V 20TH ANNIVERSARY
5 May 1999
CE Refereed Peer Review
FOCAL POINT
★One-layer closure of esophageal
incisions using the submucosa
as the holding layer, avoiding
penetration of the mucosa, and
using absorbable suture material
in an interrupted pattern permits
normal esophageal healing
following surgery.
KEY FACTS
■ The surface epithelium of the
mucosa is stratified squamous
with varying degrees of
keratinization in different
species.
■ The collateral vascular pathways
in the wall of the esophagus are
sufficient to maintain its viability
and to ensure healing of an
anastomosis when the entire
thoracic blood supply to the
esophagus is cut off.
■ One reason for the high rate
of complications following
esophageal surgery is that the
esophagus is in constant motion
from respiration and swallowing.
■ The submucosa is the functional
holding layer of the esophageal
wall.
Vol. 21, No.
Approaches to
Esophageal Sutures
The Hebrew University of Jerusalem San Juan, Puerto Rico
Rehovot, Israel Carlos M. Mongil, DVM
Merav H. Shamir, DVM
Ron Shahar, DVM, MSc
Dudley E. Johnston, MVSc
ABSTRACT: Suturing the esophagus after esophagotomy or esophageal resection and anasto-
mosis can be problematic, and complications such as suture line breakdown, leakage, and
stenosis are reported. This article discusses esophageal anatomy and physiology and compli-
cations associated with esophageal surgery; a history of suture methods used in esophageal
surgery is also provided. A new suture technique is described and evaluated based on a retro-
spective study.
F
oreign bodies, tumors, and diverticula are some of the common reasons
for performing an esophagotomy or esophageal resection and anastomosis.
The method of closing esophageal incisions is controversial. Esophageal
incisions have traditionally been closed in two layers using different suture pat-
terns and materials, and the mucosa has historically been considered the strength
layer of the esophageal wall. In 1988, Dallman1 revealed that the submucosa is
the functional holding layer of the esophagus and that including the mucosa in
the closure did not increase the strength of repair. This article presents a retro-
spective report of 21 clinical cases in which esophageal closure was performed
using the submucosa as the holding layer, avoiding penetration of the mucosa,
and using absorbable suture material in an interrupted pattern.
ESOPHAGEAL ANATOMY AND PHYSIOLOGY
The esophagus is a simple muscular tube that has peristaltic activity and
sphincters at both ends. The upper esophageal sphincter is a distinct anatomic
structure comprised of muscle fibers of the cricopharyngeus muscle and circular
muscle fibers of the proximal wall of the esophagus. The lower esophageal
sphincter performs a physiologic function (i.e., it prevents food from indiscrimi-
nately entering the esophagus from the stomach, thus keeping the esophagus
empty), but no distinct muscular structures have been identified.2,3 The lower
sphincter also has a valvelike action to prevent acidic gastric reflux into the
esophagus during inspiration when the intraluminal pressure of the esophagus is
low.
In dogs, the esophagus narrows at four places: near its origin, near its termina-
tion, at the thoracic inlet, and over the base of the heart. This explains why most
obstructing foreign bodies are found at these sites. Also, the esophagus is fixed to
Compendium May 1999 20TH ANNIVERSARY
surrounding structures at these four sites, and the short
distances between these sites prevents mobilization of
the esophagus. This must be taken into consideration
when resection and anastomosis is planned.4
Layers in the Esophageal Wall
The esophageal wall has four layers: mucosa, submu-
cosa, inner circular and outer longitudinal muscularis,
and adventitia.2 The serosa in the rest of the gastroin-
testinal (GI) tract (except the caudal half of the rectum)
represents the visceral layer of the peritoneum that re-
flects on and around the abdominal viscera. It is com-
posed mainly of mesothelial cells in a loose connective
tissue. The esophagus is surrounded by adventitia only,
except in the thorax where it is partially covered ven-
trally by mediastinal pleura. Although this attachment
is loose, the pleura can be a source of mesothelial cells
and fibrin to help seal the esophageal incision after su-
turing.4
The surface epithelium of the mucosa is stratified
squamous with varying degrees of keratinization in dif-
ferent species. The lamina propria of the mucosa is
strong and thick and is comprised of loose connective
tissue of collagenous, elastic, and reticular fibers.5 The
mucosal layer is thicker in the esophagus than in other
parts of the tubular digestive tract, primarily because it
has a thicker lamina propria. However, most of the
connective tissue in the wall of the esophagus is in the
submucosa.1
Segmental Blood Supply
The esophageal blood supply has traditionally been
described as segmental. The bronchoesophageal artery
supplies blood to the cervical and cranial portions of
the thoracic esophagus. The caudal part of the thoracic
esophagus is supplied by the left gastric artery that
crosses the diaphragm. Other segments of the thoracic
esophagus are supplied by direct segmental branches
from the thoracic aorta.2
In addition, a collateral blood supply in the wall of
the esophagus has been shown to exist. In a classic ex-
periment, Macmanus and colleagues6 devascularized
large portions of the canine esophagus (thoracic esoph-
agus, cervical esophagus, or both) by ligating the seg-
mental blood supply. The esophagus was then divided,
and a reanastomosis was performed immediately. On
postmortem examinations, no necrosis of the esopha-
gus was observed. These results confirmed that the col-
lateral vascular pathways in the wall of the esophagus
are sufficient to maintain its viability and to ensure
healing of an anastomosis when the entire thoracic
blood supply to the esophagus is cut off. The capacity
of this intrinsic blood vessel network does have a limit.
MEDIASTINAL PLEURA ■ COLLATERAL BLOOD SUPPLY ■ DIAPHRAGMATIC CONTRACTIONS
Small Animal/Exotics
Necrosis and perforation can occur (always at the level
of the second thoracic vertebra) when both the cervical
and thoracic segmental blood supplies to the esophagus
are ligated. This study suggests that the transition zone
between the cervical and thoracic esophagus has the
poorest blood supply of any part of the structure.6
COMPLICATIONS OF ESOPHAGEAL SURGERY
Complications reported after esophageal surgery in-
clude suture line breakdown, leakage, and stenosis.7,8
Several explanations for the high complication rate
have been suggested.
The absence of the serosal layer that exists in most of
the GI tract is one potential reason for postoperative
complications. The serosa is believed to exude a fibrin
clot that creates an early seal of the incision and to pro-
vide alignment of apposed tissue layers after suturing. It
is now known that the former role is performed by the
mediastinal pleura; to replace the missing latter role, a
more accurate apposition of layers after esophageal
surgery is required.9,10
Tissue rest is one of the basic requirements of wound
healing; however, the esophagus is in constant motion
because of swallowing and diaphragmatic movement.
Diaphragmatic contractions cause the line of an anasto-
mosis to move up and down as much as 3 cm. Such
movements would obviously interfere with the impor-
tant sealing process that is desirable in the early postop-
erative period.11,12
The esophageal wall poorly tolerates longitudinal
stretching and tension. When a portion of the esopha-
gus is resected, tension is created in the suture line be-
cause of lack of mobility in the esophagus. This tension
increases considerably during diaphragmatic contrac-
tions.3,12 A mortality rate of 33% was reported in dogs
with esophageal anastomosis after resection of a third of
the thoracic esophagus.13 In another experiment, a posi-
tive correlation was found between the extent of resec-
tion and the mortality rate from anastomotic break-
down.14
The segmental blood supply was thought to influ-
ence esophageal healing after suturing. However, as dis-
cussed, a rich plexus of intramural vessels exists in the
submucosa. These vessels can support segments of the
esophagus that have had their segmental blood supply
compromised. This suggests that a successful anasto-
mosis can be expected in cases of considerable segmen-
tal vascular compromise as long as there is no disrup-
tion of the intramural blood supply.4,6,11,14
Another important reason for the greater vulnerabili-
ty of the esophagus is the lack of omentum. The omen-
tum serves an important role in supporting GI anasto-
moses, and omental wrapping is the most valuable
Small Animal/Exotics 20TH ANNIVERSARY
adjunct procedure for protecting such anastomoses.
The omentum adds a supplementary layer that pro-
vides a seal after adhering to the outer layer of an anas-
tomosis, and new blood vessels arising from the omen-
tal vessels may provide additional blood supply. In
addition, phagocytic and other immune functions of
the omentum may allow local containment of anasto-
motic leakage.15
Lack of serosa, movement associated with respiration
and swallowing, and a meager blood supply compared
with the remainder of the alimentary tract all contri-
bute to potential problems that may be encountered dur-
ing and after surgery of the esophagus.3 Thus esoph-
ageal surgery requires even more exacting techniques
than does surgery on other portions of the alimentary
tract.
SUTURE METHODS
The classic two-layer inverting esophageal suture de-
veloped for humans in the 1920s was first described in
the veterinary literature in 1965.16 At that time, the
mucosa was considered to have the greatest suture-
holding capabilities of all the esophageal layers and the
submucosa was not mentioned. Mucosa was sutured in
one layer, and the muscularis (with serosa if possible)
was sutured in the other.16 It was also believed that the
closure must be leak-proof because rapid sealing with
fibrin does not occur in the esophagus as it does in the
rest of the intestinal tract.10
The method of using an inverting suture pattern to cre-
ate serosal apposition is no longer considered necessary in
surgery of the intestine or esophagus.9 Some authors still
recommend everting the muscular layer, especially if ten-
sion at the suture line is anticipated, whereas others claim
that one layer of everting suture pattern is sufficient.4,16
In 1949, Swenson described a method in which one
row of 4-0 braided silk interrupted sutures was placed
in the mucosa and the knots were tied within the lu-
men. The second layer of interrupted 4-0 silk included
the full thickness of the muscular coat and some of the
submucosa. Sutures were placed 2 to 3 mm apart.12
The practice of using nonabsorbable suture material
in the mucosa and keeping the knots within the lumen
is very much accepted today, except that polypropylene
is used more commonly than is silk.4,7,17 There appears
to be some movement away from the use of traditional
nonabsorbable suture material for esophageal suturing;
however, the literature continues to stress the necessity
of suturing the mucosa.
The most widely recommended suture pattern today
is a two-layer closure in which the first layer incorpo-
rates the mucosa and submucosa and the second layer
apposes the muscularis.3–5,7,18 Rosin stated that adher-
SUTURE MATERIAL ■ SUTURE PATTERNS ■ CIRCUMFERENTIAL MYOTOMY ■ OMENTAL FLAP
Compendium May 1999
ence to meticulous technique in suturing the esophagus
is more important than is the type of suture used.3 He
suggested that preference should be given to one of two
techniques: (1) an inner mucosal–submucosal layer of
continuous absorbable suture and an outer muscular
layer of interrupted nonabsorbable suture, or (2) an in-
ner layer of interrupted nonabsorbable sutures with the
knots tied in the lumen and an outer layer of interrupt-
ed nonabsorbable sutures. Sutures should be placed ap-
proximately 2 to 3 mm apart and 2 mm from the cut
edge and should be tied with sufficient tension so that a
tight seal forms without interfering with the blood sup-
ply.3
To enhance esophageal dilation during bolus passage,
some authors do not recommend a continuous pattern
when suturing anastomoses.4 In an experimental study
in 1993, three suture methods (i.e., double-layer apposi-
tional closure, single-layer simple interrupted closure,
and single-layer continuous closure) were compared, all
of which used absorbable sutures of polydioxanone sul-
fate through all layers of the esophageal wall.19 All meth-
ods were basically successful; however, based on mea-
surement of bursting strength and operating time, the
authors recommended either the double-layer apposi-
tional closure or the single-layer interrupted closure.
REINFORCING THE SUTURE LINE
Circumferential myotomy and omental flap are two
of the most commonly used techniques for reinforcing
esophageal anastomoses. They are especially indicated
when tension is anticipated.
A circumferential myotomy is recommended to re-
duce tension from the anastomosis site.4 Complete cir-
cular myotomy was found to interrupt the deep longi-
tudinal vessels in the submucosal vascular plexus, which
tends to adhere to the circular muscle layer and is de-
stroyed or damaged by complete myotomy. Partial cir-
cular myotomy, in which only the longitudinal muscle
layer is transected, preserves this submucosal vascular
network and yet is as effective as complete myotomy in
reducing tension.14
The omental flap is used successfully to reinforce
esophageal anastomoses. In a controlled study of anasto-
moses of the thoracic esophagus, a 25% defect was left in
the suture line and then wrapped with omentum. Only
1 of 12 dogs died following leakage from the suture
line.20 Omental grafts are used in humans to support
esophageal perforation repairs and to provide blood sup-
ply to the mediastinal area when infection is present.15
SUBMUCOSA IN THE GASTROINTESTINAL TRACT
The submucosa in the GI tract (other than the
esophagus) is the strong, fibroelastic connective tissue
Compendium May 1999 20TH ANNIVERSARY Small Animal/Exotics

that provides the strength Materials and Methods

needed for suturing the in- Case Selection
testinal wall. In 1887, Hal- The surgical records of pa-
sted was the first to show tients that underwent esoph-
that the submucosa was the ageal surgery at the Universi-
strong layer of the small in- ty of Pennsylvania School of
testine; all suture methods Veterinary Medicine and
for closing intestinal inci- The Hebrew University of
sions and anastomoses that Jerusalem’s Koret School of
have been developed since Veterinary Medicine be-
then have incorporated the tween 1989 and 1994 were
submucosa in the closure.4,5,7 evaluated. Criteria for inclu-
sion in this study included a
DALLMAN’S WORK complete surgery report, an
The mucosal layer is Figure 1A adequately documented
thicker in the esophagus clinical record, and a post-
than in other parts of the di- operative survival of at least
gestive tract (because of the 24 hours. The review of sur-
thicker lamina propria) and gical cases yielded 21 pa-
is more difficult to separate tients that met the criteria
from the submucosa. There- for this study.
fore the mucosa was be- Group 1 included 15 pa-
lieved to be the strong hold- tients that underwent esoph-
ing layer of the esophageal agotomy to remove a foreign
wall.3,10 In 1988, Dallman1 body; group 2 consisted of six
compared the ability of each patients that underwent
layer of the esophageal wall esophageal resection and
to hold sutures against ten- anastomosis, five for strictures
sion. No significant difference Figure 1B
and one for a large diverticu-
was demonstrated between Figure 1—One-layer closure of an esophageal incision using lum. All procedures were in-
the suture-holding ability of the submucosa as the strength layer. (A) The muscular and trathoracic and required in-
submucosa alone and that submucosal layers were incorporated in the closure; the nee- tercostal thoracotomy.
of the submucosa and mu- dle emerged as close as possible to the edge of the mucosa,
cosa together. The muscu- and penetration into the lumen was avoided. (B) The edges Suture Technique
laris had the least ability to of all three layers were apposed. Care was taken to avoid Group 1
hold sutures against tension. compression of tissue within the suture. Esophagotomies (n = 15)
The conclusion of this were made longitudinally. A
study was that the submucosa is the functional holding simple interrupted suture pattern was used, and the mus-
layer of the esophageal wall and that including the mu- cular and submucosal layers were incorporated in the clo-
cosa in the closure did not increase the strength of re- sure; penetration into the lumen was avoided (Figure 1A).
pair.1 Thus Dallman demonstrated that the suture- The edges of the mucosa were apposed because the deep
holding ability of the esophagus is similar to that of the layer of the mucosa was penetrated so that the needle
rest of the GI tract, rendering the assumption that the emerged as close as possible to the cut edge of the mucosa.
mucosa is the strong layer incorrect. Care was taken to avoid compression of tissue within the
suture (Figure 1B). Sutures were placed 3 mm apart and 3
A NEW SUTURE METHOD FOR THE ESOPHAGUS mm from the cut edge of the esophagus. 3-0 Polydiox-
Based on Dallman’s experimental studies, a new ap- anone sulfate (PDS) suture was used to close the incision
proach to esophageal suturing was proposed. This method in 7 dogs, 4-0 PDS in 4 dogs, 3-0 chromic gut in 3 dogs,
uses the submucosa as the holding layer, avoids penetration and 3-0 polyglactin in 1 dog (Table I).
of the mucosa, and uses one layer of absorbable suture ma-
terial in an interrupted pattern.21 The following discussion Group 2
reports on 21 cases of esophageal surgery in which Dall- The resections and anastomoses in group 2 (n = 6)
man’s experimental findings were implemented. were performed using the same suture pattern as de-

SUBMUCOSA ■ ONE-LAYER CLOSURE TECHNIQUE ■ INCLUSION CRITERIA

Small Animal/Exotics 20TH ANNIVERSARY Compendium May 1999

scribed for group 1. 3-0 TABLE I days. Two dogs (cases 3

PDS was used in two dogs, Esophagotomy in 15 Dogs
and 4) had an esopha-
4-0 PDS in one dog and gogram on days 3 and 5
one cat, 2-0 chromic gut in Esophagogram Long-Term after surgery, and no leak-
one dog, and 3-0 chromic after Clinical age was noticed. A mild
gut in one cat (Table II). Dog Suture Surgery Esophagogram Evaluation radiographic narrowing at
No. Material (days) Findings (days) a
the surgical site was re-
Postoperative 1 3-0 PDS 21 Normal 21 ported in 1 of these dogs
Treatment 2 4-0 PDS 397 Normal 397 (case 3), but there was no
In all cases, nothing was 3 4-0 PDS 5 Slight 913 clinical evidence of an
given by mouth for the first narrowing esophageal problem. All
24 hours; then soft food 4 3-0 PDS 3 Normal — dogs were reexamined 10
and water were given for 5 3-0 PDS 425 Normal 425 to 14 days after surgery
6 3-0 PDS 73 Normal 73
the first 2 weeks. Antibi- (i.e., at the time of suture
7 4-0 PDS — — 31
otics were administered be- 8 4-0 PDS — — — removal) and found to be
fore surgery and for the first 9 3-0 PDS — — 1095 clinically normal.
10 days following surgery. 10 3-0 Chromic 1248 Normal 1248 Long-term follow-up
gut (range, 21 days to 3 years
Follow-up Evaluation 11 3-0 Chromic 992 Normal 992 or more) either by tele-
Short-term evaluation gut phone or reexamination
12 3-0 PDS — — —
(days 1 to 10) was obtained was available for 12 of the
13 3-0 PDS — — 485
from the patient’s medical 14 3-0 Polyglactin — — 500 15 dogs. All dogs were in
records. Long-term evalua- 15 3-0 Chromic 90 Normal 90 good clinical condition and
tion (16 animals) was con- gut were eating regular com-
ducted by telephone inter- a
All dogs were clinically normal at these times. mercial food, and there
view with owners and was PDS = polydioxanone sulfate; — = esophagograms were not per- were no reports of dyspha-
based on information re- formed and/or no information regarding long-term clinical evalu- gia, regurgitation, or vom-
garding the consistency of ation was in the files. iting. Long-term esopha-
the food being fed and the gograms (available for 7
patient’s ability to swallow dogs; 21 to 1248 days after
TABLE II
and retain food. Postopera- surgery) revealed uniform
tive positive-contrast esoph- Esophageal Resection in 4 dogs and 2 cats esophageal diameters.
agograms using fluoroscopy Esophagogram Long-term
(9 patients) and radiogra- after ClinicalGroup 2
phy (3 patients) were ob- Case Suture Surgery Esophagogram Evaluation Contrast radiographs
tained in 12 arbitrarily se- No. Material (days) Findings (yrs) were required for diagnosis
lected patients. 16 4-0 PDS — — Died in all six animals (four
(8 days) dogs and two cats) in
Results 17 2-0 Chromic 2 and 35 Normal 6a group 2. Resections and
Group 1 gut anastomoses were per-
The mean age of the 15 18 3-0 Chromic — — 6a formed to correct esoph-
gut
dogs (9 males, 6 females) 19 4-0 PDS 30 Normal 1a ageal strictures in five ani-
in group 1 was 4 years. Ra- 20 3-0 PDS — — Died mals (cases 16 through 20).
diography was performed 21 3-0 PDS 210 Small One cat (case 16) died
in all cases to establish the diverticulum 1.5a of unrelated causes 8 days
diagnosis. Preoperative a after surgery. The cat was
Clinically normal at these times.
positive-contrast esopha- PDS = polydioxanone sulfate; — = esophagograms not performed icteric and anorectic prior
gograms were obtained in in these cases. to the esophageal surgery.
cases in which survey ra- A jejunostomy tube was
diographs failed to confirm the diagnosis. placed; the cat was fed through the tube for the first 6
During surgery, evidence of perforation of the esoph- days after surgery, at which point leakage around the
agus by a foreign body was found in 11 of the 15 pa- tube was noted. The cat died of severe peritonitis due
tients. Length of hospitalization ranged from 2 to 10 to the leakage. No leakage or stricture formation was

POSTOPERATIVE ESOPHAGOGRAMS ■ FOREIGN BODY ■ LONG-TERM FOLLOW-UP

 Compendium May 1999 20TH ANNIVERSARY Small Animal/Exotics

found at the anastomosis site on gross postmortem ex-

amination. Histologic evaluation of the affected seg-
ment of the esophagus revealed adequate tissue healing.
One dog (case 20), which had a large portion of its
thoracic esophagus resected, died from complications
caused by leakage from the anastomosis site.
The remaining two dogs and one cat that underwent
resections and anastomoses to correct esophageal stric-
tures (cases 17 through 19) recovered from surgery and
were discharged within 5 days. Short- (range, 1 to 14
days) and long-term (range, 1 to 6 years) evaluation was
available for these three
animals. All returned to a
ENDIU
MP normal diet and showed
M’

20th

CO

Figure 2—Injury to the esophageal wall by pressure necrosis

S

no clinical signs of esopha-

1 9 7
9 - 1
9 9 9

geal disease. Esophago-
ANNIVERSARY
grams were performed 30
A LookBack and 35 days after surgery
in cases 17 and 19. Esoph-
ageal diameter and motili-
Almost any textbook discussion ty were normal.
of esophageal surgery comments Resection and anastomo-
on the difficulty of and sis was performed in one
complications associated with dog to remove a large di-
the procedure. Various theories verticulum (case 21). Eigh-
have been purported to explain teen months after surgery,
these phenomena. We believe the patient was eating a
that the basic principles of commercial diet and was
esophageal suturing that have clinically normal. Seven
months after surgery, an
evolved over the past 70 years
esophagogram revealed
should change based on
persistence of a small di-
Dallman’s finding in 1988 verticulum.
(i.e., that the mucosa is the
strength layer in the wall of the Discussion
esophagus, as it is elsewhere in The use of absorbable
the gastrointestinal tract). suture material and one
The single-layer closure layer of sutures, utilization
recommended in this article of the submucosa as the
brings esophageal surgery into holding layer of the esoph-
the same realm as surgery of the agus, and avoidance of the
small and large intestine and mucosa represent a new
approach to esophageal
the urinary bladder, in which
closure. Based on a con-
single-layer appositional closures
trolled study conducted to
are commonly accepted as the compare three esophageal
preferred technique today. suture patterns in which
the sutures penetrated all
layers of the esophagus, it
was concluded that the
esophageal closure was
more likely to fail at suture
holes than at the space be-
from a foreign body (right), and resected segment of the
esophagus showing several areas of necrosis (left). Some
esophageal wall damage can be seen at the line of resection,
which was left untouched to avoid resection of an excessive
length of esophagus.
tween sutures; furthermore, all methods were found to
be adequate for proper healing of a healthy esophagus.19
It was also reported that closing the incision with one
layer of sutures took half the time required for closing
it in two layers.19
The surface epithelium of the esophagus is generally
stratified squamous with varying degrees of keratiniza-
tion.2 This epithelium and the strong, thick lamina
propria produce a mucosa that resembles skin. It is well
known that suppuration occurs around nonabsorbable
sutures left in the skin and that scar tissue forms until
the sutures are removed. It is likely that the same thing
happens in the esophagus and that nonabsorbable su-
tures left in place indefinitely can be a factor in exces-
sive scar tissue formation and stenosis. The report of a
50% mortality rate in a study in which a double layer
of nonabsorbable sutures (with the knots tied within
the lumen) was used13 supports this hypothesis.
In 1965, it was reported that peritoneal and serosal
defects sutured with fine silk in rats and rabbits yielded
a higher percentage of adhesions than occurred when
such defects were left unsutured.9 It can be assumed
that a two-layer closure is stronger and provides a
tighter seal than does a one-layer closure; however, a
two-layer closure can interfere with the blood supply to
the healing edges, and the large volume of suture mate-
rial can cause irritation.22
Procedures such as pericardial and transdiaphrag-
matic omental patching have been used to decrease the
chance of leakage from an esophageal incision. It has
been reported that contiguous mediastinal structures
become adherent to the area of anastomosis, which is as

SURFACE EPITHELIUM ■ SKINLIKE MUCOSA ■ PERITONEAL AND SEROSAL DEFECTS

Small Animal/Exotics 20TH ANNIVERSARY
effective a sealing barrier as the omentum in the ab-
domen.4
In our study of esophageal surgery in 21 animals,
only one dog died as a result of leakage from the suture
site after resection of a large portion of the thoracic
esophagus. In many cases, the sutured edges of the
esophagotomy or anastomosis were compromised by
pressure from the foreign body (Figure 2). Long-term
clinical evaluation and esophagograms showed no prob-
lems.
CONCLUSION
The analysis of clinical cases in this report is suffi-
cient and accurate to demonstrate the efficacy and safe-
ty of the new suture method. No animals were exclud-
ed from this study because of complications related to
the suture method.
We conclude that the technique of a one-layer clo-
sure of esophageal incisions using the submucosa as the
strength layer, not penetrating into the lumen, and us-
ing absorbable suture material is adequate for proper
esophageal healing. This technique is safe and does not
appear to predispose animals to postoperative compli-
cations such as leakage or stenosis. Although both PDS
and chromic surgical gut suture material were used in
this study, we strongly recommend the use of a synthet-
ic absorbable monofilament material such as PDS.
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About the Authors
Drs. Shamir, Shahar, and Johnston are affiliated with the
Department of Surgery, Veterinary Teaching Hospital, Ko-
ret School of Veterinary Medicine, The Hebrew University
of Jerusalem, Rehovot, Israel. Dr. Mongil operates a
surgery referral practice out of the Dr. Diaz Umpierre Vet-
erinary Hospital in San Juan, Puerto Rico. Dr. Shahar is a
Diplomate of the European College of Veterinary Sur-
geons and the American Board of Veterinary Practitio-
ners, Dr. Johnston is a Diplomate of the American Col-
lege of Veterinary Surgeons and the European College of
Veterinary Surgeons, and Dr. Mongil is a Diplomate of the
American College of Veterinary Surgeons.