Prior chemoradiation and retrosternal placement of conduit were risk factors for development of benign anastomotic stricture after esophagectomy using a hand-sewn technique

Abstract

BACKGROUND: Benign anastomotic stricture is a complication of esophagectomy that affects quality of life. The purpose of this study is to identify risk factors for development of such strictures after a hand-sewn anastomosis. METHODS: A retrospective study was performed on a prospectively collected database for patients who had undergone curative esophagectomy from 1994 - 2008 for esophageal cancer. Patients who had the anastomosis constructed by a one-layer continuous technique using a fine absorbable monofilament suture were included. Stricture was defined as dysphagia promoting endoscopic dilatation. Risk factors for development of stricture were identified using univariate and multivariate logistic regression analyses. RESULTS: Esophagectomy was performed in 526 patients. The median age was 66 yrs (21-89) and 423 (80.4%) were male. Benign strictures developed in 125 (23.4%) patients at a median of 55 days (range 18-2230) after surgery, requiring a median of 2 dilatations (range: 1-25); 113 (85%) needed less than 4 dilatations. Of the 125 patients, 75 (60%) developed stricture within 60 days after esophagectomy. Prior chemoradiation (OR 2.602, 95% CI (1.635-4.141), p<0.001) and retrosternal placement of conduit (OR 2.806, 95% CI (1.349-5.838), p=0.006) were independent predictive factors on multivariate analysis. Organ used for esophageal replacement, anastomtoic leakage, the site of anastomosis, and medical complications were not. When refractory stricture was defined by those requiring 4 or more dilatations, the only predictive factor was delayed appearance of stricture at 60 days or more after operation (OR 2.562, 95% CI (1.082-6.067), p=0.032). CONCLUSIONS: Neoadjuvant chemoradiation and retrosternal placement of conduit were independent predictors for development of benign anastomotic strictures after esophagectomy. Most patients required less than 4 dilatations. Delayed in appearance of stricture (more than 60 days after surgery) predicted the need of more dilatations.