Minimizing cervical esophageal anastomotic complications by a modified technique Narendar M. Gupta, M.S.*, Rajesh Gupta, M.S., Manikyam S. Rao, M.S., Vikas Gupta, M.S. Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India Manuscript received July 25, 2000; revised manuscript January 2, 2001 Abstract Background: The anastomotic leak and stricture formation after esophagectomy and cervical esophagogastric anastomosis deny patients with esophageal carcinoma the benefits of surgery. The present study was designed to ascertain whether a wide cross-sectional area at the site of anastomosis leads to lesser anastomotic complications. Methods: One hundred patients with resectable carcinoma of the esophagus were randomly distributed into two groups of 50 each. All patients underwent one-stage transhiatal esophagectomy. In group A, 3  2 cm gastric crescent was excised from the anterior wall of the gastric tube before constructing the cervical esophagogastric anastomosis. No such intervention was done in group B, which acted as control. All patients were followed up for at least 3 months for detection of anastomotic complications. Results: The incidence of anastomotic leak in the study group was significantly less in comparison with the control group (4.3% versus 20.8%; P = 0.03). Similarly, anastomotic stricture formation was significantly lower in the study group (8.5% versus 29.2%; P = 0.02). Conclusions: A wide cross-sectional area achieved at the anastomotic site by removal of gastric crescent resulted in significantly lower anastomotic complications. © 2001 Excerpta Medica, Inc. All rights reserved. Keywords: Carcinoma; Esophagus; Anastomosis; Complications One-stage esophagectomy with esophagogastric anastomo- sis is the treatment of choice for carcinoma of the esophagus [1]. The transhiatal approach with cervical esophagogastric anastomosis (CEGA) popularized by Orringer and Sloan [2] is the standard approach for the last 14 years in our unit [3]. Carcinoma esophagus is quite prevalent in this part of the country and carries a dismal prognosis due to the advanced stage of presentation in almost all of our patients. The major objective of surgery is palliation of dysphagia. However, development of anastomotic complications like leak or stricture formation offsets the possible benefits of surgery and casts doubt on the utility of such a major undertaking. Our leak rate for over 500 patients using different manual suturing techniques had varied between 10% and 20% with a high rate of stricture formation. The resultant dysphagia warrants these patients to be put on an uncomfortable dila- tation program. The present study was an attempt to bring down our anastomotic complication rate to the minimum without add- ing to the cost of the therapy. The study was designed on the basis of the hypothesis that a wide cross-sectional area at the anastomotic site may help in reducing the incidence of anastomotic leak and benign strictures. Patients and methods One hundred consecutive patients with resectable carci- noma esophagus fit to undergo transhiatal esophagectomy (THE) were included in this prospectively randomized study from July 1996 to March 1999. Patients were ran- domized into two groups of 50 each on the operation table from instructions given in a sealed envelop. The study group, group A, consisted of patients who underwent end- to-side cervical esophagogastric anastomosis after removal of a 3  2 cm gastric crescent from the anterior wall of the gastric tube. In group B, an end-to-side cervical esophago- gastric anastomosis was constructed on the anterior wall of the stomach without removal of a gastric tube crescent, and this group acted as control. * Corresponding author. Tel.: +91-172-715071; fax: +91-172- 744401, 745078. E-mail address: medinst@pgi.chd.nic.in. The American Journal of Surgery 181 (2001) 534 –539 0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved. PII: S0002-9610(01)00616-X