Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

In 1997, Lee et al. [12] described a one-stage right lateral thoracoscopic esophagectomy with intrathoracic stapled anastomosis in a series of eight patients with carcinoma of the lower esophagus. The operation was performed with a double-lumen tracheal tube to enable collapse of the right lung. The patient was placed in 45  position with the right side up. A two-team synchronous approach was used: one for the abdominal stage to perform the mobilization of the stomach through a transverse incision laparotomy, and the other team performed the thoracoscopic approach. Esophagogastric anastomosis was fashioned by a stapling device using the ligature method described by Allsop and Ng [13, 14]. A right-angled clamp inserted by the abdominal surgeon through the hiatus was applied onto the esophagus just proximal to the lesion. A transverse incision in the esophagus was placed, with adequate margin, above the tumor. The abdominal surgeon inserted the anvil (28-mm circular stapler) into the thoracic cavity through the hiatus and introduced it into the lumen of the esophagus. A Vicryl ligature was applied around the esophagus by means of Roeder’s knot to fix the anvil in the proper position and the esophagus divided as illustrated in Fig. 3. The cardioesophageal junction was transacted with a GIA linear stapler and through a transverse gastrostomy the circular stapler was inserted, the stomach introduced into the thorax, and the anastomosis performed. The operation was successful in seven patients, and the remaining patient required conversion to thoracotomy. No leakages were recorded. On short term, one patient developed a benign stenosis that required dilatation.

The anastomosis technique described by Nguyen et al. in 2001 [15] in a case report was performed through a right lateral thoracoscopy with lung block. After the laparoscopic phase, the esophagus was dissected by thoracoscopy and divided with the stapler 2 cm below the azygos vein. The esophageal specimen was retrieved through an enlarged (4 cm) posterior trocar site. Using this small incision, the anvil of 21- or 25-mm circular stapler was placed into the chest and inserted through the opening of the esophagus and secured with a handsewn pursestring suture. The circular stapler was introduced into the chest and passed through an anterior gastrostomy of the gastric conduit. A stapled end-to-side esophagogastric anastomosis was made. Most of the techniques described for circular stapled anastomosis are similar to this technique [16].

During the next years, new techniques have been described to facilitate the placement of the anvil in the proximal esophagus. Misawa et al. [17] approached the esophagus, after the laparoscopic phase, through a lateral right thoracoscopy in five patients with cancer of the middle and lower thoracic esophagus. A 5-cm-long thoracotomy was made on the fifth intercostal space. After mobilization of the esophagus, the level of transection was decided and the distal esophagus tied with a 2-0 ligature. The esophageal wall was anteriorly opened and two clamps grasped the esophageal edges allowing the Endo-Stitch^® (US Surgical) device for achieving a pursestring suture. After this, the anvil of a 25-mm circular stapler was introduced into the proximal esophagus and the pursestring tied. An Endoloop^® ligature was placed over the pursestring to reinforce it (Fig. 4). After retrieval of the distal esophagus with the lesion, the proximal end of the gastric tube was pulled out of the minithoracotomy and the circular stapler was introduced through it into a gastrostomy incision. No leakage or other postoperative complications were observed after this procedure.

Bizekis et al. [18] reported their experience with minimally invasive Ivor Lewis esophagectomy in 50 patients, the majority with tumors with extension into the cardia or a gastroesophageal junction tumor. Thirty-five patients underwent a hybrid Ivor Lewis procedure, defined as laparoscopic gastric mobilization combined with a 5-cm minithoracotomy, and the other 15 underwent the total minimally invasive approach. In the total minimally invasive procedure, after mobilization the esophagus was transacted 2–3 cm above the azygos vein, and an inferior intercostal port site was enlarged to allow the introduction of the circular stapler and for retrieval of the specimen. A 25-mm anvil was placed into the proximal esophagus and secured by means of a pursestring suture (Endo-stitch, US Surgical). The stapler was introduced into the gastric conduit and a circular anastomosis was created in a side-to-end fashion. The redundant gastric conduit was removed by using a linear stapler. In the hybrid procedure, after the laparoscopic phase, the patient was placed in the lateral position and a 5-cm minithoracotomy performed. A rib retractor was placed and the thoracic esophagus mobilized under direct vision. A stapled esophagogastric anastomosis was created in the same fashion. There were three anastomotic leaks in the hybrid group: one empyema not related to leak, one chylothorax, and one pulmonary embolism. They observed 6% mortality. Moreover, six patients developed stenosis of the anastomosis, being dilated postoperatively.

To obviate the necessity of the placement of a pursestring suture or a manually tied knot to secure the anvil, Thairu et al. [19] described a technique in which the head of the anvil was inserted through the anterior wall of the esophagus, opened with dissecting scissors. A linear staple was fired at 60° to the longitudinal axis first right and after left to the spike of the anvil thus forming a V. Around this aperture a Z-stitch was placed, which secured the anvil in place, followed by an end-to-side anastomosis. Using this technique in 18 patients, they observed no anastomotic leaks postoperatively. No midterm results were reported (e.g., stenosis).

An important development is the introduction of the anvil transorally into the proximal esophagus, as described originally by Wittgrove et al. [20] for the gastrojejunostomy construction of the gastric bypass in bariatric surgery after the initial work of Sutton et al. in 2002 using a self-adopted circular anvil system [21].

Nguyen et al. [22] described the transoral technique in a series of ten patients to perform the intrathoracic anastomosis after esophageal resection. A commercially available prepared pretilted anvil’s head tip was attached to an oral-gastric tube that was given to the anesthesiologist. The tilted configuration of the anvil improved the ease of transoral passage. After the transection of the esophagus by means of linear stapler, the tube was passed transorally until it was felt within the proximal esophageal stump. A small opening at this level was made perpendicular to the staple line and the tube was advanced through it and withdrawn until the anvil was in the right position at the end of the esophageal stump. The oral-gastric tube was removed after cutting the suture that attached it to the anvil. The head of the anvil returned to the flat position when attached to the spike of the 25-mm circular stapler to perform the anastomosis (Fig. 5). The authors applied the technique without passage problems in ten patients. Moreover, tissue donuts were complete in all cases and there were no postoperative leaks.

Campos et al. [23] confirmed the good results using the transoral anvil technique in 37 patients with a distal esophageal cancer. After the laparoscopic approach in 81% of the patients, the thoracic portion was performed using a muscle-sparing minithoracotomy in 23 patients (62%) and total thoracoscopic approach in 14 patients (37%). There were no intraoperative technical failures of the anastomosis or deaths. Five patients developed strictures (13.5%), and all were successfully treated with endoscopic dilatations. One patient had an anastomotic leak (2.7%) that was treated by reoperation and endoscopic stenting of the anastomosis.

Ben-David et al. [24] described in 2010 six patients with gastroesophageal junction cancers in whom after laparoscopic dissection and formation of the gastric conduit, the thorax was approached through a lateral right thoracoscopy. After dissection, the esophagus was divided at the level of the azygos vein using a 60-mm stapler. The transacted proximal esophagus and gastric conduit were aligned with sutures. An esophagostomy was created at the distal end of the transacted esophagus and a gastrostomy performed proximal of the end of the gastric conduit. With the aid of traction sutures, a side-to-side 6-cm linear stapled esophagogastrostomy was performed. After this, the common opening was closed with a running suture. There were no leakages of anastomosis or other postoperative complications. At a median follow-up of 9 months, no postoperative strictures were reported.

Gorenstein et al. [25] described a slight different side-to-side anastomosis technique in which the proximal esophagus was not stapled, and used the whole lumen for the construction of the side-to-side anastomosis by means of a linear stapler. Once a 4-cm anastomosis was constructed, the anterior defect was closed. Of the 31 patients operated on with this approach, one developed leakage that required reoperation. There were no other anastomotic complications. The side-to-side technique for stapled intrathoracic anastomosis is illustrated in Fig. 6.