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J Thorac Cardiovasc Surg 1996;111:1141-1148
© 1996 Mosby, Inc.

GENERAL THORACIC SURGERY

BENIGN ANASTOMOTIC STRICTURES AFTER TRANSHIATAL ESOPHAGECTOMY AND CERVICAL ESOPHAGOGASTROSTOMY: RISK FACTORS AND MANAGEMENT

Presented in part at the meeting of the American Gastroenterological Association during the Digestive Disease Week, San Diego, Calif., May 1995.

Received for publication July 11, 1995 Accepted for publication Oct. 5, 1995. Address for reprints: P. Honkoop, MD, Department of Internal Medicine II, Division of Gastroenterology (Room Ca 405), University Hospital Rotterdam—Dijkzigt, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.

Abstract

Benign stricture formation at the cervical anastomosis after transhiatal esophagectomy with gastric tube interposition is an important source of morbidity. In a large group of patients(n= 269) who had undergone transhiatal esophagectomy with gastric tube interposition, we examined surgical and nonsurgical risk factors for the development of benign strictures at the cervical anastomosis. In addition, we evaluated the results of endoscopic bougie dilation in patients in whom an anastomotic stricture developed. Results: During follow-up, 114 patients (42%) had a benign anastomotic stricture. Only a history of cardiac disease (p = 0.03), postoperative leakage at the anastomosis (p = 0.002), and a stapled rather than a hand-sewn anastomosis (p = 0.04) were found to be independent risk factors for the development of a stricture. In 27 of 60 patients with anastomotic leakage, contrast swallow examination demonstrated only a leak at the anastomosis. Endoscopic bougie dilation of anastomotic strictures was successful in 78% of patients after a median of three dilation sessions (range 1 to 28). In 3% of patients dilations were still being performed, and 19% of patients had died before normal swallowing had been achieved. In two of 519 (0.4%) dilation sessions a major complication occurred. Conclusions: (1) Patients with preoperative cardiac disease are at an increased risk for anastomotic stricture. (2) Even in patients having no symptoms, a contrast swallow can detect anastomotic leakage that results in an increased risk for the development of anastomotic strictures. (3) The benefit of the stapler device for anastomosis remains to be determined. (4) Endoscopic bougie dilation with the patient mildly sedated is a safe and effective method for the treatment of anastomotic strictures. (J THORAC CARDIOVASC SURG 1996;111:1141-8)

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