Experience with Hand-Sewn, Layered Telescoping Anastomosis in Oesophageal Cancer Surgery

By Genrong Yang, Han Wang

Affiliations

1. Department of Thoracic Surgery, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, China

doi: 10.29271/jcpsp.2026.08.1103

Sir,

Surgery is a crucial intervention for oesophageal cancer,¹ yet postoperative complications such as anastomotic leakage, stricture, and reflux oesophagitis persist. This report summa-rises our experience with the hand‑sewn layered telescoping anastomosis, discussing its advantages and key technical aspects.

Single‑lumen endotracheal intubation was used. With the patient in the left lateral decubitus position, a right‑sided artificial pneumothorax (8–10 mmHg) was established to achieve lung collapse. Thoracoscopic mobilisation of the thoracic oeso-phagus and lymph node dissection were performed. The patient was then repositioned supine. The cervical oesopha-gus was mobilised and transected via a left cervical incision along the anterior border of the sternocleidomastoid muscle. This was followed by laparoscopic gastric mobilisation and perigastric lymphadenectomy. The stomach was exteriorised through a subxiphoid mini‑laparotomy to construct a gastric tube. At the anticipated anastomotic site, the gastric tube was tailored to approximate the oesophageal diameter. The cut edge was continuously sutured for seromuscular imbri- cation. The gastric tube was then pulled up to the neck for anastomosis.

The gastric tube and oesophageal stump were approximated with a three‑bladed clamp. The posterior oesophageal mus-cular layer and gastric seromuscular layer were incised. Interrupted 3‑0 absorbable sutures were placed between these layers, with the tied suture ends on both sides left long and untrimmed (Figure 1A). The oesophageal muscular layer was circumferentially dissected distally, preserving a 1‑cm muco- sal cuff. An identical 1‑cm mucosal cuff was created on the gastric tube (Figure 1B). The oesophageal and gastric muco- sae were continuously sutured (Figure 1C). Interrupted sutures were then placed between the anterior oesophageal muscular layer and the anterior gastric seromuscular layer. Before tying the knots, an assistant gently invaginated the mucosal anastomosis into the gastric tube lumen. The knots were then tied to complete the telescoping anastomosis (Figure 1D).

Between January 2024 and March 2025, 15 oesophageal cancer patients underwent this anastomotic technique at this centre. All procedures were completed successfully. The mean cervical anastomotic time was 27.33 ± 2.89 minutes. No postoperative anastomotic leakage was observed. During the 6‑month follow‑up period, no anastomotic stricture was identified. Two patients developed reflux oesophagitis requiring pharmacological  management.

Figure 1 (A,B,C,D): (A) Posterior muscular-seromuscular interrupted approximation, (B) Mucosal cuff preparation, (C) Oesophageal–gastric tube mucosal continuous anastomosis, (D) Anterior muscular-seromuscular  interrupted  closure.

Compared with stapled anastomosis, the hand‑sewn layered telescoping technique demonstrates unique advantages in mitigating reflux, preventing leakage, and reducing stricture.²

The telescoping flap provides an anti-reflux advantage by acting as an anti-reflux barrier. By preserving 1‑cm mucosal cuffs from both the oesophagus and the gastric tube for anastomosis, the mucosal suture line is pushed into the gastric lumen, forming a valve that helps prevent the reflux of gastric contents.

The hand-sewn outer layer of the anastomosis may help reduce anastomotic leakage by employing interrupted sutures, which have less impact on the local blood supply. The layered design places the mucosal and seromuscular suture lines on different planes. If a localised leak occurs at the mucosal anastomosis, it is contained by the outer layer, preventing extravasation and promoting  healing.³

The hand-sewn telescoping anastomosis may help reduce the risk of anastomotic stricture because stapled anastomoses rely on titanium staples arranged in a B-shaped, which may limit the transverse expansion of the anastomosis. In contrast, the interrupted sutures of the hand‑sewn outer layer do not restrict circumferential dilation, potentially lowering the risk of stricture formation.⁴

When pulling the gastric tube to the neck, the lesser curvature should be rotated anteriorly. After anastomosis, the anterior wall has relatively less tension, reducing the risk of leakage at this site.

There is no consensus on the optimal length of the preserved mucosal cuff. Some scholars advocate for a 2‑cm length to enhance the anti‑reflux effect, but excessive telescoping may lead to obstruction. In our series, a 1‑cm mucosal length was used, which is sufficient to cover the anastomotic diameter and provide valvular function.⁵

In summary, the hand‑sewn layered telescoping anastomosis demonstrates significant advantages in anti‑reflux, leak pre- vention, and stricture reduction through its unique anato- mical reconstruction. Precise mucosa‑to‑mucosa and muscularis‑ to‑seromuscular alignment, the telescoping flap design, and standardised operative details are key to its success. This technique is particularly suitable for high cervical oesophageal cancers or cases with suboptimal gastric conduit conditions and  deserves  broader  clinical  application.

COMPETING  INTEREST: 
The  authors  declared  no  conflict  of  interest.

AUTHORS’  CONTRIBUTIONS: 
GY:  Drafted,  revised,  and  edited  the  manuscript.
HW:  Collected,  analysed,  and  interpreted  the  data.
Both authors approved the final version of the manuscript to be published.
 

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