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Use of EEA * stapler for substernal esophagogastric anastomosis in palliation of esophageal carcinoma
J
THORAC CARDIOVASC SURG
82:801-804, 1981
Current Technique
Use of EEA * stapler for substernal esophagogastric anastomosis in palliation of esophageal carcinoma For the patient with carcinoma of the esophagus in whom curative resection is not feasible, palliative procedures are often possible. Substernal gastric bypass is one of those palliative procedures. Although it does improve the quality of life. substernal gastric bypass is a major surgical procedure in a debilitated patient. Use of the EEA stapler to effect the gastroesophageal anastomosis, as reported here, simplifies and shortens the procedure.
Stephen A. Mills, M.D., Winston-Salem, N. C.
Curative resection in patients with carcinoma of the esophagus is often not feasible because of local tumor invasion, tracheoesophageal fistula, or distant metastasis. Optimal palliative procedures in patients with advanced disease should relieve dysphagia and aspiration and should allow the patient to swallow comfortably. Orringer and Sloan! described a technique for palliating carcinoma of the esophagus with a substernal gastric bypass after exclusion of the thoracic esophagus. Their technique required resection of the median clavicle, the sternoclavicular joint, and the adjacent upper comer of the manubrium to widen the mediastinum and allow full mobilization of the proximal esophagus. Although the postoperative morbidity and mortality of their palliative method were high, the quality of life it provided was excellent. We have simplified that technique by From the Section on Cardiothoracic Surgery, Department of Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, N. C. Received for publication May 22, 1981. Accepted for publication June 15, 1981. Address for reprints: Stephen A. Mills, M.D., Section on Cardiothoracic Surgery, Bowman Gray School of Medicine, 300 S. Hawthorne Rd., Winston-Salem, N. C. 27103. *Trademark of Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn.
utilizing the EEA stapler for the esophagogastric anastomosis and have used the technique in three patients with malignant tracheoesophageal fistula. Method
The patient is placed supine and the operative field, including the neck, chest, and abdomen, is prepared and draped in continuity. The abdomen is incised in the midline from the xiphoid to the umbilicus. The gastrocolic omentum is divided, with preservation of the right gastroepiploic artery and its anastomotic arcade. The short gastric vessels are divided thus freeing The greater curvature of the stomach is freed as far as the distal esophagus by dividing the short gastric vessels. The gastrohepatic ligament and left gastric artery are divided, care being taken to preserve the right gastric artery and its arcade. The esophagogastric junction is mobilized and encircled with a Penrose drain. The distal esophagus is divided at the cardia with the GIA * surgical stapler, and the stapled suture lines are oversewn with Lembert sutures of 4-0 silk. A pyloromyotomy or pyloroplasty is performed and the stomach is fully mobilized by a Kocher maneuver. The stomach is then placed on the anterior chest both to judge the *Trademark of Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn.
0022-5223/81/110801+04$00.40/0 © 1981 The C. V. Mosby Co.
801
802
Mills
The Journal of Thoracic and Cardiovascular
Surgery
Fig. 1. The stomach has been mobilized along the lesser and greater curvatures and divided at the gastroesophageal junction. It is supplied with blood by the right gastric and right gastroepiploic arteries. After it is certain that the mobilized stomach is long enough to reach the neck. a gastrostomy is performed just above the pylorus to allow passage of the stapler. The inset demonstrates the stapler in the stomach and its end passed through the site selected for the esophagogastric anastomosis.
Fig. 2. The stapler and stomach together are passed through the previously prepared substernal tunnel. The mobilized and divided proximal esophagus is seen within the neck.
adequacy of its length and to mark the most cephalad portion of the stomach with a silk suture . That point is the site of the proposed esophagogastric anastomosis . An oblique incision is made anterior to the border of the sternocleidomastoid muscle on either the right or the left side of the neck. The cervical esophagus is encircled with a Penrose drain , with care being taken to avoid and protect the recurrent laryngeal nerve. Blunt finger dissection into the superior mediastinum is used to free as much of the cervical esophagus as it is possible to use . The esophagus is divided distally with a GlA stapler, or additional length is obtained by dividing the esophagus and oversewing the distal end. The thoracic esophagus is thus excluded. The xiphoid is resected and a retrosternal tunnel is created by manual blunt dissection. Hypotension is avoided by avoiding prolonged compression of the anterior aspect of the heart. The substernal tunnel should be wide, and care must be taken to prevent pneumothorax while reflecting the pleura laterally. The stomach is laid on the sternum and the EEA stapler is positioned on the stomach to determine where the ga strostomy through which to insert the stapler should be made (Fig . I) . The gastrostomy is made just large enough to admit the stapler and is usually positioned approximately 5 em above the pylorus.
Volume 82 Number 5 November. 1981
Esophagogastr ic anast omosis
803
Fig. 3. The inset demonstrates placement of the 2-D Prolene purse-string suture around the distal end of the proximal esophagu s . A lateral view of the chest and neck demonstrates the purse-string suture tied over the central rod of the stapler. The stapler is ready to be approx imated and fired. The oversewn, bypassed distal esophagus is shown .
The proximal esophagus is dilated with EEA dilator s and the appropriate determination of staple cartridge size is made. The 25 mm cartridge was used in these three patients; 28 mm and 31 mm cartridges are also available . The staple cartridge without the anvil is loaded onto the EEA stapler ; the stapler is passed through the gastrostomy and directed toward the silk suture marking the most cephalad portion of the stomach; the central rod of the EEA stapler is projected against the silk suture; and the bovie is used to create an opening just large enough to admit the rod (inset. Fig. I) . The stapler and stomach are then passed gently through the substernal tunnel until the central rod of the stapler is visible within the neck (Fig. 2). A 2-0 Prolene suture is placed in purse-string fashion around the cut end of the proximal esophagus (inset. Fig. 3). The anvil is loaded onto the central stapler, the esophagus is snugged over the anvil, and the purse-string suture is tied firmly around the central rod (Fig. 3). The stapler is tightened so that the esophageal and gastric components of the anastomosis fit snugly between the cartridge and anvil , and the stapler is fired. The anvil and cartridge are separated slightly, and the entire unit is gently removed. The two rings of tissue representing cut edges of the .stomach and esophagus are removed from the anvil and carefully inspected to ensure that
they are intact. In this manner, physical approximation of the entire circumferences of the stomach and the esophagus at the anastomosis is ensured. In some patients, the anastomosis will be established behind the manubrium , and in others the short length of the sternum will permit passage of the entire cartridge beneath the sternum and manubrium so that the anastomosis will lie within the neck . If the sternum is too long to allow completion of the procedure as described, more of the stomach can be delivered through the substernal tunnel and the gastrostomy itself can be performed within the neck. The stapler can then be passed through the gastrostomy and the anastomosis performed in similar fashion. The gastrostomy is closed in two layers with 3-0 Dexon sutures for the submucosal layer and 4-0 silk Lembert sutures for the seromu scular layer. A nasogastric tube is gently advanced across the anastomosis and into the stomach. A needle catheter feeding jejunostomy is then established, and the cervical and abdominal incisions are closed in standard fashion. A chest roentgenogram is taken in the operating room to determine whether the pleural cavities have been entered. A barium swallow study is done 7 to 10 days postoperatively and , if it is satisfactory, oral nutrition is begun.
804
The Journal of Thoracic and Cardiovascular Surgery
Mills
In one of the three patients in whom this technique was used, the anterior mediastinal outlet was widened as described by Orringer and Sloan.'; in another, the stomach was brought up into the neck and the gastrostomy was done there before the rest of the procedure was completed. All three patients had complete healing of their anastomoses with establishment of oral alimentation. Although long-term survival, as expected, was poor, excellent palliation was achieved in all three patients. Radiation therapy is contraindicated for the treatment of malignant tracheoesophageal fistula because (1) necrosis of tumor may result in enlargement of the fistula and (2) it will involve treating the patient for the rest of his life without necessarily relieving the dysphagia, particularly in the patient with an annular lesion. On the other hand, substernal gastric bypass is well suited to the palliative treatment of this malignant condition. However, candidates for surgical palliation of malignant esophageal disease are often extremely debilitated and unable to withstand major surgical procedures. The technique described here is less formidable than other procedures involving either esophageal resection or bypass. 1-4 The upper midline abdominal incision and neck incision appear to be well tolerated; the ability to bypass the thoracic esophagus while avoiding the added morbidity and mortality from thoracotomy is significant. Utilization of the EEA stapler may eliminate the need to resect the medial portion of the clavicle and adjacent upper comer of manubrium, an obvious advantage. We believe that the EEA stapler represents a significant advance in esophageal surgery. West and col-
leagues" reported on 31 patients in whom end-to-side esophagogastric anastomosis was accomplished with the EEA stapling device without anastomotic leaks. Dorsey and colleagues" reported on seven patients with similar good results. We agree with Orringer and Sloan 1 that substernal gastric bypass remains a major procedure for a debilitated patient. However, we believe that the resulting improvement in the quality of life is significant and that utilizing the EEA stapler will simplify the procedure, increase its safety, and widen its application in patients with carcinoma of the esophagus. REFERENCES
2
3
4
5
6
Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J THORAC CARDIOVASC SURG 70:836-851, 1975 Garlock JH: Resection of the thoracic esophagus for carcinoma located above the arch of the aorta. Cervical esophagogastrostomy. Surgery 24: 1-8, 1948 Nakayama K: Statistical review of five-year survivals after surgery for carcinoma of the esophagus and cardiac portion of the stomach. Surgery 45:883-889, 1959 Sweet RH: The treatment of carcinoma of the esophagus and cardiac end of the stomach by surgical extirpation. Two hundred three cases of resection. Surgery 23:952-975, 1948 West PN, Marbarger JP, Martz MN, Roper CL: Esophagogastrostomy with the EEA stapler. Ann Surg 193:76-81, 1981 Dorsey JS, Esses S, Goldberg M, Stone R: Essophagogastrostomy using the Auto Suture EEA surgical stapling instrument. Ann Thorac Surg 30:308-312, 1980
THORAC CARDIOVASC SURG
82:801-804, 1981
Current Technique
Use of EEA * stapler for substernal esophagogastric anastomosis in palliation of esophageal carcinoma For the patient with carcinoma of the esophagus in whom curative resection is not feasible, palliative procedures are often possible. Substernal gastric bypass is one of those palliative procedures. Although it does improve the quality of life. substernal gastric bypass is a major surgical procedure in a debilitated patient. Use of the EEA stapler to effect the gastroesophageal anastomosis, as reported here, simplifies and shortens the procedure.
Stephen A. Mills, M.D., Winston-Salem, N. C.
Curative resection in patients with carcinoma of the esophagus is often not feasible because of local tumor invasion, tracheoesophageal fistula, or distant metastasis. Optimal palliative procedures in patients with advanced disease should relieve dysphagia and aspiration and should allow the patient to swallow comfortably. Orringer and Sloan! described a technique for palliating carcinoma of the esophagus with a substernal gastric bypass after exclusion of the thoracic esophagus. Their technique required resection of the median clavicle, the sternoclavicular joint, and the adjacent upper comer of the manubrium to widen the mediastinum and allow full mobilization of the proximal esophagus. Although the postoperative morbidity and mortality of their palliative method were high, the quality of life it provided was excellent. We have simplified that technique by From the Section on Cardiothoracic Surgery, Department of Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem, N. C. Received for publication May 22, 1981. Accepted for publication June 15, 1981. Address for reprints: Stephen A. Mills, M.D., Section on Cardiothoracic Surgery, Bowman Gray School of Medicine, 300 S. Hawthorne Rd., Winston-Salem, N. C. 27103. *Trademark of Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn.
utilizing the EEA stapler for the esophagogastric anastomosis and have used the technique in three patients with malignant tracheoesophageal fistula. Method
The patient is placed supine and the operative field, including the neck, chest, and abdomen, is prepared and draped in continuity. The abdomen is incised in the midline from the xiphoid to the umbilicus. The gastrocolic omentum is divided, with preservation of the right gastroepiploic artery and its anastomotic arcade. The short gastric vessels are divided thus freeing The greater curvature of the stomach is freed as far as the distal esophagus by dividing the short gastric vessels. The gastrohepatic ligament and left gastric artery are divided, care being taken to preserve the right gastric artery and its arcade. The esophagogastric junction is mobilized and encircled with a Penrose drain. The distal esophagus is divided at the cardia with the GIA * surgical stapler, and the stapled suture lines are oversewn with Lembert sutures of 4-0 silk. A pyloromyotomy or pyloroplasty is performed and the stomach is fully mobilized by a Kocher maneuver. The stomach is then placed on the anterior chest both to judge the *Trademark of Auto Suture Company, Division of United States Surgical Corporation, Norwalk, Conn.
0022-5223/81/110801+04$00.40/0 © 1981 The C. V. Mosby Co.
801
802
Mills
The Journal of Thoracic and Cardiovascular
Surgery
Fig. 1. The stomach has been mobilized along the lesser and greater curvatures and divided at the gastroesophageal junction. It is supplied with blood by the right gastric and right gastroepiploic arteries. After it is certain that the mobilized stomach is long enough to reach the neck. a gastrostomy is performed just above the pylorus to allow passage of the stapler. The inset demonstrates the stapler in the stomach and its end passed through the site selected for the esophagogastric anastomosis.
Fig. 2. The stapler and stomach together are passed through the previously prepared substernal tunnel. The mobilized and divided proximal esophagus is seen within the neck.
adequacy of its length and to mark the most cephalad portion of the stomach with a silk suture . That point is the site of the proposed esophagogastric anastomosis . An oblique incision is made anterior to the border of the sternocleidomastoid muscle on either the right or the left side of the neck. The cervical esophagus is encircled with a Penrose drain , with care being taken to avoid and protect the recurrent laryngeal nerve. Blunt finger dissection into the superior mediastinum is used to free as much of the cervical esophagus as it is possible to use . The esophagus is divided distally with a GlA stapler, or additional length is obtained by dividing the esophagus and oversewing the distal end. The thoracic esophagus is thus excluded. The xiphoid is resected and a retrosternal tunnel is created by manual blunt dissection. Hypotension is avoided by avoiding prolonged compression of the anterior aspect of the heart. The substernal tunnel should be wide, and care must be taken to prevent pneumothorax while reflecting the pleura laterally. The stomach is laid on the sternum and the EEA stapler is positioned on the stomach to determine where the ga strostomy through which to insert the stapler should be made (Fig . I) . The gastrostomy is made just large enough to admit the stapler and is usually positioned approximately 5 em above the pylorus.
Volume 82 Number 5 November. 1981
Esophagogastr ic anast omosis
803
Fig. 3. The inset demonstrates placement of the 2-D Prolene purse-string suture around the distal end of the proximal esophagu s . A lateral view of the chest and neck demonstrates the purse-string suture tied over the central rod of the stapler. The stapler is ready to be approx imated and fired. The oversewn, bypassed distal esophagus is shown .
The proximal esophagus is dilated with EEA dilator s and the appropriate determination of staple cartridge size is made. The 25 mm cartridge was used in these three patients; 28 mm and 31 mm cartridges are also available . The staple cartridge without the anvil is loaded onto the EEA stapler ; the stapler is passed through the gastrostomy and directed toward the silk suture marking the most cephalad portion of the stomach; the central rod of the EEA stapler is projected against the silk suture; and the bovie is used to create an opening just large enough to admit the rod (inset. Fig. I) . The stapler and stomach are then passed gently through the substernal tunnel until the central rod of the stapler is visible within the neck (Fig. 2). A 2-0 Prolene suture is placed in purse-string fashion around the cut end of the proximal esophagus (inset. Fig. 3). The anvil is loaded onto the central stapler, the esophagus is snugged over the anvil, and the purse-string suture is tied firmly around the central rod (Fig. 3). The stapler is tightened so that the esophageal and gastric components of the anastomosis fit snugly between the cartridge and anvil , and the stapler is fired. The anvil and cartridge are separated slightly, and the entire unit is gently removed. The two rings of tissue representing cut edges of the .stomach and esophagus are removed from the anvil and carefully inspected to ensure that
they are intact. In this manner, physical approximation of the entire circumferences of the stomach and the esophagus at the anastomosis is ensured. In some patients, the anastomosis will be established behind the manubrium , and in others the short length of the sternum will permit passage of the entire cartridge beneath the sternum and manubrium so that the anastomosis will lie within the neck . If the sternum is too long to allow completion of the procedure as described, more of the stomach can be delivered through the substernal tunnel and the gastrostomy itself can be performed within the neck. The stapler can then be passed through the gastrostomy and the anastomosis performed in similar fashion. The gastrostomy is closed in two layers with 3-0 Dexon sutures for the submucosal layer and 4-0 silk Lembert sutures for the seromu scular layer. A nasogastric tube is gently advanced across the anastomosis and into the stomach. A needle catheter feeding jejunostomy is then established, and the cervical and abdominal incisions are closed in standard fashion. A chest roentgenogram is taken in the operating room to determine whether the pleural cavities have been entered. A barium swallow study is done 7 to 10 days postoperatively and , if it is satisfactory, oral nutrition is begun.
804
The Journal of Thoracic and Cardiovascular Surgery
Mills
In one of the three patients in whom this technique was used, the anterior mediastinal outlet was widened as described by Orringer and Sloan.'; in another, the stomach was brought up into the neck and the gastrostomy was done there before the rest of the procedure was completed. All three patients had complete healing of their anastomoses with establishment of oral alimentation. Although long-term survival, as expected, was poor, excellent palliation was achieved in all three patients. Radiation therapy is contraindicated for the treatment of malignant tracheoesophageal fistula because (1) necrosis of tumor may result in enlargement of the fistula and (2) it will involve treating the patient for the rest of his life without necessarily relieving the dysphagia, particularly in the patient with an annular lesion. On the other hand, substernal gastric bypass is well suited to the palliative treatment of this malignant condition. However, candidates for surgical palliation of malignant esophageal disease are often extremely debilitated and unable to withstand major surgical procedures. The technique described here is less formidable than other procedures involving either esophageal resection or bypass. 1-4 The upper midline abdominal incision and neck incision appear to be well tolerated; the ability to bypass the thoracic esophagus while avoiding the added morbidity and mortality from thoracotomy is significant. Utilization of the EEA stapler may eliminate the need to resect the medial portion of the clavicle and adjacent upper comer of manubrium, an obvious advantage. We believe that the EEA stapler represents a significant advance in esophageal surgery. West and col-
leagues" reported on 31 patients in whom end-to-side esophagogastric anastomosis was accomplished with the EEA stapling device without anastomotic leaks. Dorsey and colleagues" reported on seven patients with similar good results. We agree with Orringer and Sloan 1 that substernal gastric bypass remains a major procedure for a debilitated patient. However, we believe that the resulting improvement in the quality of life is significant and that utilizing the EEA stapler will simplify the procedure, increase its safety, and widen its application in patients with carcinoma of the esophagus. REFERENCES
2
3
4
5
6
Orringer MB, Sloan H: Substernal gastric bypass of the excluded thoracic esophagus for palliation of esophageal carcinoma. J THORAC CARDIOVASC SURG 70:836-851, 1975 Garlock JH: Resection of the thoracic esophagus for carcinoma located above the arch of the aorta. Cervical esophagogastrostomy. Surgery 24: 1-8, 1948 Nakayama K: Statistical review of five-year survivals after surgery for carcinoma of the esophagus and cardiac portion of the stomach. Surgery 45:883-889, 1959 Sweet RH: The treatment of carcinoma of the esophagus and cardiac end of the stomach by surgical extirpation. Two hundred three cases of resection. Surgery 23:952-975, 1948 West PN, Marbarger JP, Martz MN, Roper CL: Esophagogastrostomy with the EEA stapler. Ann Surg 193:76-81, 1981 Dorsey JS, Esses S, Goldberg M, Stone R: Essophagogastrostomy using the Auto Suture EEA surgical stapling instrument. Ann Thorac Surg 30:308-312, 1980