|Year : 2017 | Volume
| Issue : 4 | Page : 669-672
Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer
Parth Kanaiyalal Patel, Mishal Shah, Sanjeev Patni, Shashikant Saini
Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
|Date of Web Publication||30-Jul-2018|
Dr. Parth Kanaiyalal Patel
Department of Surgical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
BACKGROUND: Anastomosis in gastrointestinal (GI) surgery is a commonly performed procedure. Irrelevant various methods of intestinal anastomosis were followed – recent advance is the use of a stapler as a device for GI anastomosis. Due to the use of staplers, technical failures are a rarity, anastomosis is more consistent and can be used at difficult locations. MATERIALS AND METHODS: Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy or video-assisted thoracoscopic surgery with linear stapler anastomosis. RESULTS: The average follow-up was approximately 9 months. Anastomotic leakage was observed in three patients. On follow-up, two patients presented with difficulty in swallowing, and on upper GI endoscopy, they were found to have anastomotic site stricture. There was no perioperative mortality. CONCLUSION: The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. As in this technique only two linear staplers are used in comparison to other techniques where three or more staplers are used, it is also cost-effective. The procedure deserves more attention and further application.
Keywords: Anastomosis leak, anastomosis stricture, carcinoma esophagus, esophagogastric anastomosis, stapled anastomosis
|How to cite this article:|
Patel PK, Shah M, Patni S, Saini S. Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer. Indian J Cancer 2017;54:669-72
| » Introduction|| |
Esophageal carcinoma is a multifaceted and complex disease with a rapidly rising incidence that exerts an increasing social and financial burden on global health-care systems. Esophagectomy is the standard of care for esophageal carcinoma and end-stage benign esophageal disease. The organ most commonly used for reconstruction after esophagectomy is the stomach., There are some advantages such as ease of construction and tension-free substitute with sufficient length. Esophagogastric anastomosis can be done either in thorax or lower neck and can be done either manually or using staplers. However, the techniques of cervical esophagogastric anastomosis (CEGA) after esophagectomy are complex and associated with postoperative complications such as anastomotic leakage, stricture formation, and gastroesophageal reflux.
One advantage of this approach is that a CEGA leak is seldom associated with mediastinitis. Although more than 98% of CEGA leaks are relatively benign and managed conservatively, there is a small incidence of severe complications that may be associated with CEGA. Furthermore, although the acute postoperative complications of a CEGA are clearly less than those associated with an intrathoracic esophagogastric anastomosis, the long-term sequelae of a cervical leak has not proven to be as minor as thought initially. As many as 50% of cervical esophagogastric anastomotic leaks result in an anastomotic stricture as fibrosis associated with healing becomes established. The subsequent need for repeated esophageal dilatations negates the merits of an operation intended to restore comfortable swallowing. They are the main causes of postoperative morbidity and poor quality of life. Hence, the technique of gastroesophageal anastomosis remains crucial.
Mechanical staplers have been widely used in esophagogastric anastomosis for their convenience and being less operator dependent. In general, two different types of staplers are widely used – the circular and linear staplers (LS). Some studies have observed that the use of a circular stapler contributes to reduced leakage but is associated with an increased risk of anastomotic strictures.,,,,,,
Anastomosis using LS, described by Collard et al. and modified by Orringer et al., is considered a major advance in reducing the incidence of anastomotic leakage and stricture. Several studies have reported that this technique is associated with reduced anastomosis-related complications. Recently, others have reported that the side-to-side esophagogastric anastomosis could decrease the rate of anastomotic leakage and stricture following esophagectomy.,,,
We modified this method as linear-stapled anastomosis using this anastomosis technique (one vertical and one horizontal) with two LSs.
| » Materials and Methods|| |
Between 2008 and August 2016, 75 patients with esophagus or gastroesophageal junction carcinoma underwent curative intent resection with LS anastomosis in our department. All patients with thoracic esophageal carcinoma and gastroesophageal junction cancer underwent esophagectomy and lymphadenectomy either via a right posterolateral thoracotomy (TTE) or transhiatal esophagectomy (THE) or video-assisted thoracoscopic surgery (VATS).
A gastric tube of 4–5 cm in diameter was created using a 75-mm linear cutter stapler and placed through the posterior mediastinum until 5–6 cm of gastric fundus rests above the level of the clavicles. The lie of the conduit was confirmed. The length of the remaining cervical esophagus was adequate enough to perform the tension free cervical esophago-gastric anastomosis.
This technique is a modification of the original side-to-side anastomosis technique described by Collard et al. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Figure 1: Approximately 2-cm gastrotomy done at the tip of stomach tube as shown by arrow|
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|Figure 2: Two stay sutures applied between posterior walls of cervical esophagus and posterior wall of conduit at a distance of about 1.5–2.0 cm. It is important to achieve alignment of the posterior wall of the cervical esophagus and the posterior wall of the conduit as the staple cartridge is advanced completely into the esophagus and stomach. 55/75-mm linear cutter stapler fired vertically to this party wall|
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|Figure 3: (a and b) The stapler is fired by advancing the knife assembly for ~4 cm length, and as the posterior walls of the esophagus and stomach are cut, a common lumen is created. After removing the stapler, the staple line is inspected for any bleeding|
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|Figure 4: Six to seven stay sutures taken between anterior walls of esophagus and conduit|
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|Figure 5: (a and b) 55/75-mm linear cutter stapler fired horizontally. At the time of firing the stapler, one should always make sure that Ryle's tube is not coming in staple line|
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A feeding tube was placed in the jejunum for early postoperative enteral nutrition support.
All patients were followed up in the intensive care unit during the immediate postoperative period. The feeding usually began on the second postoperative day (POD) through feeding jejunostomy. A gastrografine swallow examination was carried out between the 7th and 9th day before starting oral feeding.
The patients were followed up at 1, 2, 3, 6, and 12 months, and and every six months after the first year.
Stenosis at the anastomotic site was defined as stenosis which was endoscopically examined due to postoperative swallowing difficulty.
| » Results|| |
We performed this anastomosis technique for 75 esophageal cancer patients. These patients are on follow-up, and the longest follow-up time is approximately 84 months with the average follow-up being approximately 9 months. Sixty-three patients were of squamous cell carcinoma and 12 were of adenocarcinoma histology. Sixteen patients received 2 or 3 cycles of neoadjuvant chemotherapy and three patients received neoadjuvant chemo-radiotherapy. Thirty-three patients underwent TTE with feeding jejunostomy, 5 patients underwent VATS-assisted esophagectomy with feeding jejunostomy, and 37 patients underwent THE with feeding jejunostomy. In the final histopathology report, two patients had pathological Stage I, 39 patients had Stage II, and 34 patients had Stage III disease. In addition, two patients were found to achieve complete pathological response after neoadjuvant treatment, and 22 patients received either adjuvant chemotherapy or radiotherapy or both depending on their final histopathological report. There was no perioperative mortality.
The anastomotic leakage was observed in three patients, one on the 5th POD, second on the 9th POD, and third on the 12th POD. The leakage was diagnosed by contrast swallow radiography and salivary content in neck drain. All three patients were treated conservatively. On follow-up, two patients presented with difficulty in swallowing, and on upper gastrointestinal (GI) endoscopy, they were found to have anastomotic site stricture. Chylothorax occurred in two patients, one required transthoracic ligation of the injured thoracic duct on the 6th POD and the other was managed conservatively. In one patient, who had persistent post operative air leak in ICD, surgical intervention was required to repair the pulmonopleural fistula. One patient developed feeding jejunostomy site small bowel intussusceptions after 1 month of surgery, which was managed by exploratory laparotomy.
Locoregional recurrence and distant metastasis on follow-up were seen in 7 and 9 patients, respectively.
| » Discussion|| |
Initially, all gastroesophageal anastomoses were hand sewn eventually giving way to stapled anastomosis. The disadvantage of hand-sewn anastomosis is that it requires a long operating time and a higher level of expertise. With the development of mechanical stapling devices, digestive anastomosis has become much more efficient. These instruments are simple to use and have contributed to making anastomosis more routine, reproducible, and faster, decreasing the time of intervention. Further, these devices are invaluable for performing anastomosis in restricted spaces. After the popularization of stapled anastomosis, now the hand-sewn approach is only used in incidences of a misfired stapler, when it is technically difficult to use a stapler due to anastomotic considerations, or if there is not enough gastric conduit to overlap the anastomosis sufficiently. The stapled anastomosis has the advantages of reducing the operation time and validity of anastomosis, especially anastomosis at the apex of thorax because of poor exposure for hand-sewn anastomosis. However, nonrandomized comparison of hand-sewn and stapled esophagogastric anastomoses suggested a higher stricture rate when the stapled technique was used.,
The reasons why stricture rate was more common with the stapled method include (i) lack of accurate mucosa-to-mucosa apposition when performing anastomosis; (ii) tissue necrosis beyond the stapled line, inflammation, and delayed epithelialization may predispose to excessive fibrosis and stricture formation; (iii) circumferentially placed unabsorbable metal staples do not allow the lumen to dilate beyond the size obtained originally. Moreover, the stapled anastomotic technique has other shortcomings, such as circular stapler anastomosis in the neck is inconvenient and has proven to be awkward for constructing a cervical esophageal anastomosis, and the balloon used to dilate postoperative anastomotic stricture can be easily torn by metal staples resulting in dilatation failure.
Some series have compared mechanical esophagogastric anastomoses with manual anastomoses. Beitler and Urschel compared manual anastomoses with mechanical anastomoses in a meta-analysis and found that the risks for anastomotic leakage were comparable but that mechanical esophagogastric anastomosis caused more stenoses than manual anastomosis. Esophageal anastomotic leak is among the leading causes of perioperative morbidity and mortality after an esophagectomy.
In 1984, Steichen reviewed the varieties of stapled esophageal anastomoses available at the time. He suggested the use of a GIA™ stapler for an end-to-side anastomosis either in the chest or lower neck. This technique, however, did not gain widespread popularity.
Therefore, it is necessary to develop a new anastomotic technique. A new partially stapled anastomosis was described by Collard and modified by Orringer et al., It has the advantages of reducing the incidence of leaks and stenosis. Orringer et al. performed a side-to-side stapled CEGA in 114 patients with esophageal carcinoma; the rate of anastomotic leakage was 2.7% and the rate of anastomotic stricture was 12%. In our study, anastomosis leak occurred in three out of 75 patients (4%) and anastomosis stricture in two out of 75 patients (2.6%).
Collard et al. described a side-to-side staple technique for construction of the CEGA using the smaller and easier to use Endo-GIA™ stapler in 16 patients. Their cervical anastomosis was performed at the tip of the mobilized stomach which created a functional end-to-end esophagogastric connection.
It is believed that subsequent gastroesophageal reflux is minimized if the end of the cervical esophagus is anastomosed to the gastric wall in the neck several centimeters below the tip of the stomach as an end-to-side anastomosis.
The described anastomosis technique using linear staples has clear advantages over both manual anastomosis and the circular EEA stapler anastomosis, which has not proved to be readily adaptable to a cervical anastomosis. It is simpler and requires no oral or retrograde gastric insertion of the instrument. Stapler across the gastric and esophageal walls placed side by side to create a V-shaped opening between the two lumina provides at least 3-cm long anastomosis which is less likely to develop strictures and more likely to provide comfortable swallowing. The final anterior closure of the anastomotic site is hand sewn in the technique described by Collard et al.; in this technique, we modified the technique by a transverse firing of linear cutter stapler.
Limitation of the technique
The linear-stapled anastomosis has some drawbacks. This technique needs a longer esophageal remnant. Therefore, patients with tumor located at the upper third of the esophagus might not be appropriate for this technique. This limitation is also applicable in other stapling techniques using LS.
Limitations of the study
This study also had some limitations including inadequate follow-up; nine patients had a follow-up of <3 months. We recognize that the strength of the study would be improved with a longer follow-up. However, we considered that most dysphagia and anastomotic strictures related to the anastomotic technique would occur within the initial 3 months after the operation. By that time, we might obtain an effective comparison. After 3 months, other influencing factors such as adjuvant radiation might play a role and impair the comparison; more patients would be lost to follow-up, some patients would undergo postoperative radio/chemotherapy, while some may die. Therefore, an unbiased long-term comparison is difficult.
| » Conclusion|| |
The linear-stapled esophagogastric anastomosis is a safe and effective anastomotic technique, which can decrease the rate of leak, postoperative dysphagia, and anastomotic stricture. The procedure deserves more attention and further application.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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