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)