title: Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management.
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.
authors.affiliation: Department of Internal Medicine II, Division of Gastroenterology, University Hospital Rotterdam-Dijkzigt, Rotterdam, The Netherlands.
authors.forename: P
authors.initials: P
authors.lastname: Honkoop
authors.forename: P D
authors.initials: PD
authors.lastname: Siersema
authors.forename: H W
authors.initials: HW
authors.lastname: Tilanus
authors.forename: L P
authors.initials: LP
authors.lastname: Stassen
authors.forename: W C
authors.initials: WC
authors.lastname: Hop
authors.forename: M
authors.initials: M
authors.lastname: van Blankenstein
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods*; D004106:Dilatation; D004938:Esophageal Neoplasms / Q000601:surgery*; D004940:Esophageal Stenosis / Q000209:etiology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004945:Esophagoscopy; D004946:Esophagostomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology* / Q000601:surgery; D012086:Reoperation; D012307:Risk Factors; D013528:Surgical Staplers; D013529:Surgical Wound Dehiscence / Q000209:etiology / Q000601:surgery; D013536:Suture Techniques; D016896:Treatment Outcome