An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function

Esophagogastric anastomotic leaks represent one of the more frequent complications after esophagectomy causing significant morbidity and occasional mortality. This novel side-to-side staple line-on-staple line technique creates a larger diameter anastomosis while simultaneously maintaining conduit blood supply reducing the incidence of anastomotic leaks and strictures. Demonstrating the procedure will be Kenneth Kesler, a Harris B Shumacker Professor of Thoracic Surgery at the Indiana University Simon Cancer Center.

To perform the initial laparotomy, use electrocautery to make an upper midline incision including the xiphoid process and place a self-retaining abdominal wall retractor within the incision for peritoneal cavity exposure. Perform a wide Kocher maneuver to mobilize the entire duodenum from the retroperitoneum and temporarily place a standard size laparotomy sponge under the duodenum to elevate the conduit. Place a nasogastric tube along the greater curvature to avoid manipulation of the right gastroepiploic vessels before cauterizing and dividing the omental blood vessels with a standard energy device to divide the gastrocolic ligament.

Score the peritoneum circumferentially around the diaphragmatic crest with electrocautery and temporarily place a Penrose drain around the intraabdominal esophagus. Ligate the left gastroepiploic and short gastric vessels with a combination of suture and surgical clips before dividing these vessels with electrocautery. Use vascular endo staplers to clear the lesser gastric curve of fat and blood vessels typically located three to five centimeters distal to the gastroesophageal function and beginning from the greater gastric curve into the cleared area on the lesser gastric curve, use three to five 60 millimeter endoscopic staplers to cleave the upper gastric fundus and cardia from the remainder of the stomach.

For gastric conduit creation, de-bulk lesser omental fat around the right gastric vessels to allow the conduit to be straightened and lengthened. To secure the stomach and to provide outward retraction, create a narrow uniform seven to eight centimeter diameter conduit with an initial fire of the 100 millimeter stapler which delivers two rows of 4.8 millimeter staples aiming just beneath the previous staple line. Then complete the conduit construction with two or three additional fires of the 60 millimeter endoscopic tri-stapler into the cleared area on the lesser gastric curve.

When all of the staples have been placed, inspect the tip of the conduit. Within three to five minutes, punctate bright red bleeding should be observed through the lesser curve staple line representing a good conduit perfusion. When the punctate bleeding is observed, perform a standard Heineke-Mikulicz pyloroplasty to ensure good conduit emptying and comfortably stretch the conduit toward the neck without undue tension to make an initial estimate of how high in the chest the conduit will reach.

Next, open the right pleura through the diaphragmatic crest and place the conduit tip into the right chest keeping the lesser curve staple line facing rightward. Then temporarily close the abdomen with a few interrupted fascial sutures and skin staples. To initiate the thoracic phase of the procedure, place the patient in the left lateral decubitus position and perform a serratus muscle sparing right thoracotomy through the fifth intercostal space.

Divide the intercostal muscle under the incision within three to five centimeters of the vertebral body posteriorly and the sternum anteriorly allowing additional movement of the fifth and sixth ribs with minimal risk of fracture or bruising. Excise the arch of the azygos vein and divide the inferior pulmonary ligament to facilitate delivery of the conduit into the right chest until there is no redundancy limiting the tension on the right gastric and right gastroepiploic vascular pedicles to determine the superior extent of the esophageal dissection needed. Then carefully occlude the lymphatics with surgical clips and dissect the esophageal wall from the surrounding mediastinal soft tissues at the level of the tracheal carina superiorly to a level at which the tip of the conduit reaches without tension usually three to five centimeters superior to the carina.

For esophagogastric anastomosis creation, align the mid left lateral aspect of the upper third of the intrathoracic esophagus over the lesser curve staple line. Place four tacking sutures approximately two to three centimeters apart to maintain the alignment and transect the esophagus one centimeter distal to the inferior set of tacking sutures. Create a corresponding one to two centimeter opening in the conduit across the lesser curve staple line and place interrupted sutures within the common lumen incorporating the adjacent conduit and esophageal walls beginning in the middle through the lesser curve staple line and progressing to either side.

The length of the cut end of the esophagus is typically somewhat longer than the end of the gastric conduit so the lips of the conduit should be removed over the lesser curve staple line rather than extending the right laterally to preserve the collateral blood supply. To optimize the length of the side-to-side communication between the esophagus and the conduit, use an oscillating saw to trim five millimeters from the distal plastic tip of the stapler cartridge and fire the stapler to cut through and re-staple the lesser curve staple line. Then place the narrow anvil of a 45 millimeter endoscopic stapler with a 4.1 millimeter staple height in the esophageal lumen and the large anvil in the conduit.

Close the open common lumen in two layers of sutures beginning with an inner layer of inverted interrupted 3-0 polyglactin suture and followed by a second layer of interrupted 3-0 silk using a Lembert technique. Over secure the upper aspect of the lesser curve conduit staple line with interrupted 3-0 silk sutures in a Lembert fashion extending inferiorly until the right gastric vessels are encountered. When all of the sutures have been placed, have the anesthesiologist place a nasogastric tube into the conduit to the level of the crest by palpation.

For anastomoses created near the thoracic inlet, use a pleural flap to seal the anastomosis in the posterior mediastinum. Then close the thoracotomy incision. To perform a re-laparotomy, with the patient in the supine position, re-open the midline laparotomy incision and carefully push any excess right gastroepiploic fat upward through the left diaphragm crest into the chest.

Use interrupted 2-0 silk sutures to secure the right gastroepiploic fat and conduit to the diaphragmatic crest and place a feeding jejunostomy tube as necessary. Then after removing the laparotomy sponge, formally close the midline laparotomy incision. From 2009 to 2017, a total of 368 patients were identified who underwent a staple line-on-staple line intrathoracic esophagogastric anastomosis and of these, 12 had anastomotic leaks.

Of the staple line-on-staple line patients, 18 required a median of two dilatations for symptomatic anastomotic strictures and supplemental jejunostomy feedings were required in only 11.1%of these patients following hospital discharge. In contrast, of the 112 patients identified who underwent thoracoscopic end-to-end mechanical stapler anastomosis over the same time interval, 16.1%demonstrated anastomotic leaks and 14.3%exhibited symptomatic strictures despite all of these patients being maintained on a limited diet with supplemental jejunostomy tube feedings for at least one month following surgery. Demographic and comorbidities of both staple line-on-staple line and end-to-end mechanical stapler anastomosis groups were statistically similar.

However, there was a trend toward more cardiac disease in the staple line-on-staple line cohort. This novel and easily adaptable and reproducible technique can significantly reduce anastomotic complications following esophagectomy and can optimize upper gastrointestinal tract function.