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Esophageal anastomoses: sutured and stapled

Jon shenfine and Glyn G. Jamieson

PRINCIPLES AND JUSTIFICATION

The penalties of anastomotic leak from an esophageal anastomosis can be severe. They vary from mortality to a prolonged and traumatic hospital stay or considerable postoperative morbidity, particularly with respect to dysphagia from strictures. This interferes with postoperative quality of life. The causes of anastomotic dehiscence are undoubtedly multifactorial, with both local and systemic factors playing a role. The esophagus itself has no serosa and longitudinal muscles hold sutures poorly. Surgical exposure may also be awkward and gastric fundal perfusion can be compromised through a number of factors. Surgeons have striven to reduce anastomotic-related complications through a variety of surgical approaches and techniques. The fact that most of these variations persist suggests that debate continues over the optimum technique and even the optimum site of the anastomosis.

SITE AND APPROACH

Reconstruction of the continuity of the alimentary tract following esophagectomy is typically completed in the neck or the chest. It is generally perceived that cervical anastomoses are associated with lower mortality if a leak occurs, since drainage through an opened cervical wound is regarded as less life-threatening than a leak in the chest. However, not infrequently, a cervical leak passes through the thoracic inlet, and cervical anastomoses are thought to be associated with a higher risk of leak, anastomotic stricture, and recurrent laryngeal nerve injury than intrathoracic reconstructions. Therefore, the main factor that drives the operative approach should be oncological necessity. For example, a cervical approach and anastomosis may be required to provide adequate longitudinal clearance of an upper third esophageal squamous cell carcinoma; equally, a transthoracic approach and anastomosis may be necessary for a type III junctional adenocarcinoma where the proximal gastric resection might compromise conduit length. Thereafter, the site of anastomosis is dependent on surgical preference, experience, and the proposed radicality of the associated nodal dissection. In addition, there has been a recent and dramatic expansion in minimally invasive surgical approaches to esophagectomy. These approaches employ similar anastomotic techniques but the literature suggests that they are associated with a higher rate of postoperative gastric necrosis. Robot-assisted surgery with improved optics and articulated instruments that allow fine control within a confined space is now an option and should in theory complement a minimally invasive approach. However, there have been reports of increased airway injuries, long operating times, and an extremely high cost. The potential benefits of these new approaches and technology are still being evaluated.

Essentially, both hand-sewn and stapled anastomotic techniques can be applied equally to either neck or chest with minor variations. The variety of surgical techniques for anastomosis makes it difficult to compare them. In addition, the underlying clinical heterogeneity of patients in most cases requires an individualized approach to surgical treatment.

CONDUIT

The stomach is the most commonly used organ for reconstruction following esophagectomy (see Chapter 30, “Use of the stomach as an esophageal substitute”). It is flexible and has a plentiful blood supply, allowing for ease of construction of a well-vascularized, tension-free conduit. This approach is uncomplicated and associated with an excellent long-term functional result. There are a number of circumstances where a colonic or jejunal interposition may be used and more appropriate (refer to Chapter 31, “Use of the colon as an esophageal substitute”), but this chapter will only focus on an esophagogastric anastomosis. One very important point is that the gastric conduit should be fashioned such that it retains as much width as possible (at least 5-6 cm). This has been shown to reduce the risk of gastric ischemia and necrosis, by preserving the intramural vascular arcades.

HAND-SEWN TECHNIQUES

Thoracic

The anastomosis should be undertaken in the apex of the thoracic cavity, above the level of the azygos vein. The esophagus is transected and the specimen resected for histology (and “back table” dissection of nodal stations). Four fullthickness stay sutures are placed at 3, 6, 9, and 12 o’clock positions in the esophagus, to aid safe manipulation and prevent retraction of layers (see Figure 29.1 ). The gastric conduit is checked for vascularity and length. The conduit is brought up to the apex of the chest lying posterior to the esophagus. Two nonabsorbable sutures are used to anchor the apex of the conduit to the esophagus as high as is practicable. An “esophageal lumen”-sized gastrotomy is made on the anterior stomach wall, a minimum of 2 cm from the newly sutured or stapled margin of the tubularized conduit to minimize the risk of angle of sorrow gastric necrosis (see Figure 29.2 ). The authors favor a single-layer continuous anastomosis but there are other excellent alternative suturing techniques that can be employed, such as a two-layer interrupted closure. In all cases, full-thickness stitches are taken, ensuring at least 4-5 mm of tissue in each bite, and moving around the span by 3-4 mm.

The anastomosis is started in the posterior midline using a double-ended needled 3-0 monofilament absorbable suture. The knot is thrown intraluminally and midlength so that equal spans of suture are available for each needle (see Figure 29.3 ). Care should be taken to draw the gastric conduit up to the esophagus rather than the other way around, otherwise there is risk of the sutures cutting out through the serosa-less longitudinal muscles of the esophageal wall. An over-and-over running suture is fashioned “inside out” on the stomach and “outside in” on the esophagus. Once one side of the posterior wall is completed, the suture is left “outside” the stomach and the other suture commenced but going inside out on the esophagus and outside in on the conduit, with the last throw situated on the outside of the esophagus.

The sutures are then completed anteriorly, over and over, so that when they meet they can be tied securely across the suture line (see Figure 29.4 ). If there is any concern about the anastomotic integrity, further “external” horizontal mattress sutures may be placed to buttress the anastomosis. The nasogastric tube is readvanced through the join and into the distal stomach and secured at the nose.

There is often a reasonable amount of redundant greater curve fat/omentum. The authors recommend placing this between the conduit and the airway, and then wrapping the omentum over the anastomosis. Some surgeons perform a modified loose fundoplication over the anterior surface of the anastomosis using interrupted nonabsorbable sutures, believing it reduces reflux.

Cervical

The cervical hand-sewn anastomosis bears similarities to the thoracic approach. However, the anastomosis is usually constructed on the posterior aspect of the gastric conduit rather than anteriorly. The authors prefer to use a longitudinal gastrotomy rather than transverse to minimize ischemia. As well, the authors perform a single-layer join with full-thickness interrupted absorbable sutures, as this uses less gastric conduit length (see Figures 29.5 through 29.7). Care should be taken when transecting the esophagus to ensure that enough esophagus is present to facilitate the anastomosis. A simple rule to follow is to ensure there is enough esophagus to reach the skin for esophagostomy should this be required. Once completed, the anastomosis is gently returned into the wound so that the join sits neatly in the lower part of the wound. The wound is drained and closed.

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