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Novel Procedure of Circular Stapler–Guided Nasogastric Tube Insertion during Esophageal Reconstruction
SURGEON AT WORK
Novel Procedure of Circular Stapler–Guided Nasogastric Tube Insertion during Esophageal Reconstruction Naritaka Tanaka, MD, PhD, Tatsuya Miyazaki, MD, PhD, Daigo Ozawa, MD, Shigemasa Suzuki, MD, Takehiko Yokobori, MD, PhD, Takanori Inose, MD, PhD, Makoto Sohda, MD, PhD, Takayuki Asao, MD, PhD, Hiroyuki Kato, MD, PhD, Hiroyuki Kuwano, MD, PhD, FACS
Figure 1. (A) Silk suture is threaded through the frontal holes of the anvil head. (B) The silk is used to create a loop of approximately 3 cm. (C) Schema of A. (D) Schema of B.
Nasogastric tube placement with the distal tip slightly distal to the esophagogastric anastomosis is important after esophagectomy. The purpose of nasogastric tube placement is to inject liquid dye for the leak test, decompress esophagogastric anastomosis, reduce the risk of pulmonary complications, and monitor the surgical site for postoperative bleeding. We usually perform esophageal reconstruction of the gastric tube through a retrosternal or posterior mediastinal approach. In the retrosternal approach, insertion of the nasogastric tube is often difficult because of the tortuosity of the remnant esophagus. The circular stapling
Disclosure Information: Nothing to disclose. Received August 3, 2011; Revised September 7, 2011; Accepted September 12, 2011. From the Department of General Surgical Science, Gunma University, Graduate School of Medicine, Maebashi, Japan (Tanaka, Miyazaki, Ozawa, Suzuki, Yokobori, Inose, Sohda, Asao, Kuwano) and Department of Surgical Oncology, Dokkyo Medical University, Mibu-machi, Japan (Kato). Correspondence address: Naritaka Tanaka, MD, PhD, Department of General Surgical Science, Gunma University, Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan. email: [email protected]
© 2011 by the American College of Surgeons Published by Elsevier Inc.
e35
ISSN 1072-7515/11/$36.00 doi:10.1016/j.jamcollsurg.2011.09.009
e36
Tanaka et al
Nasogastric Tube Insertion Using Stapler
J Am Coll Surg
Figure 2. (A) A nasogastric tube is ligated to the anvil head with the silk loop. (B) The nasogastric tube is pulled by the silk threads and removed from the tip of the gastric tube to outside the body. (C) Schema of A and B.
technique is used for the anastomosis of the cervical esophagus and gastric tube. When the nasogastric tube is fed outside the body from the proximal end of the gastric tube through the nose after anastomosis, the anastomotic region can be damaged occasionally, which can contribute to risk of anastomotic leakage. Therefore, when nasogastric tube insertion has been difficult, we have performed an insertion method using a Nelaton catheter.1 More recently, we developed an insertion technique using the EEA circular stapler set (Covidien Japan). Although the Nelaton catheter method is useful, this new method is simpler and faster. Here we describe our novel technique.
METHODS Surgical technique
We performed an anastomosis of the cervical esophagus and gastric tube by using a 25-mm circular stapling technique. The cervical esophagus was surgically removed and the distal stump of the esophagus was opened. Before creating the anastomosis, we threaded a silk thread through
two of the frontal holes of an anvil head to form a 3-cm loop (Fig. 1A). Of the 3 holes in the anvil head, we use the 2 that are located horizontally when the anvil head is angled. This loop technique enables smooth feeding of the nasogastric tube outside the body from the proximal tip of the gastric tube because the anvil head of the EEA circular stapler is usually tilted at a similar angle when the anastomosis is formed (Fig. 1B). We then fed the nasogastric tube outside the body from the proximal tip of the gastric tube through the nose and ligated the silk loop to the distal end of the nasogastric tube (Fig. 2A). The anvil head, joined to the nasogastric tube, was then placed in the cervical esophagus and fixed in the stump of the esophagus. The circular stapler is inserted from the tip of the gastric tube and the center shaft of circular stapler penetrates the presumptive region of anastomosis. The center shaft is joined to the anvil center rod and anastomosis of the cervical esophagus and gastric tube is performed. After anastomosis, the anvil head is angled and extracted from the proximal end of the gastric tube. At the same time, the nasogastric tube is re-
Vol. 213, No. 6, December 2011
moved from the tip of the gastric tube by pulling on the silk threads (Fig. 2B). At this time, it is necessary to ensure that the nasogastric tube is not under tension. The nasogastric tube in the anastomosis is easily fed from the tip of the gastric tube to the distal side of the esophagogastric anastomosis. This technique is the same as that commonly used for circular stapling anastomosis, except that an anvil head is ligated to the nasogastric tube with silk.
DISCUSSION Insertion of a nasogastric tube is necessary after esophagectomy, primarily to decompress the esophagogastric anastomosis, reduce the risk of pulmonary complication, and monitor postoperative bleeding. Some authors have stated that a nasogastric tube for decompression after minimally invasive esophagectomy is unnecessary2; however, other authors recommend using a decompression tube placed through the cervical esophagus.3 A circular stapler provides an end to side esophagogastric anastomosis. After the anastomosis is created, feeding a nasogastric tube manually from the tip of the gastric tube through the nose to outside the body is difficult because the angle of the anastomosis is sharp and can place mechanical stress on the anastomotic region with the risk of rupturing sutures. In addition, blindly grasping the nasogastric tube in the cervical esophagus can damage the esophageal mucosa. Several reports have been published on alternative techniques for inserting the nasogastric tube under endoscopic guidance4,5; however, these procedures often require substantial time and effort. In the past, we had performed an insertion method using a Nelaton catheter and this method was useful and certain1; however, the anastomosis can be damaged when the Nelaton catheter is inserted from the proximal end of the gastric tube. In addition, an anesthesiologist is necessary to ligate the Nelaton catheter and nasogastric tube, and there is the disadvantage of the wide range of diverse sur-
Tanaka et al
Nasogastric Tube Insertion Using Stapler
e37
gical techniques. On the other hand, in our method, the operator ligates the anvil head and nasogastric tube at the surgical field. We devised the method described here for performing a procedure combining anastomosis and insertion of a nasogastric tube and taking advantage of the characteristics of a circular stapler. This technique is currently limited to a particular stapler because the tip of the anvil head already has holes to accommodate the silk thread. This method provides a safe and useful means for feeding a nasogastric tube from the distal side of the anastomosis through the nose and can be performed during the same procedure. Author Contributions
Study conception and design: Tanaka Analysis and interpretation of data: Tanaka Drafting of manuscript: Kuwano Critical revision: Kuwano
REFERENCES 1. Kuwano H, Maekawa S, Morita M, et al. Use of a nasogastric tube and a Nelaton catheter for esophageal reconstruction. Surg Gynecol Obstet 1991;173:230–232. 2. Nguyen NT, Slone J, Wooldridge J, et al. Minimally invasive esophagectomy without the use of postoperative nasogastric tube decompression. Am Surg 2009;75:929–931. 3. Schuchert MJ, Pettiford BL, Landreneau JP, et al. Transcervical gastric tube drainage facilitates patient mobility and reduces the risk of pulmonary complications after esophagectomy. J Gastrointest Surg 2008;12:1479–1484. Epub 2008 Jun 17. 4. Jiang F, Yu MF, Ren BH, et al. Nasogastric placement of sump tube through the leak for the treatment of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. J Surg Res 2010 Jul 30. [Epub ahead of print]. 5. Lin CH, Liu NJ, Lee CS, et al. Nasogastric feeding tube placement in patients with esophageal cancer: application of ultrathin transnasal endoscopy. Gastrointest Endosc 2006;64:104–107.
Novel Procedure of Circular Stapler–Guided Nasogastric Tube Insertion during Esophageal Reconstruction Naritaka Tanaka, MD, PhD, Tatsuya Miyazaki, MD, PhD, Daigo Ozawa, MD, Shigemasa Suzuki, MD, Takehiko Yokobori, MD, PhD, Takanori Inose, MD, PhD, Makoto Sohda, MD, PhD, Takayuki Asao, MD, PhD, Hiroyuki Kato, MD, PhD, Hiroyuki Kuwano, MD, PhD, FACS
Figure 1. (A) Silk suture is threaded through the frontal holes of the anvil head. (B) The silk is used to create a loop of approximately 3 cm. (C) Schema of A. (D) Schema of B.
Nasogastric tube placement with the distal tip slightly distal to the esophagogastric anastomosis is important after esophagectomy. The purpose of nasogastric tube placement is to inject liquid dye for the leak test, decompress esophagogastric anastomosis, reduce the risk of pulmonary complications, and monitor the surgical site for postoperative bleeding. We usually perform esophageal reconstruction of the gastric tube through a retrosternal or posterior mediastinal approach. In the retrosternal approach, insertion of the nasogastric tube is often difficult because of the tortuosity of the remnant esophagus. The circular stapling
Disclosure Information: Nothing to disclose. Received August 3, 2011; Revised September 7, 2011; Accepted September 12, 2011. From the Department of General Surgical Science, Gunma University, Graduate School of Medicine, Maebashi, Japan (Tanaka, Miyazaki, Ozawa, Suzuki, Yokobori, Inose, Sohda, Asao, Kuwano) and Department of Surgical Oncology, Dokkyo Medical University, Mibu-machi, Japan (Kato). Correspondence address: Naritaka Tanaka, MD, PhD, Department of General Surgical Science, Gunma University, Graduate School of Medicine, 3-39-22, Showa-machi, Maebashi, Gunma 371-8511, Japan. email: [email protected]
© 2011 by the American College of Surgeons Published by Elsevier Inc.
e35
ISSN 1072-7515/11/$36.00 doi:10.1016/j.jamcollsurg.2011.09.009
e36
Tanaka et al
Nasogastric Tube Insertion Using Stapler
J Am Coll Surg
Figure 2. (A) A nasogastric tube is ligated to the anvil head with the silk loop. (B) The nasogastric tube is pulled by the silk threads and removed from the tip of the gastric tube to outside the body. (C) Schema of A and B.
technique is used for the anastomosis of the cervical esophagus and gastric tube. When the nasogastric tube is fed outside the body from the proximal end of the gastric tube through the nose after anastomosis, the anastomotic region can be damaged occasionally, which can contribute to risk of anastomotic leakage. Therefore, when nasogastric tube insertion has been difficult, we have performed an insertion method using a Nelaton catheter.1 More recently, we developed an insertion technique using the EEA circular stapler set (Covidien Japan). Although the Nelaton catheter method is useful, this new method is simpler and faster. Here we describe our novel technique.
METHODS Surgical technique
We performed an anastomosis of the cervical esophagus and gastric tube by using a 25-mm circular stapling technique. The cervical esophagus was surgically removed and the distal stump of the esophagus was opened. Before creating the anastomosis, we threaded a silk thread through
two of the frontal holes of an anvil head to form a 3-cm loop (Fig. 1A). Of the 3 holes in the anvil head, we use the 2 that are located horizontally when the anvil head is angled. This loop technique enables smooth feeding of the nasogastric tube outside the body from the proximal tip of the gastric tube because the anvil head of the EEA circular stapler is usually tilted at a similar angle when the anastomosis is formed (Fig. 1B). We then fed the nasogastric tube outside the body from the proximal tip of the gastric tube through the nose and ligated the silk loop to the distal end of the nasogastric tube (Fig. 2A). The anvil head, joined to the nasogastric tube, was then placed in the cervical esophagus and fixed in the stump of the esophagus. The circular stapler is inserted from the tip of the gastric tube and the center shaft of circular stapler penetrates the presumptive region of anastomosis. The center shaft is joined to the anvil center rod and anastomosis of the cervical esophagus and gastric tube is performed. After anastomosis, the anvil head is angled and extracted from the proximal end of the gastric tube. At the same time, the nasogastric tube is re-
Vol. 213, No. 6, December 2011
moved from the tip of the gastric tube by pulling on the silk threads (Fig. 2B). At this time, it is necessary to ensure that the nasogastric tube is not under tension. The nasogastric tube in the anastomosis is easily fed from the tip of the gastric tube to the distal side of the esophagogastric anastomosis. This technique is the same as that commonly used for circular stapling anastomosis, except that an anvil head is ligated to the nasogastric tube with silk.
DISCUSSION Insertion of a nasogastric tube is necessary after esophagectomy, primarily to decompress the esophagogastric anastomosis, reduce the risk of pulmonary complication, and monitor postoperative bleeding. Some authors have stated that a nasogastric tube for decompression after minimally invasive esophagectomy is unnecessary2; however, other authors recommend using a decompression tube placed through the cervical esophagus.3 A circular stapler provides an end to side esophagogastric anastomosis. After the anastomosis is created, feeding a nasogastric tube manually from the tip of the gastric tube through the nose to outside the body is difficult because the angle of the anastomosis is sharp and can place mechanical stress on the anastomotic region with the risk of rupturing sutures. In addition, blindly grasping the nasogastric tube in the cervical esophagus can damage the esophageal mucosa. Several reports have been published on alternative techniques for inserting the nasogastric tube under endoscopic guidance4,5; however, these procedures often require substantial time and effort. In the past, we had performed an insertion method using a Nelaton catheter and this method was useful and certain1; however, the anastomosis can be damaged when the Nelaton catheter is inserted from the proximal end of the gastric tube. In addition, an anesthesiologist is necessary to ligate the Nelaton catheter and nasogastric tube, and there is the disadvantage of the wide range of diverse sur-
Tanaka et al
Nasogastric Tube Insertion Using Stapler
e37
gical techniques. On the other hand, in our method, the operator ligates the anvil head and nasogastric tube at the surgical field. We devised the method described here for performing a procedure combining anastomosis and insertion of a nasogastric tube and taking advantage of the characteristics of a circular stapler. This technique is currently limited to a particular stapler because the tip of the anvil head already has holes to accommodate the silk thread. This method provides a safe and useful means for feeding a nasogastric tube from the distal side of the anastomosis through the nose and can be performed during the same procedure. Author Contributions
Study conception and design: Tanaka Analysis and interpretation of data: Tanaka Drafting of manuscript: Kuwano Critical revision: Kuwano
REFERENCES 1. Kuwano H, Maekawa S, Morita M, et al. Use of a nasogastric tube and a Nelaton catheter for esophageal reconstruction. Surg Gynecol Obstet 1991;173:230–232. 2. Nguyen NT, Slone J, Wooldridge J, et al. Minimally invasive esophagectomy without the use of postoperative nasogastric tube decompression. Am Surg 2009;75:929–931. 3. Schuchert MJ, Pettiford BL, Landreneau JP, et al. Transcervical gastric tube drainage facilitates patient mobility and reduces the risk of pulmonary complications after esophagectomy. J Gastrointest Surg 2008;12:1479–1484. Epub 2008 Jun 17. 4. Jiang F, Yu MF, Ren BH, et al. Nasogastric placement of sump tube through the leak for the treatment of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. J Surg Res 2010 Jul 30. [Epub ahead of print]. 5. Lin CH, Liu NJ, Lee CS, et al. Nasogastric feeding tube placement in patients with esophageal cancer: application of ultrathin transnasal endoscopy. Gastrointest Endosc 2006;64:104–107.