Challenges in esophageal reconstruction
Management of the Cervical Esophagogastric Anastomotic Stricture

https://doi.org/10.1053/j.semtcvs.2006.11.001Get rights and content

Esophagogastric anastomotic stricture following esophagectomy with a gastric esophageal substitute can be a vexing problem for the patient and treating physician. We describe the clinical practice at a single center with extensive experience in esophageal surgery for management of this complication.

Section snippets

Association with Anastomotic Leak

Without question, the prevention of an anastomotic leak is the key to a successful functional outcome of a cervical esophagogastric anastomosis. In our initial experience with the side-to-side stapled cervical esophagogastric anastomosis, we observed not only an anastomotic leak rate of less than 3%, but also a dramatic reduction in the need for late postoperative anastomotic dilatations.11

In the patient who experiences a cervical esophageal anastomotic leak, the neck wound is opened widely at

Technique of Anastomotic Dilation

Functional assessment of the health of the esophageal replacement following transhiatal esophagectomy at our institution is primarily subjective based on the patient’s ability to tolerate a mechanical soft diet. Long-term follow-up is important to gauge the functional status following transhiatal esophagectomy and a cervical esophagogastric anastomosis. The presence and degree of dysphagia is assessed at each postoperative visit based on patient symptoms and the frequency with which anastomotic

Insurance Issues

We have found that many insurance companies initially will not provide reimbursement for a Maloney dilator dispensed from the clinic for home use; an esophageal dilator is not among the traditional “durable goods” (eg, a cane or walker) for which medical insurers will pay. Once this “equipment” is defined in an explanatory letter by the surgeon as a “vital and medically necessary” durable good, reimbursement is generally provided. Furthermore, having found that patients can perform

Indications for Endoscopy or Further Intervention

In general, patients with a cervical esophagogastric anastomotic stricture undergo outpatient bougienage without the need for endoscopic examination, regardless of whether the gastric conduit was placed in the posterior mediastinum or in a retrosternal position. In those patients in whom the anatomy at the anastomosis simply prevents passage of even a 28-Fr dilator, initial endoscopic guide-wire dilation facilitated by conscious sedation is necessary. Once the anastomotic stricture has been

Conclusions

While generally not life-threatening, cervical dysphagia due to anastomotic stricture impairs quality of life following restorative operations28 for the treatment of a variety of malignant and benign esophageal disorders. The development of anastomotic techniques utilizing the linear stapler has reduced the incidence of postoperative stricture, particularly in the absence of an anastomotic leak. Regardless of operative technique, stricture following cervical esophagogastric anastomosis remains

References (28)

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