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  Table of Contents  
LETTERS TO THE EDITOR
Year : 2019  |  Volume : 56  |  Issue : 3  |  Page : 278-279
 

Cervical esophagogastric anastomosis using a modified linear cutter stapler technique in esophageal cancers following neoadjuvant chemoradiation


Department of Surgical Oncology, Cancer Institute, Chennai, Tamil Nadu, India

Date of Web Publication19-Jul-2019

Correspondence Address:
Arvind Krishnamurthy
Department of Surgical Oncology, Cancer Institute, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_665_18

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How to cite this article:
Krishnamurthy A. Cervical esophagogastric anastomosis using a modified linear cutter stapler technique in esophageal cancers following neoadjuvant chemoradiation. Indian J Cancer 2019;56:278-9

How to cite this URL:
Krishnamurthy A. Cervical esophagogastric anastomosis using a modified linear cutter stapler technique in esophageal cancers following neoadjuvant chemoradiation. Indian J Cancer [serial online] 2019 [cited 2019 Oct 14];56:278-9. Available from: http://www.indianjcancer.com/text.asp?2019/56/3/278/263044




I have read with interest the article entitled “Cervical esophago-gastric anastomosis using linear cutter stapler in esophageal cancer” by Patel et al.[1] I must appreciate the authors on their modified technique of esophagogastric anastomosis as initially described by Collard et al.[2] Incidentally, in the same issue of the journal we had published our initial results of managing patients with locally advanced resectable esophageal cancers with neoadjuvant chemoradiation approach.[3]

In the series presented by Patel et al., nearly three-fourth of the patients underwent upfront surgery, the majority (55%) being early staged (Stages I and II) esophageal cancers. Only three patients (4%) in their cohort were managed by neoadjuvant chemoradiation. We have successfully used a similar technique but with slight technical modifications in our series of patients who were all managed by neoadjuvant chemoradiation approach. The gut continuity in all our patients was maintained by anastomosing the esophageal remnant to the fashioned gastric conduit in the cervical region using our modified linear cutter stapler technique.

The salient steps in our technical modifications (as highlighted in italics below) of the linear cutter stapler technique are as follows:

The stapled gastric conduit with a width of around 4 cm was created as long as possible along with the adjoining greater omentum, taking care to preserve both the right gastroepiploic vessels and the right gastric vessels. The esophagus was pulled up in the neck and was transected in the neck, so as to ensure at least a 6-cm length for the posterior anastomosis, that is, between the posterior wall of the gastric conduit and the posterior wall of the remnant esophagus [Figure 1]a.
Figure 1: (a and b) The esophagus was pulled up in the neck and was transected in the neck, so as to ensure at least a 6-cm length for the posterior anastomosis, i.e., between the posterior wall of the gastric conduit and the posterior wall of the remnant esophagus. (c) The anterior anastomosis between the esophageal remnant and the gastric conduit was transversely placed at least 2–3 cm below and across the posterior staple line. (d) The esophagogastric anastamosis being wrapped with the part of the greater omentum that was harvested alongside the gastric conduit

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We preferred to perform our esophagogastric anastomosis using an NTLC linear cutter stapler which allowed for 3D stapling technology. A 75-mm linar cutter stapler was used for posterior anastomosis, whereas another 75-mm linear cutter stapler was used for anterior anastomosis. Another difference in the techniques was that we placed the anvil of the linear cutter stapler in the esophagus and the cartridge end of the stapler (1.5 mm stapler height closure) through a small posterior gastrostomy made closer to the greater omental side of the gastric conduit to match the maximum length of the properly aligned and pulled up esophageal remnant. The gastrostomy in our technique was at least 2–3 cm below the tip of the fashioned gastric conduit as against the placement of the gastrostomy just distal to the tip of the gastric conduit by the authors [Figure 1]a and [Figure 1]b. The 6-cm length of both the gastric conduit and the remnant esophagus ensured a comfortable tension-free posterior anastomosis as seen in [Figure 1]a and [Figure 1]b.

The anterior anastomosis (1.5 mm stapler height closure) was completed along the well-vascularized remnant esophagus after lifting it up with the 4 stay sutures along with the pulled up gastric conduit after ascertaining that the nasogastric tube was well away from the transversely placed anterior anastomotic line. The anterior anastomosis between the esophageal remnant and the gastric conduit was transversely placed at least 2–3 cm below and across the posterior staple line [Figure 1]c.

In summary, the salient modifications of our technique include the additional length of the posterior anastomosis, the choice and placement of the linear stapler device, the position of the gastrostomy (2–3 cm below the tip of the fashioned gastric conduit), and the level of firing of the linear stapler for the transversely placed anterior anastomosis (at least 2–3 cm below and across the posterior staple line). We additionally performed two steps to further safeguard the esophagogastric anastomosis; first, we placed one seromuscular suture to bury both the lateral ends of the gastric conduit. Second, we wrapped the esophagogastric anastomosis with a part of the greater omentum that was harvested alongside the gastric conduit [Figure 1]d.

As all our patients were managed by neoadjuvant chemoradiation approach, wherein the vascularity is believed to be even more compromised, the leak rates in our series were about 6.25%, all of which were minor and were managed conservatively. The stricture rate of our series was 3.1%, which incidentally included the patient who had developed a minor leak.

In conclusion, we broadly agree with the technique as suggested by the authors and further state that this technique with the technical modifications as described above can be safely used even in the setting of neoadjuvant chemoradiation. Furthermore, we reiterate that this stapling technique should be exclusively reserved only for tumors of the middle and the lower-third esophagus.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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.  Back to cited text no. 1
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2.
Collard JM, Romagnoli R, Goncette L, Otte JB, Kestens PJ. Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy. Ann Thorac Surg 1998;65:814-7.  Back to cited text no. 2
    
3.
Krishnamurthy A, Mohanraj N, Radhakrishnan V, John A, Selvaluxmy G. Neoadjuvant chemo-radiation for locally advanced resectable carcinoma esophagus: A single-centre experience from India with a brief review of the literature. Indian J Cancer 2017;54:646-51.  Back to cited text no. 3
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