A new method for intrathoracic anastomosis in laparoscopic esophagectomy

End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes

PURPOSE

The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups.

METHODS

We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications.

RESULTS

Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups.

CONCLUSIONS

The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.

Modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy: early outcomes and technical details

Thoracoscopic intrathoracic esophagogastrostomy is a technically demanding operation; these technical requirements restrict the extensive application of minimally invasive Ivor-Lewis esophagectomy. In an attempt to reduce the difficulty of this surgical procedure, this study developed a modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy. During the entirety of this modified approach, neither technically challenging operations such as intrathoracic suturing or knotting, nor special instruments such as an OrVil system or a reverse-puncture head are required. Between October 2015 and January 2016, 15 consecutive patients with cancer in the distal third of the esophagus or the gastric cardia underwent this modified surgical procedure. The good short-term outcomes that were achieved suggest that the modified anastomotic technique is safe and feasible for thoracolaparoscopic Ivor-Lewis esophagectomy.

Modified anastomotic technique for thoracolaparoscopic Ivor Lewis esophagectomy: early outcomes and technical details

Thoracoscopic intrathoracic esophagogastrostomy is a technically demanding operation; these technical requirements restrict the extensive application of minimally invasive Ivor Lewis esophagectomy. In an attempt to reduce the difficulty of this surgical procedure, we developed a modified anastomotic technique for thoracolaparoscopic Ivor Lewis esophagectomy. During the entirety of this modified approach, neither technically challenging operations such as intrathoracic suturing, or knotting, nor special instruments such as an OrVil system or a reverse-puncture head are required. Between Octomber 2015 and January 2016, 15 consecutive patients with cancer in the distal third of the esophagus or the gastric cardia underwent this modified surgical procedure. The good short-term outcomes that were achieved suggest that the modified anastomotic technique is safe and feasible for thoracolaparoscopic Ivor Lewis esophagectomy.

Thoracoscopic Esophagojejunostomy in the Upper Mediastinum After Thoracoscopic Esophagectomy with Total Gastrectomy

BACKGROUND

Esophagectomy and esophageal reconstruction with organs other than the gastric tube are complicated and difficult surgical procedures. We developed a new method of thoracoscopic esophagectomy with intrathoracic esophagojejunostomy in the upper mediastinum when the gastric tube cannot be used as an esophageal substitute for reconstruction.

MATERIALS AND METHODS

Total gastrectomy, preparation of pedicled jejunal conduit, and transhiatal lower mediastinal dissection were done under laparotomy. Upper and middle mediastinal dissection was performed thoracoscopically. After esophageal transection with a linear stapler above the arch of the azygos vein, an anvil was inserted transorally. A circular stapler-inserted jejunal conduit was introduced to the upper mediastinum via the transhiatal route with relaparotomy. Esophagojejunostomy was completed by double stapling technique.

RESULTS

We completed this procedure for 10 consecutive cases without conversion to thoracotomy. The median operation time, amount of blood loss, duration of intrathoracic anastomosis, and number of dissected total and thoracic nodes was 741 (665-1019) minutes, 835 (380-2090) ml, 94.5 (70-211) minutes, and 59 (16-165) and 30 (10-54) nodes, respectively. There was no anastomotic leakage, conduit necrosis, or hospital mortality. Two cases showed delayed anastomotic stenosis. The median body weight loss 3 months after surgery was 13.9%. The overall 5-year survival rate was 90% (stage I, 100% and stage III, 83.3%).

CONCLUSIONS

Thoracoscopic esophagectomy with intrathoracic esophagojejunostomy is safe and curative. This operation can be performed as a minimally invasive surgical procedure for esophageal cancer patients in whom the stomach cannot be used as a reconstruction conduit.

Minimally invasive and robotic Ivor Lewis esophagectomy

Esophageal cancer is the eighth most common malignancy and the sixth most common cause of cancer-related death worldwide. Esophagectomy provides a curative treatment but carries significant morbidity and mortality. Ivor Lewis esophagectomy (ILE) is one of the most commonly employed open techniques of esophagectomy. Minimally invasive approaches have been explored in ILE in an effort to reduce operative morbidity. This article reviews recent literature of minimally invasive Ivor Lewis esophagectomy (MI-ILE), discusses its clinical outcomes, and introduces the robotic approach in MI-ILE. MI-ILE has demonstrated comparable postoperative outcomes to open ILE, and it has shown potential to reduce blood loss and length of hospitalization. Due to limited studies, no significant improvement of long-term survival has been reported in MI-ILE. Robotic ILE is safe and feasible, but more studies are needed to prove identifiable benefits. Randomized controlled trials comparing MI-ILE or robotic ILE with conventional open ILE are warranted to determine the optimal surgical procedure for the treatment of esophageal cancer.

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

OrVil™-assisted anastomosis in laparoscopic upper gastrointestinal surgery: friend of the laparoscopic surgeon

BACKGROUND

An increasing number of minimally invasive oesophagogastrectomies (MIOG) are being performed. However, the complexity of the surgical skills required and the steep learning curve have thus far confined the minimally invasive approach to selected tertiary centres. The oesophagogastric and the oesophagojejunal anastomosis can be challenging and often time-consuming. The recently developed transorally inserted anvil (OrVil(™)) is a technique aimed to simplify the anastomotic procedure. The aim of the study was to evaluate the safety, feasibility, and efficacy of OrVil(™)-assisted anastomosis during laparoscopic surgery in a tertiary upper-GI cancer centre.

METHODS

From July 2008 to July 2010, 53 consecutive patients underwent MIOG for cancer performed by one surgeon at our institution. Thirty patients underwent laparoscopic Ivor-Lewis oesophagectomy (ILO) and 23 patients underwent laparoscopic gastrectomy. Of the latter group, 13 had a total gastrectomy (TG) and 10 had a subtotal gastrectomy (SG). The gastrointestinal anastomosis was checked with intraoperative endoscopy in all cases.

RESULTS

There were three in-hospital deaths. Median hospital stay was 14 days for oesophagectomies and 11 days for gastrectomies. There were three anastomotic leaks (5.6%), all in the oesophageal group, successfully treated conservatively. Two patients needed conversion to open surgery (3.7%), 3 patients (5.6%) required re-exploration (for bleeding, infected haematoma, and diaphragmatic hernia), and 18 patients (34%) had respiratory complications (pneumonia, pleural effusions, respiratory failure). Four patients developed anastomotic stricture requiring endoscopic balloon dilatation. The average number of lymph nodes harvested was 22 (range = 11-39) and 26 (range = 5-78) for oesophagectomies and gastrectomies, respectively.

CONCLUSIONS

The principles of a good anastomosis are good vascular supply, must be tension-free, and the use of a high-quality surgical technique. The use of the OrVil(™) in laparoscopic upper-gastrointestinal surgery is safe and does not have an increased complication rate. It is quicker and easier compared to the traditional purse-string technique and it may help to expand the adoption of MIOG surgery.

Minimally invasive oesophagectomy: current status and future direction

BACKGROUND

Oesophagectomy is one of the most challenging surgeries. Potential for morbidity and mortality is high. Minimally invasive techniques have been introduced in an attempt to reduce postoperative complications and recovery times. Debate continues over whether these techniques are beneficial to morbidity and whether oncological resection is compromised. This review article will analyse the different techniques employed in minimally invasive oesophagectomy (MIO) and critically evaluate commonly reported outcome measures from the available literature.

METHODS

Medline, Embase, Science Citation Index, Current Contents, and PubMed databases were used to search English language articles published on MIO. Thirty-one articles underwent thorough analysis and the data were tabulated where appropriate. To date, only level III evidence exists. Where appropriate, comparisons are made with a meta-analysis on open oesophagectomy.

RESULTS

Positive aspects of MIO include at least comparable postoperative recovery data and oncological resection measures to open surgery. Intensive care unit requirements are lower, as is duration of inpatient stay. Respiratory morbidity varies. Negative aspects include increased technical skill of the surgeon and increased equipment requirements, increased operative time and limitation with respect to local advancement of cancer. With increasing individual experience, improvements in outcome measures and the amenability of this approach to increasing neoplastic advancement has been shown.

CONCLUSION

MIO has outcome measures at least as comparable to open oesophagectomy in the setting of benign and nonlocally advanced cancer. Transthoracic oesophagectomy provides superior exposure to the thoracic oesophagus compared to the transhiatal approach and is currently preferred. No multicentre randomised controlled trials exist or are likely to come into fruition. As with all surgery, careful patient selection is required for optimal results from MIO.