- Email: [email protected]
Varieties of Stapled Anastomoses of the Esophagus
Symposium on Surgical Stapling Techniques
Varieties of Stapled Anastomoses of the Esophagus
Felicien M. Steichen, M.D.*
To many surgeons, speed and efficiency of stapled visceral closures and anastomoses are the most outstanding qualities of mechanical suture devices. To others, the apparent diminished trauma, neatness, and regularity of mechanical suture lines, as well as the reduced duration of the potential for contamination from an open viscus, are the most remarkable features. In addition, and of paramount importance, are the safety and reliability of mechanical suture lines; this is especially so in esophageal and low rectal anastomoses performed with an end-to-end anastomosing instrument near the end of an always-tedious and prolonged operation, which is at times also a difficult and physically taxing one. Even the most experienced surgeon would find it difficult to match the precision and regularity of a machine used for a single performance, when this effort is correctly guided by human hands and thought. Our experience, and that of others with special interest in operations at both ends of the gastrointestinal tract, shows a striking reduction in the number of anastomotic leaks with mechanical sutures compared to manual suture lines, although admittedly in historically sequential rather than prospective randomized, double-blind studies. 1· 3 · 6 • 8 · 9 In choosing our operation for a given esophageal condition, it is important to consider the extent of the esophagus to be resected; the need for removal of adjoining organs such as the larynx, a portion or all of the stomach, the spleen, and regional lymph nodes; and the timing of"adjuvant" treatment modalities such as hyperalimentation, radiotherapy, and chemotherapy, as well as additional technical details such as radical neck dissection, tube pharyngostomy, gastrostomy, feeding jejunostomy, and perioperative esophageal dilatation. At times, only a palliative procedure is possible. Text continued on page 498. *Director, Department of Surgery, Lenox Hill Hospital, New York, and Professor of Surgery, New York Medical College, Valhalla, New York
Surgical Clinics of North America-Yo!. 64, No. 3, June 1984
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Figure 1. Peroral placement of EEA instrument. A, The smaller caliber 25-mm cartridge should be maneuvered through the mouth by the surgeon who uses one hand outside the operating field to hold the instrument and advance it into the pharylll(, and the other hand to palpate the advancing cartridge and anvil and to guide it with the index finger, placed into the esophageal lumen, down to the future anastomotic site. A Penrose drain, placed from the mouth through the open esophagus and pulled over the cartridge at the oral end, is also helpful in guiding the instrument into place and in avoiding false directions, collision with endotracheal tubes, and trauma to the mucosa. B, The right colon based on the midcolic vessels or the left colon based on the left colic vessels may be used for end-to-end esophagocolostomy. If the right colon is used, the terminal ileum is closed with the TA 55 instrument: the anvil is placed into the cecum through a stab wound, followed by tightening of the pursestring suture around the central rod. If the left colon is used, the CIA closure line used in preparation of the colon segment is excised, and a pursestring is placed, either with the modified Furniss clamp or by over-and-over suture around the edge of the open bowel. C, The fully mobilized stomach, based on the right gastroepiploic artery and arcade, is closed at the gastroesophageal junction and along the lesser curvature with the TA 90 stapler. The anvil is advanced through a stab wound in the apex of the gastric fundus, and the gastric and esophageal pursestring sutures are tied and the end-to-end esophagogastrostomy performed. D, If the reverse gastric tube includes the pylorus and part of the first portion of the duodenum, the pursestring suture is placed around the open duodenal lumen; no overlapping of staple lines will occur. If, however, the reverse gastric tube was started in the prepyloric area, the vertical CIA and horizontal circular EEA lines will overlap and the angles of the Twill need one or two reinforcing manual sutures. F, The reverse gastric tube is based on the left gastroepiploic artery and arcade. E, The isoperistaltic tube is based on the right gastroepiploic artery and arcade. Based on our experillnce with placing the EEA anastomotic line through the greater curvature angle of a linear TA 90 closure in proximal gastrectomy for esophagogastrostomy, in distal gastr~ctomy for gastroduodenostomy and through the center of a TA 55 rectal stump closure in anterior resection for low colorectostomy, we anticipate no major problems with the T-shaped overlapping of CIA and EEA staple lines. D, Sutures used to reinforce the CIA closure of the gastric tube should be separate ones, near the end of the tube, to assure safe resection of the gastric doughnut (a divided running suture might become unraveled by the excision of the gastric tube doughnut).
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Figure 2. Cervical esophagocolostomy with the CIA-TA or EEA-TA instruments placed through the operative site. In Figures A through C, the technique of anastomosis first followed by resection of the specimen (adapted by Welter of Luxembourg to the Billroth II gastrectomy and by Ravitch to the functional end-to-end bowel anastomosis) using CIA and TA staplers is illustrated. A, The cecum is placed alongside the cervical esophagus; the CIA instrument is introduced through matching stab wounds in both viscera, which for the cecum is some 5 em from its blind end and for the cervical esophagus in its mid- to proximal segment. Encroachment of the CIA tip into the lateral lower aspect of the pharynx is well tolerated and adds to the margin of esophageal resection in upper thoracic malignancies. If the left colon is used for substitution or bypass, the colon stab wound is placed 5 em below the staple closure of the cut end of the colon. B, Mter side-to-side anastomosis, the lumen of the esophagus and the now-common CIA stab wound are closed with one application of the TA 55 instrument, and the specimen is resected on the lower edge of the stapler. C, The final result is illustrated: the cologastrostomy was performed in a similar end-to-side fashion with CIA-TA staples, a Finney pyloroplasty was made with CIA-TA instruments, and bowel continuity was reestablished with the now-familiar functional end-to-end anastomosis. The technique illustrated in Figures D through F is best suited to the right colon-cecum used as esophageal replacement or bypass. Conceivably, placement of the 25-mm or 27-mm EEA cartridge could take place through a colotomy if the left colon were used, and the central rod could be advanced through the middle of a linear closing staple line, as we now do in other operative situations (see Fig. lD) D, The EEA instrument, without the anvil, is placed through an open lumen of the' terminal ileum, which has been left long for that purpose, and the central rod is brought out through the base of the previously excised appendix. The anvil is then attached to the central rod. In general, the 25-mm EEA cartridge is best suited, but the ileum may contract, and dilatation with a Foley catheter or Hegar dilators would be helpful. E, Mter tightening both pursestring sutures, end-to-end anastomosis is performed. F, The EEA instrument has been disengaged, the ileum closed near the cecal wall, and the excess tissue removed beyond the TA edge ..
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Figure 3. Esophagogastrostomy with the EEA-TA and CIA-TA techniques. If the fully mobilized stomach is used for replacement or bypass, it may be anastomosed to the esophagus in the neck or high in the chest, just below the thoracic inlet by either the EEA or CIA instrument, whichever lends itself best to a given anatomic status. A, Primarily for palliative bypass, the entire stomach may be used with the stomach guided into the neck retrosternally, without opening the chest. In this case the EEA instrument is placed into the stomach through a prepyloric gastrotomy incision. While the esophagus to gastric fundus anastomosis takes place in the lower neck, the handles of the EEA instrument are squeezed from below the xyphoid. The EEA introduction site is then closed manually or with staples, as the case may be. 5 B, The stomach can be anastomosed to the thoracic esophagus in the posterior mediastinum with the EEA instrument through a separate right or left thoracotomy approach. We prefer the right-sided approach, which is here illustrated after the stomach has been mobilized through a separate midline abdominal incision. The EEA instrument, without the anvil, is placed through the thoracotomy and an anterior gastrotomy into the gastric lumen. The central rod is brought out through a small, pursestring wound at the apex of the fundus to the left of the gastroesophageal junction TA 55 closure; the anvil is attached, advanced into the esophagus, and the esophageal pursestring tightened. Following end-to-end anastomosis, the EEA instrument is removed and the gastrotomy closed mucosa-to-mucosa with TA stapler. C, The end-to-side esophagogastrostomy, using the CIA instrument, is feasible for both intrathoracic and low cervical anastomosis if sufficient length is available to overlap the two organs involved without tension. One arm of the CIA staple is placed into the open esophagus and the other one into the stomach, through an anterior stab wound some 5 em below the fundic cul-de-sac. D, Following end-to-side anastomosis, the now-common CIA opening, consisting of the anterior esophageal rim and the inferior lip of the gastric stab wound, is closed mucosa-to-mucosa with theTA instrument.
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Figure 4. Esophagogastrectomy and -ostomy (Chassin"s GIA-TA triangulating technique)! A, Following resection of the specimen, the esophagus is advanced over the stomach, and the GIA instrument is placed, with one arm into the esophageal lumen and one arm into the stomach, through an anterior stab wound some 5 em below the gastric TA 90 closure. B, Following the linear esophagogastrostomy, the now-common GIA opening is bisected, with two stay sutures gently separating the distal GIA lines (and esophagogastric angles) and a third stay suture joining the middle of the anterior esophageal rim to the middle of the lower lip of the gastric stab wound. C, By twice applying the TA 55 stapler obliquely, the remaining opening is closed mucosa-to-mucosa, with the GIA lines widely separated, thus in effect creating a triangular, pyramidal-shaped anastomosis.
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Figure 5. Esophagogastrectomy and -ostomy with the EEA stapler. A, Following esophagogastrectomy, the esophageal pursestring suture is placed manually with a running over-and-over suture if the esophageal wall and cut surface is too thick to accommodate the modified Furniss pursestring clamp. B, The EEA instrument, without the anvil, is placed inside the stomach through a midanterior gastrotomy, and the central rod is brought out through the center of a pursestring, some 3 to 4 em below the TA 90 gastric closure. C, Alternatively, if more length is required to assure a safe anastomosis, the central rod can be brought out near or through the angle of the TA 90 gastric closure and the greater curvature. In this case, the remaining stomach assumes the shape of an elongated tube after anastomosis.
Illustration continued on following page.
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Figure 5 (Continued). D, The nose-cone anvil is attached to the center rod and is advanced into the esophageal lumen, held open by the three Babcock or Adson clamps. E, The esophageal and gastric pursestring sutures are tied and the anvil is closed against the cartridge. F, After the inverting end-to-side esophagogastrostomy has been accomplished, the anvil and cartridge are disengaged, removed from the stomach, and the gastrotomy is closed mucosa-to-mucosa with the TA 55 stapler. G, If sufficient stomach is available, the lesser and greater curvature may be folded over the anastomosis and sutured together to protect the anastomosis and create a fundoplication of sorts. Most often this is not possible without excessive tension and should then not be done.
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Figure 6. Palliative side-to-side esophagogastrostomy in continuity. In patients with carcinoma of or near the gastroesophageal junction, in whom curative resection is not a hopeful possibility, or is even contraindicated, very satisfactory palliation can be obtained by this technique described by Kwun and Kirschner. 3 A, Through a low left thoracic approach and the enlarged diaphragmatic hiatus, the first three or four vasa brevia are ligated and divided with the LDS stapler, leaving the spleen intact. B, The fundus of the stomach is then rolled into the lower mediastinum and matching stab wounds are placed in its medial wall and the lateral esophageal wall. 5 to 6 em proximal to the tumor. C, The side-to-side esophagogastrostomy is then accomplished with the CIA instrument, and the common CIA stab wound is closed manually or with the TA 55 instrument.
B
D
c Figure 7. Colon interposition for fibrous, fixed benign stricture of the esophagus. In patients with fibrous stricture of the esophagus due to gastroesophageal reflux, where pre- or intraoperative dilatation has not been successful, replacement of the lower esophagus and gastroesophageal junction becomes necessary. Our preferred substitute organ is the transverse colon. A, An appropriate segment of transverse colon, based on the midcolic artery, is liberated through an upper midline abdominal incision. B, A rim of gastric fundus is left on the specimen, which is closed with the TA 90 instrument. The remaining gastric fundus (see E) is closed with the TA 90 instrument and the stomach is trans-sected (not shown) between both TA 90 staple lines. Matching stab wounds are placed in the healthy esophagus proximal to the stricture and into the transverse colon segment, some 5 em below its closed end. The CIA anastomosis is then performed before removing the specimen. C, Following removal of the CIA instrument, the lumen of the esophagus and the now-common CIA stab wound are closed with theTA 55 instrument, and the specimen is excised on the lower edge of theTA stapler. D, A different approach is shown with the use of the EEA stapler, in which the specimen is removed first and an end-to-end inverting esophagocolostomy performed with the stapler introduced from below, the full length of the colon segment. E, A side-to-side cologastrostomy using the CIA-TA technique completes reconstruction of the alimentary tract.
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D Figure 8. The combined Collis-Nissen procedure for a shortened esophagus. This operation is indicated in patients with a shortened esophagus due to reflux esophagitis, generally associated with a dilatable stricture; it is performed through a low left posterolateral thoracotomy. A, The fundus of the stomach is pulled into the posterior mediastinum through the enlarged hiatus and, using the CIA instrument, a 5- to 6-cm gastric tube is created in continuity with the esophagus. B, Reinforcing sutures are used routinely when the CIA instrument is applied to both walls of the stomach. So as not to narrow the gastric tube, its lumen is kept slightly greater than that of the esophagus, as the CIA instrument is placed. C, The greater curvature is mobilized and a Nissen fundoplication is performed using the remaining fundus. D, The stomach is then replaced below the diaphragm, and the hiatus is closed above the fundoplication and below the stricture.
c Figure 9. Reconstruction of bowel continuity following total gastrectomy. A, Mter total gastrectomy, the jejunum is transected with the CIA instrument some lO to 20 em distal to the ligament of Treitz-the length of the duodenojejunal segment depends on the mode of reconstruction-and the "cane" of the distal jejunal loop is brought into contact with the esophageal stump. The EEA stapler is placed into the open lumen of the jejunum without the anvil and the center rod is brought out through an antimesenteric stab wound in the apex of the "cane." The anvil is attached, pursestring sutures are tied, and end-to-side anastomosis is performed. B, The excess jejunum is closed with the TA 55 instrument and excised on the lateral edge of the stapler. Continuity is now re-established some 40 em below this anastomosis in a Roux-en-Y fashion between the duodenojejunal segment and the efferent jejunal loop with the CIA-TA technique (see 9D). If no more than a jejunal loop is required and seems desirable, this type of reconstruction satisfies all basic anatomic requirements. The availability of stapling instruments, however, has made the one-stage creation of gastric substitutes an attractive alternative to the simple anatomic reconstruction of alimentary tract continuity (see 9A and 9C). Shown in 9A is the Paulino pouch created with three or four applications of the CIA instrument and closure of the CIA stab wounds with the TA instrument. In 9C a HuntLawrence pouch, similarly created with three applications of the CIA stapler, is anastomosed directly to the esophagus with the EEA instrument.
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A
B Figure 10. Modified Tanner procedure using the EEA instrument (VanKemmel). A, Following dissection of the lower esophagus and separation of the vagus nerves from the esophageal wall, after ligation of the coronary vein and all the venous plexuses in the lesser omentum and the splenic artery (>0.9 mm), the EEA instrument is placed into the lower esophagus through a midanterior gastrotomy. The anvil is separated from the cartridge some 3 to 4 em above the esophagogastric junction, and with a strong ligature a circumferential esophageal groove is created at the level of the anvil-cartridge separation. B, The anvil is closed against the cartridge and the EEA is activated; this creates an esophago-esophagostomy that produces only one doughnut. The varices are stapled within the anastomosis. The EEA is then disengaged, removed, and the gastrotomy closed with the TA instrument. C, The inner aspect of the anastomosis with the varices interrupted and hemostatically stapled is depicted.
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Figure 11. Disconnection of esophagogastric varices with the SGIA instrument (RineckerDanek). A, Following ligation of the coronary vein, all enlarged venous plexuses in the lesser omentum, and the splenic artery if larger than 0. 9 em, a stab wound is produced in the lesser curvature just below the esophagogastric junction. The PGIA instrument without the blade in the pusher-knife assembly or the SGIA instrument that is furnished without a blade is then used in two applications to create linear, subcardial hemostatic suture lines. B, The result of the application of the PGIA or SGIA instrument in the anterior wall is demonstrated; the instrument is now applied to the posterior wall. For each application, one arm of the instrument is in the lumen of the stomach and the other one is outside. When both staple lines are accomplished, the end result is a circular staple line of four alternating rows.
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Table 1. Substitute Organs in Esophageal Surgery DIAGNOSIS
LOCATION AND EXTENT
PRIMARY
SUBSTITUTE
OPERATION
ORGAN
Squamous cell carcinoma
Cervical esophagus
Laryngo-pharyngoesophagectomy (radical neck dissection)
Reverse gastroduodenal tube
Squamous cell carcinoma
Upper and middle thoracic esophagus
Total esophagectomy
Reverse gastric tube; esophagocoloplasty
Squamous cell carcinoma Adenocarcinoma
Lower esophagus Total or thoracic esophagectomy and Esophagogastric proximal extended (EG) junction gastrectomy
Esophagocoloplasty
Squamous cell carcinoma Adenocarcinoma
Thoracic esophagus E-G junction
Palliation only
Bypass with stomach or colon Esophagogastrostomy in continuity
Extensive fibrous stricture (lye, radiotherapy)
Thoracic esophagus
Esophagectomy if possible; bypass only if unresectable
Reverse gastric tube; esophagocoloplasty
Localized fibrous Thoracic stricture, transitional esophagus and epithelium, "Barrett's E-G junction esophagus
Thoracic esophagectomy including E-G junction
Colon interposition
Localized "soft" stricture and reflux esophagitis Portal hypertension
Collis esophagogastroplasty
Nissen fundoplication
Ligation of esophageal varices, coronary vein, splenic artery
None required
Distal esophagus and E-G junction Esophageal varices
Palliation only
Esophagogastrostomy
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Based on all these factors, the organ chosen for replacement or bypass should be that which: (1) conforms best to the preoperative anatomic findings and intraoperative situation in each patient; (2) assures deglutition and the passage of food most efficiently; (3) reduces morbidity and mortality related to the choice of operation; and (4) is usable in all age groups, preferably in a one-stage operation. The choice of esophageal replacement or bypass in turn determines the type of anastomosis between the esophagus and the substitute organ, as well as the mode of gastrointestinal continuity7 (see also Table 1 and Figs. 1 through 11).
REFERENCES l. Akiyama, H.: Personal communication, June 1981. 2. Chassin, J. L.: Stapling technic for esophagastrostomy after esophagogastric resection. Ann. J. Surg., 136:399, 1978. 3. Fekete, F., Brei!, P., Rousse, H., eta!.: EEA stapler and omental graft in esophagogastrectomy. Ann. Surg., 193:825, 1981. 4. Kwun, K.-B., and Kirschner, P. A.: Palliative side-to-side oesophagogastrostomy for unresectable carcinoma of the oesophagus and cardia. Thorax, 36:441, 1981. 5. Mills, S. A.: Use of the EEA: Stapler for substernal esophagogastric anastomosis in palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 82:801, 1981. 6. Molina, J. E., Lawton, B. R., Meyers, W. D., eta!.: Esophagogastrectomy for adenocarcinoma of the cardia. Ann. Surg., 195:146, 1982. 7. Steichen, F. M.: The creation of autologous substitute organs with stapling instruments. Am. J. Surg., 134:659, 1977. 8. Steichen, F. M., and Ravitch, M. M.: Stapling in Surgery. Chicago, Year Book Medical Publishers, 1984. 9. West, P. N., Marbarger, J. P., Martz, M. N., eta!.: Esophagogastrostomy with the EEA stapler. Ann. Surg., 192:76, 1981.
Department of Surgery Lenox Hill Hospital 100 East 77th Street New York, New York 10021
Varieties of Stapled Anastomoses of the Esophagus
Felicien M. Steichen, M.D.*
To many surgeons, speed and efficiency of stapled visceral closures and anastomoses are the most outstanding qualities of mechanical suture devices. To others, the apparent diminished trauma, neatness, and regularity of mechanical suture lines, as well as the reduced duration of the potential for contamination from an open viscus, are the most remarkable features. In addition, and of paramount importance, are the safety and reliability of mechanical suture lines; this is especially so in esophageal and low rectal anastomoses performed with an end-to-end anastomosing instrument near the end of an always-tedious and prolonged operation, which is at times also a difficult and physically taxing one. Even the most experienced surgeon would find it difficult to match the precision and regularity of a machine used for a single performance, when this effort is correctly guided by human hands and thought. Our experience, and that of others with special interest in operations at both ends of the gastrointestinal tract, shows a striking reduction in the number of anastomotic leaks with mechanical sutures compared to manual suture lines, although admittedly in historically sequential rather than prospective randomized, double-blind studies. 1· 3 · 6 • 8 · 9 In choosing our operation for a given esophageal condition, it is important to consider the extent of the esophagus to be resected; the need for removal of adjoining organs such as the larynx, a portion or all of the stomach, the spleen, and regional lymph nodes; and the timing of"adjuvant" treatment modalities such as hyperalimentation, radiotherapy, and chemotherapy, as well as additional technical details such as radical neck dissection, tube pharyngostomy, gastrostomy, feeding jejunostomy, and perioperative esophageal dilatation. At times, only a palliative procedure is possible. Text continued on page 498. *Director, Department of Surgery, Lenox Hill Hospital, New York, and Professor of Surgery, New York Medical College, Valhalla, New York
Surgical Clinics of North America-Yo!. 64, No. 3, June 1984
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Figure 1. Peroral placement of EEA instrument. A, The smaller caliber 25-mm cartridge should be maneuvered through the mouth by the surgeon who uses one hand outside the operating field to hold the instrument and advance it into the pharylll(, and the other hand to palpate the advancing cartridge and anvil and to guide it with the index finger, placed into the esophageal lumen, down to the future anastomotic site. A Penrose drain, placed from the mouth through the open esophagus and pulled over the cartridge at the oral end, is also helpful in guiding the instrument into place and in avoiding false directions, collision with endotracheal tubes, and trauma to the mucosa. B, The right colon based on the midcolic vessels or the left colon based on the left colic vessels may be used for end-to-end esophagocolostomy. If the right colon is used, the terminal ileum is closed with the TA 55 instrument: the anvil is placed into the cecum through a stab wound, followed by tightening of the pursestring suture around the central rod. If the left colon is used, the CIA closure line used in preparation of the colon segment is excised, and a pursestring is placed, either with the modified Furniss clamp or by over-and-over suture around the edge of the open bowel. C, The fully mobilized stomach, based on the right gastroepiploic artery and arcade, is closed at the gastroesophageal junction and along the lesser curvature with the TA 90 stapler. The anvil is advanced through a stab wound in the apex of the gastric fundus, and the gastric and esophageal pursestring sutures are tied and the end-to-end esophagogastrostomy performed. D, If the reverse gastric tube includes the pylorus and part of the first portion of the duodenum, the pursestring suture is placed around the open duodenal lumen; no overlapping of staple lines will occur. If, however, the reverse gastric tube was started in the prepyloric area, the vertical CIA and horizontal circular EEA lines will overlap and the angles of the Twill need one or two reinforcing manual sutures. F, The reverse gastric tube is based on the left gastroepiploic artery and arcade. E, The isoperistaltic tube is based on the right gastroepiploic artery and arcade. Based on our experillnce with placing the EEA anastomotic line through the greater curvature angle of a linear TA 90 closure in proximal gastrectomy for esophagogastrostomy, in distal gastr~ctomy for gastroduodenostomy and through the center of a TA 55 rectal stump closure in anterior resection for low colorectostomy, we anticipate no major problems with the T-shaped overlapping of CIA and EEA staple lines. D, Sutures used to reinforce the CIA closure of the gastric tube should be separate ones, near the end of the tube, to assure safe resection of the gastric doughnut (a divided running suture might become unraveled by the excision of the gastric tube doughnut).
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Figure 2. Cervical esophagocolostomy with the CIA-TA or EEA-TA instruments placed through the operative site. In Figures A through C, the technique of anastomosis first followed by resection of the specimen (adapted by Welter of Luxembourg to the Billroth II gastrectomy and by Ravitch to the functional end-to-end bowel anastomosis) using CIA and TA staplers is illustrated. A, The cecum is placed alongside the cervical esophagus; the CIA instrument is introduced through matching stab wounds in both viscera, which for the cecum is some 5 em from its blind end and for the cervical esophagus in its mid- to proximal segment. Encroachment of the CIA tip into the lateral lower aspect of the pharynx is well tolerated and adds to the margin of esophageal resection in upper thoracic malignancies. If the left colon is used for substitution or bypass, the colon stab wound is placed 5 em below the staple closure of the cut end of the colon. B, Mter side-to-side anastomosis, the lumen of the esophagus and the now-common CIA stab wound are closed with one application of the TA 55 instrument, and the specimen is resected on the lower edge of the stapler. C, The final result is illustrated: the cologastrostomy was performed in a similar end-to-side fashion with CIA-TA staples, a Finney pyloroplasty was made with CIA-TA instruments, and bowel continuity was reestablished with the now-familiar functional end-to-end anastomosis. The technique illustrated in Figures D through F is best suited to the right colon-cecum used as esophageal replacement or bypass. Conceivably, placement of the 25-mm or 27-mm EEA cartridge could take place through a colotomy if the left colon were used, and the central rod could be advanced through the middle of a linear closing staple line, as we now do in other operative situations (see Fig. lD) D, The EEA instrument, without the anvil, is placed through an open lumen of the' terminal ileum, which has been left long for that purpose, and the central rod is brought out through the base of the previously excised appendix. The anvil is then attached to the central rod. In general, the 25-mm EEA cartridge is best suited, but the ileum may contract, and dilatation with a Foley catheter or Hegar dilators would be helpful. E, Mter tightening both pursestring sutures, end-to-end anastomosis is performed. F, The EEA instrument has been disengaged, the ileum closed near the cecal wall, and the excess tissue removed beyond the TA edge ..
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Figure 3. Esophagogastrostomy with the EEA-TA and CIA-TA techniques. If the fully mobilized stomach is used for replacement or bypass, it may be anastomosed to the esophagus in the neck or high in the chest, just below the thoracic inlet by either the EEA or CIA instrument, whichever lends itself best to a given anatomic status. A, Primarily for palliative bypass, the entire stomach may be used with the stomach guided into the neck retrosternally, without opening the chest. In this case the EEA instrument is placed into the stomach through a prepyloric gastrotomy incision. While the esophagus to gastric fundus anastomosis takes place in the lower neck, the handles of the EEA instrument are squeezed from below the xyphoid. The EEA introduction site is then closed manually or with staples, as the case may be. 5 B, The stomach can be anastomosed to the thoracic esophagus in the posterior mediastinum with the EEA instrument through a separate right or left thoracotomy approach. We prefer the right-sided approach, which is here illustrated after the stomach has been mobilized through a separate midline abdominal incision. The EEA instrument, without the anvil, is placed through the thoracotomy and an anterior gastrotomy into the gastric lumen. The central rod is brought out through a small, pursestring wound at the apex of the fundus to the left of the gastroesophageal junction TA 55 closure; the anvil is attached, advanced into the esophagus, and the esophageal pursestring tightened. Following end-to-end anastomosis, the EEA instrument is removed and the gastrotomy closed mucosa-to-mucosa with TA stapler. C, The end-to-side esophagogastrostomy, using the CIA instrument, is feasible for both intrathoracic and low cervical anastomosis if sufficient length is available to overlap the two organs involved without tension. One arm of the CIA staple is placed into the open esophagus and the other one into the stomach, through an anterior stab wound some 5 em below the fundic cul-de-sac. D, Following end-to-side anastomosis, the now-common CIA opening, consisting of the anterior esophageal rim and the inferior lip of the gastric stab wound, is closed mucosa-to-mucosa with theTA instrument.
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Figure 4. Esophagogastrectomy and -ostomy (Chassin"s GIA-TA triangulating technique)! A, Following resection of the specimen, the esophagus is advanced over the stomach, and the GIA instrument is placed, with one arm into the esophageal lumen and one arm into the stomach, through an anterior stab wound some 5 em below the gastric TA 90 closure. B, Following the linear esophagogastrostomy, the now-common GIA opening is bisected, with two stay sutures gently separating the distal GIA lines (and esophagogastric angles) and a third stay suture joining the middle of the anterior esophageal rim to the middle of the lower lip of the gastric stab wound. C, By twice applying the TA 55 stapler obliquely, the remaining opening is closed mucosa-to-mucosa, with the GIA lines widely separated, thus in effect creating a triangular, pyramidal-shaped anastomosis.
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Figure 5. Esophagogastrectomy and -ostomy with the EEA stapler. A, Following esophagogastrectomy, the esophageal pursestring suture is placed manually with a running over-and-over suture if the esophageal wall and cut surface is too thick to accommodate the modified Furniss pursestring clamp. B, The EEA instrument, without the anvil, is placed inside the stomach through a midanterior gastrotomy, and the central rod is brought out through the center of a pursestring, some 3 to 4 em below the TA 90 gastric closure. C, Alternatively, if more length is required to assure a safe anastomosis, the central rod can be brought out near or through the angle of the TA 90 gastric closure and the greater curvature. In this case, the remaining stomach assumes the shape of an elongated tube after anastomosis.
Illustration continued on following page.
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Figure 5 (Continued). D, The nose-cone anvil is attached to the center rod and is advanced into the esophageal lumen, held open by the three Babcock or Adson clamps. E, The esophageal and gastric pursestring sutures are tied and the anvil is closed against the cartridge. F, After the inverting end-to-side esophagogastrostomy has been accomplished, the anvil and cartridge are disengaged, removed from the stomach, and the gastrotomy is closed mucosa-to-mucosa with the TA 55 stapler. G, If sufficient stomach is available, the lesser and greater curvature may be folded over the anastomosis and sutured together to protect the anastomosis and create a fundoplication of sorts. Most often this is not possible without excessive tension and should then not be done.
VARIETIES OF STAPLED ANASTOMOSES OF THE ESOPHAGUS
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Figure 6. Palliative side-to-side esophagogastrostomy in continuity. In patients with carcinoma of or near the gastroesophageal junction, in whom curative resection is not a hopeful possibility, or is even contraindicated, very satisfactory palliation can be obtained by this technique described by Kwun and Kirschner. 3 A, Through a low left thoracic approach and the enlarged diaphragmatic hiatus, the first three or four vasa brevia are ligated and divided with the LDS stapler, leaving the spleen intact. B, The fundus of the stomach is then rolled into the lower mediastinum and matching stab wounds are placed in its medial wall and the lateral esophageal wall. 5 to 6 em proximal to the tumor. C, The side-to-side esophagogastrostomy is then accomplished with the CIA instrument, and the common CIA stab wound is closed manually or with the TA 55 instrument.
B
D
c Figure 7. Colon interposition for fibrous, fixed benign stricture of the esophagus. In patients with fibrous stricture of the esophagus due to gastroesophageal reflux, where pre- or intraoperative dilatation has not been successful, replacement of the lower esophagus and gastroesophageal junction becomes necessary. Our preferred substitute organ is the transverse colon. A, An appropriate segment of transverse colon, based on the midcolic artery, is liberated through an upper midline abdominal incision. B, A rim of gastric fundus is left on the specimen, which is closed with the TA 90 instrument. The remaining gastric fundus (see E) is closed with the TA 90 instrument and the stomach is trans-sected (not shown) between both TA 90 staple lines. Matching stab wounds are placed in the healthy esophagus proximal to the stricture and into the transverse colon segment, some 5 em below its closed end. The CIA anastomosis is then performed before removing the specimen. C, Following removal of the CIA instrument, the lumen of the esophagus and the now-common CIA stab wound are closed with theTA 55 instrument, and the specimen is excised on the lower edge of theTA stapler. D, A different approach is shown with the use of the EEA stapler, in which the specimen is removed first and an end-to-end inverting esophagocolostomy performed with the stapler introduced from below, the full length of the colon segment. E, A side-to-side cologastrostomy using the CIA-TA technique completes reconstruction of the alimentary tract.
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D Figure 8. The combined Collis-Nissen procedure for a shortened esophagus. This operation is indicated in patients with a shortened esophagus due to reflux esophagitis, generally associated with a dilatable stricture; it is performed through a low left posterolateral thoracotomy. A, The fundus of the stomach is pulled into the posterior mediastinum through the enlarged hiatus and, using the CIA instrument, a 5- to 6-cm gastric tube is created in continuity with the esophagus. B, Reinforcing sutures are used routinely when the CIA instrument is applied to both walls of the stomach. So as not to narrow the gastric tube, its lumen is kept slightly greater than that of the esophagus, as the CIA instrument is placed. C, The greater curvature is mobilized and a Nissen fundoplication is performed using the remaining fundus. D, The stomach is then replaced below the diaphragm, and the hiatus is closed above the fundoplication and below the stricture.
c Figure 9. Reconstruction of bowel continuity following total gastrectomy. A, Mter total gastrectomy, the jejunum is transected with the CIA instrument some lO to 20 em distal to the ligament of Treitz-the length of the duodenojejunal segment depends on the mode of reconstruction-and the "cane" of the distal jejunal loop is brought into contact with the esophageal stump. The EEA stapler is placed into the open lumen of the jejunum without the anvil and the center rod is brought out through an antimesenteric stab wound in the apex of the "cane." The anvil is attached, pursestring sutures are tied, and end-to-side anastomosis is performed. B, The excess jejunum is closed with the TA 55 instrument and excised on the lateral edge of the stapler. Continuity is now re-established some 40 em below this anastomosis in a Roux-en-Y fashion between the duodenojejunal segment and the efferent jejunal loop with the CIA-TA technique (see 9D). If no more than a jejunal loop is required and seems desirable, this type of reconstruction satisfies all basic anatomic requirements. The availability of stapling instruments, however, has made the one-stage creation of gastric substitutes an attractive alternative to the simple anatomic reconstruction of alimentary tract continuity (see 9A and 9C). Shown in 9A is the Paulino pouch created with three or four applications of the CIA instrument and closure of the CIA stab wounds with the TA instrument. In 9C a HuntLawrence pouch, similarly created with three applications of the CIA stapler, is anastomosed directly to the esophagus with the EEA instrument.
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A
B Figure 10. Modified Tanner procedure using the EEA instrument (VanKemmel). A, Following dissection of the lower esophagus and separation of the vagus nerves from the esophageal wall, after ligation of the coronary vein and all the venous plexuses in the lesser omentum and the splenic artery (>0.9 mm), the EEA instrument is placed into the lower esophagus through a midanterior gastrotomy. The anvil is separated from the cartridge some 3 to 4 em above the esophagogastric junction, and with a strong ligature a circumferential esophageal groove is created at the level of the anvil-cartridge separation. B, The anvil is closed against the cartridge and the EEA is activated; this creates an esophago-esophagostomy that produces only one doughnut. The varices are stapled within the anastomosis. The EEA is then disengaged, removed, and the gastrotomy closed with the TA instrument. C, The inner aspect of the anastomosis with the varices interrupted and hemostatically stapled is depicted.
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Figure 11. Disconnection of esophagogastric varices with the SGIA instrument (RineckerDanek). A, Following ligation of the coronary vein, all enlarged venous plexuses in the lesser omentum, and the splenic artery if larger than 0. 9 em, a stab wound is produced in the lesser curvature just below the esophagogastric junction. The PGIA instrument without the blade in the pusher-knife assembly or the SGIA instrument that is furnished without a blade is then used in two applications to create linear, subcardial hemostatic suture lines. B, The result of the application of the PGIA or SGIA instrument in the anterior wall is demonstrated; the instrument is now applied to the posterior wall. For each application, one arm of the instrument is in the lumen of the stomach and the other one is outside. When both staple lines are accomplished, the end result is a circular staple line of four alternating rows.
I
I
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Table 1. Substitute Organs in Esophageal Surgery DIAGNOSIS
LOCATION AND EXTENT
PRIMARY
SUBSTITUTE
OPERATION
ORGAN
Squamous cell carcinoma
Cervical esophagus
Laryngo-pharyngoesophagectomy (radical neck dissection)
Reverse gastroduodenal tube
Squamous cell carcinoma
Upper and middle thoracic esophagus
Total esophagectomy
Reverse gastric tube; esophagocoloplasty
Squamous cell carcinoma Adenocarcinoma
Lower esophagus Total or thoracic esophagectomy and Esophagogastric proximal extended (EG) junction gastrectomy
Esophagocoloplasty
Squamous cell carcinoma Adenocarcinoma
Thoracic esophagus E-G junction
Palliation only
Bypass with stomach or colon Esophagogastrostomy in continuity
Extensive fibrous stricture (lye, radiotherapy)
Thoracic esophagus
Esophagectomy if possible; bypass only if unresectable
Reverse gastric tube; esophagocoloplasty
Localized fibrous Thoracic stricture, transitional esophagus and epithelium, "Barrett's E-G junction esophagus
Thoracic esophagectomy including E-G junction
Colon interposition
Localized "soft" stricture and reflux esophagitis Portal hypertension
Collis esophagogastroplasty
Nissen fundoplication
Ligation of esophageal varices, coronary vein, splenic artery
None required
Distal esophagus and E-G junction Esophageal varices
Palliation only
Esophagogastrostomy
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Based on all these factors, the organ chosen for replacement or bypass should be that which: (1) conforms best to the preoperative anatomic findings and intraoperative situation in each patient; (2) assures deglutition and the passage of food most efficiently; (3) reduces morbidity and mortality related to the choice of operation; and (4) is usable in all age groups, preferably in a one-stage operation. The choice of esophageal replacement or bypass in turn determines the type of anastomosis between the esophagus and the substitute organ, as well as the mode of gastrointestinal continuity7 (see also Table 1 and Figs. 1 through 11).
REFERENCES l. Akiyama, H.: Personal communication, June 1981. 2. Chassin, J. L.: Stapling technic for esophagastrostomy after esophagogastric resection. Ann. J. Surg., 136:399, 1978. 3. Fekete, F., Brei!, P., Rousse, H., eta!.: EEA stapler and omental graft in esophagogastrectomy. Ann. Surg., 193:825, 1981. 4. Kwun, K.-B., and Kirschner, P. A.: Palliative side-to-side oesophagogastrostomy for unresectable carcinoma of the oesophagus and cardia. Thorax, 36:441, 1981. 5. Mills, S. A.: Use of the EEA: Stapler for substernal esophagogastric anastomosis in palliation of esophageal carcinoma. J. Thorac. Cardiovasc. Surg., 82:801, 1981. 6. Molina, J. E., Lawton, B. R., Meyers, W. D., eta!.: Esophagogastrectomy for adenocarcinoma of the cardia. Ann. Surg., 195:146, 1982. 7. Steichen, F. M.: The creation of autologous substitute organs with stapling instruments. Am. J. Surg., 134:659, 1977. 8. Steichen, F. M., and Ravitch, M. M.: Stapling in Surgery. Chicago, Year Book Medical Publishers, 1984. 9. West, P. N., Marbarger, J. P., Martz, M. N., eta!.: Esophagogastrostomy with the EEA stapler. Ann. Surg., 192:76, 1981.
Department of Surgery Lenox Hill Hospital 100 East 77th Street New York, New York 10021