Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition.
BACKGROUND
Reports of esophageal anastomotic complications often involve more gastric than colonic reconstructions and are incomplete because of fragmented followup by physicians unfamiliar with the surgical procedure.


METHODS
Three hundred ninety-three consecutive esophagectomy patients had prevalence and risk factors determined for graft ischemia and anastomotic leak; 363 of these patients followed for more than 1 month (median 15 months) had prevalence and risk factors determined for anastomotic stricture.


RESULTS
Conduit ischemia occurred in 36 (9.2%) and anastomotic leak in 43 patients (10.9%). Risk factor for ischemia was comorbid conditions requiring therapy (Odds ratio [OR]: 2.2 [95% CI 1.1-4.3]), and for leak were ischemia (OR: 5.5 [95% CI 2.5-12.1]), neoadjuvant therapy (OR: 2.2 [95% CI 1.1-4.5]), and comorbid conditions (OR: 2.1 [95% CI 1.1-3.9]). A stricture developed in 80 patients (22.0%). Risk factors were ischemia (OR: 4.4 [95% CI 2.0-9.6]), anastomotic leak (OR: 3.8 [95% CI 1.9-7.6]), and increasing preoperative weight (p = 0.022). The prevalence of ischemia was similar after gastric (10.4%) versus colonic (7.4%) reconstruction; leak and stricture were more common (14.3% versus 6.1%, p = 0.013, 31.3% versus 8.7%, p < 0.0001, respectively) and strictures were more severe (11.2% versus 2%, p = 0.001) after gastric pull-up. Patients free of ischemia and leak who developed stricture were more likely to have had a gastric pull-up (25% versus 7%, p < 0.0001). Dilatation was effective treatment in 93% of patients.


CONCLUSIONS
After esophagectomy 10% of patients will develop conduit ischemia or an anastomotic leak and 22% will develop anastomotic stricture. Anastomotic leak and strictures are more common and the strictures are more severe after gastric pull-up compared with colon interposition. Dilatation is a safe and effective treatment.
Briel
John W
JW
Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033, USA.
Tamhankar
Anand P
AP
Hagen
Jeffrey A
JA
DeMeester
Steven R
SR
Johansson
Jan
J
Choustoulakis
Emmanouel
E
Peters
Jeffrey H
JH
Bremner
Cedric G
CG
DeMeester
Tom R
TR
D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000401:mortality; D002404:Catheterization; D003106:Colon / Q000098:blood supply / Q000637:transplantation; D004940:Esophageal Stenosis / Q000209:etiology*; D016629:Esophagectomy / Q000009:adverse effects* / Q000401:mortality; D004947:Esophagus / Q000098:blood supply / Q000601:surgery*; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology*; D008297:Male; D011183:Postoperative Complications; D015995:Prevalence; D012307:Risk Factors; D013270:Stomach / Q000098:blood supply / Q000637:transplantation; D013529:Surgical Wound Dehiscence / Q000209:etiology*