Usage of “Reversal Penetrating Technique” with Ancillary Trocar in Minimally Invasive Ivor Lewis Esophagectomy

Introduction

Circular stapler is frequently used for intrathoracic esophagogastric anastomosis in Ivor Lewis minimally invasive esophagectomy (MIE). ¹ Esophagogastric anastomosis with circular stapler comprises two main steps: placement of anvil into the proximal esophagus and alignment of the anvil rod with stapler shaft to achieve anastomosis. Although a variety of anastomotic techniques have been described, the aforementioned two steps are indispensable. To complete the two steps under thoracoscopy, especially the appropriate placement of anvil into the esophageal stump, remains technically challenging.

The Orvil device (DST Series EEA Orvil Device; Covidien) was reported to reduce the difficulty of placement of anvil into the esophageal remnant. ² However, application of Orvil device is more expensive than using ordinary circular stapler (ECS 25 mm; Ethicon Endo-Surgery), and extra assistance from the anesthesiologist to put in a transoral introduction tube to delivering the anvil is needed. Herein, we describe a much easier method, reversal penetrating technique (RPT), which can facilitate the anvil placement by using an ordinary circular stapler.

Patients and Methods

Thirty patients (written informed consent was obtained) underwent Ivor Lewis MIE using RPT in this study. The clinical characteristic and follow-up data were recorded for evaluation (Table 1).

Procedures

Under laparoscopy, gastric mobilization, gastric conduit creation, and feeding jejunal tube placement are finished as a routine procedure. In the thoracoscopic phase, the patient is placed in the left lateral decubitus position with single-lung ventilation. Four thoracic ports are used. A 1 cm camera port is placed in the seventh intercostal space at the middle axillary line. A 0.5 cm port is placed in the same intercostal space at the scapular line. A 1.5 cm port is made in the anterior axillary line at the sixth intercostal space. A 4 cm incision expanded with a trocar sleeve is placed in the fourth intercostal space at the anterior axillary line.

Thoracic esophagus is mobilized above the arch of the azygos vein to ensure a safe oncological distance from the tumor. Meantime, the esophagus-surrounded mediastinal lymphatic tissue, subcarinal lymph nodes, and the recurrent laryngeal nerve lymph nodes are retrieved. Thereafter, the gastric conduit is introduced into the thorax through extended diaphragmatic hiatus.

The RPT procedure includes three steps: (1) an anvil set (Fig. 1) is established. First, a 2-0 Prolene suture is secured through the tip hole of the ancillary trocar included in a circular stapling device (ECS 25 mm; Ethicon Endo-Surgery) with a knot tied over 10 times. Second, the ancillary trocar is inserted into the anvil rod. (2) A longitudinal incision is made on the esophageal anterior wall more than 3 cm proximal to the tumor margin. After the esophageal cavity is sterilized with polyvinylpyrrolidone iodine, esophageal mucosa is inspected under thoracoscope to ensure oncologically intact under gross vision. Then the anvil set is introduced into the proximal esophagus lumen through the incision. (3) After the stitch reversal penetrates the anterior esophagus wall, the anvil set is pulled out by drawing the suture and then esophagus is transected appropriately with linear stapler (Fig. 2A–F). Then, the ancillary trocar is detached from the anvil rod. After the circular stapler is docked with the anvil, the intrathoracic anastomosis is completed in a side-to-side manner, ³ and then the excess gastric conduit tip is also transected.

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FIG. 1.

The anvil set, ancillary trocar is fixed with a multiple-tied 2-0 Prolene suture.

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FIG. 2.

(A) Anterior esophageal incision is made. (B) The anvil set is introduced into the esophageal lumen. (C) The position that the ancillary trocar piercing the esophageal wall is depended on where the stitch penetrating the esophageal wall. (D) The anvil shaft is pulled out by drawing the suture. (E) The proximal esophagus is transected with linear stapler. (F) The anvil placement is completed.

Results

In all the cases, the MIE procedure was completed successfully without converting to open approach and there were no intraoperative technical failures of the RPT anastomoses. The mean anvil fixation time for RPT, which is defined as the duration between incising the esophageal wall and finishing the esophageal transaction after pulling the anvil rod out of the esophageal wall, was 7 minutes. All the surgical margins were proved negative by frozen pathological examination. The mean operating time for the thoracoscopic phase was 112 minutes (range, 95–182 minutes). The median blood loss was 96 mL (range, 50–215 mL). Postoperative major complications are shown in Table 1.

Each patient was scheduled for barium swallow on the sixth postoperative day to exclude anastomotic leak or gastric tube necrosis before they started oral intake on the seventh postoperative day. None of them needed reoperation or died during perioperative period. The mean postoperative hospital stay was 11 days (range, 8–18 days). The mean dissected lymph nodes were 38 (range, 20–69). Their pathological stage classification varied from stage I to stage III (according to the American Joint Committee on Cancer). Six patients had stage I, 15 had stage II, and 9 had stage III disease.

The median follow-up time was 25 months (range, 3–36 months). All the patients were arranged to follow-up at 2 weeks for the first time after discharge, then every 3 months for the first year, and half yearly thereafter. At present, only one patient was lost to follow-up. Discomforts including dysphagia, vomiting, and nausea were recorded. Three patients complained about discomfort in swallowing solid foods. No patient complained for difficulties in swallowing semiliquid foods. All patients were scheduled to receive gastrosocopy examination yearly after surgery. At present, 26 patients had received gastrosocopy one or more times. No anastomotic recurrence was found and all the anastomoses were wide enough to enable the going through of a 10-mm endoscope (Fig. 3d). At the time of analysis, one patient died from distant metastasis.

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FIG. 3.

(A) Preoperatively, megaesophagus is shown by barium swallow. (B) Preoperative chest CT scan demonstrates extremely dilated esophageal cavity. (C) On postoperative day 6, esophagoraphy demonstrates satisfactory anastomosis and the remnant esophagus is as wide as gastric conduit. (D) A 10-mm endoscope after surgery shows a satisfactory anastomosis, although it indicates a sign of circular stapler had cut across the linear staple line.

Discussion

As minimally invasive Ivor Lewis esophagectomy is increasingly performed, different types of thoracoscopic esophagogastric anastomoses have been described. Thoracoscopic anastomoses can be performed through hand-sewn or stapled technique. Stapled (circular or side-to-side) anastomoses were considered to be superior to a traditional hand-sewn anastomosis, resulting in less postoperative dysphagia and less need for stricture dilation. ⁴ Presently, transoral (Orvil device) and transthoracic anvil introduction are two main methods in circular stapled intrathoracic anastomoses. ² RPT seems to be a modified technique that provides an easier transthoracic anvil introduction than the already mentioned methods.

A circular stapled anastomosis requires appropriate amount of tissue to be involved in the anastomotic doughnuts, excessive or inadequate tissue involvement will impede the anastomosis or even cause leakage. In purse-string technique, ⁵ the whole circle of the esophageal stump is always collected to participate in anastomosis. When using RPT, only part of the esophageal stump margin is involved. Therefore, superiority of RPT is remarkable when encountering patients with redundant esophageal tissues such as obstruction-induced dilation or diffuse esophageal spasm.

For instance, a patient with end-stage achalasia was diagnosed as having distal esophageal carcinoma and secondary megaesophagus (Fig. 3a, b). If a purse-string technique was used in this Ivor Lewis MIE case, redundant esophageal tissue enrollment would hinder a safe anastomosis. In this case, RPT method was used and proved to be an appropriate choice (Fig. 3c). Actually, it was achieved with side-to-side anastomosis by using a circular stapler. Although the circular stapler will cut across the linear staple line when using RPT, it seems to be safe and feasible based on our initial experiences and gastroscope follow-up (Fig. 3d).

When using circular staplers, anastomotic leak may occur if the exit hole of the anvil shaft is excessively or eccentrically expended. In addition purse-string sutures around the anvil shaft are thus recommended to prevent this complication. ⁶ During the RPT procedure, the ancillary trocar with its fixed multiple-tied knots plays the role of a dilator that stabilizes the anvil set on the stump by facilitating passage of the anvil rod through a minimal exit hole. Hence, additional purse-string sutures around the anvil rod are omitted. As a simple method for anvil introduction into the esophageal remnant, RPT reduces the difficulties in performing anastomosis by avoiding man-made endoscopic trimming and suturing, which is needed in hand-sewn purse-string technique.

Compared with the Orvil approach, RPT is less complicated as it omits the need to send the prepared pretilted anvil's head into the esophagus stump by an anesthetist. It also causes less injury of the proximal esophageal mucosa and less spillage of saliva in the wound, which contribute to decreasing the possibilities of iatrogenic infection. The RPT method, by leaving out the usage of specific Orvil circular stapler and transoral anvil introduction tube, is less costly than Orvil anastomosis. Therefore, it might be particularly useful to those who do not have access to the Orvil.

RPT is time saving according to our experience, the mean anvil fixation time of RPT is less than hand-sewn purse-string technique. When performing RPT, the ancillary trocar and anvil rod should be pulled out of the esophageal wall at the same site where the Prolene stitch pierces. By doing that, the anvil rod exit hole is minimized and anvil placement in the esophageal stump is stabilized.

Besides, the ancillary trocar should penetrate the esophageal wall 2 cm or more above the esophageal incision. As the esophageal incision was made 3 cm or more proximal to the tumor margin, each anastomosis is ensured 5 cm or more distance from the tumor. It ensures an oncological safe margin and proper esophageal mucosa remained in the stump after linear stapler transection. Since the anvil set requires longer intact thoracic esophagus to be inserted in, RPT is originally believed to be suitable for the patients with distal esophageal cancer. However, with the application of flexible linear stapler (Endo GIA™ Universal; Covidien), RPT can be performed much more proximally.

Conclusions

RPT is a safe and efficient surgical technique for thoracoscopic gastroesophageal anastomosis. This technique simplifies the procedure of anvil placement into the esophageal stump. It seems to be an alternative to Orvil device with ideal cost performance.