Decreasing complication rates with stapled esophagojejunostomy following a learning curve

BACKGROUND: Recently, two reports of clinical trials on gastric cancer surgery have reported high mortality following extended lymph node dissection. In these reports, anastomotic leakage at the esophagojejunostomy was observed in approximately 10% of patients, with high mortality. These data highlight the importance of avoiding this complication. In this article, we report the use of a stapler to achieve a safe anastomosis, with low incidences of leakage and postoperative stenosis. METHODS: From January 1985 to December 1997, we performed 1234 esophagojejunal anastomoses at the National Cancer Center Hospital. Records of the 1234 patients were reviewed to evaluate changes in anastomotic techniques and changes in the incidence of anastomotic leakage. In this series, 588 stapled anastomoses were carried out between 1992 and 1997. These were evaluated to calculate the incidence of leakage and stenosis, with special reference to the use of supplementary sutures around the stapled anastomosis. Statistical analysis was performed by the chi2 test. RESULTS: This series showed an overall increase in the use of staplers to form the esophagojejunal anastomosis, and a decrease in the incidence of leakage. In 1995, all anastomoses were stapled, with a leakage rate of less than 1.0%. In the last 6 years of the series (1992-1997), the leakage rate was 1.0% and the incidence of postoperative stenosis was 1.2%. The results were not improved by supplementary sutures around the stapled anastomosis. CONCLUSION: These data show that a stapled esophagojejunal anastomosis without supplementary sutures is a safe way to create a esophagojejunal anastomosis, with results superior to those with hand suturing. We believe the stapled anastomosis should become the "gold standard" for esophagojejunal anastomosis.