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344 Sutured anastomoses
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A row of interrupted horizontal mattress sutures are
5
placed between the esophagus and the conduit. The
suture is a 3/0 absorbable monofilament and is placed seromuscularly in the conduit and in the longitudinal and circular muscle layers of the esophagus. These are positioned
3–4 mm apart and taking about 3 mm of the esophagus or
stomach wall. The sutures are held in hemostats prior to the
conduit being parachuted or snugged into position and the
sutures gently tied. The lateral sutures are left long and held in
hemostats acting as marker stays.
5
The back wall of the anastomosis is now completed with
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full thickness interrupted sutures at approximately
3 mm intervals. These are continued across the anterior wall,
knots lying intra- or extraluminally. The initial stays are
removed as encountered. The importance of clearly identifying and including the submucosa in each bite is stressed, as
this is the strongest layer of the serosal deficient esophagus.
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The anterior layer of horizontal mattress sutures can be
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finished using the lateral marker stays to help guide the
position of the lateral sutures.
In an attempt to reduce tension on the anastomosis, buttressing sutures from the conduit to the diaphragm or mediastinal pleura are occasionally inserted.
CONTINUOUS SINGLE LAYER – INTRATHORACIC
ANASTOMOSIS
The preparation is the same and again stay sutures are
placed in the four quadrants of the esophagus. The gastrotomy can be made full thickness initially, but it is our preference to make it through the seromuscular layer only at
this stage. This prevents bleeding and spillage of gastric contents.
Operation 345
7
8
The back wall of the anastomosis is started in the midline
8
or at the left extremity with a double-ended needled 3/0
monofilament suture. The bite is either full thickness through
the stomach wall, or through the seromuscular layer, and full
thickness through the esophagus again taking great care to
incorporate the submucosa. The knot is thrown intra- or
extra-luminally and mid length giving an equal span of suture
for each needle.
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With the gastric seromuscular layer incised, the back and
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side walls are completed with an over-and-over running
stitch from “inside”–out on the stomach and outside–in on
the esophagus. Once the posterior aspect of the anastomosis
is finished the suture is brought “inside” out of the stomach.
If the seromuscular suture on stomach has been used the
mucosa is now divided with scissors, taking care to suck away
all gastric content. The anterior suture is then inserted, again
in an over-and-over fashion passing from outside–in on the
stomach and from inside–out on the esophagus. When the
posterior suture is reached, the two sutures are tied securely.
An antireflux anastomosis
INTRODUCTION
Rudolf Nissen in 1938 undertook a resection of the gastroesophageal junction in a young woman, and following an endto-side esophagogastrostomy he buried the anastomosis to
guard against leakage. He found subsequently that the patient
developed no reflux and it was this case which led to the antireflux operation popularly known as a Nissen fundoplication.
9
Given that reflux can be a major detrimental factor in quality of life after an esophagectomy, it is perhaps surprising that
Nissen’s example has not been followed.
The performance of a modified fundoplication requires
just two prerequisites. First that approximately 3–4 cm of
intrathoracic esophagus is present and second that the
gastric conduit can reach up or nearly up to the apex of the
thorax.
ANTIREFLUX ANASTOMOSIS WHEN GASTRIC CONDUIT IS
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MAINLY INTACT
The preparation of the esophagus is identical to that
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the surgeon to place his left hand behind the stomach after its
apex has been sutured to the esophagus and the anastomosis
constructed, by applying upwards pressure on the part of the
stomach to be wrapped around the anastomosis. A threesuture fundoplication is now constructed with interrupted
nonabsorbable sutures placed 5–10 mm apart on the stomach. The proximinal suture also incorporates the esophageal
wall. As with antireflux surgery, the aim is to make a loose
wrap. We have not used a bougie but concede it may be
helpful.
described in the hand-sewn technique. It is useful for
Operation 347
10
ANTIREFLUX ANASTOMOSIS WHEN GASTRIC CONDUIT HAS
BEEN MADE MORE TUBULAR
The tubed stomach is brought up as an inverted J and
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the bend in the J is sutured to the esophagus. The limb
of the stomach to the right of the esophagus is now brought
over the anastomosis and sutured with between two and four
interrupted nonabsorbable sutures.
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POSTOPERATIVE CARE
It is important to realize that these modified fundoplications
can act just as effectively as a one-way valve as fundoplications carried out for reflux disease. Therefore we always use a
nasogastric tube to keep the stomach decompressed until day
7 or 8 postoperatively, when a contrast swallow is performed
to make sure that the stomach is emptying adequately (and
coincidentally to check for an anastomotic leak).
OUTCOME
Clinical anastomotic leak rates of less than 5% are readily
achievable using these techniques. Integrating an antireflux
anastomosis into our clinical practice has neither affected the
anastomotic leak rate nor the anastomotic stricture rate
(25%). However, it has significantly reduced symptoms of
severe post-operative reflux from 63% to 12%. We stress the
basic surgical principles of producing a well vascularized, tension free anastomosis with minimal surgical trauma, but, this
must be combined with intensive post-operative care to help
maintain tissue oxygenation.
FURTHER READING
Aly A, Jamieson GG, Pyragius M, et al. Antireflux anastomosis following
esophagectomy. Australian and New Zealand Journal of Surgery
2004;74: 434–8.
Chasseray VM, Kiroff GK, Buard JL, et al. Cervical or thoracic
anastomosis for esophagectomy for carcinoma. Surgery, Gynecology
and Obstetrics 1989; 169: 55–62.
Collard JM, Romagnoli R, Goncette L, et al. Terminalized semimechanical
side-to-side suture technique for cervical esophagogastrostomy.
Annals of Thoracic Surgery 1998; 65: 814–17.
Dan HL, Bai Y, Meng H, et al. A new three-layer-funnel-shaped
esophagogastric anastomosis for surgical treatment of esophageal
carcinoma. World Journal of Gastroenterology 2003; 9: 22–5.
Lerut T, Coosemans W, Decker G, et al. Anastomotic complications after
esophagectomy. Digestive Surgery 2002; 19: 92–8.
Orringer MB, Iannettoni MD, Marshall B. Eliminating the cervical
esophagogastric anastomotic leak with a side-to-side stapled
anastomosis. Journal of Thoracic and Cardiovascular Surgery 2000;
119: 277–88.
Patil PK, Patel SG, Mistry RC, et al. Cancer of the esophagus:
esophagogastric anastomotic leak – a retrospective study of
predisposing factors. Journal of Surgical Oncology 1992; 49: 163–7.
Santos RS, Raftopoulos Y, Singh D, et al., Utility of total mechanical
stapled cervical esophagogastric anastomosis after esophagectomy:
a comparison to conventional anastomotic techniques. Surgery
2004; 134: 917–25.
Urschel JD. Esophagogastrostomy anastomotic leaks complicating
esophagectomy: a review. American Journal of Surgery 1995; 169:
634–40.
Urschel JD, Blewett CJ, Bennett WF, et al. Handsewn or stapled
esophagogastric anastomoses after esophagectomy for cancer:
meta-analysis of randomized controlled trials. Diseases of the
Esophagus 2001; 14: 212–17.
Walther B, Johansson J, Johnsson F, et al. Cervical or thoracic
anastomosis after esophageal resection and gastric tube
reconstruction: a prospective randomized trial comparing sutured
neck anastomosis with stapled intrathoracic anastomosis.
Surgery 2003; 238: 803–12; discussion 812–14.
Annals of
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Stapling techniques for anastomoses of
the esophagus
GLYN G. JAMIESON MS, MD, FRACS, FRCS, FACS
Dorothy Mortlock Professor of Surgery, University of Adelaide; Professor and Chairman, Department of Surgery, Royal Adelaide Hospital,
Adelaide, South Australia, Australia
PRINCIPLES AND JUSTIFICATION
Controlled trials have not established that stapled anastomoses are either better or worse than manually sutured anastomoses. Such trials, however, have usually been performed
in units expert in the techniques of esophageal surgery. In the
hands of less expert surgeons the stapled anastomosis is quite
likely to be safer, because the anastomosis is standardized and
probably has a better blood supply than a manually constructed anastomosis.
Attention to detail is still of paramount importance,
however, and the overriding principles of lack of tension and
provision of the best possible blood supply apply for
stapled anastomoses just as for manually constructed
anastomoses.
TECHNIQUE
The esophagus receives its blood supply through intramural
vascular anastomoses, so that long segments of it can be
mobilized without jeopardizing its blood supply. Therefore,
3–5 cm of the esophagus proximal to where it is to be divided
should be mobilized.
If an automatic purse-string device is used, it is applied
1
before dividing the esophagus. If a nasogastric tube lies
in the esophagus, it is withdrawn to a point several centimeters above the site of division. The purse-string device is
placed in position and closed. A heavy tie is then placed
around the esophagus distal to the purse-string device to prevent spillage of esophageal contents.
1
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The esophagus is now divided flush with the purse-string
2
device, which is opened and removed. The ends of the
purse-string suture are retrieved and held in a pair of artery
forceps. Esophageal contents in the proximal esophagus are
suctioned out. There are two points at which the purse-string
may not be held optimally close to the esophagus. These
points are at either side where the anterior and posterior rows
of staples meet. The author secures the furthest point by placing a single over-and-over suture to incorporate the pursestring. The nearest point is where the purse-string will be tied,
and as it lies directly under vision this is not usually a problem. If necessary, an over-and-over suture can be placed here,
after the first throw of the knot on the purse-string has been
made.
3
2
The esophagus contracts and retracts after being divided,
and six stay sutures can be used to give excellent control
3
of the mouth of the esophagus. These stay sutures are placed
taking a 5- to 7-mm bite of the full thickness of the
esophageal wall, and they usually pass through the esophageal
wall incorporating the purse-string suture.
Some surgeons prefer to insert the purse-string suture
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manually. To do this, a 0 polypropylene or monofilament nylon suture on a round-bodied needle is used. The
suture begins on the anterior wall of the esophagus, passing
from outside to inside, and then is continued around the
esophagus with an over-and-over running suture taking bites
of 4–5 mm in depth and 4–5 mm apart. When one-third of
the circumference of the esophagus has been traversed, the
loop of the over-and-over suture can be held by a pair of Allis
or Babcock forceps, as this will later be used as a stay suture.
Similarly, when two-thirds of the circumference has been
dealt with, another pair of Allis or Babcock forceps can be
used to hold a second loop. The final suture is brought to the
outside of the esophagus, and both ends of the purse-string
suture and the two loop stay sutures keep the mouth of the
esophagus open.
The esophagus is now dilated with either metal dilators or
a large Foley catheter with a 25-mL balloon, which the author
has found to be very effective. The catheter is lubricated and
then inserted well into the esophagus. The balloon is slowly
but firmly inflated, and the catheter is pulled down the esophagus. The bag of the balloon tends to bring a lot of mucus
with it, and so a suction device should be held at the mouth of
the esophagus as the catheter is withdrawn.
Technique 351
5
4
An appropriately sized staple head is chosen (usually
5
25 mm or 28 mm). Holding the six stay sutures (or the
Allis or Babcock forceps) facilitates the placement of the anvil
within the esophagus. Once it is in position, the purse string
is tied snugly against the shaft of the anvil. If the surgeon is
unhappy with the purse-string suture at this stage, a further
purse string can be placed with the anvil in position.
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The main stapler is introduced into the organ being
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joined to the esophagus, and the shaft is brought through
the wall of the organ.
The anvil is clicked into position on the main shaft of the
stapler. The two parts of the stapler are closed, with care taken
that no extraneous tissue is caught between the esophagus
and the organ to which it is being joined. Closure is completed. A final check is made to see that the tissue is free all the
way around the staple head, and the instrument is fired.
The parts of the head are separated by turning the appropriate part of the stapler, and the whole device is removed by
using a gently rocking motion while at the same time maintaining a pulling traction on the instrument and supporting
the anastomosis with the opposite hand. Once the instrument
has been removed, the rings of stapled tissue are inspected to
make sure that they are complete. If there is any doubt about
the anastomosis, saline can be instilled into the esophagus
above the anastomosis to check that the join is watertight.
It is debatable if anything further should be done. If a gastroesophageal anastomosis has been constructed in the chest,
the author constructs the anastomosis on the anterior wall of
the stomach so that the remaining posterior wall can be
brought up above the anastomosis to form a fundoplication.
Such a fundoplication may prevent the troublesome complication of reflux.
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Use of the stomach as an esophageal substitute
ARNULF H. HÖLSCHER MD, FACS, FRCS
Professor of Surgery and Chairman, Department of Visceral and Vascular Surgery, University of Cologne Medical School; Director, Department
of Visceral and Vascular Surgery, Medical Center University of Cologne, Cologne, Germany
J. RÜDIGER SIEWERT MD
Professor, Director, and Chairman, Department of Surgery, Technical University of Munich, Munich, Germany
HISTORY
The use of the stomach as an esophageal substitute was introduced by Kirschner in 1920 as a nonresectional operative
bypass. His operation consisted of skeletonization of the
greater curvature of the stomach, and the mobilized stomach
was then brought subcutaneously up to the divided cervical
esophagus. The application of this procedure using either the
orthotopic or the retrosternal route after esophagectomy and
the standardization of this method was largely due to the
work of Ong, Nakayama, and Akiyama.
PRINCIPLES AND JUSTIFICATION
The reconstruction of intestinal transit after esophagectomy
is normally made using stomach or colon. The small bowel is
used much less frequently for complete substitution of the
esophagus. Small bowel interposition does have a place, however, for partial esophageal replacement of both proximal and
distal esophagus.
Gastric interposition is the simplest form of esophageal
replacement. Furthermore, as it guarantees good long-term
functional results, it has become the method of first choice as
an esophageal substitute, especially after esophagectomy for
cancer. Only when the stomach is not available because of
previous operations or in benign esophageal diseases is
colonic interposition used.
An important question to be answered in planning an
esophageal replacement is where to site the esophagoenteral
anastomosis. If intrathoracic anastomoses are performed,
they should be carried out near the apex of the pleura.
Anastomotic leakage is less likely to occur with intrathoracic
anastomosis than with cervical anastomosis, but the consequences of such a leak are much more serious. With regard to
oncologic radicality (remaining esophagus) and long-term
results, both types of anastomosis are similar.
Finally, the site for the esophageal substitute must be
chosen. Antesternal subcutaneous placement is usually not
indicated. This leaves the posterior and anterior mediastinal
routes available.
Swallowing, at least in the early postoperative phase, is
more normal when the interposition is in the posterior mediastinum. One should also note that the distance through the
posterior mediastinum is the shortest. If an intrathoracic
anastomoses is performed in the upper thorax, the gastric
conduit can only be placed in the posterior mediastinum. In
case of cervical anastomoses both routes are possible. The
posterior mediastinal route should be avoided for reconstruction if a high-risk for local recurrence exists especially after R1
or R2 resection. If a postoperative radiotherapy of the former
tumor site is planned, the anterior mediastinum should be
preferred for reconstruction in order to avoid radiation damage of the gastric conduit.
PREOPERATIVE ASSESSMENT AND
PREPARATION
The stomach may be used as an esophageal substitute only if
it has not previously been operated on. After gastric resections the length will be insufficient and after vagotomy procedures the vascularization is doubtful. If lesser procedures
(such as suturing of a bleeding ulcer or closure of a perforation) have been performed, then a transposition of the stomach may be possible, but the vascularity should be checked at
the beginning of the operation. A preoperative gastroscopy
should be carried out to exclude any mucosal pathology and
to confirm the borders of the esophageal tumor. If the cancer
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