Despite the development of minimally invasive techniques for esophageal cancer resection, esophagectomy is still associated with a significant risk of perioperative morbidity. After a successful esophageal resection, the creation of a safe anastomosis is essential to reduce the risk of leakage and related complications. This is specially important in Ivor-Lewis esophagectomy in which the anastomosis is performed the thorax. A leak in this localization could be associated with fatal consequences.
Despite the fact that intrathoracic anastomosis are associated with lower risk of leak and estenosis rates than cervical anastomosis, the creation of a safe anastomosis is one of the main concerns of gastroesophageal surgeons. The best anastomotic technique for Ivor-Lewis minimally invasive esophagectomy is still unknown.
The first description of a totally endoscopic Ivor-Lewis esophagectomy with intrathoracic handsewn anastomosis was reported by Watson in 1999. Both thoracoscopic and robotic approaches have been described.
Three different stapled anastomotic techniques have been described:
- Transthoracic circular stapled anastomosis
- Transoral circular stapled anastomosis
- Side-to-side stapled anastomosis
The transthoracic circular stapled technique was first described by Lee in 1997 and modified by Nguyen in 2001. After laparoscopic phase, the esophagus is dissected by thoracoscopy and divided 2 cm below the azygos vein. Using a small thoracotomy, the anvil of the circular stapler is placed into the chest and inserted through an opening in the esophagus and secured with a handsewn pursestring suture. The stapler is introduced into the chest and passed through an anterior gastrostomy on the gastric conduit. A stapled end-to-side esophagogastric anastomosis is made. To obviate the necessity of the pursestring Thairu described a technique in which the anvil is introduced through the anterior wall of the esophagus opened with scissors and linear stapler is fired at 60º to the longitudinal axis, first right and then left, in the shape of a V.
The transoral introduction of the anvil as described for gastrojejunostomies for gastric bypass was an important development. A commercially available prepared pretilted anvil’s head tip is attached to an oral-gastric tube. After transection of the esophagus the tube is passed transorally until felt within the proximal esophageal stump. A small opening at this level allows the tube to be advanced through it and withdraw until the anvil is in the right position at the end of the esophageal stump. The oral-gastric tube is removed after cutting the suture attached to the anvil allowing the anvil to return to the flat position.
For the side-to-side technique, after dissection, the esophagus is divided at the level of the azygos vein using a 60mm stapler. The transected esophagus and gastric conduit are aligned with sutures and a esophagostomy and gastrostomy are performed. With the aid of traction sutures a side-to-side 6 cm linear stapled esophagogastrostomy is performed. The common opening is closed with running suture.
Despite the new developments, esophagectomy for cancer is still associated with a significant risk of perioperative morbidity and mortality. To reduce both morbidity and mortality it is important to create a safe esophagogastric anastomosis with low risk of leakage.
Some authors have reported a higher incidence of dysphagia and stricture with the handsewn technique compared with circular stapled and side-to-side stapled anastomoses. Moreover, a meta analysis comparing handsewn to side-to-side linear stapled anastomosis showed a lower leak rate and stricture rate in the linear stapled anastomosis group. Possible causes for this could be:
- That the stapled anastomoses are considered to be more expedient and less traumatic than handsewn anastomoses.
- The linear stapled anastomosis provides a triple-layered staple construction that is less traumatic and more waterthight than the handsewn anastomosis.
Circular stapled anastomoses seem safe and with similar leak and stricture rates as other techniques although reported experience with this technique is lower than with handsewn or linear stapled techniques.