The Art and Science of Esophageal Anastomosis

Abstract

The esophageal anastomosis is prone to leak and development of stricture. Tumor recurrence at the anastomosis is also a difficult problem to treat. Many aspects of the esophageal anastomosis are controversial. The choice of the site of the anastomosis is dependent on the location of the tumor and the method of esophagectomy. An adequate proximal resection margin ensures a low incidence of anastomotic recurrence. Leak from the esophageal anastomosis is largely technique-dependent. A hand-sewn or anastomosis with a circular stapler are equally safe though in some studies the later resulted in a higher stricture rate. This is avoided with the use of a semi-mechanical method with a linear stapler. Gastric conduit ischemia also predisposes to leaks; ischemic pre-conditioning of the gastric conduit though promising in the laboratory, has failed to result in better clinical outcome. Meticulous construction of the anastomosis and careful preparation of the gastric conduit with a tension free anastomosis are the keys to success. Death from anastomotic leak should be uncommon with modern peri-operative care.