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Eur J Cardiothorac Surg 2005;28:291-295
© 2005 Elsevier Science NL
Original articles |
Department of Thoracic Surgery, Jiangsu Institute of Cancer Research, Baziting 42, Nanjing, 210009, People's Republic of China
Received 23 November 2004; received in revised form 7 April 2005; accepted 11 April 2005.
* Corresponding author. Tel./fax: +86 25 83353520. (Email: fcw{at}public1.ptt.js.cn).
Abstract
Objective: A new reusable circular stapler for cervical esophagogastric anastomosis (CEGA) has been used to substitute the traditional method of hand-sewn cervical anastomosis. Methods: Over a 2-year period (09/1998–11/2000), the stapler was engaged on operations of 112 patients with thoracic esophageal carcinoma, and the anastomosis was performed through both cervical and thoracic incision. The operative approaches were through left thoracotomy in 85 cases, and through right thoracotomy in 27 cases. The results were analyzed retrospectively. Results: All of the 112 CEGA operations were successfully performed on the patients who underwent esophageal resections, and no operative mortality and anastomotic leakage occurred. Excluding the two patients with the anastomotic recurrent carcinoma, anastomotic stricture occurred in 12 cases (10.9%, n=110). Median time to the presentation of anastomotic stricture was 4.3 months (range 2.6–25.3 months), and the median number of dilatations was 3 (range 1–5). When divided into the 24 and 26mm groups, the respective incidences of stricture were 12.3 (7/57) and 9.4% (5/53), respectively, and the statistical results of the two sizes of staplers were essentially the same (P=0.6691). Eight patients experienced nonanastomotic-related complications (7.3%, n=110), in which there were three cases of recurrent laryngeal nerve injury, four cases of the left side pneumothorax, and one case of perforation of the proximal stomach. There was also a case of stapling gauze at anastomosis. Some of the complications were closely related to the initially improper use of the new stapler's craft. Conclusions: The results indicate that CEGA using the new circular stapling device in surgery of the esophageal carcinoma is a very effective procedure to improve the anastomotic technique from a traditional hand-sewn anastomosis to a stapled anastomosis and can reduce the incidence of complications.
Key Words: Esophageal neoplasm • Surgery • Cervical anastomosis • Stapler
1. Introduction
The esophagogastric anastomosis can be hand-sewn or stapled. It is almost always easier to perform the cervical esophagogastric anastomosis (CEGA) by hand than by stapler, because the esophageal substitute is limited in length, the proximal esophageal segment is short, and the space available to maneuver the stapler is confined. Some authors [1,2] described a side-to-side staple technique for construction of CEGA by using Endo-GIA stapler, and showed that this side-to-side stapled CEGA had a obvious advantage over a mechanical anastomosis with the circular stapler, which had not proven to be readily adaptable to a cervical anastomosis. We improved a reusable circular stapling device to add a joint to the cent shaft for CEGA (Manufactured by: New Energy Medical and Hygienic Instrument General Factory, in Changzhou, P. R. of China. The stapler is only commercially available inside of China). Our retrospective studies show that the new stapler has its ease of anastomotic construction directly through both cervical and thoracic incision and its utility in CEGA.
2. Materials and methods
From September 1998 to November 2000, 112 patients who had squamous cell carcinoma of the thoracic esophagus and underwent esophagectomy had their CEGA constructed by using the new reusable circular stapler. There were 83 men and 29 women whose age distribution ranged from 46 to 68 with a mean age of 60.5. The operative approaches were through the left thoracotomy in 85 cases, and through the right thoracotomy in 27 cases. The cervical anastomosis was constructed with 24 and 26mm circular staplers. All patients who had whole stomach used as the esophageal substitute and had CEGA at the left neck are listed in Table 1 . Completed data of the 112 patients who underwent stapled CEGA are given in Table 2 .
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2.1. Main features of the new reusable circular stapler for CEGA
(1) A joint is added to the center shaft at the position of 2.7cm from the anvil, and can be revolved up to 200°. The minimal included angle of the joint is 80°. (2) Length of the center shaft is only 2.7cm when it bends at the joint so that the center shaft can be easily introduced through thoracic inlet into the esophageal bed for the performance of the stapled anastomosis in thoracic cavity. (3) The ring at the top of the anvil is used to be temporarily sutured to the gastric tube in purpose to prevent from the sliding into mouth during the operation, and to ease the procedure to advance the gastric tube into stomach after completion of the anastomosis (Fig. 1 ).
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The two approaches do the same steps of CEGA. The chest must remain open while the anastomosis is completed in the left neck. Through the left cervical incision, pull out the esophagus, enlarge the thoracic inlet with fingers through the opening of cervical and thoracic incisions, and transect esophagus partially no less than 2cm from the edge to be anastomosed. Pull out the gastric tube and suture the gastric tube to the ring at top of the anvil with 7 silk suture, and then introduce the sizing anvil of the stapler into the esophagus. After inserting the anvil into the lumen of proximal esophagus, tell the anesthesia to pull the gastric tube gently to keep the anvil at the end of the esophagus. Make a pursestring suture by hand suture, tie a pursestring suture, and transect the esophagus (Fig. 2 ). Introduce the center shaft through thoracic inlet into esophageal bed as the joint bends (Fig. 3 ). Insert the stapler through the intrathoracic cardia, puncture the trocar of the stapler through the fundus, and attach the center shaft into the stapler shaft in thoracic cavity and turn the adjusting knob clockwise to prepare the anastomosis. Before firing the instrument, make sure that the anastomosis is to keep from improper approximation of tissue (Fig. 4 ). Fire the stapler, and turn the adjusting knob counter-clockwise. The stapler, with anvil, is pulled out through the cardia (intrathoracic) and the suture from the ring at top of the anvil to the gastric tube is cut with scissors. Pull and advance the gastric tube downward into the intrathoracic stomach for postoperative gastric decompression. Check two complete circular ‘doughnuts’ from the esophageal and gastric ends. If there be any doubt of their integrity, the anastomoses were reinforced with interrupted nonabsorbable sutures through cervical incision. Staple the cardia with the linear stapler, suture a gastric tube, and close the thoracic inlet by suturing pleura and gastric fundus (Fig. 5 ). Finally, check the thoracic cavity, place the cervical and chest drainages, and close the incisions layer by layer.
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The data of 112 patients who underwent stapled CEGA are listed in Table 2. The new reusable circular stapler was successfully used for CEGA in all patients during the 2-year period.
Among the patients with stapled CEGA, no hospital deaths occurred. Dysphagias were found with 18 patients (16.1%, n=112) during the follow-up. Four of these patients did not have any stricture with barium swallow examination and fiberoptic endoscopy. Two patients with upper mediastinal recurrence that was confirmed by chest CT scan had malignant anastomotic strictures within 16 and 20 months, respectively. These two patients had previously undergone three and five times dilatation of benign strictures individually. With the exception of two patients who had anastomotic recurrent carcinoma, anastomotic stricture occurred in 12 (10.9%, n=110). Median time to presentation of anastomotic stricture was 4.3 months with a range of 2.6–25.3 months. Two patients required 1 dilatation, three required 2 dilatations, four required 3 dilatations, two required 4 dilatations and one required 5 dilatations. The median number of dilatations was 3 in a range of 1–5. Dilation achieved normal swallowing for 11 (91.7%, n=12) patients. In one case, dilations were still being performed at the end of this study period. No complications resulted from dilatations. When separated into 24 and 26mm groups, the respective incidences of stricture were 12.3 (7/57) and 9.4% (5/53) and the relationship between the two sizes of stapler had no difference (P=0.6691). Eight patients experienced a variety of nonanastomotic-related complications (7.3%, n=110). Three patients had recurrent laryngeal nerve injury after operations and healed completely 1 month later in one case and 2 months later in two cases. Four patients had left pneumothorax and the air was from the drainage of cervical incision on the second postoperative day; a chest tube was placed, and the neck wound was packed. One patient with fever and purulent drainage from left side of chest had perforation of the proximal stomach on postoperative day 7 and his neck wound was opened at the bedside, but anastomotic leak was never documented by drainage from the neck wound. The closure and intercostal drainage was followed by recovery and jejunostomy tube feedings were done. He was discharged 3 months later, and the perforation healed completely. Stapling gauze within the staple line occurred in one patient and was immediately recognized by inspecting anastomosis when the anastomosis was completed. After the stapled gauze was cut, the incomplete side of anastomosis was closed with interrupted nonabsorbable sutures. Among 112 patients with stapled anastomoses undergoing CEGA, 111 patients were discharged within 14–16 days after surgery. At the time point when the data were analyzed, 37 patients had died, and of whom 32 died of tumor-related causes.
4. Discussion
The cervical anastomoses consistently have higher leak rates than the intrathoracic anastomoses. The average rate of the leaks is about 10–25% for the cervical anastomoses and less than 10% for the thoracic anastomoses [3]. Based on a collective review of the complications of CEGA with stapled and hand-sewn (Table 3 ), the mean incidence of cervical anastomotic leak occurred in 16 (8.2%) of 195 stapled anastomoses and in 51 (18.7%) of 273 manually sutured anastomoses. The stapled anastomoses had lower anastomotic leak rates (P=0.0054). On the other hand, the mean incidence of the anastomotic strictures was 122 (38.4%) out of 318-stapled anastomoses and 121 (41.9%) out of 289 manually sutured. Both of the anastomotic techniques had no different anastomotic stricture rates (P=0.5651).
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Collard [1] and Orringer [2] reported a side-to-side staple technique for construction of CEGA after transhiatal esophagectomy by using Endo-GIA stapler. Honkoop [6] also reported to use a circular stapler for CEAG (EEA or ILS). Skultety and associates [8] reported a transoral technique of CEGA by using a circular stapler. Those processes of CEGA were performed at the neck incision, which would mobilize more gastric fundus into the neck. Our new circular stapler is to add a joint to the cent shaft, and not to require oral or retrograde gastric insertion of the instrument. These technical refinements can avoid mobilizing gastric fundus into the neck, and minimize gastric trauma. We believe that the high leak rate and gastric tip necrosis after CEGA may mainly result from gastric fundal trauma and the compression of stomach at the narrow thoracic inlet.
The greater reliability of our new circular stapler for CEGA has been a major factor in reducing the postoperative morbidity and mortality. Technical problems occurred in five patients, which might result from operator's errors. Oral intake of liquids is begun on the fifth postoperative day after the gastric tube is removed, and it is advanced to a mechanical soft diet by the 10th day. If the patient does not show leak or abnormal neck wound and other significant abnormality, he is discharged between 14 and 16 days after the surgery. A barium swallow examination is not routinely required for discharged patients. We believe that most infected or abnormal cervical wounds after CEGA mainly result from leak or occult leak. After the patients have eaten soft diet for 4 or more days before discharge, it is improbable to miss any anastomotic leak.
The exact reason for a higher stricture rate for stapled anastomoses is not clear. Experimental studies [9] and clinical experience [10,11] have shown a fundamental difference between hand-sewn and stapled anastomoses. The stapled anastomoses leaves a mucosal defect that granulates, contracts, and epithelializes. In addition, a nonabsorbable circumferential double-row staple and smaller diameters may restrict the capacity of the lumen to dilate. Since the cervical esophageal lumen is narrower than other levers of esophagus, we only use two sizes of staplers. The selection in size is determined primarily by the caliber of the esophagus, and a large size is used whenever possible in the operation. Treatment of anastomotic stricture by dilatation maintains satisfactory swallowing in most benign strictures in this series. In order to find anastomotic recurrence at an early stage, repeated biopsy of the strictures is important.
5. Conclusions
The new stapler for CEGA is a major advance in the technique for the surgery of esophageal carcinoma and allows rapid and reliable esophagogastric anastomosis. Its simpler technique and fewer complications may be used to substitute for the method of hand-sewn CEGA.
References
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