Challenges in esophageal reconstructionManagement of the Cervical Esophagogastric Anastomotic Stricture
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
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Cited by (18)
Primary repair of long gap esophageal atresia in a neonate employing circular myotomy on upper pouch and a novel hemicircular myotomy on the distal pouch
2019, Journal of Pediatric Surgery Case ReportsCitation Excerpt :Complications associated with primary esophageal repair are well described. These include stricture formation, anastomotic leaks, sepsis, gastroesophageal reflux in the long term, pneumonia and esophageal motility issues [32–34]. Incidence of anastomotic leak in EA repair surgery is 4–36% [35–40] (0–100% in the long gap group likely secondary to high anastomotic tension) [40–42].
Refractory cervical esophagogastric anastomotic strictures: Management and outcomes
2011, Journal of Thoracic and Cardiovascular SurgeryA randomized comparison of electrocautery incision with Savary bougienage for relief of anastomotic gastroesophageal strictures
2009, Gastrointestinal EndoscopyCitation Excerpt :Patient satisfaction after therapy at 6-month follow-up was also significantly better with EI than with SB (P = .002). Dysphagia caused by stricture formation after an esophagogastrostomy is a common complication and can be refractory to treatment.1-4,6-9,11-16 These strictures often lead to dysphagia and food regurgitation, which severely impair quality of life and adequate food intake.
Analysis of Cervical Esophagogastric Anastomotic Leaks After Transhiatal Esophagectomy: Risk Factors, Presentation, and Detection
2009, Annals of Thoracic SurgeryCitation Excerpt :With the above regimen, the majority of anastomotic cutaneous fistulas seal within 2 weeks [6]. Long-term management of the CEGA stricture is more of a challenge and may require that the patient learn the technique of self-esophageal dilation [7]. Only a few reports have attempted to identify risk factors for the CEGAL.
Esophageal Mythology
2008, Journal of the American College of SurgeonsCitation Excerpt :After discharge from the hospital, for the first few months after the esophagectomy, an aggressive followup dilation program is undertaken in patients who have had a leak. This includes instruction in self-dilation, if necessary, to achieve softening of the stricture, with initially frequent dilations and prevention of severe late stenosis.20 Comfortable swallowing is the result in most patients so treated.
The Use of Self-Expanding Silicone Stents in Esophagectomy Strictures: Less Cost and More Efficiency
2008, Annals of Thoracic SurgeryCitation Excerpt :Thus, if a single dilation endoscopic procedure can be spared, the cost of dilation and stenting is equivalent, and if more than one dilation can be spared, than early dilation and stenting becomes more cost efficient. The endoscopic management of anastomotic strictures related to upper gastrointestinal operations [11], acid/alkali-induced strictures [12], and postradiation-induced strictures has been well established and optimized to involve some form of endoscopic dilation procedure, either with Savary-Gilliard or balloon dilators [12, 13]. Both dilation techniques have been found to be safe and efficacious but ultimately are operator-dependent based on the loose interpretation of how much dilation at one endoscopic procedure is enough; how often a patient should be reendoscoped and redilated, and what type of topical or injectable agents [14] have been found to be effective.