title: Fate of the esophagogastric anastomosis.
abstract: OBJECTIVE
  The study objective was to evaluate histopathology of the esophagogastric anastomosis after esophagectomy, determine time trends of histologic changes, and identify factors influencing those findings.
  
  
  METHODS
  A total of 231 patients underwent 468 upper gastrointestinal endoscopies with anastomotic biopsy a median of 3.5 years after esophagectomy. Mean age was 59 ± 12 years, 74% (171) were male, and 96% (222) were white. Seventy-eight percent (179) had esophagectomy for cancer, 13% (30) had chemoradiotherapy, and 13% (30) had prior esophageal surgery. The anastomosis was 20 ± 2.0 cm from the incisors. Anti-reflux medications were used in 59% of patients (276/468) at esophagoscopy. Histopathology was graded as normal (0), consistent with reflux (1), cardia mucosa (2), intestinal metaplasia (3), and dysplasia (4). Repeated-measures nonlinear time-trend analysis and multivariable analyses were used.
  
  
  RESULTS
  Grades 0 and 1 were constant, 5% and 92% at 10 years, respectively. Anti-reflux medication, induction therapy, and higher anastomosis were predictive of less grade 1 histopathology. Grades 2 and 3 increased with time: 12% and 33% at 5 years and 4% and 16% at 10 years, respectively. No variable was predictive of grade 2 or 3 (P > .15) except passage of time. No patient's condition progressed to dysplasia or cancer.
  
  
  CONCLUSIONS
  The esophagogastric anastomosis is subject to gastroesophageal reflux. To minimize histopathologic changes of reflux, the anastomosis should be constructed as high as possible (closer to incisors) and anti-reflux medications prescribed. Surveillance endoscopy, if performed, will document a time-related progression of reflux-related histopathologic changes. However, during surveillance, intestinal metaplasia is uncommon and progression to cancer rare.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA. ricet@ccf.org
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Rice
authors.forename: John R
authors.initials: JR
authors.lastname: Goldblum
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Rybicki
authors.forename: Jeevanantham
authors.initials: J
authors.lastname: Rajeswaran
authors.forename: Sudish C
authors.initials: SC
authors.lastname: Murthy
authors.forename: David P
authors.initials: DP
authors.lastname: Mason
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D001706:Biopsy; D016145:Endoscopy, Digestive System; D016629:Esophagectomy / Q000009:adverse effects*; D004947:Esophagus / Q000473:pathology / Q000601:surgery*; D005260:Female; D005743:Gastrectomy; D005748:Gastric Fundus / Q000473:pathology / Q000601:surgery*; D005764:Gastroesophageal Reflux / Q000188:drug therapy / Q000209:etiology* / Q000473:pathology; D006801:Humans; D016015:Logistic Models; D008297:Male; D008679:Metaplasia; D008875:Middle Aged; D017711:Nonlinear Dynamics; D009820:Ohio; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D018570:Risk Assessment; D012307:Risk Factors; D013908:Thoracotomy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D054328:Proton Pump Inhibitors