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Stapling technic for esophagogastrostomy after esophagogastric resection
MODERN OPERATIVE TECHNICS
Stapling Technic for Esophagogastrostomy After Esophagogastric Resect ion Jameson
L. Chassin, MD, Flushing,
New York
Although resection followed by esophagogastric anastomosis is the accepted therapy for operable malignancy of the distal esophagus and proximal stomach, a number of surgeons have found that their rates of anastomotic leakage and death after this operation were excessive. For this reason some have even abandoned esophagogastrectomy for malign sncy of the proximal stomach in favor of total gastr,ectomy and esophagojejunostomy because the latter has a lower mortality [ 1,2]. On the other hand, in agreement with Fisher, Brawley, and Kieffer [3] and Boyd et al (41, I have found the use of end-to-side esophagogastric anastomosis to be both efficacious a:ld safe. Although good results can be obtained with this operation with expert hand suturing, the esophageal a.nastomosis may sometimes be difficult to perform a Id may be time-consuming. Since 1973 I have developed and applied a technic for esophagogastric a-nastomosis utilizing AutoSuture@ stapling devices instead of sutures. This technic requires only 1 or 2 minutes of operating time and has been performed successfully with no leakage or mortality.
Material
Tumors of Distal Esophagus or Proximal Stomach
Incision. A left thoracoabdominal incision is made, using the sixth intercostal space. The diaphragm is opened circumferentially with an incision approximately 3.0 cm from its peripheral insertion to preserve the phrenic nerve. Mobilization of Stomach and Esophagus. The spleen is mobilized, the posterior wall of the stomach is elevated, the celiac nodes are swept toward the specimen, and the left gastric artery and coronary vein are ligated near their points of origin. The stomach is dissected away from its ligamentous attachments to the diaphragm. The upper portion of the gastrohepatic ligament is divided, including an accessory left hepatic artery, as are the vagus nerves. Omentum is divided outside the vascular arcade along the greater curvature of the stomach, carefully preserving the right gastroepiploic vessels.
and Methods
Since 1973 twelve patients (9 male, 3 female) have undergone resection for carcinoma of the esophagus or upper stomach by the stapler technic. Operations were performed by me or by residents under my supervision at the Booth Memorial Medical Center. These patients ranged in age fr)m t,hirty-seven to eight-two years, with a median of seventy-four years. Pathologic examination of the surgical specimens discl, )sed squamous cell carcinoma of the esophagus in three patients, adenocarcinoma in the vicinity of the esophagogestric junction in six, and malignant lymphoma or reticulum cell sarcoma of the upper stomach in three.
From the Department of Surgery, New York University School of Medicine, and the Booth Memorial Medical Center Affiliate. Flushing, New York. Reprint requests should be addressed to Jameson L. Chassin, MD, Booth Memorial Medical Center, Flushing, New York 11355.
Volume 136, September 1976
Figure 1. TA-90 stapler across the gastric fundus for tumor at the cardia.
399
Chassin
Figure 2. Sfab wound in the anterior wall of stomach located 6.0 cm below the cephalad margin.
A TA-90 stapling device is then applied across the upper portion of the stomach at a site at least 6.0 cm away from the tumor. (Figure 1.) A Payr clamp may be applied on the specimen side, and the stapling device is closed, after which a scalpel is used to divide the stomach flush with the TA-90 stapler. Although this stapled closure is of the everting type, it is not reinforced with inverting sutures. An extensive Kocher maneuver is performed to permit elevation of the gastric pouch well up into the mediastinum. Similarly, the lower esophagus is dissected beyond the inferior pulmonary vein and up to the aorta, whenever necessary, to achieve sufficient length for a proper margin above the tumor. In dividing the esophagus on the upper aspect of the specimen, the proximal esophagus is not clamped. The end must be left open for proper application of this technic. After removal of the specimen, absence of tumor at the esophageal margin is verified by frozen section examination. There should be no hesitation on the part of the surgeon to liberate the esophagus behind the arch of the aorta and to perform the anastomosis above and to the left of the aorta whenever this is required. To accomplish this maneuver, it will be necessary to resect posterior segments of two additional ribs. Technic of Anastomosis. This anastomosis involves attaching the posterior aspect of the distal esophagus to the anterior wall of the gastric pouch. Consequently, when only enough esophagus and stomach are available to permit end-to-end anastomosis, the staple technic is contraindicated. There must be sufficient overlap so that 6.0 cm of esophagus will lie freely over the front of the gastric pouch. Liberation of this length of esophagus by sharp dissection, avoiding trauma and intramural hematoma, has not resulted in impairing its blood supply. The surgeon should observe free oozing of blood from the cut end of esophagus.
400
Figure 3. G/A stapler with one blade in the gastric lumen and the other in the esophagus.
A stab wound is made, approximately 1.5 cm long in the gastric’ pouch (Figure 2), and the GIA’stapling device (TA-55) is used to construct the posterior layer of the esophagogastric anastomosis by inserting one fork into the open end of esophagus and the other into the gastric stab wound. (Figure 3.) The depth of insertion should be 3.5 to 4.0 cm. The GIA device is closed and then fired. This step will leave the end of the esophagus open as well as leave an open stab wound in the gastric pouch. (Figure 4.) These are stapled in an everting fashion by triangulation with two applications of the TA-55 autosuture device. To accomplish this, a 4-O temporary guy suture is inserted through the full thickness of the anterior esophageal wall and at the midpoint of the remaining opening in the gastric wall. (Figure 5.) After this suture is tied, Allis clamps are applied to approximate the full thickness of the everted esophageal and gastric walls. The first Allis clamp is applied just behind the termination of the previous GIA line of staples on the patient’s left. (Figure 4.) The Allis clamps and the suture are held in such a fashion that the TA-55 device can be applied just beneath the Allis clamps and the suture. (Figure 6.) The TA-55 stapler is then tightened and fired. Redundant esophageal and gastric tissues are excised flush with the TA-55 device utilizing a Mayo scissors but leaving the guy suture intact. (Figure 7.) The identical procedure is then utilized to close the right side of the esophagogastric defect by applying additional Allis clamps to achieve approximation here. Another application of the TA-55 autosuture device is necessary to complete the closure. (Figure 8.) It is essential that a small portion of the right hand termination of the GIA stapled
The American Journal of Surgery
Stapling Technic for Esophagogastrostomy
Figure 4. Completed sis.
posterior
layer of stapled
anastomo-
anastomosis be included in the final TA-55 staple line, The same guy suture should also be included for a second time in this last application of the TA-55. In this fashion there is no possibility of leaving any gap between the various staple lines. A useful technic for checking that such an error has not been committed is via the Levin tube, by inflating tte gastric pouch with several hundred milliliters of saline and tinting with methylene blue. By gently compressing tEe distal portion of the gastric pouch between the surgeon’s fingertips, any leakage of saline from the suture line can be detected. If sufficient gastric pouch is available, a modified type of Nissen fundoplication may be accomplished, if desired, by suturing stomach partially around the esophagus in such fashion as to form an inkwell. At this point, if the hiatus of the diaphragm constricts the gastric pouch, an incision is made in the crux so as to enlarge the hiatus. Sutures of 3-O cotton are utilized to attach the seromuscular coat of the stomach to the edge of t+e hiatus to prevent future herniation of small intestine into the chest. Next, it is important to suture the gastric pouch to the mediastinal pleura to eliminate tension on the anastomosis. Caution should be exercised to avoid entering tk.e gastric lumen with these sutures, as gastropleural fistulas have been reported after this error [3]. Pyloromyotomy is performed to alleviate stasis in the vagot.omized stomach. (Figure 9.) Closure. The incision in the diaphragm is closed with interrupted 2-O cotton sutures. After excising a small segment of cartilage, the costal margin is approximated with one or two sutures of monofilament 2-O stainless steel
Volume 136, September 1978
Figure 5. Approximation of the esophagus and gastric stab wound for a triangulated everting stapled closure of the anterior layer of anastomosis. The guy sutures pass through the walls of the esophagus and stomach.
wire. The thorax is closed with pericostal sutures of # 2 chromic catgut and continuous sutures of Dexon@ to each of the muscular layers. The abdominal incision is closed in the fashion of Tom Jones with interrupted 2-O stainless steel wire. A #36 chest tube is brought out through the ninth intercostal space for closed suction drainage. Postoperative Care. A plastic nasogastric tube is used to provide mild suction to the gastric pouch for approximately four days. Patients who have lost 10 pounds or more of weight are placed on intravenous hyperalimentation prior to and after surgery. Postoperatively, all patients are kept exclusively on intravenous fluids, receiving nothing by mouth until the seventh postoperative day. At that time roentgenographic examination of the esophagogastric anastomosis is carried out. In the absence of radiographic or clinical evidence of leakage, liquids and purees are then offered, progressing to a full soft diet in a few days. Administration of antibiotics, which is initiated 4 to 6 hours prior to operation, is continued until the thoracic drainage tube is removed. Tumors of Middle Esophagus
Incision. With the patient positioned so that the right hip and shoulder are elevated approximately 30 degrees, an incision is made in the right fourth or fifth intercostal space. A short segment of one or more costal cartilages is excised as necessary for exposure. The right lung is collapsed and retracted forward. The mediastinal pleura is
401
Chassin
Figure 6. Application of TA-55 stapler to the left half of the anterior layer.
incised, and the azygos vein is divided. The esophagus together with tumor is dissected from the apex of the thorax to the esophageal hiatus. An upper midline incision is then made into the abdominal cavity. Mobilization of Stomach. This step is similar to that described for lower esophageal lesions, except that the spleen may be preserved at the option of the surgeon. Advancement of Stomach into the Right Chest. The right crux of the diaphragm is divided transversely until the hiatus is sufficiently enlarged to permit easy passage of the stomach into the mediastinum and then into the right hemithorax. The cardiac end of the stomach will reach without tension to the apex of the right chest. The esophagogastric junction is dissected free of areolar tissue. A TA-55 autosuture stapling device is applied to the gastric side of this junction. The stapler is closed and fired. An occluding clamp is then placed on the distal esophagus, and the esophagogastric junction is divided with a scalpel flush with the stapler. Technic of Anastomosis. At a suitable site above the tumor, the proximal esophagus is divided, leaving its proximal end open. If there is sufficient slack in the esophagus, a stapled anastomosis is constructed exactly as described above. The cardiac end of the stomach is sutured to the prevertebral fascia at the apex of the thorax. Nissen fundoplication may be performed if desired. Closure. The thorax and abdomen are closed in routine fashion.
402
Figure 7. Excision of redundant tissue beyond the line of staples.
Results There have been no hospital deaths in this series. To determine the incidence of anastomotic leaks, each patient underwent esophageal roentgenography with an aqueous contrast medium on the seventh postoperative day. In no case was there any suggestion of leakage either by x-ray films or by clinical manifestations. The diameter of the stoma has been noted to be larger than that seen in the usual handsewn esophagogastric anastomosis on x-ray films. No patient required postoperative esophageal dilatation. Most notable among the complications were abscesses that developed in the left subphrenic space subsequent to splenectomy in two patients and combined with resection of a gastric malignant lymphoma in one and adenocarcinoma in the other. Other complications included heart failure in two patients, one with pneumonitis and one with a subcutaneous wound infection. The number of days of postoperative hospitalization varied from eleven to thirty-seven, with a median of fifteen days. It should be noted that the majority of these patients were in their eighth decade of life.
The American Journal of Surgery
Stapling Technic for Esophagogastrostomy
Figure 9. Appearance to-side anastomosis.
Figure 8. Apprication of TA-55 stapler to the right ha/f of the anterior layer.
Comments
Esophagogastrectomy for carcinoma is an operation notable for a high fatality rate. Table I is a summary of 2,156 cases abstracted from major reviews published on this subject in the past ten years. These papers report the experience of reputable institutions such as John Hopkins [3], Memorial [5], and Barnes [6] Hospitals, and the Mayo Clinic [7], as well as of authorities in this field, such as Belsey and Hiebert [8], Ellis [7], Collis [9], Lortat-Jacob [IO], and Skinner [II]. Nevertheless, the average mortality reported comes to 23 per cent. Approximately half the deaths in most reports were attributed to anastomotic leakage. Although the present series is small by comparison, it is striking because of the absence of any leaks or deaths. In the case of the two patients who developed left subphrenic abscesses, it should be noted that the anastomotic suture lines were well up in the mediastinum. Consequently, these two complications cannot be attributed to anastomotic failure. It was emphasized by Cole, Petit, and Bernard [6] that intraabdominal sepsis occurred with frequency after resection of gastric malignancy. Subphrenic abscess in these cases appears to be secondary to the contamination by virulent organisms during the opera-
Volume 136, September 1979
of completed
back-to-front,
end-
tive procedure, and it occurs occasionally even in patients who have received preoperative intestinal antibacterial agents as well as prophylactic antibiotics before and during the operation. After a long and sometimes difficult resection in an elderly patient, the availability of a technic of esophagogastric anastomosis which can be accomplished in a matter of seconds constitutes a welcome epilogue. Nevertheless, this is not the only advantage. It is my impression that the end-to-side anast,omosis also tends to reduce postoperative gastroesophageal regurgitation. This coincides with the findings of Fisher, Brawley, and Kieffer [3], who performed a similar type of anastomosis with sutures. None of the patients in the present series complained of symptoms indicating regurgitation, yet in only one case was a Nissen fundoplication (modified) performed. Although it is believed that the present technic of anastomosis played a role in preventing regurgitation, it is also recognized that 75 per cent of the patients in this series had gastric neoplasms with low acid secretion and they might not have developed esophagitis after any anastomosis. It is not clear whether the esophagogastric anastomosis should be supplemented by fundoplication whenever possible, as advocated by Boyd et al [4]. Fundoplication of the Nissen type cannot be performed in most patients who require excision of the gastric cardia for carcinoma in t.his vicinity, as there will not be sufficient width in the residual gastric pouch for a complete gastric wraparound. Modified partial gastric wraps may be improvised, but there are inadequate data to support their efficacy or the necessity of adding this step in gastric cancer.
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Chassin
TABLE I
Deaths and Leaks After Esophagogastric Anastomoses
No. of Authors
Cases
Cole [6] 1968 Humphrey [5] 1968 Maillard [ IO] 1969 Koch [ I] 1969 Gunnlaugsson [ 71 1970 Collis [9] 1971
53 243 472 17 541 l-50 51-300 301-400 400 65 31 140 56 1-17 18-40 40 28 70 2,156 12
lnberg [z] 1971 Fisher [3] 1972 Belsey [8] 1974 Boyd [4] 1975 Skinner [ 7I] 1976
Hermreck [ 721 1976 Sefton [ 731 1977 Total Present series
Rate of Anastomotic Leakage Total Fatal 13%
0 0 18%
8% 17% 24% 6% 24% 2% 6% 6% 8% 0 11% 2% 41% 0 18% 14%
0
10% 0
19%
12% 0 14%
No. of Deaths 13 (24%) 61 (25%) 160 (34%) 9 (53%) 70 (13%) 26 (52%) 38 (15%) 12 (12%) 76 (19%) 10 (15%) 4 (13%) 39 (28%) 5 (9%) 11 (65%) 0 11 (28%) 6(21%) 21(30%) 485 (23%) 0
of technical error in any new technic, surgeons who have had no experience with stapled anastomoses elsewhere in the gut should either obtain instruction or attempt the technic in an animal laboratory prior to application in humans. Summary
A technic of esophagogastrostomy is described for constructing an end-to-side, back-to-front anastomosis using stapling devices. Twelve consecutive cases are reported with no deaths and no anastomotic leaks. Addendum
Since this paper was submitted for publication, four additional patients underwent esophagogastrectomy by the stapling technic described. There was no clinical or radiographic evidence of leakage and there were no deaths.
References
Finally, there appears to be an intrinsic advantage in the use of a device that can apply thirty-three staples simultaneously with great accuracy and minimal trauma as compared with insertion of multiple sutures often in a situation requiring an awkward position for the surgeon’s hand and needle holder. Although the everting nature of the anterior portion of the suture line violates surgical tradition of long standing, extensive experience with stapling devices in other parts of the intestinal tract has confirmed the safety of this technic [14] provided basic precautions are observed. If the tissues being approximated in any stapled anastomosis are unsually thick or edematous so that compression to a thickness of 2.0 mm by the stapling device will result in necrosis, the stapling technic is contraindicated. Similarly, if the tissues have been thinned out to such an extent that application of a standardized staple will not firmly hold the tissue, this technic must not be used. We observed the latter situation on one occasion. Considerable traction was being applied to the esophagus at the same time that the GIA stapler was fired. This resulted in sufficient thinning out of the esophageal wall as to make the anastomosis hazardous. In this case the stapled anastomosis was repeated at a higher level with the esophagus in a fully relaxed position with an excellent result. Relaxation of the esophagus permits more muscle and mucosa to be included in each staple bite, whereas thinning the organ by traction may result in stapling tissue no thicker than tissue paper. Since there are possibilities
404
1. Kock NG, Lewin E, Peterson S: Partial or total gastrectomy for adenocarcinoma of the cardia. Acta Chir Stand 135: 340, 1969. 2. lnberg MV, Linna MI, Scheinin TM, Vanttinen E: Anastomotic leakage after excision of esophageal and high gastric carcinema. AmJ Surg 122: 540, 1971. 3. Fisher RD. Brawley RK, Kieffer RF: Esophagogastrostomy in the treatment of carcinoma of the distal two-thirds of the esophagus. Ann Thorac Surg 14: 658, 1972. 4. Boyd AD, Cukingnan R, Engelman RM, Localio SA, Slattery L, Tice DA, Bardin JA, Spencer FC: Esophagogastrostomy, analysis of 55 cases. J Thorac Cardiovasc Surg 70: 817, 1975. 5. Humphrey CR, Cliffton EF: Carcinoma of the distal part of the esophagus and cardia of the stomach. Surg Gynecof Obstet 127: 737, 1968. 6. Cole WR, Petit R, Bernard HR: Factors affecting incidence of anastomotic leaks following esophagogastrectomy. Ann Thorac Surg 6: 396, 1968. 7. Gunnlaugsson GH, Wychulis AR, Roland C, Ellis FH Jr: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynecol Obstet 130: 997.1970. 8. Belsey R, Hiebert CA: An exclusive right thoracic approach for cancer of the middle third of the esophagus. Ann Thorac Surg 18: 1, 1974. 9. Collis JL: Surgical treatment of carcinoma of the esophagus and cardia. BrJSurg58: 801, 1971. 10. Maillard JN, Launois B, Lagausie P, Lellouch J, Lot-tat-Jacob JL: Cause of leakage at the site of anastomosis after esophagogastric resection for carcinoma. Surg Gynecol Obstet 127: 1014, 1969. 11. Skinner DB: Esophageal malignancies, experience with 110 cases. Surg C/in North Am 56: 137, 1976. 12. Hermreck AS, Crawford DG: The esophageal anastomotic leak. Am J Surg 132: 794, 1976. 13. Sefton GK, Cooper DJ, Grech P, Giddings AEB: Assessment and resection of carcinoma at the gastroesophaoeal function. Surg Gynecol Obstet 144: 563, l-977. 14. Steichen FM, Ravitch MM: Mechanical sutures in surgery. Br JSurg60: 191, 1973.
The American Journal of Surgery
Stapling Technic for Esophagogastrostomy After Esophagogastric Resect ion Jameson
L. Chassin, MD, Flushing,
New York
Although resection followed by esophagogastric anastomosis is the accepted therapy for operable malignancy of the distal esophagus and proximal stomach, a number of surgeons have found that their rates of anastomotic leakage and death after this operation were excessive. For this reason some have even abandoned esophagogastrectomy for malign sncy of the proximal stomach in favor of total gastr,ectomy and esophagojejunostomy because the latter has a lower mortality [ 1,2]. On the other hand, in agreement with Fisher, Brawley, and Kieffer [3] and Boyd et al (41, I have found the use of end-to-side esophagogastric anastomosis to be both efficacious a:ld safe. Although good results can be obtained with this operation with expert hand suturing, the esophageal a.nastomosis may sometimes be difficult to perform a Id may be time-consuming. Since 1973 I have developed and applied a technic for esophagogastric a-nastomosis utilizing AutoSuture@ stapling devices instead of sutures. This technic requires only 1 or 2 minutes of operating time and has been performed successfully with no leakage or mortality.
Material
Tumors of Distal Esophagus or Proximal Stomach
Incision. A left thoracoabdominal incision is made, using the sixth intercostal space. The diaphragm is opened circumferentially with an incision approximately 3.0 cm from its peripheral insertion to preserve the phrenic nerve. Mobilization of Stomach and Esophagus. The spleen is mobilized, the posterior wall of the stomach is elevated, the celiac nodes are swept toward the specimen, and the left gastric artery and coronary vein are ligated near their points of origin. The stomach is dissected away from its ligamentous attachments to the diaphragm. The upper portion of the gastrohepatic ligament is divided, including an accessory left hepatic artery, as are the vagus nerves. Omentum is divided outside the vascular arcade along the greater curvature of the stomach, carefully preserving the right gastroepiploic vessels.
and Methods
Since 1973 twelve patients (9 male, 3 female) have undergone resection for carcinoma of the esophagus or upper stomach by the stapler technic. Operations were performed by me or by residents under my supervision at the Booth Memorial Medical Center. These patients ranged in age fr)m t,hirty-seven to eight-two years, with a median of seventy-four years. Pathologic examination of the surgical specimens discl, )sed squamous cell carcinoma of the esophagus in three patients, adenocarcinoma in the vicinity of the esophagogestric junction in six, and malignant lymphoma or reticulum cell sarcoma of the upper stomach in three.
From the Department of Surgery, New York University School of Medicine, and the Booth Memorial Medical Center Affiliate. Flushing, New York. Reprint requests should be addressed to Jameson L. Chassin, MD, Booth Memorial Medical Center, Flushing, New York 11355.
Volume 136, September 1976
Figure 1. TA-90 stapler across the gastric fundus for tumor at the cardia.
399
Chassin
Figure 2. Sfab wound in the anterior wall of stomach located 6.0 cm below the cephalad margin.
A TA-90 stapling device is then applied across the upper portion of the stomach at a site at least 6.0 cm away from the tumor. (Figure 1.) A Payr clamp may be applied on the specimen side, and the stapling device is closed, after which a scalpel is used to divide the stomach flush with the TA-90 stapler. Although this stapled closure is of the everting type, it is not reinforced with inverting sutures. An extensive Kocher maneuver is performed to permit elevation of the gastric pouch well up into the mediastinum. Similarly, the lower esophagus is dissected beyond the inferior pulmonary vein and up to the aorta, whenever necessary, to achieve sufficient length for a proper margin above the tumor. In dividing the esophagus on the upper aspect of the specimen, the proximal esophagus is not clamped. The end must be left open for proper application of this technic. After removal of the specimen, absence of tumor at the esophageal margin is verified by frozen section examination. There should be no hesitation on the part of the surgeon to liberate the esophagus behind the arch of the aorta and to perform the anastomosis above and to the left of the aorta whenever this is required. To accomplish this maneuver, it will be necessary to resect posterior segments of two additional ribs. Technic of Anastomosis. This anastomosis involves attaching the posterior aspect of the distal esophagus to the anterior wall of the gastric pouch. Consequently, when only enough esophagus and stomach are available to permit end-to-end anastomosis, the staple technic is contraindicated. There must be sufficient overlap so that 6.0 cm of esophagus will lie freely over the front of the gastric pouch. Liberation of this length of esophagus by sharp dissection, avoiding trauma and intramural hematoma, has not resulted in impairing its blood supply. The surgeon should observe free oozing of blood from the cut end of esophagus.
400
Figure 3. G/A stapler with one blade in the gastric lumen and the other in the esophagus.
A stab wound is made, approximately 1.5 cm long in the gastric’ pouch (Figure 2), and the GIA’stapling device (TA-55) is used to construct the posterior layer of the esophagogastric anastomosis by inserting one fork into the open end of esophagus and the other into the gastric stab wound. (Figure 3.) The depth of insertion should be 3.5 to 4.0 cm. The GIA device is closed and then fired. This step will leave the end of the esophagus open as well as leave an open stab wound in the gastric pouch. (Figure 4.) These are stapled in an everting fashion by triangulation with two applications of the TA-55 autosuture device. To accomplish this, a 4-O temporary guy suture is inserted through the full thickness of the anterior esophageal wall and at the midpoint of the remaining opening in the gastric wall. (Figure 5.) After this suture is tied, Allis clamps are applied to approximate the full thickness of the everted esophageal and gastric walls. The first Allis clamp is applied just behind the termination of the previous GIA line of staples on the patient’s left. (Figure 4.) The Allis clamps and the suture are held in such a fashion that the TA-55 device can be applied just beneath the Allis clamps and the suture. (Figure 6.) The TA-55 stapler is then tightened and fired. Redundant esophageal and gastric tissues are excised flush with the TA-55 device utilizing a Mayo scissors but leaving the guy suture intact. (Figure 7.) The identical procedure is then utilized to close the right side of the esophagogastric defect by applying additional Allis clamps to achieve approximation here. Another application of the TA-55 autosuture device is necessary to complete the closure. (Figure 8.) It is essential that a small portion of the right hand termination of the GIA stapled
The American Journal of Surgery
Stapling Technic for Esophagogastrostomy
Figure 4. Completed sis.
posterior
layer of stapled
anastomo-
anastomosis be included in the final TA-55 staple line, The same guy suture should also be included for a second time in this last application of the TA-55. In this fashion there is no possibility of leaving any gap between the various staple lines. A useful technic for checking that such an error has not been committed is via the Levin tube, by inflating tte gastric pouch with several hundred milliliters of saline and tinting with methylene blue. By gently compressing tEe distal portion of the gastric pouch between the surgeon’s fingertips, any leakage of saline from the suture line can be detected. If sufficient gastric pouch is available, a modified type of Nissen fundoplication may be accomplished, if desired, by suturing stomach partially around the esophagus in such fashion as to form an inkwell. At this point, if the hiatus of the diaphragm constricts the gastric pouch, an incision is made in the crux so as to enlarge the hiatus. Sutures of 3-O cotton are utilized to attach the seromuscular coat of the stomach to the edge of t+e hiatus to prevent future herniation of small intestine into the chest. Next, it is important to suture the gastric pouch to the mediastinal pleura to eliminate tension on the anastomosis. Caution should be exercised to avoid entering tk.e gastric lumen with these sutures, as gastropleural fistulas have been reported after this error [3]. Pyloromyotomy is performed to alleviate stasis in the vagot.omized stomach. (Figure 9.) Closure. The incision in the diaphragm is closed with interrupted 2-O cotton sutures. After excising a small segment of cartilage, the costal margin is approximated with one or two sutures of monofilament 2-O stainless steel
Volume 136, September 1978
Figure 5. Approximation of the esophagus and gastric stab wound for a triangulated everting stapled closure of the anterior layer of anastomosis. The guy sutures pass through the walls of the esophagus and stomach.
wire. The thorax is closed with pericostal sutures of # 2 chromic catgut and continuous sutures of Dexon@ to each of the muscular layers. The abdominal incision is closed in the fashion of Tom Jones with interrupted 2-O stainless steel wire. A #36 chest tube is brought out through the ninth intercostal space for closed suction drainage. Postoperative Care. A plastic nasogastric tube is used to provide mild suction to the gastric pouch for approximately four days. Patients who have lost 10 pounds or more of weight are placed on intravenous hyperalimentation prior to and after surgery. Postoperatively, all patients are kept exclusively on intravenous fluids, receiving nothing by mouth until the seventh postoperative day. At that time roentgenographic examination of the esophagogastric anastomosis is carried out. In the absence of radiographic or clinical evidence of leakage, liquids and purees are then offered, progressing to a full soft diet in a few days. Administration of antibiotics, which is initiated 4 to 6 hours prior to operation, is continued until the thoracic drainage tube is removed. Tumors of Middle Esophagus
Incision. With the patient positioned so that the right hip and shoulder are elevated approximately 30 degrees, an incision is made in the right fourth or fifth intercostal space. A short segment of one or more costal cartilages is excised as necessary for exposure. The right lung is collapsed and retracted forward. The mediastinal pleura is
401
Chassin
Figure 6. Application of TA-55 stapler to the left half of the anterior layer.
incised, and the azygos vein is divided. The esophagus together with tumor is dissected from the apex of the thorax to the esophageal hiatus. An upper midline incision is then made into the abdominal cavity. Mobilization of Stomach. This step is similar to that described for lower esophageal lesions, except that the spleen may be preserved at the option of the surgeon. Advancement of Stomach into the Right Chest. The right crux of the diaphragm is divided transversely until the hiatus is sufficiently enlarged to permit easy passage of the stomach into the mediastinum and then into the right hemithorax. The cardiac end of the stomach will reach without tension to the apex of the right chest. The esophagogastric junction is dissected free of areolar tissue. A TA-55 autosuture stapling device is applied to the gastric side of this junction. The stapler is closed and fired. An occluding clamp is then placed on the distal esophagus, and the esophagogastric junction is divided with a scalpel flush with the stapler. Technic of Anastomosis. At a suitable site above the tumor, the proximal esophagus is divided, leaving its proximal end open. If there is sufficient slack in the esophagus, a stapled anastomosis is constructed exactly as described above. The cardiac end of the stomach is sutured to the prevertebral fascia at the apex of the thorax. Nissen fundoplication may be performed if desired. Closure. The thorax and abdomen are closed in routine fashion.
402
Figure 7. Excision of redundant tissue beyond the line of staples.
Results There have been no hospital deaths in this series. To determine the incidence of anastomotic leaks, each patient underwent esophageal roentgenography with an aqueous contrast medium on the seventh postoperative day. In no case was there any suggestion of leakage either by x-ray films or by clinical manifestations. The diameter of the stoma has been noted to be larger than that seen in the usual handsewn esophagogastric anastomosis on x-ray films. No patient required postoperative esophageal dilatation. Most notable among the complications were abscesses that developed in the left subphrenic space subsequent to splenectomy in two patients and combined with resection of a gastric malignant lymphoma in one and adenocarcinoma in the other. Other complications included heart failure in two patients, one with pneumonitis and one with a subcutaneous wound infection. The number of days of postoperative hospitalization varied from eleven to thirty-seven, with a median of fifteen days. It should be noted that the majority of these patients were in their eighth decade of life.
The American Journal of Surgery
Stapling Technic for Esophagogastrostomy
Figure 9. Appearance to-side anastomosis.
Figure 8. Apprication of TA-55 stapler to the right ha/f of the anterior layer.
Comments
Esophagogastrectomy for carcinoma is an operation notable for a high fatality rate. Table I is a summary of 2,156 cases abstracted from major reviews published on this subject in the past ten years. These papers report the experience of reputable institutions such as John Hopkins [3], Memorial [5], and Barnes [6] Hospitals, and the Mayo Clinic [7], as well as of authorities in this field, such as Belsey and Hiebert [8], Ellis [7], Collis [9], Lortat-Jacob [IO], and Skinner [II]. Nevertheless, the average mortality reported comes to 23 per cent. Approximately half the deaths in most reports were attributed to anastomotic leakage. Although the present series is small by comparison, it is striking because of the absence of any leaks or deaths. In the case of the two patients who developed left subphrenic abscesses, it should be noted that the anastomotic suture lines were well up in the mediastinum. Consequently, these two complications cannot be attributed to anastomotic failure. It was emphasized by Cole, Petit, and Bernard [6] that intraabdominal sepsis occurred with frequency after resection of gastric malignancy. Subphrenic abscess in these cases appears to be secondary to the contamination by virulent organisms during the opera-
Volume 136, September 1979
of completed
back-to-front,
end-
tive procedure, and it occurs occasionally even in patients who have received preoperative intestinal antibacterial agents as well as prophylactic antibiotics before and during the operation. After a long and sometimes difficult resection in an elderly patient, the availability of a technic of esophagogastric anastomosis which can be accomplished in a matter of seconds constitutes a welcome epilogue. Nevertheless, this is not the only advantage. It is my impression that the end-to-side anast,omosis also tends to reduce postoperative gastroesophageal regurgitation. This coincides with the findings of Fisher, Brawley, and Kieffer [3], who performed a similar type of anastomosis with sutures. None of the patients in the present series complained of symptoms indicating regurgitation, yet in only one case was a Nissen fundoplication (modified) performed. Although it is believed that the present technic of anastomosis played a role in preventing regurgitation, it is also recognized that 75 per cent of the patients in this series had gastric neoplasms with low acid secretion and they might not have developed esophagitis after any anastomosis. It is not clear whether the esophagogastric anastomosis should be supplemented by fundoplication whenever possible, as advocated by Boyd et al [4]. Fundoplication of the Nissen type cannot be performed in most patients who require excision of the gastric cardia for carcinoma in t.his vicinity, as there will not be sufficient width in the residual gastric pouch for a complete gastric wraparound. Modified partial gastric wraps may be improvised, but there are inadequate data to support their efficacy or the necessity of adding this step in gastric cancer.
403
Chassin
TABLE I
Deaths and Leaks After Esophagogastric Anastomoses
No. of Authors
Cases
Cole [6] 1968 Humphrey [5] 1968 Maillard [ IO] 1969 Koch [ I] 1969 Gunnlaugsson [ 71 1970 Collis [9] 1971
53 243 472 17 541 l-50 51-300 301-400 400 65 31 140 56 1-17 18-40 40 28 70 2,156 12
lnberg [z] 1971 Fisher [3] 1972 Belsey [8] 1974 Boyd [4] 1975 Skinner [ 7I] 1976
Hermreck [ 721 1976 Sefton [ 731 1977 Total Present series
Rate of Anastomotic Leakage Total Fatal 13%
0 0 18%
8% 17% 24% 6% 24% 2% 6% 6% 8% 0 11% 2% 41% 0 18% 14%
0
10% 0
19%
12% 0 14%
No. of Deaths 13 (24%) 61 (25%) 160 (34%) 9 (53%) 70 (13%) 26 (52%) 38 (15%) 12 (12%) 76 (19%) 10 (15%) 4 (13%) 39 (28%) 5 (9%) 11 (65%) 0 11 (28%) 6(21%) 21(30%) 485 (23%) 0
of technical error in any new technic, surgeons who have had no experience with stapled anastomoses elsewhere in the gut should either obtain instruction or attempt the technic in an animal laboratory prior to application in humans. Summary
A technic of esophagogastrostomy is described for constructing an end-to-side, back-to-front anastomosis using stapling devices. Twelve consecutive cases are reported with no deaths and no anastomotic leaks. Addendum
Since this paper was submitted for publication, four additional patients underwent esophagogastrectomy by the stapling technic described. There was no clinical or radiographic evidence of leakage and there were no deaths.
References
Finally, there appears to be an intrinsic advantage in the use of a device that can apply thirty-three staples simultaneously with great accuracy and minimal trauma as compared with insertion of multiple sutures often in a situation requiring an awkward position for the surgeon’s hand and needle holder. Although the everting nature of the anterior portion of the suture line violates surgical tradition of long standing, extensive experience with stapling devices in other parts of the intestinal tract has confirmed the safety of this technic [14] provided basic precautions are observed. If the tissues being approximated in any stapled anastomosis are unsually thick or edematous so that compression to a thickness of 2.0 mm by the stapling device will result in necrosis, the stapling technic is contraindicated. Similarly, if the tissues have been thinned out to such an extent that application of a standardized staple will not firmly hold the tissue, this technic must not be used. We observed the latter situation on one occasion. Considerable traction was being applied to the esophagus at the same time that the GIA stapler was fired. This resulted in sufficient thinning out of the esophageal wall as to make the anastomosis hazardous. In this case the stapled anastomosis was repeated at a higher level with the esophagus in a fully relaxed position with an excellent result. Relaxation of the esophagus permits more muscle and mucosa to be included in each staple bite, whereas thinning the organ by traction may result in stapling tissue no thicker than tissue paper. Since there are possibilities
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1. Kock NG, Lewin E, Peterson S: Partial or total gastrectomy for adenocarcinoma of the cardia. Acta Chir Stand 135: 340, 1969. 2. lnberg MV, Linna MI, Scheinin TM, Vanttinen E: Anastomotic leakage after excision of esophageal and high gastric carcinema. AmJ Surg 122: 540, 1971. 3. Fisher RD. Brawley RK, Kieffer RF: Esophagogastrostomy in the treatment of carcinoma of the distal two-thirds of the esophagus. Ann Thorac Surg 14: 658, 1972. 4. Boyd AD, Cukingnan R, Engelman RM, Localio SA, Slattery L, Tice DA, Bardin JA, Spencer FC: Esophagogastrostomy, analysis of 55 cases. J Thorac Cardiovasc Surg 70: 817, 1975. 5. Humphrey CR, Cliffton EF: Carcinoma of the distal part of the esophagus and cardia of the stomach. Surg Gynecof Obstet 127: 737, 1968. 6. Cole WR, Petit R, Bernard HR: Factors affecting incidence of anastomotic leaks following esophagogastrectomy. Ann Thorac Surg 6: 396, 1968. 7. Gunnlaugsson GH, Wychulis AR, Roland C, Ellis FH Jr: Analysis of the records of 1,657 patients with carcinoma of the esophagus and cardia of the stomach. Surg Gynecol Obstet 130: 997.1970. 8. Belsey R, Hiebert CA: An exclusive right thoracic approach for cancer of the middle third of the esophagus. Ann Thorac Surg 18: 1, 1974. 9. Collis JL: Surgical treatment of carcinoma of the esophagus and cardia. BrJSurg58: 801, 1971. 10. Maillard JN, Launois B, Lagausie P, Lellouch J, Lot-tat-Jacob JL: Cause of leakage at the site of anastomosis after esophagogastric resection for carcinoma. Surg Gynecol Obstet 127: 1014, 1969. 11. Skinner DB: Esophageal malignancies, experience with 110 cases. Surg C/in North Am 56: 137, 1976. 12. Hermreck AS, Crawford DG: The esophageal anastomotic leak. Am J Surg 132: 794, 1976. 13. Sefton GK, Cooper DJ, Grech P, Giddings AEB: Assessment and resection of carcinoma at the gastroesophaoeal function. Surg Gynecol Obstet 144: 563, l-977. 14. Steichen FM, Ravitch MM: Mechanical sutures in surgery. Br JSurg60: 191, 1973.
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