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

Double purse-string suture technique for circular-stapled anastomosis during robotic Ivor Lewis esophagectomy

Background

With the advantage of the robotic suturing capacity, the purse-string suture is technically simple and convenient. This study aimed to present our technical aspects and initial results of robotic Ivor Lewis esophagectomy using two purse-string sutures for circular-stapled anastomosis.

Methods

After stomach mobilization, gastric conduit formation, esophagus mobilization and two-field lymphadenectomy, the first robotic hand-sewn purse-string suture was applied to the esophageal muscular layer with an adequate margin above the tumor. A longitudinal incision in the anterior wall of the esophagus was made and the circular stapler anvil was inserted. The esophagus was transected by scissors 1 cm caudal to the first purse-string suture and the purse-string tied to secure the anvil. Then the second robotic hand-sewn purse-string suture was applied to the whole-layer of the proximal end of the esophagus and tied. Finally, the anvil was connected to the body of the stapler and fired.

Results

The clinical data of ten patients who underwent robotic Ivor Lewis esophagectomy with an intrathoracic circular-stapled end-to-side anastomosis from February 2022 to April 2022 were collected. There were seven male and three female patients and had a mean age of 63.2 ± 7.6 years. Tissue donuts were complete in all cases and all operations were successfully performed without conversions. The mean overall operative time was 358.2 ± 40.3 min. The mean estimated blood loss was 83.2 ± 15.6 ml. The median length of hospital stay was 11.5 ± 4.1 days. All the patients had an uneventful postoperative period.

Conclusion

Two purse-string sutures are necessary to obtain a tight seal of the esophageal tissue around the anvil to avoid potential anastomotic leak and are an essential process for the safety of circular-stapled anastomosis during robotic Ivor Lewis esophagectomy.

Pre-embedded cervical circular stapled anastomosis in esophagectomy

Background

Mechanical anastomosis is now widely used in surgery for esophageal cancer. An anastomotic fistula is still the most dangerous complication in mechanical anastomosis, especially for patients who undergo cervical anastomosis. However, due to the high anastomosis position and limited space, conventional embedding and suspension are rarely performed. This study aimed to introduce the steps of an improved embedded method in cervical circular stapled anastomosis and evaluate its efficacy in reducing complications.

Methods

In total, 31 patients who underwent minimally invasive esophagectomy were enrolled into the study. Pre‐embedded cervical esophagogastrostomy with a circular stapler was adopted after thoracoscopic and laparoscopic esophagectomy for esophageal cancer.

Results

The results of surgical duration, blood loss, mean duration of hospitalization and operation complications such as anastomotic fistula, anastomotic stenosis and gastroesophageal reflux were recorded. The operative procedure lasted between 205–300 minutes with an average of 260.3 minutes. The postoperative recovery was good, with no complications such as anastomotic fistula, anastomotic stricture and pulmonary complication, except for two cases of gastroesophageal reflux. The postoperative hospital stay was 8–14 days with an average of 10.3 days.

Conclusion

Our data revealed that pre‐embedded cervical circular stapled anastomosis is an alternative for patients with good stomach length, which can decrease the occurrence rate of anastomotic fistula by full peripheral embedding of anastomotic stoma.

Key points

This new technique can significantly reduce the risk of anastomotic leakage.

This study adds further details enabling a smooth pre‐embedded procedure to be performed.

Ergonomic thoracic port design for video-assisted thoracoscopic minimally invasive esophagectomy and lymphadenectomy: a preliminary pilot study

Background

Video-assisted minimally invasive esophagectomy (MIE) has been widely applied in clinical practice. However, the optimal port design for thoracoscopic esophagectomy and lymphadenectomy has not been well established. Here we introduced our novel ergonomic thoracic port design as well as our novel procedures of lymphadenectomy via tissue interactive retraction and compared its effects with that of conventional port design in this pilot study.

Methods

Patients undergoing McKeown MIE from January 2018 to December 2018 in one surgical team were randomly assigned into the ergonomic port design group and conventional port design group. Data of baseline characteristics, perioperative outcomes, and ergonomic assessment were collected and compared between the two groups.

Results

A total of 70 patients undergoing curative McKeown MIE were randomly assigned and there were 35 patients in each group. The baseline characteristics between the two groups were comparable and well-matched. Moreover, there was no significant difference of number of total dissected lymph nodes, positive lymph nodes and total dissected mediastinal lymph nodes between the two groups. As for perioperative outcomes, there was also no significant difference of in-operating time and blood loss in the thoracic part between the two groups. However, there were significantly less times of forced pause of the surgeon by fatigue during thoracic part in the ergonomic group compared to conventional group (mean time: 1.1 vs. 7.4, respectively; P<0.001) and the symptom score referable to the musculoskeletal system by the surgeon was significantly lower in the ergonomic group than in the conventional group (2.3 vs. 7.6; P<0.001). Postoperatively, there was no significant difference of hospital stay duration and rate of complication and 30-day mortality between the two groups.

Conclusions

Our novel thoracoscopic port design and procedures of lymphadenectomy was proved to be feasible and ergonomic, which could be easily mastered by most of the thoracic surgeons.

Robot-assisted esophagogastric reconstruction in minimally invasive Ivor Lewis esophagectomy

Background

Although the incidence of esophagogastric junction cancer has increased considerably in recent years, the application of minimally invasive Ivor Lewis esophagectomy, especially in East Asia, is still much rarer than the McKeown approach. The reconstruction of the alimentary tract is one of the main technical challenges under traditional endoscopy. The robotic surgical system with high-resolution 3D images and multiarticulate instruments may help simplify this procedure. Here, we describe our experience in the gastric tube and esophagogastric anastomosis construction, and the initial clinical results for Ivor Lewis robot-assisted minimally invasive esophagectomy (RAMIE).

Methods

A retrospective study of all patients undergoing Ivor Lewis RAMIE with circular stapled anastomosis at a single institution from December 2016 to June 2018 was performed. Operative and postoperative outcomes were recorded.

Results

Twenty-four patients [median age, 63 years (range, 49-77 years)] underwent Ivor Lewis RAMIE during the study period with a four-arm robotic platform. Four patients (16.7%) received neoadjuvant therapy. The median estimated blood loss was 120 mL (range, 50-210 mL). The median operating time was 352.5 min (range, 259-485 min). There was no conversion to an open surgical procedure. Postoperative complications occurred in 3 (12.5%) patients. Complications included pneumonia in two patients (8.3%) and mediastinitis in 1 (4.2%). The median stay in the intensive care unit was 1 d (range, 0-8 d) and the median postoperative hospital stay was 11 d (range, 8-30 d). All patients had an R0 resection. The median number of nodes removed was 19 (range, 11-30) and the median number of positive nodes removed was 1 (range, 0-8).

Conclusions

Our initial results indicate that Ivor Lewis RAMIE may be a safe and feasible alternative to open and endoscopic Ivor Lewis esophagectomy.