A safe and reproducible anastomotic technique for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with the trans-oral anvil.
OBJECTIVE
In expert hands, the intrathoracic oesophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardised 25 mm/4.8mm circular-stapled anastomosis using a trans-orally placed anvil.


METHODS
We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis oesophagectomy at a tertiary referral centre. The oesophago-gastric anastomosis was created using a 25-mm anvil (Orvil, Autosuture, Norwalk, CT, USA) passed trans-orally, in a tilted position, and connected to a 90-cm long polyvinyl chloride delivery tube through an opening in the oesophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (end-to-end anastomosis stapler (EEA XL) 25 mm with 4.8-mm staples, Autosuture, Norwalk, CT, USA) inserted into the gastric conduit. Primary outcomes were leak and stricture rates.


RESULTS
Thirty-seven patients (mean age 65 years) with distal oesophageal adenocarcinoma (n=29), squamous cell cancer (n=5) or high-grade dysplasia in Barrett's oesophagus (n=3) underwent an Ivor Lewis oesophagectomy between October 2007 and August 2009. The abdominal portion was operated laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle-sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis.


CONCLUSIONS
The circular-stapled anastomosis with the trans-oral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis oesophagectomy.
Department of Surgery, University of California San Francisco, San Francisco, CA, USA. campos@surgery.wisc.edu
Guilherme M
GM
Campos
David
D
Jablons
Lisa M
LM
Brown
René M
RM
Ramirez
Charlotte
C
Rabl
Pierre
P
Theodore
D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D057868:Anastomotic Leak / Q000209:etiology; D004938:Esophageal Neoplasms / Q000601:surgery*; D004940:Esophageal Stenosis / Q000209:etiology; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D004945:Esophagoscopy; D004947:Esophagus / Q000601:surgery; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D011183:Postoperative Complications; D011446:Prospective Studies; D013270:Stomach / Q000601:surgery; D017792:Surgical Stapling / Q000009:adverse effects / Q000379:methods*