SINGLE LAYER CONTINUOUS HAND SUTURED ESOPHAGOGASTRIC ANASTOMOSIS IN THORACOLAPAROSCOPIC IVOR LEWIS ESOPHAGECTOMY FOR LOWER ESOPHAGEAL CARCINOMA

Dr. Pradeep jainDirectorDepartment of Laparoscopic GI, GI Oncology, Bariatric and Minimal Access SurgeryFortis Hospital, Shalimar Bagh, New Delhi

Introduction

Minimally invasive Ivor-Lewis Esophagectomy - a technically challenging procedure but good results in hand of experts

The major post op morbidity is often related to anastomotic leak

Various methods used to create esophagogastric anastomosis for the want of perfect anastomosis

Still the leak rate of 0-10% and stenosis 0-25% So far no Thoracoscopic single layer continuous

hand sewn anastomosis reported

AIM

To see the safety of thoracoscopic hand sutured single layer continuous anastomosis with monofilament absorbable suture

Methodology

SETTING This study was conducted in Department of Laparoscopic GI, GI

Oncology, Bariatric and Minimal Access Surgery, Fortis Hospital, Shalimar Bagh, New Delhi from July 2012 and July 2013.

STUDY DESIGN Prospectively collected data of 5 patient were retrospectively

reviewed

SAMPLE SIZE 5 patients(4 distal esophageal adenocarcinoma and 1

gastroesophageal adeno carcinoma) in the age group of 55-72 years who underwent thoracolaparoscopic Ivor Lewis esophagectomy

Methodology

INCLUSION CRITERIA Adeno carcinoma of lower 1/3rd of esophagus and

GE junction tumors Radiologically upto T3 stage tumors Post Chemotherapy downstaged locally advanced

tumor

EXCLUSION CRITERIA Upper and middle 1/3rd esophageal tumors Metastatic tumors 

Methodology

Techniques: First stage- Abdominal portion Patient was placed in Lloyd davis position. Pneumoperitoneum was created and 5 abdominal ports were placed. Taking care of lower esophageal/ GE junction tumor esophageal

hiatus was dissected. Omentum was divided beyond greater curvature gastric arcade. Celiac lymphnodal dissection was done and left gastric vessels were

ligated at their origin. Gastric tube created by sequential firings of endo GIA stapler (blue

cartridge) started just below crow’s foot to gastric fundus 7-10 cm away from tumor margin.

Pyloroplasty was not done. Feeding jejunostomy was done 20 cm distal to duodenojejunal

flexure.

Methodology

Second stage- Thoracic part Patient was placed in prone position. Four ports were placed in right pleural cavity. Azygous vein was clipped and divided. Esophagus dissected

from surrounding structures along with peri esophageal, subcarinal and hiatal lymph nodes.

Thoracic esophagus divided just at the level of azygus vein and gastric tube pulled into thoracic cavity along with lower esophagus with tumor.

Upper end of gastric tube divided and thoracoscopic end to end single layer continuous esophagogastric anastomosis was created by 2-0 PDS suture.

Specimen was put into endobag and extracted outside through 5 cm thoracotomy wound.

video

Methodology

Postoperative care: Feeding by jejunostomy tube was started the

very next day

On third post operative day Gastrograffin study was performed and oral liquids were started

By seventh postoperative day patients were shifted to semisolid diet

Results

Five patients (mean age 62 years; range 55 to 72) with distal esophageal adenocarcinoma (n=4) and gastroesophageal adeno carcinoma (n=1) undewent thoracolaparoscopic Ivor Lewis Esophagectomy between July 2012 and July 2013

Out of five patients two patients had received neoadjuvant chemotherapy

Mean blood loss during surgery 310 ml Mean operative time – 338 minutes Mean hospital stay- 8 days

Results

No intra-operative complications, anastomotic leak, postoperative major postoperative morbidity or deaths

On HPE proximal, distal and radial margins were free from malignant cells

A median of 15 lymph nodes (range 13 to 22) were dissected from each specimen

Follow up period 2.5 months to 1 year

Discussion

Major morbidity after Intrathorasic anastomosis revolves around integrity of intrathorasic anastomosis

very few reports of thoracoscopic manual anastomosis in literature (two layered or interrupted ) with varying rates of leak

In our method thoracoscopic , manual, single layer, continuous, monofilament absorbable appears to be safe as there was no leak or post op dysphasia

watson DI, et al . Totally endoscopic Ivor Lewis esophagectomy. Surg.endoscopy.1999;13(3):293-297Cadiere et al .Ivor Lewis esophagectomy with manual esophagogastric anastomosis by thoracoscopy

in prone position and laparoscopy. Surg. Endoscopy 2010 June;24(6):1482-5Behzadi A et al . Esophagectomy: The influence of stapled versus hand –sewn anastomosis on

outcome . J Gasrointest Surg. 2005 Nov 9(8) : 1031-40Blackmon SH et al . Propensity matched analusis of three techniques for Intrathorasic anastomosis .

Ann Thorac Surg 2007 May; 83(5) 1805-13 Single layer, continuous, hand sewn method for esophageal anastomosis. Prospective evaluation in

218 patients . Simon Law et al. Arch Surg 2005; 140(1): 33-39

Conclusion

Single layer continuous hand sutured esophagogastric anastomosis is feasible and as safe as any other methods of anastomosis in minimally invasive Ivor Lewis esophagectomy.

This is faster and cheaper

However for the validation of this technique , a large prospective comparative studies between various anastomotic methods are required

Thanks