Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis

Abstract

Objective: The purpose of the study was to compare in prospective randomized fashion a manually sutured esophagogastric anastomosis in the neck and a stapled in the chest after esophageal resection and gastric tube reconstruction.

Summary background data: Despite the fact that all reconstructions after esophagectomy will result in a cervical or a thoracic anastomosis, controversy still exists as to the optimal site for the anastomosis. In uncontrolled studies, both neck and chest anastomoses have been advocated. The only reported randomized study is difficult to evaluate because of varying routes of the substitute and different anastomotic techniques within the groups. The reported high failure rate of stapled anastomoses in the neck and the fact that most surgeons prefer to suture cervical anastomoses made us choose this technique for anastomosis in the neck. Our routine and the preference of most surgeons to staple high thoracic anastomoses became decisive for type of thoracic anastomoses.

Methods: Between May 9, 1990 and February 5, 1996, 83 patients undergoing esophageal resection were prospectively randomized to receive an esophagogastric anastomosis in the neck (41 patients) or an esophagogastric anastomosis in the chest (42 patients). To evaluate selection bias, patients undergoing esophageal resection during the same period but not randomized (n = 29) were also followed and compared with those in the study (n = 83). Objective measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery. The long-term survival rates were compared with the log-rank test.

Results: Two patients (1.8%) died in hospital, and the remaining 110 patients were followed until death or for a minimum of 60 months. The genuine 5-year survival rate was 29% for chest anastomoses and 30% for neck anastomoses. The overall leakage rate was 1.8% (2 cases of 112) with no relation to mortality or anastomotic method. All patients in the randomized group had tumor-free proximal and distal resection lines, but 1 patient in the nonrandomized group had tumor infiltrates in the proximal resection margin. At 3, 6, and 12 months after operation, there was no difference in anastomotic diameter between the esophagogastric anastomosis in the neck and in the thorax (P = 0.771), and both increased with time (P = 0.004, ANOVA repeated measures). Body weight development was the same in the two groups. With similar results in randomized and nonrandomized patients, study bias was eliminated.

Conclusions: When performed in a standardized way, neck and chest anastomoses after esophageal resection are equally safe. The additional esophageal resection of 5 cm in the neck group did not increase tumor removal and survival; on the other hand, it did not adversely influence morbidity, anastomotic diameter, or eating as reflected by body weight development.

FIGURE 1. The gastric tube substituting the esophagus was created by serial applications of a linear cutting stapling device, TLC 55 (Ethicon, Stockholm, Sweden) parallel to and at a distance of 6 cm from the greater curvature, starting approximately 8 cm proximal to the pylorus at the Crow’s foot (A). When the patients were randomized to receive a neck anastomosis, a running, single-layer end-to-end technique with 4–0 Polydioxanone (PDS II, Ethicon, Sweden) was used through all the layers (B). When the patients were randomized to chest anastomosis (C), the esophagogastrostomy was performed, end-to-greater curvature, by insertion of a circular stapling device (Premium CEEA or Premium CEEA Plus, Autosuture, Sweden) through the subsequently resected (TLH 90 or TL 60, Ethicon, Sweden) lesser curvature. By this technique, everting staple lines in the proximal part of the substitute, the circulation in the most critical part could be evaluated. Care was taken to insert the subsequent stapler in the angle of the previous staple row. The crossings of the staple lines were oversewn; otherwise, no form of reinforcing sutures were used.

FIGURE 2. The width of the anastomoses was calculated by inserting an aortic occlusion catheter (Fogarty occlusion catheter, model 62-080-8/22F, Bentley-Edwards, Irvine, CA) along with the endoscope. With a syringe we inflated the balloon exactly to the width of the anastomosis (A ml, arrows). After deflating the balloon, the catheter was withdrawn without disconnecting it from the syringe. Outside the patient, the balloon was reinflated (A ml, arrows) and the diameter was measured with a vernier caliper (B mm).

FIGURE 3. Anastomotic diameters in the randomized patients who volunteered for serial measurements 3, 6, and 12 months and occasionally at less than 3 months and more than 12 months after surgery. Number of patients (n), mean, and 95% confidence interval are shown. ANOVA (repeated measures model) was used to test for differences. The few patients, 3 in the neck group and 1 in the chest group, that sought medical attention prior to the scheduled follow-up (<3 months) were measured, dilated, but not included in the ANOVA calculations because of small numbers.

FIGURE 4. Dysphagia score in patients randomized to neck or chest anastomosis. Grade 0 = no dysphagia; Grade 1 = occasional episodes; Grade 2 = required liquids to clear; Grade 3 = food impaction requiring medical treatment. There were no differences between groups or within groups from 3 to 12 months.

FIGURE 5. The body weight (kg) development following gastric pull-up esophagectomy during the first postoperative year was similar for patients randomized to neck or chest anastomoses (P = 0.883, ANOVA repeated measures model). Mean and 95% confidence interval are shown.

FIGURE 6. Cumulative survival rates (Kaplan-Meier) by anastomotic site in 74 randomized patients with esophageal cancer. It is seen from the censored data (living patients), marked with plus signs (+), that all patients are followed until death or >5 years, resulting in a genuine 5-year survival rate of 29% (chest anastomoses) and 30% (neck anastomoses), respectively. Median survival time for neck anastomoses was 23.1 months (95% confidence interval, 6.9–39.4 months), and for chest anastomoses 23.0 months (95% confidenceinterval, 4.9–41.0 months).