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J Thorac Cardiovasc Surg 2007;133:581-582
© 2007 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth NHS Trust, Plymouth, Devon, United Kingdom.
Received for publication August 12, 2006; accepted for publication September 28, 2006. * Address for reprints: Enoch Akowuah, MD, MRCS, Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth NHS Trust, Plymouth Devon, PL6 8DH, United Kingdom. (Email: akowuah{at}yahoo.com).
Inkwelling (reinforcement of the gastroesophageal anastomosis) may reduce anastomotic leak rates after Ivor Lewis esophagogastrectomy. The technique was first described by Procter1
in 1967 and is routinely used by surgeons.
However, as our understanding of the causes of anastomotic dehiscence has improved, for example, the role of preoperative and postoperative nutritional status, and new surgical techniques have developed, principally the use of stapling devices, the usefulness of the inkwelling procedure in reducing anastomotic leak is debatable. A possible drawback of inkwelling is that it may lead to a narrowing of the gastroesophageal anastomotic site and therefore potentially increase the incidence of benign esophageal strictures. We routinely performed inkwelling of the gastroesophageal anastomotic site in our practice. However, after a review of our data suggested that inkwelling did not affect the rate of anastomotic dehiscence, the technique was abandoned.2 In this study, we compared the rates of benign esophageal stricture in patients having Ivor Lewis gastroesophagectomy, with or without inkwelling.
A retrospective review of all patients who underwent Ivor Lewis gastroesophageal resections from 1992 to 2004 in our unit was performed. Inkwelling was performed with 3-0 double-ended Prolene polypropylene sutures (Ethicon, Inc, Somerville, NJ). The adventitia of the proximal stomach and distal esophagus were anastomosed in 4 equidistant areas with a partial-thickness horizontal mattress technique as described by Proctor.1 The stitches were placed at least 2 cm from the stapled anastomosis and therefore led to inkwelling of the anastomosis within the gastric tube (Figure 1).
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A total of 495 patients were studied. The in-hospital mortality was 7.5% (37 deaths). Anastomotic leak rate including asymptomatic leaks diagnosed during postoperative screening and clinical anastomotic dehiscence occurred in 33 (6.7%) patients.
Mean age was 66 years (SD = 9.6 years); 337 (68%) of the patients were male. Tumor histologic classification was as follows: adenocarcinoma, 348 (70.3%) patients; squamous cell carcinoma, 109 (22%) patients; and undifferentiated 7 (1.4%) patients. The remaining 6.6% of tumors were of mixed histologic type (16 patients), oat cell (3 patients), anaplastic (10 patients), large cell (1 patient), and neuroendocrine (1 patient).
The Ivor Lewis esophagogastrectomy cohort was divided into two groups. Group A, 376 (76%) patients, had inkwelling performed and group B, 119 patients (24%), did not. Anastomotic leak rates were similar in the two groups (23 [6.1%] patients in group A versus 10 [8.4%] patients in group B; P = .4).
In group A, 183 (48.7%) patients had a benign stricture necessitating dilatation compared with only 39 (34.8%) patients with a stricture in group B (P < .001). Patients in group A underwent a mean of 2.5 (SD = 1.8) procedures, with 1.19 (SD =1.3) procedures for patients in group B (P = .03).
Benign anastomotic stricture necessitating dilation is a frequent complication after esophageal resection. The reported incidences vary from 10% to 50%.3 When it occurs early after the procedure, it delays weight gain and general recovery. When it occurs as a late complication, it significantly impairs the quality of life of the patients. In this study, we have shown that inkwelling significantly increases the incidence of benign anastomotic stricture after Ivor Lewis esophagogastrectomy without affecting that rate of anastomotic dehiscence. Of note is that our study shows a high rate of benign anastomotic stricture. A similar incidence of benign anastomotic stricture has been reported in other series.4 The incidence of stricture is influenced considerably by its definition and the quality of follow-up. In our center, patients are followed up every 6 months for life, and this may explain our high stricture detection rate.
Our study is limited by the fact that it is a retrospective nonrandomized study; therefore, we were not able to control for other factors that may have influenced stricture formation, for example, staple size.5
In conclusion, life expectancy is limited in most patients after Ivor Lewis esophagogastrectomy; 5-year survival in our unit is 22%,2 and so for the majority of patients the benefit of the procedure is excellent palliation with rapid and long-term relief of dysphagia. The development of anastomotic stricture therefore reduces the benefit of the operation and casts doubts on the utility of palliation. Inkwelling of the gastroesophageal anastomosis increases benign anastomotic stricture formation.
References
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