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Esophagectomy: Cervical gastroesophageal anastomosis (modified Collard) operative techniques.

last modified on: Tue, 05/26/2020 - 12:25

Iowa Thoracic Protocols

Please direct questions and comments to Evgeny V. Arshava, MD     evgeny-arshava@uiowa.edu

 

Before the stapler is fired to create the posterior wall of the anastomosis, the seromuscular side stitches additionally secure the conduit to the esophagus and the full-thickness corners stitches are placed for the inner running layer of the anterior wal

 

See also other sections in Thoracic Surgery

Transhiatal Esophagectomy

Three-field (McKeown) Esophagectomy

Thoracic duct ligation

Chylothorax

Reconstruction after total laryngectomy (with gastropharyngeal anastomosis)

Esophageal Myotomy and Diverticulectomy for Epiphrenic and Midesophageal Diverticula

 

 

GENERAL CONSIDERATIONS

  • Transhiatal Esophagectomy

  • Three-Incision (McKeown) Esophagectomy

 

  • The advantage of a semi-mechanical over a hand sewn technique is that it allows the construction of a very large-bore anastomosis. This decreases the risk of a clinically significant stricture after potential anastomotic a leak.

  • The postoperative symptomatic gastroesophageal reflux may be less with an end-to-side anastomosis (modified Collard) as compared to an end-to-end (Collard).  

 

CONTRAINDICATION

  • Length of the gastric conduit is not sufficient to reach the neck for the anastomosis (the esophagectomy then requires an Ivor Lewis approach )

  • Tumor of the upper third of the esophagus, as achieving adequate margin would not leave sufficient esophagus for a stapled anastomosis. In this cases gastropharyngeal anastomosis is required (see Reconstruction after total laryngectomy (with gastropharyngeal anastomosis))

  •  There is unfavorable cervical anatomy (prior radiation, severe cervical spine arthritis).

  • Prior cervical operations  are not absolute contraindications for a cervical anastomosis:

    • Recurrent laryngeal nerves function needs to be assessed in patients with prior neck operations (especially thyroidectomy).

    • Anastomosis is easily performed after prior carotid endarterectomy

    • We do not perform cervical anastomosis in patients with prior anterior neck fusion and hardware in place.

    • Aberrant left subclavian artery is not a contraindication as the vessel is located behind the esophagus and does not need to be dissected.

Preoperative CTA demonstrating an aberrant retroesophageal left subclavian artery in patient who underwent uncomplicated three incision esophagectomy.

 

OPERATIVE PROCEDURE

For intraoperative images of thoracic and abdominal phases of the esophagectomy see:

  • We emphasize the importance of intraoperative and early postoperative normovolemic volume status of the patient and avoidance of vasoconstrictors. Hypovolemia and vasoconstrictors may further jeopardize relatively ischemic tip of a gastric conduit and increase the risk on an anastomotic leak.

 

 

Cervical dissection  

 

  • Cricoid cartilage is the surface landmark for the cricopharyngeus muscle (functional upper esophageal sphincter) at the beginning of the esophagus.

  • A 6 cm skin incision is made along the anterior border of the left sternocleidomastoid muscle, starting at the sternal notch and extending to the level of the cricoid cartilage.

  • The platysma is divided, and dissection is continued medially to the sternocleidomastoid muscle, the carotid sheath, and laterally to the trachea and the thyroid.

Esophagectomy for esophageal carcinoma cervical gastroesophageal anastomosis Omohyoid muscle is dissected and divided

 

  • The strap muscles are divided with electrocautery.

Esophagectomy for esophageal carcinoma cervical gastroesophageal anastomosis Strap muscles are dissected and divided

 

  • Inferior thyroid artery is an internal landmark located at the level of the cricoid cartilage and the cricopharyngeus muscle (functional upper esophageal sphincter).

  • The middle thyroid vein and the inferior thyroid artery are divided.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Inferior thyroid artery needs to be divided

 

  • Care is taken to protect the recurrent laryngeal nerve. Use finger to retract the trachea and not the metal retractor.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Care is taken to protect the recurrent laryngeal nerve

 

  • The deep cervical fascia is incised and, with further dissection towards the vertebral bodies, the esophagus identified, gently mobilized circumferentially, and encircled with a Penrose drain.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis The deep cervical fascia is incised and esophagus is  mobilized circumferentially

 

  • The esophagus is further dissected into the superior mediastinum with gentle traction and finger dissection, reaching the dissection completed during the chest phase.

  • The esophagus is divided with a linear stapler in the neck incision (the NG tube is pulled back), preserving as much cervical esophagus as possible. 

The esophagus is generously mobilized out of  the superior mediastinum and divided

 

 

Cervical anastomosis

  • After the gastric conduit is gently delivered through the mediastinum into the neck without torsion cervical anastomosis is performed using the Modified Collard technique as described by Dr. Orringer.

  • The site of the gastrotomy is marked.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Gastrotomy site is marked 3 cm distal to the tip of the staple line

 

  • In very rare cases of a long available gastric tube length, its tip  can be shortened (as it is prone to ischemia) within the cervical incision with the linear cutting stapler to avoid its intrathoracic tortuosity before starting the anastomosis.

  • Packing the corner of a sponge under the gastric tip into the mediastinum at this point decreases slippage of the stomach into the mediastinum until the anastomosis is complete. The esophagus is aligned over the gastric tip.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Cervical esophagus and tip of the gastric  conduit are aligned

 

  • The staple line of the esophagus is sharply removed. The NG tube is advanced out of the esophagus to help retract and align the esophagus for the anastomosis (alternatively pulled back proximally into the esophagus).

Esophagectomy cervical gastro esophageal anastomosis Staple line on the cervical esophagus is removed and NG advanced to help retract and align esophagus

 

  • A gastrotomy is performed 3 cm distal to the tip of the staple line. Interrupted, full-thickness sutures are placed to align the midpoints posteriorly and anteriorly on the gastric conduit and esophagus for the anastomosis. 

Esophagectomy Interrupted full thickness sutures are placed to align the midpoints of the posterior and anterior walls of the  cervical anastomosis

 

  • A 45 mm long linear cutting stapler is placed into the cervical esophagus and gastric conduit to create the posterior wall of the anastomosis.

linear cutting stapler is placed into the cervical esophagus and gastric conduit

 

  • Before the stapler is fired, additional seromuscular stitches are used to secure the tip of the conduit to the esophagus on each side proximally. The full thickness sutures for the running inner layer are placed into opposite corners at this point as well.

Esophagectomy cervical gastro esophageal anastomosis side stitches secure conduit to esophagus  the corners stitches  placed for running layer

 

  • The stapler is fired to create the back wall of the anastomosis.

Esophagectomy cervical gastro esophageal anastomosis modified Collard technique as described by Orringer Stapler is fired to create the back wall of the anastomosis

 

  • An NG tube is advanced through the anastomosis under direct visualization and positioned near the pylorus. This is confirmed by palpation through the abdomen at the end of the case before the NG is firmly secured at the nose.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Nasogastric tube is advanced through the anastomosis  and positioned near pylorus

 

  • The anterior aspect of the anastomosis is then completed with a full-thickness, running inner full-thickness layer of 3-0 or 4-0 PDS sutures run from opposite corners to meet in the middle.

Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Running full thickness inner layer is started from each corner to meet in  the middle

 

  • Running sutures are tied in the middle.

  • Esophagectomy Opposite sutures are tied in the middle to complete the running inner full thickness layer of the cervical gastro esophageal anastomosis
  • Interrupted seromuscular stitches of or 4-0 silk (KP, JK) or 3-0 Vicryl (EA) are used for the outer layer.

  • Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis Interrupted seromuscular sutures are used for the outer layer
  • The supporting gastric conduit sponge can be removed at this point to allow anastomosis retract behind the manubrium. 

  • Esophagectomy for esophageal carcinoma cervical gastro esophageal anastomosis the supporting sponge is removed and anastomosis is allowed to retract behind manubrium
  • A 10 Fr JP (KP, EA) or Penrose (JK) darin is placed by the anastomosis and directed into the superior mediastinum along the conduit.

  • The platysma is loosely approximated to the sternocleidomastoid muscle with a three or four interrupted absorbable sutures. The skin is closed with running 4-0 Nylon.

 

for POSTOPERATIVE CARE  and OUTPATENT FOLLOW-UP  see :

  • Transhiatal Esophagectomy

  • Three-Incision (McKeown) Esophagectomy

  • If patient develops signs of the neck incision infection (most likely clinically significant anastomotic leak) :

    • Nylon stitches and the platysma switches are removed.  Wound is gently explored with the finger all the way down to the level to the esophageal anastomosis to break all loculations.

    • Packing is performed minimum twice a day, but more frequently as needed as needed based on the amount of drainage. We recommend against vacuum assisted therapy for neck wounds.

    • Patients with anastomotic leaks are at risk for developing anastomotic stricture and should undergo endoscopy within 2-4weeks, with dilation if needed

  • Esophagectomy for esophageal carcinoma cervical gastroesophageal anastomosis postoperative Flexible endoscopy demonstrating patent anastomosis

 

 

 

Suggested literature

 

Collard JM, Romagnoli R, Goncette L, Otte JB, Kestens PJ. Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy. Ann Thorac Surg 1998;65:814-7.

Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-88. 

 

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We would like to thank all the nurses and operative room technicians at the University of Iowa Hospitals and Clinics and the Iowa City VAMC for their dedication and expertise in the care of our patients.