Prevention of anastomotic leakage in esophagogastroplasty (anatomical, experimental and clinical study)

Background. Anastomotic leakage after esophagogastroplasty is a severe complication attributed to insufficient conduit length and ischemia of its proximal segment. A method combining graft lengthening and perfusion improvement without microsurgical intervention is needed. Material and methods. A translational study was performed: right gastroepiploic artery (RGEA) angiography (n=20), anatomical seromyotomy study (n=23), experiments in rabbits (n=20) and pigs (n=10). Clinical phase included two independent observations: intraoperative laser Doppler flowmetry (LDF) in 22 patients with standard reconstruction (descriptive analysis of patients not included in comparative study) and comparative study of 84 patients (seromyotomy with ligation of 2–3 gastric branches of RGEA, n=34; control, n=50). Microcirculation (M, SO2), conduit elongation, complication rate and mortality were assessed. Results. Anastomosis between gastroepiploic arteries was absent in 50% of cases. Seromyotomy elongated conduit by 8.8±3.5 cm (r=−0.85 between baseline length and elongation). Experimentally, technique increased proximal perfusion (p<0.01). A 31.6% perfusion decrease in anastomotic zone was detected in 22 patients (p<0.001). In comparative study, perfusion in the study group exceeded the control group by 72% (p=2.8·10–8). Proportion of complication-free patients increased from 8% to 35% (p=0.0036; NNT=4), pneumonia rate decreased from 24% to 6% (p=0.037), and mortality decreased from 14% to 0% (p=0.038). A trend towards lower leakage rate (14%→3%, p=0.135) was observed with 52% power. Conclusion. Seromyotomy with ligation of gastric branches of RGEA is a pathogenetically reasonable method for prevention of ischemic complications, increasing conduit length and improving microcirculation without microsurgical intervention.