Telescopic esophageal anastomosis: operative technique, clinical experiences

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Nonspecific motility disorders, irritable esophagus, and chest pain

This paper presents commentaries on whether Starling's law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic- and gender-based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high-resolution manometry in noncardiac chest pain; whether pH-impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.

Stents for benign and malignant esophageal strictures

This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.

Embedded cervical esophagogastrostomy: a simple and convenient method using a circular stapler after esophagectomy for esophageal carcinomas

Background

Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.

Methods

In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.

Results

A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.

Conclusions

Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.

Cervical esophagogastric anastomosis with invagination after esophagectomy

PURPOSE: To evaluate the incidence of fistula and stenosis of the cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach after subtotal esophagectomy. METHODS: We studied 54 patients who underwent subtotal esophagectomy, 45 (83.3%) patients with carcinoma and nine (16.6%) with advanced megaesophagus. In all cases the cervical esophagogastric anastomosis was performed with the invagination of the proximal esophageal stump inside the stomach. RESULTS: Three (5.5%) patients had a fistula at the esophagogastric anastomosis, two of whom with minimal leakage of air or saliva and with mild clinical repercussion; the third had a low output fistula that drained into the pleural space, and this patient developed empyema that showed good progress with drainage. Fibrotic stenosis of anastomosis occurred in thirteen (24%) subjects and was treated successfully with endoscopic dilatation. CONCLUSION: Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula and stenosis, thus becoming an attractive option for the reconstruction of alimentary transit after subtotal esophagectomy.

Esophagogastric anastomosis with invagination into stomach: New technique to reduce fistula formation

AIM: To present a new technique of cervical esophagogastric anastomosis to reduce the frequency of fistula formation.

METHODS: A group of 31 patients with thoracic and abdominal esophageal cancer underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube. In the region elected for anastomosis, a transverse myotomy of the esophagus was carried out around the entire circumference of the esophagus. Afterwards, a 4-cm long segment of esophagus was invaginated into the stomach and anastomosed to the anterior and the posterior walls.

RESULTS: Postoperative minor complications occurred in 22 (70.9%) patients. Four (12.9%) patients had serious complications that led to death. The discharge of saliva was at a lower region, while attempting to leave the anastomosis site out of the alimentary transit. Three (9.7%) patients had fistula at the esophagogastric anastomosis, with minimal leakage of air or saliva and with mild clinical repercussions. No patients had esophagogastric fistula with intense saliva leakage from either the cervical incision or the thoracic drain. Fibrotic stenosis of anastomoses occurred in seven (22.6%) patients. All these patients obtained relief from their dysphagia with endoscopic dilatation of the anastomosis.

CONCLUSION: Cervical esophagogastric anastomosis with invagination of the proximal esophageal stump into the stomach tube presented a low rate of esophagogastric fistula with mild clinical repercussions.

[Comparative study of end-to-end cervical esophagogastric anastomosis with or without invagination after esophagectomy for cancer]

OBJECTIVE

To assess the incidence of fistula and stenosis of cervical esophagogastric anastomosis with invagination of the esophageal stump into the gastric tube in esophagectomy for esophagus cancer.

METHODS

Two groups of patients with thoracic and abdominal esophagus cancer undergoing esophagectomy and esophagogastroplasty were studied. Group I comprised 29 patients who underwent cervical esophagogastric anastomosis with invagination of the proximal esophageal stump segment within the stomach, in the period of 1998 to 2007 while Group II was composed of 36 patients submitted to end-to-end cervical esophago-gastric anastomosis without invagination during the period of 1989 to 1997.

RESULTS

In Group I, esophagogastric anastomosis by invagination presented fistula with mild clinical implications in 3 (10.3%) patients, whereas in Group II, fistulas with heavy saliva leaks were observed in 11 (30.5%) patients. The frequency of fistulas was significantly lower in Group I patients (p=0.04) than in Group II. In Group I, fibrotic stenosis of anastomoses occurred in 7 (24.1%) subjects, and 10 patients (27.7%) in Group II evolved with stenosis, while no significant difference (p=0.72) was found between the two groups.

CONCLUSION

In esophagectomy for esophagus cancer, cervical esophagogastric anastomosis with invagination presented a lower rate of esophagogastric fistula versus anastomosis without invagination. Stenosis rates in esophagogastric anastomosis proved similar in both approach with or without invagination.

[Surgical treatment for early Barrett cancer]

Adenocarcinomas in Barrett's oesophagus are more commonly diagnosed at an early stage due to effective surveillance programmes. Subtotal oesophagectomy with extended lymphadenectomy is considered the best curative treatment for patients with early adenocarcinoma of the oesophagus. However, such treatment carries substantial morbidity and compromises quality of life. Limited resection, minimal invasive surgical procedures or endoscopic mucosal ablation have been proposed as less invasive alternatives. A comparison of treatment associated morbidity, recurrence rate, long-term survival and functional outcome suggests that none of these alternative methods can be universally recommended. An individualized strategy should be employed based on staging (tumour penetration into the mucosa/submucosa, presence of lymph node metastasis), multicentricity, length of the underlying Barrett mucosa and risk factors of the patient. Surgical resection (radical or limited) remains the treatment of choice for tumours invading the submucosa, or multicentric and recurrent tumours after endoscopic mucosectomy.

Anastomotic stricture complicating esophagectomy

Regardless of the definition, anastomotic strictures are a common complication after esophagectomy and adversely affect quality of life. They are best avoided by careful surgical technique that minimizes conduit ischemia during preparation, placement, and anastomosis. Anastomotic technique must assure an adequate anastomotic area. The Collard anastomosis, a significant advance in the construction of esophagogastric anastomoses, routinely assures adequate anastomotic area and thus assures fewer anastomotic strictures. The use of small-diameter (21-mm and 25-mm) circular staplers is discouraged, because they are unquestionably associated with the occurrence of major anastomotic strictures. Anastomotic leaks precede many anastomotic strictures, but strictures are not inevitable after leaks. Other variables are less reliably associated with anastomotic strictures. Treatment requires diagnosis and exclusion of recurrent cancer and other causes of stricture. Dilation is safe, but diligence with repeated sessions is necessary to restore swallowing. Reoperation is rarely required.