Intrathoracic Linear Stapled Esophagogastric Anastomosis: An Alternative to the End to End Anastomosis

Lyall A. Gorenstein, MD, Marc Bessler, MD, and Joshua R. Sonett, MD

Department of Surgery, Division of Cardiothoracic Surgery, Division of Minimally Invasive Surgery, New York Presbyterian Hospital, New York, New York

Minimally invasive esophagectomy (MIE) is gradually gaining acceptance as an oncological sound procedure. The advantages of MIE arise from avoidance of a thoracotomy or laparotomy, resulting in decreased pulmonary morbidity and generally a faster recovery, yet not compromising the surgical benet of esophagectomy in patients with cancer of the esophagus. No single technique of esophagectomy has proven itself superior to another

from either an oncologic or survival perspective. The MIE is a technically demanding procedure that requires advanced endoscopic skills, especially when performing an intrathoracic anastomosis. We present an alternative intrathoracic anastomotic technique to the commonly performed EEA anastomosis. (Ann Thorac Surg 2011;91:314 6) 2011 by The Society of Thoracic Surgeons

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here are various approaches to a minimally invasive esophagectomy (MIE) [1 4], as there are with an open esophagectomy. With the increasing incidence of adenocarcinoma of the gastroesophageal junction, a minimally invasive IvorLewis esophagectomy is an excellent procedure in that it affords wide resection margins, complete celiac dissection, and mediastinal lymph node dissection. Compared with a minimally invasive transhiatal esophagectomy or three-hole esophagectomy, there is a lower incidence of recurrent laryngeal injury and better swallowing in the immediate postoperative period. Performing a reliable minimally invasive intrathoracic esophagogastric anastomosis is challenging. In general, most Ivor Lewis resections for esophageal cancer currently being performed use standard established anastomotic techniques, which are very reliable and have a low incidence of anastomotic leaks or postoperative strictures [5]. However, the commonly performed two-layered hand-sewn anastomosis can not be easily adapted to a minimally invasive Ivor Lewis esophagectomy. Most centers performing a minimally invasive Ivor Lewis esophagectomy use the EEA stapler. There are certain technical aspects to using this stapler when performing an MIE, which can be challenging; these aspects include inserting an adequate-sized EEA instrument through a narrow intercostal space, placing the anvil into a nondilated esophagus, and intracorporeal suturing of the pursestring to hold the anvil in place. As our experience in MIE increased, our anastomotic technique

evolved from a partially hand-sewn anastomosis to a completely linear stapled anastomosis.

Technique
During the intra-abdominal component of the mobilization, the gastric tube is initiated, but not completed. A double lumen endotracheal tube is inserted, and the patient is placed in a left lateral decubitus position supported by a bean bag. The table is exed maximally to allow placing the thoracoscope in the eighth or ninth intercostal space. Rotating the patient toward the left until they are nearly prone displaces the lung without the need for an additional port to retract the lung. We place our 5-cm utility incision opposite the azygous vein as far anteriorly as possible, usually in the fourth intercostal space. A third port is placed just inferior to the scapula (Fig 1). The azygous vein is divided with a linear stapler. The esophagus is mobilized approximately 5 to 7 cm above the azygous vein, maintaining the dissection adjacent to the longitudinal muscle so that the recurrent laryngeal nerves or membranous trachea are not injured. The esophagus is divided with the harmonic stapler above the azygous vein. We than complete the gastric tube staple line with the linear stapler. The esophagogastectomy specimen is placed in a large specimen bag and is retrieved through the utility port. We routinely open the specimen to examine the gross surgical margin prior to having the pathologist evaluate the microscopic margin. The gastric conduit is placed posterior to the divided esophagus. Adequate esophageal mobilization is essential to allow the esophagus to overlap 4 to 5 cm onto the stomach. The tip of the stomach should lie at the apex of the chest, which will prevent redundancy of the conduit
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.02.115

Accepted for publication Feb 26, 2010. Presented at the Surgical Motion Picture Session of the Fifty-sixth Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 4 7, 2009. Address correspondence to Dr Sonett, 161 Fort Washington Ave, New York, NY 10032; e-mail: js2106@columbia.edu.

2011 by The Society of Thoracic Surgeons Published by Elsevier Inc

Ann Thorac Surg 2011;91:314 6

HOW TO DO IT GORENSTEIN ET AL LINEAR INTRATHORACIC ANASTOMOSIS

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Fig 1. Left lateral decubitus positioning with extreme anterior rotation of the table. The specimen is removed through the anterior port, and the linear stapler is used to nish the anastomosis.

Fig 3. The linear stapler is introduced through the posterior/inferior port.

Comment
There are several features of this technique that are unique and vary from the EEA anastomosis. The anterior utility incision, which is used to perform the majority of the dissection, allows retrieval of the specimen and closure of the anterior gastrotomy of the anastomosis. Because it is placed more anteriorly, the intercostal space is wider, which allows several instruments to be simultaneously inserted through it. In addition to being very functional, we also nd the more anterior intercostal

Fig 2. Stay sutures placed with the endostitch align the stomach and the esophagus.

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and improve gastric emptying. The harmonic stapler is used to perform a transverse gastrotomy. Interrupted stay sutures are placed at the corners of the anastomosis (Fig 2). The sutures are used as stay sutures brought out

through the most posterior anterior port sites. The linear stapler is placed through the inferior port, which is aligned with the anastomosis. Traction on the stay sutures facilitates inserting the linear stapler (Fig 3). We create a 4-cm staple line between the stomach and the esophagus (Fig 4). A third stay suture is placed in the anterior defect midway between the two corner sutures. The anterior defect can usually be closed with a single ring of the linear stapler placed through the anterior utility incision (Fig 5). After completing the anastomosis, an upper endoscopy across the anastomosis insures that there is no torsion of the stomach and that the anastomosis is adequate. If it seems that there is a redundant stomach in the right chest, we will gently push the excess stomach back into the abdomen. Preventing the redundant stomach from bowing into the pleural space greatly improves gastric emptying and postoperative quality of life. Suturing the stomach to the right crus of the diaphragm reduces the risk of intestinal hiatal hernias postoperatively.

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HOW TO DO IT GORENSTEIN ET AL LINEAR INTRATHORACIC ANASTOMOSIS

Ann Thorac Surg 2011;91:314 6

incisions are less painful. The linear stapler is simpler to manipulate in the pleural space than by using an EEA device. There are several difcult steps to successfully create an endoscopic intrathoracic EEA anastomosis; namely, these steps involve inserting the anvil into the esophagus, the pursestring suture that holds it in place, and attaches the anvil to the stapler. Unless a large EEA anastomosis is made, there is a risk of postoperative dysphagia if any scarring develops at the anastomosis. The linear side-to-side anastomosis that is described here is large and rarely stenotic. As our experience with MIE has increased, our techniques have also evolved. The port sites and utility incision have been standardized. We believe this anastomotic technique has several advantages when performing a minimally invasive Ivor-Lewis esophagectomy in comparison with an anastomosis performed by using the EEA device. Since January 2007, our group has performed 77 minimally invasive esophagectomies, of which 31 had an intrathoracic anastomosis using the technique described

Fig 5. The linear is inserted through the anterior port and is articulated. Traction on the stay sutures allows closing the anterior defect.

herein. There was one postoperative leak that required a return to the operating room. A leak occurred at the corner of the anastomosis where the anterior gastrotomy is closed. This was easily repaired and buttressed with an intercostal muscle ap. There were no other anastomotic complications in this group of patients. The linear stapled anastomotic technique described is reliable and very easy to learn. Thoracic surgeons who are learning to perform an MIE with an intrathoracic anastomosis may want to consider this anastomotic technique.

FEATURE ARTICLES Fig 4. A linear side to side anastomosis (4-cm long) is created between the posterior wall of the esophagus and the anterior wall of the stomach.

References
1. Enestyedt CK, Perry KA, Kim C, et al. Trends in the management of esophageal carcinoma based on provider volume: treatment practices of 618 esophageal surgeons. Dis Esophagus 2010;23:136 44. 2. Biere SS, Cuesta MA, van der Peet DL. Minimally invasive esophagectomy for cancer: a systematic review and metaanalysis. Minerva Chir 2009;64:12133. 3. Santillan AA, Farma JM, Shah NR, et al. Minimally invasive surgery for esophageal cancer. J Natl Compr Canc Netw 2008;6:879 84. 4. Carr SR, Luketich JD. Minimally invasive esophagectomy. An update on the options available. Minerva Chir 2008;63:48195. 5. Mathisen DJ, Grillo HC, Wilkens EW Jr., et al. Transthoracic esophagectomy: a safe approach to carcinoma of the esophagus. Ann Thorac Surg 1988;45:137 43.