Gastric tube pull-up after esophagectomy for cancer

  • Paulo Costa Professor Catedrático, Director de Serviço, FACS, FRCS (Eng), Clínica Universitária de Cirurgia I – Faculdade de Medicina da Universidade de Lisboa (FMUL) e Hospital de Santa Maria (CHLN)
  • Rui Esteves Assistente Hospitalar Graduado de Cirurgia Geral e Assistente da FMUL, Clínica Universitária de Cirurgia I – Faculdade de Medicina da Universidade de Lisboa (FMUL) e Hospital de Santa Maria (CHLN)
  • Patrícia Lages Assistente Hospitalar de Cirurgia Geral e Assistente da FMUL, Clínica Universitária de Cirurgia I – Faculdade de Medicina da Universidade de Lisboa (FMUL) e Hospital de Santa Maria (CHLN)
  • Filipa Ferreira Interna do Complementar de Cirurgia Geral, Clínica Universitária de Cirurgia I – Faculdade de Medicina da Universidade de Lisboa (FMUL) e Hospital de Santa Maria (CHLN)


Introduction: Anastomotic complications are responsible for significant morbidity after oesophagectomy for cancer. Cervical oesophagogastrostomy is associated with high incidence of anastomotic leaks (0 – 18%) and stenosis (1- 43%). The aim of this study was to address the reliability of our method of preparation of the gastric tube, the pull-up of the gastric conduit and the esophagogastrostomy, based on a consecutive series of esophagetomies for cancer.

Material and Methods: Retrospective analysis of the last 50 consecutive patients, with oesophageal carcinoma, 7 female and 43 males, median of age 63 [46-85] years. Oesophagocoloplasties were excluded from the group. A gastric tube was pulled-up to the thorax (n=3) or the neck (n=47). Gentle manipulation of the stomach in all the steps of its mobilization, preservation of the gastric vascularization of the tube (details for preserving the right and left gastric vascular  arcades and networks were focused), the technique to carry out the gastric pull-up and the hand-sewn end-to-lateral anastomosis to the posterior face of the tube were key technique details presented. Homeostatic monitoring was guaranteed. Clinical, endoscopic and radiologic control of the anastomosis was done. Endoscopic control of bleeding and stenosis was achieved on demanding cases.

Results: 2 anastomotic leaks and 1 detected only on radiologic study. No gastric tube necrosis. 1 haemorrhage endoscopic controlled. 11 cases of post-operative stenosis required one ore more dilatation sessions through the first year. Hospital stays, median – 19 [9-64] days. Mortality: 8 weeks – 8%; in hospital – 14%. Survival median – 17 [3 – 75] months.

Conclusions: A reliable preparation of the gastric tube for pulling up is founded on key technique points. Strict adherence to a meticulous preservation of the gastric tube vascularization is mandatory for minimizing complications. Control of the homeostasis during the operative procedure and in the post-operative period was a significant issue in our experience. Early diagnosis and fixing of complication is crucial for getting good results.

Keywords: gastric tube, gastric tube pull-up, cervical oesophagogastrostomy 


Download data is not yet available.


Hulscher JB, Tijssen JG, Obertop H, et al. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 2001; 72: 306-13.

Orringer MB. Transhiatal esophagectomy without thoracotomy. In Cohn LH, Patterson A (eds.) Operative Techniques in Thoracic and Cardiovascular Surgery, Spring 2005 Edition. Elsevier, Inc, Philadelphia, PA, pp. 63-83.

Yang K, Chen H, Chen XZ, et al. Transthoracic resection versus non-transthoracic resection for gastroesophageal junction cancer: a meta- -analysis. Plos one 2007; 6: e37698.

Chang AC, Hong J, Birkmeyer, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008; 85: 424-9.

Barreto JC, Posner MC. Transhiatal versus transthoracic esophagectomy for esophageal cancer. World J Gastroenterol 2010; 16(30): 3804-10

Lagarde SM, Vrouenraets BC, Stassen LPS, et al. Evidence-based surgical treatment of esophageal cancer: overview of high-quality studies.
Ann Thorac Surg 2010; 89: 1319-26.

Merrit RE, Whyte RI, D’Arcy NT, et al. Morbidity and mortality after esophagectomy following neoadjuvant chemoradiation. Ann Thorac
Surg 2011;92: 2034–40.
8 Bierre SS, Maas KW, Cuesta MA, et al. Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-
-analysis. Dig Surg 2011; 28(1): 29-35.
9 Pinotti HV. Acesso ao esôfago torácico por transecção mediana do diafragma. São Paulo, Atheneu (Brasil), 1999.
10 DeMeester TR. Esophageal replacement with colon interposition. Operative Techniques in Cardiac & Thoracic Surgery 1997; 2 (1): 73-86.
11 Goh AH, Park KGM. Transhiatal oesophagectomy: a simple technique to carry out gastric or colonic conduit pull-up. Surgeon 2007; 5(1):
12 Lerut T, Coosemans W, De Leyn P, et al. Anastomotic complications after esophagectomy. Dig Surg 2002; 19: 92-8.
13 Rouvelas I, Lindblad M, Zeng W, et al. Impact of hospital volume on long-term survival after esophageal cancer surgery. Arch Surg 2007;
14 Dikken JL, Wouters MW, Lemmens VEP, et al. Influence of hospital type on outcomes after oesophageal and gastric cancer surgery. Br J Surg
2012; 99: 954-963.
15 Kozower BD, Stukenborg GJ. Hospital esophageal cancer resection volume does not predict patient mortality risk. Ann Thorac Surg 2012;
93: 1690-8.
16 D’Cunha J, Rueth NM, Groth SS, et al. Esophageal stents for anastomotic leaks and perforations. J Thorac Cardiovasc Surg 2011; 142:
17 Freeman RK, Vyverberg A, Ascioti AJ. Esophageal stent placement for the treatment of acute intrathoracic anastomotic leaks after esopha-
gectomy. Ann Thorac Surg 2011; 92: 204-8.
18 Feith M, Gillen S, Schuster T, et al. Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation
remains a problem. Clin Gastroenterol Hepatol 2011; 9(3): 202-10.
19 Oezcelik A, Banki F, Ayazi S, et al. Detection of gastric conduit ischemia or anastomotic breakdown after cervical esophagogastrostomy: the
use of computed tomography scan versus endoscopy. Surg Endosc 2010; 24: 1948-51.
20 Scheepers JJG, van der Peet DL, Veenhof AA, et al. Systematic approach of postoperative gastric conduit complications after esophageal
resection. Dis Esophagus 2010; 23: 117-21.
21 Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic complications following esophagectomy. Semin Thorac Cardiovasc Surg
2004; 16(2): 124-32.
22 Tang H, Xue L, Hong J, et al. A method for early diagnosis and treatment of intrathoracic esophageal anastomotic leakage: prophylatic
placement of a drainage tube adjacent to the anastomosis. J Gastrointest Surg 2012; 16: 722-27.
23 Shackcloth MJ, McCarron E, Kendall J, et al. Randomized clinical trial to determine the effect of nasogastric drainage on tracheal acid
aspiration following oesophagectomy. Br J Surg 2006; 93(5): 547-52
24 Daryaei P, Vaghef Davari F, Mir M, et al. Omission of nasogastric tube application in postoperative care of esophagectomy. World J Surg
2009; 33(4): 773-77.
25 Palmes D, Weilinghoff M, Colombo-Benkmann M, et al. Effect of pyloric drainage procedures on gastric passage and bilereflux after eso-
phagectomy with gastric conduit reconstruction. Langenbecks Arch Surg 2007; 392: 135-41.
26 Katsoulis IE, Robotis I, Kouraklis G, et al. Duodenogastric reflux after esophagectomy and gastric pull-up: the effect of the route of recons-
truction. World J Surg 2005; 29: 174-81.
27 Tsubuku T, Fujita H, Tanaka T, et al. What influences the acidity in the gastric conduit in patients who underwent cervical esophagogastros-
tomy for cancer? Dis Esophagus 2011; 24: 575-82.
28 Nakabayashi T, Mochiki E, Kamiyama Y, et al. Gastric motor activity in gastric pull-up esophagectomized patients with and without reflux
symptoms. Ann Thorac Surg 2012; 94: 1114-7.
29 Swanson EW, Swanson SJ, Swanson RS. Endoscopic pyloric ballon dilatation obviates the need for pyloroplasty at esophagectomy. Surg
Endosc 2012; 26: 2023-28.
30 Oezcelik A, DeMeester SR, Hindoyan K, et al. Circular stapled pyloroplasty: a fast and effective technique for pyloric disruption during
esophagectomy with gastric pull-up. Dis Esophagus 2011; 24: 423-29.
31 Veeramootoo D, Shore AC, Shields B, et al. Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy. Surg Endosc 2010; 24: 1126-31.
32 Orringer MB, Iannettoni MD, Whyte RI. Catastrophic complications of the cervical esophagogastric anastomosis. J Thorac Cardiovasc Surg 1995; 110: 1493-1501.
33 Schröder W, Stippel D, Beckurts KTE, et al. Intraoperative changes of mucosal pCO2 during gastric tube formation. Langenbecks Arch Surg 2001; 386: 324-27.
34 Pham TH, Perry KA, Enestvedt CK, et al. Decreased conduit perfusion measured by spectroscopy is associated with anastomotic complica- tions. Ann Thorac Surg 2011; 91: 380-6.
35 Schröder W, Stippel D, Gutschow, et al. Postoperative recovery of microcirculation after gastric tube formation. Langenbecks Arch Surg 2004; 389: 267-71.
36 Diana M, Hübner M, Vuilleumier H, et al. Redistribution of gastric blood flow by embolization of gastric arteries before esophagectomy. Ann Thorac Surg 2011; 91: 1546-51.
37 Bludau M, Hölscher AH, Vallböhmer D, et al. Ischemic conditioning of the gastric conduit prior to esophagectomy improves mucosal oxygen saturation. Ann Thorac Surg 2010; 90: 1121-27.
38 Yoshimi F, Asato Y, Ikeda S, et al. Using the supercharge technique to additionally revascularize the gastric tube after a subtotal esophagec- tomy for esophageal cancer. Am J Surg 2006; 191: 284-87.
39 Takeda FR, Cecconello I, Szachnowicz S, et al. Anatomic study of gastric vascularization and its relationship to cervical gastroplasty. J Gas- trointest Surg 2005; 9: 132-37.
40 Matsuda T, Kaneda K, Takamatsu M, et al. Reliable preparation of the gastric tube for cervical esophagogastrostomy after esophagectomy for esophageal cancer. Am J Surg 2010; 199: e61-e64.
41 Kono K, Sugai H, Omata H, et al. Transient bloodletting of the short gastric vein in the reconstructed gastric tube improves gastric micro- circulation during esophagectomy. World J Surg 2007; 31: 780-84.
42 Tabira Y, Sakaguchi T, Kuhara H, et al. The width of a gastric tube has no impact on outcome after esophagectomy. Am J Surg 2004; 187: 417-21.
43 Collard JM, Tinton N, malaise J, et al. Esophageal replacement: gastric tube or whole stomach? Ann Thorac Surg 1995; 60: 261-7.
44 Yildirim S, Köksal H, Celayir F. Colonic interposition vs gastric pull-up after total esophagectomy. J Gastrointest Surg 2004; 8: 675-78.
45 Briel JW, Tamhankar AP; Hagen JA, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric
pull-up versus colon interposition. J Am Coll Surg 2004; 198: 536-542.
46 Motoyama S, Kitamura M, Saito R, et al. Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal
cancer. Ann Thorac Surg 2007; 83: 1273-8.
47 Kim RH, Takabe K. methods of esophagogastric anastomoses following esophagectomy for cancer: a systematic review. J Surg Oncol 2010;
101(6): 527-33.
48 Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomo-
sis. J Thorac Cardiovasc Surg 2000; 119: 277-88.
49 Santos RS, Raftopoulos Y, Singh D, et al. Utility of total mechanical stapled cervical esophagogastric anastomosis after esophagectomy: a
comparision to conventional anastomotic techniques. Surgery 2004; 136: 917-25.
50 Gupta NM, Gupta R, Manikyam SR, et al. Minimizing cervical esophageal anastomotic complications by a modified technique. Am J Surg
2001; 181: 534-39.
51 Honda M, Hori Y, Nakada A, et al. Use of adipose tissue-derived stromal cells for prevention of esophageal stricture after circumferential
EMR in a canine model. Gastrointest Endosc 2011; 73(4): 777-84.
How to Cite
COSTA, Paulo et al. Gastric tube pull-up after esophagectomy for cancer. Revista Portuguesa de Cirurgia, [S.l.], n. 25, p. 9-21, jan. 2014. ISSN 2183-1165. Available at: <>. Date accessed: 30 nov. 2023.
Original Papers