Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis

Background: Although the acute postoperative complications of a cervical es ophagogastric anastomosis are less than those with an intrathoracic esophag eal anastomosis, the long-term sequelae of a cervical anastomotic leak are not as minor as initially reported. Nearly 50% of cervical anastomotic leak s result in an anastomotic stricture, and the subsequent need for chronic d ilatations negates the merits of an operation intended to restore comfortab le swallowing. Objective: This study was undertaken to determine whether co nstruction of a side-to-side stapled cervical esophagogastric anastomosis a fter transhiatal esophagectomy could reliably eliminate the majority of ana stomotic leaks. Methods: In 114 consecutive patients undergoing transhiatal esophagectomy, a functional side-to-side cervical esophagogastric anastomo sis was constructed with the Auto Suture Endo-GIA II stapler (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn) applied directly through the cervical wound. This side-to-side stapled anastomosis has 3 rows of staples. Early postoperative anastomotic morbidity, subseque nt need for anastomotic dilatations, and patient satisfaction with swallowi ng were evaluated. Results: Before the side-to-side stapled anastomosis, th e incidence of cervical esophagogastric anastomosis leak in over 1000 patie nts undergoing transhiatal esophagectomy having a manually sewn anastomosis varied from 10% to 15%, Among the 111 survivors of transhiatal esophagecto my and a side-to-side stapled anastomosis, there were 3 (2.7%) clinically s ignificant anastomotic leaks. This lowered incidence of leaks has contribut ed to reduction in the average length of stay after an uncomplicated transh iatal esophagectomy to 7 days and has provided more comfortable swallowing, ease of subsequent esophageal dilatations, and greater patient satisfactio n. Conclusions: Construction of the cervical esophagogastric anastomosis wi th a side-to-side stapled anastomosis greatly reduces the frequency of anas tomotic leaks and later strictures. The side-to-side stapled anastomosis is a major technical advance in the progression of refinements of transhiatal esophagectomy and a cervical esophagogastric anastomosis.