chest 38 0
Open Ivor-Lewis chest 76 2
Nguyen et al. Minimally Invasive 3-hole neck 47 3
Minimally Invasive Ivor-Lewis chest 51 5
Ben-David et al.Minimally Invasive 3-hole (82) & transhiatal (18) (# of leaks in each not documented)neck 100 4
Open hybrid Ivor-Lewis (majority are, but number not documented)chest 32 4
Price et al. Open & Minimally Invasive Ivor-Lewis (254), 3-hole (49), transhiatal (115), thoracoabdominal (6), minimally invasive Ivor-Lewis (8) (# leaks in each not documented)neck 164 34
Open & Minimally Invasive Ivor-Lewis (254), 3-hole (49), transhiatal (115), thoracoabdominal (6), minimally invasive Ivor-Lewis (8) (# leaks in each not documented)chest 268 16
Schroder et al. Open Ivor-Lewis chest 181 17
Open Ivor-Lewis (but w/ischemic conditioning of gastric conduit via laparoscopic mobilization of stomach 4-5 days prior to surgery)chest 238 18
Pham et al. Minimally Invasive 3-hole neck 44 4
Open Ivor-Lewis chest 46 5
Recent Reported Leak Rate
6%
Recent review of STS database 11.3% leak rate in 2,315 patients
Incidence of Strictures or Post-op
Dilatations
Paper Surgery Technique Location Total Cases Strictures
Nguyen et al. Minimally Invasive neck 47 11
Minimally Invasive chest 51 14
Price et al. Open & Minimally Invasive neck 164 40
Open & Minimally Invasive chest 268 37
Pham et al. Minimally Invasive neck 44 3
Open chest 46 0
Chang et al. not specified neck 225 97
not specified chest 643 222
28%
Avoiding Complications Surgical Parameters
• The conduit (usually stomach) needs to be:
– Well-vascularized
– Adequately mobilized (reduce tension)
– Treated gently
– Ischemic portion resected
• The anastomosis needs to be:
– Sufficiently wide
– Closed securely (water-tight)
Surgical Factors Proposed as
Affecting Anastomosis • Anatomical Location (neck, chest)
– Physical constraints • Space
• Tension
• Distance (available proximal esophagus)
• Type of operation (cavities involved, open vs MIE)
• Conduit used (whole vs tube)
• Trauma while handling the conduit
• Technique (incorporating mucosa, no excessive sutures)
• Coverage of anastomosis (omentum)
• Surgeon’s experience
• Blood loss
• Running suture vs. interrupted vs. 2 layers
Patient Factors that May Affect
Anastomosis • Nutritional status (albumin/pre-albumin)
• Prior radiation +/-chemotherapy
• Diabetes
• Vascular disease
• Hypotension
• Hypoxemia
• Obesity/Body and neck habitus
• Gender
• Smoking history
• Prior gastric or esophagael surgery
Anastomotic Methods
• Hand-sewn
• Linear-stapled
• Circular-stapled
• Hybrid
Q55. Which factor is most likely
predisposing to leak?
a. Tension
b. Location
c. Preop chemorad
d. Technique
Hand-Sewn Anastomosis
• Multi-layer vs Single
layer
• Include mucosa
• Longitudinal muscle
• End to side
• Interrupted vs running
• Type of suture
*Adult Chest Surgery
McGraw Hill
Linear-Stapled Anastomosis
*Adult Chest Surgery
McGraw Hill
Tips on Stapled Anastomosis
• Usually side to side
• Make sure conduit orientation is correct
• Tension on conduit just right
• Avoid the tip
• Cover with omentum if available
• Make sure it is not too narrow
• You can leave an NGT through the gastric tip
• Side to side can be double barreled or up and down, relevant in the chest
Esophagectomy Movies
and Much More
Visit the AATS Learning Center
Exhibit Hall, Aisle 400
Sunday May 5th starting at 5 pm
Through Tuesday May 7th
*Maas et al Surgical Endoscopy 2012 26;1795-1803
Circular Stapler Approach
Circular Stapler
• Anvil can be placed
open or trans-oral
• The bigger the better
• Dilate carefully
• Anvil can be fixed in by
purse-string or tie
*Maas et al Surgical Endoscopy 2012 26;1795-1803
Hybrid Anastomosis
Incidence of Leaks
Orringer 2000 SMA (3/114) 2.7%
HSA (n>1000) 14%
Collard 1998 SMA 6.2%
Casson 2002 SMA (3/38) 7.9%
HSA (12/53) 22.6%
Jo 2006 SMA (n=13) 0%
Katariya (meta-analysis)1994 HSA (n>1300) 15%
Singh 2001 SMA 6%
HSA 23%
Ercan 2005 SMA 4%
HSA 11%
Behzadi 2005 SMA 5.3%
HSA 12.7%
Lerut SMA 2.4%
HSA 9.4%
Incidence of Strictures
Orringer 2000 SMA 35%
HSA (n>1000) 48%
Collard 1998 SMA (1/16) 6.7%
HSA (10/24) 41.7%
Casson 2002 SMA 7.9%
HSA 17%
Jo 2006 SMA (1/13) 7.7%
Singh 2001 SMA 19%
HSA 58%
Ercan 2005 SMA 66%
HSA 90%
Behzadi 2005 SMA 14.6%
HSA 34%
Lerut SMA 32.5% HSA 50.0%
Comparison Between Leak in
Chest and Neck
Luketich et al Annals of surgery 2012 256;95-103
Comparison between Stricture
Rates Chest vs Neck
Pham et al 2010 American Journal of Surgery 199;594-598
Analysis of 432 Anastomosis
Price et al Ann Thorac Surg 2013;95:1154-1162
Price et al Ann Thorac Surg 2013;95:1154-1162
Johansen et al. Ann Surg 2009. 250; 667-673
Conclusions • Hand-sewn anastomosis is associated with more
complications but not higher mortality
• Linear stapled or modified anastomoses have fewer complications
• Clinically significant leaks occur with the same frequency in the chest and neck
• Size matters (EEA>25 if possible)
• Location and case dependent (affects what is possible)
• Post op PPI have a role in reducing strictures
• Evolution continues (Dogma is incorrect)