Abstract
Aim
Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results.
Background & Methods
Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded
Results
The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality (<30 days) was 0%
Conclusion
Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis.
It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.
Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers