A method of gastric conduit elevation via the posterior mediastinal pathway in thoracoscopic subtotal esophagectomy

Rational Gastric Conduit Stump Closure Method Using Endo GIA Radial Reload in End-to-Side Anastomosis of the Esophagogastric Conduit

Background: The lack of tension at the anastomosis site and the blood flow of the gastric conduit are important to prevent anastomotic leakage in the anastomosis of the esophagogastric conduit. This study reports a gastric conduit stump closure method using Endo GIA™ Radial Reload in end-to-side anastomosis of the esophagogastric conduit, especially focusing on blood flow. Methods: A 4-cm conduit was created to ensure an intramural vascular network. The gastric conduit was elevated to the neck through the posterior mediastinal route, and end-to-side anastomosis of the esophagus and gastric conduit was performed using a circular stapler. Closure of the gastric stump with an Endo GIA Radial Reload was performed 2 cm proximal to the anastomosis on the end side of the esophagogastric conduit. The lesser curvature of the stump of the gastric conduit is the most frequent site of anastomotic leakage as it has the least blood flow, and the pressure is highest when the pressure inside the gastric conduit increases. Therefore, the gastric conduit stump was closed using the Endo GIA Radial Reload to resect the intersection of the gastric stump and lesser curvature from which the gastric conduit was created. The gastric conduit stump is gently curved; therefore, the pressure applied to the gastric conduit stump could be dispersed when the intragastric pressure increases. Results: No anastomotic leakage was observed among the 21 patients who underwent this method. Conclusion: This method is a novel anastomosis method to prevent anastomotic leakage in an end-to-side anastomosis of the esophagogastric conduit.

Dislocation of the gastric conduit reconstructed via the posterior mediastinal route is a significant risk factor for anastomotic disorder after McKeown esophagectomy

BACKGROUND

Anastomotic disorder of the reconstructed gastric conduit is a life-threating morbidity after thoracic esophagectomy. Although there are various reasons for anastomotic disorder, the present study focused on dislocation of the gastric conduit (DGC).

METHODS

The study cohort comprised 149 patients who underwent transthoracic esophagectomy. The relationships between DGC and peri- and postoperative morbidities were analyzed retrospectively. Data were analyzed to determine whether body mass index (BMI) and extension of the gastric conduit were related to DGC. Uni- and multivariate Cox regression analyses were performed to identify the factors associated with anastomotic disorder.

RESULTS

DGC was significantly related to anastomotic leakage (P < .001), anastomotic stricture (P = .018), and mediastinal abscess/empyema (P = .031). Compared with the DGC-negative group, the DGC-positive group had a significantly larger mean preoperative BMI (23.01 ± 3.26 kg/m2 vs. 21.22 ± 3.13 kg/m2, P = .001) and mean maximum cross-sectional area of the gastric conduit (1024.75 ± 550.43 mm2 vs. 619.46 ± 263.70 mm2, P < .001). Multivariate analysis revealed that DGC was an independent risk factor for anastomotic leakage (odds ratio: 4.840, 95% confidence interval: 1.770-13.30, P < .001). Body weight recovery tended to be better in the DGC-negative group than in the DGC-positive group, although this intergroup difference was not significant.

CONCLUSION

DGC reconstructed via the posterior mediastinal route is a significant cause of critical morbidities related to anastomosis. In particular, care is required when performing gastric conduit reconstruction via the posterior mediastinal route in patients with a high BMI.

Efficacy of camera sleeve in conveyance of conduits

BACKGROUND

Esophageal substitutes need conveyance from the abdomen into the neck for restoration of alimentary continuity. Reports suggest that the use of plastic camera sleeve may prove advantageous in restoring conveyance. This study aims to evaluate the practicability of this approach, specifically, in laparoscopy-assisted surgeries.

METHODS

The efficacy of camera sleeve in conduit transposition was prospectively evaluated over 2 years. The following parameters were assessed: success/failure; time taken; blood loss; adequacy of length of the conduit delivered into the neck; conduit orientation; ease of procedure through different routes; conduit damage; complications; and drawbacks.

RESULTS

The technique was used in 25 consecutive patients. Two ileo-colonic, 13 gastric, and 10 colonic conduits were transposed. Posterior mediastinal, retro-sternal, and ante-sternal routes were used in 15, 8, and 2 cases, respectively. There were no failures. The technique was easy to adopt. It added &lt; 10 minutes to the procedure. It entailed no additional blood loss. Adequate length of the conduit was transposed into the neck, atraumatically. Conduits maintained their orientation without effort. Although no complications per se were associated with its use, extra conduit length became transposed into the neck, twice, necessitating its trimming/adjustment. In one case, traction suture became avulsed from the conduit, midway in the tunnel. This could easily be rectified by pulling out the sleeve from the neck, which brought up the conduit along with it, as desired.

CONCLUSIONS

Use of camera sleeve proves efficacious in interposition of esophageal substitutes.