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The creation of autologous substitute organs with stapling instruments
The Creation of Autologous Substitute Organs with Stapling Instruments Felicien M. Steichen, MD, Pittsburgh, Pennsylvania
Replacement of the esophagus, stomach, and urinary bladder as well as colorectal function is indicated in a variety of congenital, acquired benign and malignant conditions. Satisfactory reconstructive technics should be associated with low morbidity and mortality; should be completed in one stage at the same time the diseased organ is removed; should be adaptable to variations in anatomy, unexpected technical challenges, and all age groups; and should substitute for lost function on a permanent basis. In esophageal replacement with the reversed gastric tube or various segments of colon, in gastric replacement wth a jejunal pouch, in bladder substitution with an ileal loop, and in the substitution of colorectal function with an ileal pouch, we have found the use of stapling instruments to be invaluable in the accomplishment of these goals. The stapling instruments accomplish various technical functions [l-4]. The TA30, TA5.5, and TA90 instruments introduce linear, terminal, or tangential suture lines, 30,55, or 90 mm long, respectively. The GIA instrument is used for dividing and anastomosing bowel. The LDS stapler serves to ligate and simultaneously divide vessels, strands of mesentery, and omentum. Malnourished patients, in whom a one-stage excision and reconstruction would have been unthinkable in the past, are now prepared with intravenous hyperalimentation or elemental diets if they can swallow. Patients with esophageal and bladder cancers often receive preoperative radiation therapy. Their nutritional rehabilitation can thus proceed while radiation is administered. From the Departments of Surgery, Veterans Administration Hospital and University of Pittsburgh Health Center, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania. Reprint requests should be addressed to Felicien M. St&hen, MD, Surgical Service, Veterans Adminlstration Hospital, University Drive C, Pittsburgh, Pennsylvania 15240.
Votume 134, November 1077
Segmental or Total Replacement of the Esophagus (Figures 1 and 2)
Partial or total replacement of the esophagus is required in wide-spaced esophageal atresia, nonremediable strictures due to gastroesophageal reflux and lye burns, and potentially curable malignant neoplasms. For this replacement, we use the reversed gastric tube of Gavriliu-Heimlich or various segments of the colon [5-81. If both stomach and colon are available, our preference goes to the reversed gastric tube [9]. All patients with squamous cell carcinoma of the esophagus and no distant metastases have preoperative radiation to a total dose of 6,000 to 6,500 r. The neck and epigastrium are irradiated up to 3,500 to 4,000 r. The abdomen is explored first in all cases of malignant disease, and if there are metastases in the liver along the celiac axis or the lesser curvature of the stomach, esophageal excision and replacement are not performed. In all patients with metastases, an intraesophageal prosthesis is placed for palliation. The reversed gastric tube represents an extension of the Beck-Jianu tube, used in the past for permanent gastrostomy and suggested for replacement of the esophagus via an antethoracic, subcutaneous tunnel [10,11]. Use of the colon as an esophageal substitute was first proposed in 911 by Kelling [12]. We have used all three segments of colon (ascending, transverse, and descending) depending on length of colon required, anatomic approach (chest versus abdomen), anatomy of colic vessels, and redundancy of mesocolon [13]. Right and transverse coloplasties are based on the midcolic artery; descending coloplasties are supplied by the left colic artery and are used in an antiperistaltic fashion. The length of colon required for bypass
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Figure 1. Reversed Gastric Tube ot Gavrii/u-he/milch. (A ) To achieve up ward mobiiity ot the /e/t gastroepiploic vessels, spienectomy is necessary. in children less than two ydars of age, a shorter gastric tube w/ii be obtained by ieawing the sp/een intact. The spienic vessels are ligated and dlvlded dlrectly on the sp/enic capsuie in ordef to zdy the ieft gastt~epipioic vessels and , (S) After sp/enectomy, the posterior per/toneum Is incised and the pancreas ia ekvated In a med/al dhectkn, to the ieff botder ot the aorta. 771/smaneuver w/ii increase upward mobi/ity ot the gastric tube. (C) The r/ght gastm@p/o/c artery b /@ted and transected 2 cm proximal to the py/ot-us.7% gastroepip/oic a-de, based on the lefl gastroepiploic vessels, is then deveioped by repeated applications ot the IDS stapler, pWipher8l to. the arcade. (D) The greater curvature ot the stomach is then incised vertically to its long axis, 2 cm proximal to the pyiorus. A #36 French bougie is positioned inside and along the greater curvature, as a guide tor the G/A instrument. The reversed gastric tube is fashioned by repeated applications of the G/A, parallel to the greater curvature. (E) 77~ stapied gastric and tube suture lines 816&Horced by N/III//&Jof intenupted sutures of catgut.
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Figure 7 continued. (F) The proximal esophago-tube anastomosis is a manual one. If the esophagus is removed, the gastric tube is brought up through the mediastinum, especially in patients with laryngo-pharyngo-esophagectomy who require a permanent tracheostomy. If esophagectomy is not indicated, the gastftc tube ts advanced through a retrostemal route. (G) Gavriliu’s extension of the reversed gastric tube attows for very htgh anastomoses in the neck. The first portion of the duodenum and the pylorus are included in the construct/on of the tube for 6 to 6 cm of added length. The right side of the gastroepiploic arcade is preserved and the duodenum is severed with the GIA instrument. Next, the G/A instrument is applied at the lesser curvature, 2 cm proximal to the pylorus, in the difectton of the greater curvature. As the G/A suture line comes with/n 2 cm of the greater curvature, the CIA is used in an upward direction as described in Figure ID. (H) The gastric remnant is anastomosed to the duodenal stump in a two layer Billroth I fashion. Pytoromyotomy of this extended reversed gastric tube is indicated. In the neck, the first portion of the duodenum is anastomosed to the pharynx in a two layer anastomosis after excision of the temporary GIA suture line.
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Figure 2. Esophagocoloplasty. (A) The proximal third of the stomach is liberated along both curvatures with the LDS instrument. (6) The gastric fundus Is then transected between two lines of T#90 staples, using the instrument as a guide to divide the stomach. The adequacy of the colic vessels and the width of the corresponding mesocolon aie then examined, and the segment chosen for co/op/asty (in this case the ascending co/on) is then elevated from Its posterior peritoneal atfachments. (C) The distal ileum is transected near the ileocecal valve with the G/A stapler; both bowel ends are closed slmultaneously. (0)
The midtransverse colon is similarly severed distal to the midcollc artery.
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Figure 2 continued. (E) The anfimesenteric corners of fhe staple-closed, proximal ileum and distal transverse colon are then excised. Both bowel loops are approximated in a shotgun fashion. (F) The GIA instrument is placed inside the proximal ileum and fhe distal colon, and bowel confinuity is established by anatomic side-to-side anastomosis. (G, H) The TA55 instrument is fhen used 10 close the GIA introduction sites in an evetiing fashion, transforming the anatomic side-to-side anaslomosis into a funcfionai end-lo-end anastomosis. The completed functional end-to-end ileocoiostomy is shown.
is measured with an umbilical tape extending from the epigastrium to the proposed site of proximal anastomosis, and this measurement is used on the colon segment along the mesocolon insertion. After elevation from its posterior attachments of the colon segment to be used, the vascular supply to the segment is tested by temporarily occluding with bulldog clamps those vessels that will have to be severed in order to obtain sufficient length (ileocolic and right colic arteries for ascending colon, proximal and distal marginal artery for transverse and descending colon). If a thoracic anastomosis is indicated, the colon segment is brought up through the posterior mediastinum. If, on the other hand, a cervical anastomosis is contemplated, then the colon segment may be brought through the posterior mediastinum or through a retrosternal tunnel. If the operation is performed for cervical esdphageal carcinoma, where laryngectomy is also indicated, then the colon is placed behind the permanent tracheostomy and is anastomosed manually to the pharynx. In patients with carcinoma of the thoracic esophagus, we prefer to place the esophagocolic anasto664
mosis into the neck because of greater technical ease in that location and lesser morbidity in case leakage should occur. To achieve this goal, the cervical esophagus is liberated after the thoracic esophagus has been dissected through a separate right anterolateral thoracotomy or by blind manual tunneling from the abdomen and from the neck. Paulino Gastric Substitute
(Figure 3)
The Paulino jejunal pouch for gastric substitution is a modification of the Hunt-Lawrence pouch [14-161. Technically, it has the advantage of requiring anastomosis, between the esophagus and a loop of jejunum only, rather than the entire jejunal pouch. The pouch itself can be constructed after the more difficult esophagojejunal anastomosis has been completed. Functionally, the Paulino pouch allows for complete mixture of food, bile, and duodenal and pancreatic secretions, and it avoids all possibility of food regurgitation into the esophagus. In total gastrectomy, the duodenum is closed with the TA55 instrument and is severed between this instrument, placed distally, and a proximal Kocher clamp. The entire specimen consisting of stomach, The American Journal of Surgery
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(I) An IncIdental appendectomy I8 performed with fhe LOS and G/A Instruments. (J) 7Re suture //ne obtained by this tech&
I8 not relnfofced a8 are none of the stap/e rtuture //no8 In this operstlon.
(K) Through a r/rig/e Stab wound In the pylorus, a Hnney py/ofop/aSry I8 performed with the Q/A Insfrument. 7he stomach I8 anchored to the Second port/on of the duodenum w/th a suture. The pylorlc 8tab wound I8 C/OSedIn an evertlng rash/on w/th the TAM Instrument. A gastrostomy, not Shown In these dfawhIg8, b foutlnely done.
greater omentum, node-bearing tissue along the lesser curvature, tail of pancreas, spleen, and possibly segment(s) of involved and resectable bowel is then freed from below upwards and from right to left. The specimen is left attached to the esophagus and is used as a handle to introduce the posterior and outer row of a double layer end-to-side esophagojejunostomy. After transection of the esophagus and removal of the specimen, the inner layer as well as the outer anterior layer of this anastomosis is then completed [I 71. In the chest, this same anastomosis can be performed with the GIA instrument. Volume 184. Novombw 1977
Continent Neal Reservoir by Kock (Flgure 4)
A permanent incontinent ileostomy is required in patients with ulcerative and neoplastic diseases of the colon and rectum necessitating total proctocolectomy. The patient is left to contend with skin irritation and odor by the liquid intestinal contents and the need for wearing an appliance constantly. In 1962, Kock constructed a new type of ileal conduit for replacement of the urinary bladder, based on the principle of opposing peristaltic movements that neutralized the propulsive action of the ileal segment, 665
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Figure 2 continued. (L ) The midtransverse mesocoion is then severed down to its roof, at the level of the transection of the transverse colon, leaving the midcoiic artery on the side of the segment to be used for colon transposition. The iieocoiic and right colic arteries are ligated and divided with the LDS, proximal to the marginal artery of Drummond. (M) The segment of colon is then pulled upwards behind the stomach. With the lower portion of the colon segment positioned along the anterior wall of the lesser curvature, its antlmesocoilc corner is excised, and a stab wound is performed through the midanterior gastric wall. (N) The G/A is introduced into the colon segment and into the gastric lumen, and an end-to side cologastrostomy is performed.
and he has since applied the same principle to construct a continent ileal reservoir [18-221. The use of stapling instruments reduces operative time and blood loss significantly in this technic. The technic for construction of this ileal reservoir remains the same as first used by Kock: a bowel segment of 30 cm for the pouch and a segment distal to the pouch of 10 cm for the nipple and stoma are used. The 30 cm segment is folded into a U shape and the antimesenteric borders of the two 15 cm segments are apposed. Of importance is the fact that the GIA instrument is loaded with special units that contain the same staple cartridge as in other applications, but the knife blade is removed from the pusher-knife assembly. By using these special loading units, it is possible to place four parallel rows of staples without
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the inervening section of tissues between each pair of staple lines [23]. Examination of nipple competence should always be performed prior to wound closure. For this, 100 cc of saline are injected into the pouch with the afferent loop occluded by a noncrushing bowel clamp. If the pouch is continent, the saline will distend it, and it can only be emptied by a catheter introduced through the nipple. At the end of the procedure, the pouch is then brought through the mesenteric opening as described by Kock and is positioned in the pelvis. The efferent loop is brought out through a previously planned opening in the right lower quadrant and is anchored to the peritoneum and to the fascia with interrupted silk sutures.
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(0, P) The GIA introduction sites are then closed in an everting fashion, and the end-to-side coiogastrostomy is completed. ( 0) The proximal anastomosis is performed in the neck after the fully dissected thoracic esophagus has been delivered through the thoracic inlet. Through stab wounds in the midcervical esophagus and in the colon, 5 cm below its blind end, a long esophagocoiic anastomosis is performed with the G/A instrument. (R) The end-to-side cervical esophagocoiostomy is completed by closing the esophagus and the stab wound in the lateral wail of the colon, obliquely, with one application of the TA55 instrument. The esophageal specimen is removed distally to this ciosure. (S) The anastomosis in the neck may be a manual one, especially in patients with carcinoma ot the cervical esophagus requiring esophagoiaryngectomy. For such cases, the remaining pharynx would not be long enough to accommodate the GiA and TA instruments.
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Figure 3. Pauline Gastric Substitute. A Jejunal segment for the construct/on of the Roux-en-Y loop Is selected, 20 to 25 cm from the 5gament of Treltz at a level where the vascular arcades become wider. The bowel Is transected and closed (C) with the G/A instrument. The mesentery Is incised down to Its root and the vessels encountered at the foot of the vascular arcade are clamped, severed, and tied. (A) The esqhagojejunal anastomosls is performed manually or wfth the GIA. The jejunal segment leading from the esophagus to the Paulin pouch should measure 35 to 40 cm and the pouch #se/f anywhere from 76 to 2 1 cm. The desired length of the pouch will determlne the number of gla applications. The Paul/no pouch is created by approximating In a Roux-en-Y fashion the closed-off proximal duodenojejunal segment and the continuous distal jejunum. (6) A kmg end-to&de anastomosis is performed by usig the G/A stapler three times: First from below through the amputated corner of the proximal jejunum and a parallel stab wound In the continuous distal jejunum. The remaintng distance of the proposed jejunal pouch Is then divided in ha/f, kissing stab wounds are produced at that level, and the G/A instrument is applied downwards and upwants through the same stab wounds. The second GIA suture lines, coming from above downwards, overlap with those introduced first from below upwards. (C, D) ff necessary, a 21 cm reservoir can be obtained by apply/r& the G/A instrument four times through an added proximal stab wound. In this variation of the basic technic the proximal duodenojejunal limb is shown to fall to the right of the efferent jejunal loop and both an antlperistaltic and isoperistakic hmb are used since this may have some virtue in order to retain food and digestive juices longer In the pouch. (E) The GIA Introduction sites are closed transversely with the TA55 stapler.
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Figure 4. The Continent iieai Reservoir by Kock. (A ) Kissing stab wounds are made in the apposed lateral borders of the bowel segments 15 cm from the distal end (turn around) of the iieai loop. The arms of the GiA instrument, ioaded with special stapie cartrkfge~ are introduced into the bowel lumina, the pusher bars are advanced, and four posterior staple lines are created. Prior to removal of the htNlllsld, the ante&r bowel walls corresponding to the 4 to 5 cm suture line obtained with each GIA applicatkm ars inctsed onto the G/A forks used as a cutting guide. (t3) The G/A is applied a total of four more times to complete the posterior wail of the pouch. Each time the small bowel is incised anteriorly on the forks of the instrument. ( C) The nippie is created by grasping the anterior wall of the efferent toop at a I6vei 5 cm distal to the lumen of the future pouch. The bowel Is invaginated into the pouch. (D) The shape of the nipple is maintatned by anchoring U-shaped sutures of silk and two lateral applkations of the G/A loaded with the special loading units.
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,, INVERTED I’
STAPLE
LINE
\
\ \I \
Figure 4 conflnued. (E) The anferior wall of fhe atierenf ioop is incised over a disfance of 5 cm. the tlaf bowel segment representing the tufure pouch is then turned upon ifsett along a transverse axis and the serosal surfaces of this segment are apposed. (F) The laferal walls of fhe pouch are closed wifh two appllcafions of fhe TA90 stapler, and excess tissue is excised using fhe edge of -the stapler as a guide. (G, H) The TAB0 slap/e lines are converted info inverting suture lines by turning the pouch right side out, thus giving the pouch Ifs permanent shape. (I) The antecior bowel edges exfendlng 6efween the nrpPreand the atterenf bowel are closed with a run&g suture of catguf, reinforced wifh inferrupfed silk sutures. The nipple is also anchored externally wlfh interrupted silk sutures.
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A
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Figure 5. iieai Conduit for Bladder Substitution. (A ) A suitable iieai segment is identified, supported by a wide vasculararcade, 10 to 12 cm proximal to the iieocecai valve. The supporting mesentery is carefully isolated proximally, and distally vessels are tied and ligated. The proximal and distal ends of the iieai segment are then transected and closed with the GiA instrument. The bowel closures are not inverted. (B, C, 0) Bowel continuity is reestablished anterior to the iieai conduit by a functional end-to-end anastomosis. (E) The proximal end of the iieai conduit is anchored posteriorly after ureteroiie~i anastomo$es in one layer have been performed. if feasible, the mesentery of the iieai conduit may be used for pari or ail of the mesenteric closure, resulting in a solid anchoring of the conduit rebqeritoneaity. The distal ileum is brought out through a previously elected and prepared s#e on the abdomen; it is anchored to the peritoneum and the fascia. The stapie line is excised after the abdomen has been closed and the /lea/ opening is immediately “matured” with interrupted sutures to the skin.
Heal Conduit for Bladder Substitution (Figure 5)
The ileal conduit for supravesical urinary diversion was first described by Bricker [24,25]. This operation using a 15 cm segment of ileum (or sigmoid colon) is now widely performed, often by surgeons who do not operate on the intestinal tract on a regular basis. The use of stapling instruments will simplify and accelerate the intestinal component of bladder excision and substitution [26-281. Summary
10.
11. 12. 13.
After partial or total esophagectomy, total gastrectomy, pancolectomy, and urinary cystectomy, it becomes necessary to reestablish continuity and/or replace function by the creation of a substitute organ obtained from the various portions of the gastrointestinal tract. Ideally, the creation of the substitute organ should be undertaken at the same operation in which the original organ is excised. At times, however, the surgeon may elect a two-stage approach by replacing the afflicted organ during a separate operation either prior to or after excision, as dictated by the circumstances surrounding each individual patient. The use of stapling instruments has greatly facilitated the precision, neatness, and speed with which substitute organs can be constructed. This is especially spectacular in those patients in whom a one-stage procedure is elected.
20. 21. 22.
References
23.
1. Ravitch MM, Lane R, Cornell WP, Rivarola A, McEnany T: Closure of duodenal, gastric and intestinal stumps with staples, experimental and clinical studies. Ann Surg 163: 573, 1966. 2. Ravitch MM, Steichen FM: Techniques of staple suturing in the gastrointestinal tract. Ann Surg 175: 815, 1972. 3. Steichen FM: The use of staplers in anatomical side-to-side and functional end-to-end enteroanastomoses. Surgery 64: 948, 1968. 4. Steichen FM, Ravitch MM: Mechanical sutures in surgery. Br JSurg 60: 191, 1973. 5. Burrington JD, Stephens CA: Esophageal replacement with gastric tube in infants and children. J Ped Surg 3: 246, 1968.
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15. 16.
17.
18.
19.
24. 25.
26.
27.
28.
Gavriliu D: Aspects of esophageal surgery. Curr Probl Surg Chicago, Year Book Medical, October 1975. Heimlich HJ: Esophagoplasty with reversed gastric tube. Am J Surg 123: 80, 1972. Parker EF, Gregorie HB: Carcinoma of the esophagus. Curr Probl Surg, Chicago, Year Book Medical, April 1967. Steichen FM: Total esophageal replacement with extended reversed gastric tube (Gavriliu II). ACS Thoracic Surgery Film Session, Chicago, October 14, 1976. Beck C, Carrel A: Demonstation of specimens illustrating a method of formation of a prethoracic esophagus. 111Med J 7: 463,. 1905. Jianu A: Gastrostomie und oesophagusplastik. Dfsch Ztschr Chir 118: 383, 1912. Kelling GE: besophagusplastik mit Hilfe desQuerkolon. Zentralbl Chir 38: 1209, 1911. Steichen FM: Esbphagectomy and esophagocoloplasty in one stage. ACS General Film Session, San Francisco 1972. Hunt CJ: Construction of food pouch from segment of jejunum as substitute for stomach in total gastrectomy. Arch Surg 64: 601, 1952. Lawrence W Jr: Reservoir construction after total gastrectomy; an instructive case. Ann Surg 155: 191, 1962. Paulino F, Roselli A: Carcinoma of the stomach, with special reference to total gastrectomy. Curr Probl Surg, Chicago, Year Book Medical, December 1973. Steichen -FM, Finkler JG: Extended total gastrectomy with Paulino jejunal pouch reconstruction. ACS General Film Session, San Francisco, October 14, 1975. Beahrs OH, Kelly KA, Adson MA, Chong GC: lleostomy with ileal reservoir rather than ileostomy alone. Ann Surg 179: 634, 1974. Kock NG: Intra-abdominal “reservoir” in patients with permanent ileostomy: preliminary observations on a procedure resulting in fecal “continence” in five ileostomy patients. Arch Surg 99: 223, 1969. Kock NG: Continent ileostomy. Prog Surg 12: 180, 1973. Kock NG: Personal communication, July 1976. Thow GB, Castro AF, Beahrs OH, Goligher JC, Kock NG: Present status of the continent ileostomy. Dis Co/on Rectum 19: 189. 1976. Loubeau JM, Steichen FM, Muldowney DM: Kock ileal reservoir: two techniques. ACS General Film Session, Chicago, October 14. 1976. Bricker EM: Bladder substitution after pelvic evisceration. Surg ClinNorfhAm30: 1511, 1950. Bricker EM: Substitution for the urinary bladder by the use of isolated ileal segments. Surg C/in NorIh Am August, 1956, p. 1117. Arnheim FK, Stept LA, Rabinowitz R: The construction of an ileal conduit using the surgical staplers. ACS General Film Session, San Francisco, October 14, 1975. Draper JW, Fernandes M, Lavengood RW Jr, Tolanico RD, Ward JN, Ray P: Ureteroileal conduit: modifications of the surgical technique. J Ural 106: 664, 197 1. Johnson, DE, Fuerst DE: Use of autosuture for constructon of ileal conduits. J Ural 109: 821, 1973.
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Replacement of the esophagus, stomach, and urinary bladder as well as colorectal function is indicated in a variety of congenital, acquired benign and malignant conditions. Satisfactory reconstructive technics should be associated with low morbidity and mortality; should be completed in one stage at the same time the diseased organ is removed; should be adaptable to variations in anatomy, unexpected technical challenges, and all age groups; and should substitute for lost function on a permanent basis. In esophageal replacement with the reversed gastric tube or various segments of colon, in gastric replacement wth a jejunal pouch, in bladder substitution with an ileal loop, and in the substitution of colorectal function with an ileal pouch, we have found the use of stapling instruments to be invaluable in the accomplishment of these goals. The stapling instruments accomplish various technical functions [l-4]. The TA30, TA5.5, and TA90 instruments introduce linear, terminal, or tangential suture lines, 30,55, or 90 mm long, respectively. The GIA instrument is used for dividing and anastomosing bowel. The LDS stapler serves to ligate and simultaneously divide vessels, strands of mesentery, and omentum. Malnourished patients, in whom a one-stage excision and reconstruction would have been unthinkable in the past, are now prepared with intravenous hyperalimentation or elemental diets if they can swallow. Patients with esophageal and bladder cancers often receive preoperative radiation therapy. Their nutritional rehabilitation can thus proceed while radiation is administered. From the Departments of Surgery, Veterans Administration Hospital and University of Pittsburgh Health Center, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania. Reprint requests should be addressed to Felicien M. St&hen, MD, Surgical Service, Veterans Adminlstration Hospital, University Drive C, Pittsburgh, Pennsylvania 15240.
Votume 134, November 1077
Segmental or Total Replacement of the Esophagus (Figures 1 and 2)
Partial or total replacement of the esophagus is required in wide-spaced esophageal atresia, nonremediable strictures due to gastroesophageal reflux and lye burns, and potentially curable malignant neoplasms. For this replacement, we use the reversed gastric tube of Gavriliu-Heimlich or various segments of the colon [5-81. If both stomach and colon are available, our preference goes to the reversed gastric tube [9]. All patients with squamous cell carcinoma of the esophagus and no distant metastases have preoperative radiation to a total dose of 6,000 to 6,500 r. The neck and epigastrium are irradiated up to 3,500 to 4,000 r. The abdomen is explored first in all cases of malignant disease, and if there are metastases in the liver along the celiac axis or the lesser curvature of the stomach, esophageal excision and replacement are not performed. In all patients with metastases, an intraesophageal prosthesis is placed for palliation. The reversed gastric tube represents an extension of the Beck-Jianu tube, used in the past for permanent gastrostomy and suggested for replacement of the esophagus via an antethoracic, subcutaneous tunnel [10,11]. Use of the colon as an esophageal substitute was first proposed in 911 by Kelling [12]. We have used all three segments of colon (ascending, transverse, and descending) depending on length of colon required, anatomic approach (chest versus abdomen), anatomy of colic vessels, and redundancy of mesocolon [13]. Right and transverse coloplasties are based on the midcolic artery; descending coloplasties are supplied by the left colic artery and are used in an antiperistaltic fashion. The length of colon required for bypass
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Figure 1. Reversed Gastric Tube ot Gavrii/u-he/milch. (A ) To achieve up ward mobiiity ot the /e/t gastroepiploic vessels, spienectomy is necessary. in children less than two ydars of age, a shorter gastric tube w/ii be obtained by ieawing the sp/een intact. The spienic vessels are ligated and dlvlded dlrectly on the sp/enic capsuie in ordef to zdy the ieft gastt~epipioic vessels and , (S) After sp/enectomy, the posterior per/toneum Is incised and the pancreas ia ekvated In a med/al dhectkn, to the ieff botder ot the aorta. 771/smaneuver w/ii increase upward mobi/ity ot the gastric tube. (C) The r/ght gastm@p/o/c artery b /@ted and transected 2 cm proximal to the py/ot-us.7% gastroepip/oic a-de, based on the lefl gastroepiploic vessels, is then deveioped by repeated applications ot the IDS stapler, pWipher8l to. the arcade. (D) The greater curvature ot the stomach is then incised vertically to its long axis, 2 cm proximal to the pyiorus. A #36 French bougie is positioned inside and along the greater curvature, as a guide tor the G/A instrument. The reversed gastric tube is fashioned by repeated applications of the G/A, parallel to the greater curvature. (E) 77~ stapied gastric and tube suture lines 816&Horced by N/III//&Jof intenupted sutures of catgut.
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Figure 7 continued. (F) The proximal esophago-tube anastomosis is a manual one. If the esophagus is removed, the gastric tube is brought up through the mediastinum, especially in patients with laryngo-pharyngo-esophagectomy who require a permanent tracheostomy. If esophagectomy is not indicated, the gastftc tube ts advanced through a retrostemal route. (G) Gavriliu’s extension of the reversed gastric tube attows for very htgh anastomoses in the neck. The first portion of the duodenum and the pylorus are included in the construct/on of the tube for 6 to 6 cm of added length. The right side of the gastroepiploic arcade is preserved and the duodenum is severed with the GIA instrument. Next, the G/A instrument is applied at the lesser curvature, 2 cm proximal to the pylorus, in the difectton of the greater curvature. As the G/A suture line comes with/n 2 cm of the greater curvature, the CIA is used in an upward direction as described in Figure ID. (H) The gastric remnant is anastomosed to the duodenal stump in a two layer Billroth I fashion. Pytoromyotomy of this extended reversed gastric tube is indicated. In the neck, the first portion of the duodenum is anastomosed to the pharynx in a two layer anastomosis after excision of the temporary GIA suture line.
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Figure 2. Esophagocoloplasty. (A) The proximal third of the stomach is liberated along both curvatures with the LDS instrument. (6) The gastric fundus Is then transected between two lines of T#90 staples, using the instrument as a guide to divide the stomach. The adequacy of the colic vessels and the width of the corresponding mesocolon aie then examined, and the segment chosen for co/op/asty (in this case the ascending co/on) is then elevated from Its posterior peritoneal atfachments. (C) The distal ileum is transected near the ileocecal valve with the G/A stapler; both bowel ends are closed slmultaneously. (0)
The midtransverse colon is similarly severed distal to the midcollc artery.
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E
Figure 2 continued. (E) The anfimesenteric corners of fhe staple-closed, proximal ileum and distal transverse colon are then excised. Both bowel loops are approximated in a shotgun fashion. (F) The GIA instrument is placed inside the proximal ileum and fhe distal colon, and bowel confinuity is established by anatomic side-to-side anastomosis. (G, H) The TA55 instrument is fhen used 10 close the GIA introduction sites in an evetiing fashion, transforming the anatomic side-to-side anaslomosis into a funcfionai end-lo-end anastomosis. The completed functional end-to-end ileocoiostomy is shown.
is measured with an umbilical tape extending from the epigastrium to the proposed site of proximal anastomosis, and this measurement is used on the colon segment along the mesocolon insertion. After elevation from its posterior attachments of the colon segment to be used, the vascular supply to the segment is tested by temporarily occluding with bulldog clamps those vessels that will have to be severed in order to obtain sufficient length (ileocolic and right colic arteries for ascending colon, proximal and distal marginal artery for transverse and descending colon). If a thoracic anastomosis is indicated, the colon segment is brought up through the posterior mediastinum. If, on the other hand, a cervical anastomosis is contemplated, then the colon segment may be brought through the posterior mediastinum or through a retrosternal tunnel. If the operation is performed for cervical esdphageal carcinoma, where laryngectomy is also indicated, then the colon is placed behind the permanent tracheostomy and is anastomosed manually to the pharynx. In patients with carcinoma of the thoracic esophagus, we prefer to place the esophagocolic anasto664
mosis into the neck because of greater technical ease in that location and lesser morbidity in case leakage should occur. To achieve this goal, the cervical esophagus is liberated after the thoracic esophagus has been dissected through a separate right anterolateral thoracotomy or by blind manual tunneling from the abdomen and from the neck. Paulino Gastric Substitute
(Figure 3)
The Paulino jejunal pouch for gastric substitution is a modification of the Hunt-Lawrence pouch [14-161. Technically, it has the advantage of requiring anastomosis, between the esophagus and a loop of jejunum only, rather than the entire jejunal pouch. The pouch itself can be constructed after the more difficult esophagojejunal anastomosis has been completed. Functionally, the Paulino pouch allows for complete mixture of food, bile, and duodenal and pancreatic secretions, and it avoids all possibility of food regurgitation into the esophagus. In total gastrectomy, the duodenum is closed with the TA55 instrument and is severed between this instrument, placed distally, and a proximal Kocher clamp. The entire specimen consisting of stomach, The American Journal of Surgery
Autologous Substitute Organs
(I) An IncIdental appendectomy I8 performed with fhe LOS and G/A Instruments. (J) 7Re suture //ne obtained by this tech&
I8 not relnfofced a8 are none of the stap/e rtuture //no8 In this operstlon.
(K) Through a r/rig/e Stab wound In the pylorus, a Hnney py/ofop/aSry I8 performed with the Q/A Insfrument. 7he stomach I8 anchored to the Second port/on of the duodenum w/th a suture. The pylorlc 8tab wound I8 C/OSedIn an evertlng rash/on w/th the TAM Instrument. A gastrostomy, not Shown In these dfawhIg8, b foutlnely done.
greater omentum, node-bearing tissue along the lesser curvature, tail of pancreas, spleen, and possibly segment(s) of involved and resectable bowel is then freed from below upwards and from right to left. The specimen is left attached to the esophagus and is used as a handle to introduce the posterior and outer row of a double layer end-to-side esophagojejunostomy. After transection of the esophagus and removal of the specimen, the inner layer as well as the outer anterior layer of this anastomosis is then completed [I 71. In the chest, this same anastomosis can be performed with the GIA instrument. Volume 184. Novombw 1977
Continent Neal Reservoir by Kock (Flgure 4)
A permanent incontinent ileostomy is required in patients with ulcerative and neoplastic diseases of the colon and rectum necessitating total proctocolectomy. The patient is left to contend with skin irritation and odor by the liquid intestinal contents and the need for wearing an appliance constantly. In 1962, Kock constructed a new type of ileal conduit for replacement of the urinary bladder, based on the principle of opposing peristaltic movements that neutralized the propulsive action of the ileal segment, 665
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Figure 2 continued. (L ) The midtransverse mesocoion is then severed down to its roof, at the level of the transection of the transverse colon, leaving the midcoiic artery on the side of the segment to be used for colon transposition. The iieocoiic and right colic arteries are ligated and divided with the LDS, proximal to the marginal artery of Drummond. (M) The segment of colon is then pulled upwards behind the stomach. With the lower portion of the colon segment positioned along the anterior wall of the lesser curvature, its antlmesocoilc corner is excised, and a stab wound is performed through the midanterior gastric wall. (N) The G/A is introduced into the colon segment and into the gastric lumen, and an end-to side cologastrostomy is performed.
and he has since applied the same principle to construct a continent ileal reservoir [18-221. The use of stapling instruments reduces operative time and blood loss significantly in this technic. The technic for construction of this ileal reservoir remains the same as first used by Kock: a bowel segment of 30 cm for the pouch and a segment distal to the pouch of 10 cm for the nipple and stoma are used. The 30 cm segment is folded into a U shape and the antimesenteric borders of the two 15 cm segments are apposed. Of importance is the fact that the GIA instrument is loaded with special units that contain the same staple cartridge as in other applications, but the knife blade is removed from the pusher-knife assembly. By using these special loading units, it is possible to place four parallel rows of staples without
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the inervening section of tissues between each pair of staple lines [23]. Examination of nipple competence should always be performed prior to wound closure. For this, 100 cc of saline are injected into the pouch with the afferent loop occluded by a noncrushing bowel clamp. If the pouch is continent, the saline will distend it, and it can only be emptied by a catheter introduced through the nipple. At the end of the procedure, the pouch is then brought through the mesenteric opening as described by Kock and is positioned in the pelvis. The efferent loop is brought out through a previously planned opening in the right lower quadrant and is anchored to the peritoneum and to the fascia with interrupted silk sutures.
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(0, P) The GIA introduction sites are then closed in an everting fashion, and the end-to-side coiogastrostomy is completed. ( 0) The proximal anastomosis is performed in the neck after the fully dissected thoracic esophagus has been delivered through the thoracic inlet. Through stab wounds in the midcervical esophagus and in the colon, 5 cm below its blind end, a long esophagocoiic anastomosis is performed with the G/A instrument. (R) The end-to-side cervical esophagocoiostomy is completed by closing the esophagus and the stab wound in the lateral wail of the colon, obliquely, with one application of the TA55 instrument. The esophageal specimen is removed distally to this ciosure. (S) The anastomosis in the neck may be a manual one, especially in patients with carcinoma ot the cervical esophagus requiring esophagoiaryngectomy. For such cases, the remaining pharynx would not be long enough to accommodate the GiA and TA instruments.
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Figure 3. Pauline Gastric Substitute. A Jejunal segment for the construct/on of the Roux-en-Y loop Is selected, 20 to 25 cm from the 5gament of Treltz at a level where the vascular arcades become wider. The bowel Is transected and closed (C) with the G/A instrument. The mesentery Is incised down to Its root and the vessels encountered at the foot of the vascular arcade are clamped, severed, and tied. (A) The esqhagojejunal anastomosls is performed manually or wfth the GIA. The jejunal segment leading from the esophagus to the Paulin pouch should measure 35 to 40 cm and the pouch #se/f anywhere from 76 to 2 1 cm. The desired length of the pouch will determlne the number of gla applications. The Paul/no pouch is created by approximating In a Roux-en-Y fashion the closed-off proximal duodenojejunal segment and the continuous distal jejunum. (6) A kmg end-to&de anastomosis is performed by usig the G/A stapler three times: First from below through the amputated corner of the proximal jejunum and a parallel stab wound In the continuous distal jejunum. The remaintng distance of the proposed jejunal pouch Is then divided in ha/f, kissing stab wounds are produced at that level, and the G/A instrument is applied downwards and upwants through the same stab wounds. The second GIA suture lines, coming from above downwards, overlap with those introduced first from below upwards. (C, D) ff necessary, a 21 cm reservoir can be obtained by apply/r& the G/A instrument four times through an added proximal stab wound. In this variation of the basic technic the proximal duodenojejunal limb is shown to fall to the right of the efferent jejunal loop and both an antlperistaltic and isoperistakic hmb are used since this may have some virtue in order to retain food and digestive juices longer In the pouch. (E) The GIA Introduction sites are closed transversely with the TA55 stapler.
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Steichen
Figure 4. The Continent iieai Reservoir by Kock. (A ) Kissing stab wounds are made in the apposed lateral borders of the bowel segments 15 cm from the distal end (turn around) of the iieai loop. The arms of the GiA instrument, ioaded with special stapie cartrkfge~ are introduced into the bowel lumina, the pusher bars are advanced, and four posterior staple lines are created. Prior to removal of the htNlllsld, the ante&r bowel walls corresponding to the 4 to 5 cm suture line obtained with each GIA applicatkm ars inctsed onto the G/A forks used as a cutting guide. (t3) The G/A is applied a total of four more times to complete the posterior wail of the pouch. Each time the small bowel is incised anteriorly on the forks of the instrument. ( C) The nippie is created by grasping the anterior wall of the efferent toop at a I6vei 5 cm distal to the lumen of the future pouch. The bowel Is invaginated into the pouch. (D) The shape of the nipple is maintatned by anchoring U-shaped sutures of silk and two lateral applkations of the G/A loaded with the special loading units.
The American Journal of Surgery
Autologous Substitute Organs
,, INVERTED I’
STAPLE
LINE
\
\ \I \
Figure 4 conflnued. (E) The anferior wall of fhe atierenf ioop is incised over a disfance of 5 cm. the tlaf bowel segment representing the tufure pouch is then turned upon ifsett along a transverse axis and the serosal surfaces of this segment are apposed. (F) The laferal walls of fhe pouch are closed wifh two appllcafions of fhe TA90 stapler, and excess tissue is excised using fhe edge of -the stapler as a guide. (G, H) The TAB0 slap/e lines are converted info inverting suture lines by turning the pouch right side out, thus giving the pouch Ifs permanent shape. (I) The antecior bowel edges exfendlng 6efween the nrpPreand the atterenf bowel are closed with a run&g suture of catguf, reinforced wifh inferrupfed silk sutures. The nipple is also anchored externally wlfh interrupted silk sutures.
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Figure 5. iieai Conduit for Bladder Substitution. (A ) A suitable iieai segment is identified, supported by a wide vasculararcade, 10 to 12 cm proximal to the iieocecai valve. The supporting mesentery is carefully isolated proximally, and distally vessels are tied and ligated. The proximal and distal ends of the iieai segment are then transected and closed with the GiA instrument. The bowel closures are not inverted. (B, C, 0) Bowel continuity is reestablished anterior to the iieai conduit by a functional end-to-end anastomosis. (E) The proximal end of the iieai conduit is anchored posteriorly after ureteroiie~i anastomo$es in one layer have been performed. if feasible, the mesentery of the iieai conduit may be used for pari or ail of the mesenteric closure, resulting in a solid anchoring of the conduit rebqeritoneaity. The distal ileum is brought out through a previously elected and prepared s#e on the abdomen; it is anchored to the peritoneum and the fascia. The stapie line is excised after the abdomen has been closed and the /lea/ opening is immediately “matured” with interrupted sutures to the skin.
Heal Conduit for Bladder Substitution (Figure 5)
The ileal conduit for supravesical urinary diversion was first described by Bricker [24,25]. This operation using a 15 cm segment of ileum (or sigmoid colon) is now widely performed, often by surgeons who do not operate on the intestinal tract on a regular basis. The use of stapling instruments will simplify and accelerate the intestinal component of bladder excision and substitution [26-281. Summary
10.
11. 12. 13.
After partial or total esophagectomy, total gastrectomy, pancolectomy, and urinary cystectomy, it becomes necessary to reestablish continuity and/or replace function by the creation of a substitute organ obtained from the various portions of the gastrointestinal tract. Ideally, the creation of the substitute organ should be undertaken at the same operation in which the original organ is excised. At times, however, the surgeon may elect a two-stage approach by replacing the afflicted organ during a separate operation either prior to or after excision, as dictated by the circumstances surrounding each individual patient. The use of stapling instruments has greatly facilitated the precision, neatness, and speed with which substitute organs can be constructed. This is especially spectacular in those patients in whom a one-stage procedure is elected.
20. 21. 22.
References
23.
1. Ravitch MM, Lane R, Cornell WP, Rivarola A, McEnany T: Closure of duodenal, gastric and intestinal stumps with staples, experimental and clinical studies. Ann Surg 163: 573, 1966. 2. Ravitch MM, Steichen FM: Techniques of staple suturing in the gastrointestinal tract. Ann Surg 175: 815, 1972. 3. Steichen FM: The use of staplers in anatomical side-to-side and functional end-to-end enteroanastomoses. Surgery 64: 948, 1968. 4. Steichen FM, Ravitch MM: Mechanical sutures in surgery. Br JSurg 60: 191, 1973. 5. Burrington JD, Stephens CA: Esophageal replacement with gastric tube in infants and children. J Ped Surg 3: 246, 1968.
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15. 16.
17.
18.
19.
24. 25.
26.
27.
28.
Gavriliu D: Aspects of esophageal surgery. Curr Probl Surg Chicago, Year Book Medical, October 1975. Heimlich HJ: Esophagoplasty with reversed gastric tube. Am J Surg 123: 80, 1972. Parker EF, Gregorie HB: Carcinoma of the esophagus. Curr Probl Surg, Chicago, Year Book Medical, April 1967. Steichen FM: Total esophageal replacement with extended reversed gastric tube (Gavriliu II). ACS Thoracic Surgery Film Session, Chicago, October 14, 1976. Beck C, Carrel A: Demonstation of specimens illustrating a method of formation of a prethoracic esophagus. 111Med J 7: 463,. 1905. Jianu A: Gastrostomie und oesophagusplastik. Dfsch Ztschr Chir 118: 383, 1912. Kelling GE: besophagusplastik mit Hilfe desQuerkolon. Zentralbl Chir 38: 1209, 1911. Steichen FM: Esbphagectomy and esophagocoloplasty in one stage. ACS General Film Session, San Francisco 1972. Hunt CJ: Construction of food pouch from segment of jejunum as substitute for stomach in total gastrectomy. Arch Surg 64: 601, 1952. Lawrence W Jr: Reservoir construction after total gastrectomy; an instructive case. Ann Surg 155: 191, 1962. Paulino F, Roselli A: Carcinoma of the stomach, with special reference to total gastrectomy. Curr Probl Surg, Chicago, Year Book Medical, December 1973. Steichen -FM, Finkler JG: Extended total gastrectomy with Paulino jejunal pouch reconstruction. ACS General Film Session, San Francisco, October 14, 1975. Beahrs OH, Kelly KA, Adson MA, Chong GC: lleostomy with ileal reservoir rather than ileostomy alone. Ann Surg 179: 634, 1974. Kock NG: Intra-abdominal “reservoir” in patients with permanent ileostomy: preliminary observations on a procedure resulting in fecal “continence” in five ileostomy patients. Arch Surg 99: 223, 1969. Kock NG: Continent ileostomy. Prog Surg 12: 180, 1973. Kock NG: Personal communication, July 1976. Thow GB, Castro AF, Beahrs OH, Goligher JC, Kock NG: Present status of the continent ileostomy. Dis Co/on Rectum 19: 189. 1976. Loubeau JM, Steichen FM, Muldowney DM: Kock ileal reservoir: two techniques. ACS General Film Session, Chicago, October 14. 1976. Bricker EM: Bladder substitution after pelvic evisceration. Surg ClinNorfhAm30: 1511, 1950. Bricker EM: Substitution for the urinary bladder by the use of isolated ileal segments. Surg C/in NorIh Am August, 1956, p. 1117. Arnheim FK, Stept LA, Rabinowitz R: The construction of an ileal conduit using the surgical staplers. ACS General Film Session, San Francisco, October 14, 1975. Draper JW, Fernandes M, Lavengood RW Jr, Tolanico RD, Ward JN, Ray P: Ureteroileal conduit: modifications of the surgical technique. J Ural 106: 664, 197 1. Johnson, DE, Fuerst DE: Use of autosuture for constructon of ileal conduits. J Ural 109: 821, 1973.
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