Oesophagogastrectomy using stapling instruments

Oesophagogastrectomy is generally considered to be the treatment of choice for resectable tumours of the oesophagus. We have, since January 1980, used stapling instruments whenever possible for the resection and anastomosis. We have also, since June 1983, employed a left thoracotomy approach for lesions of the gastric cardia and mid- or lower oesophagus. One hundred and sixty four patients underwent oesophagogastrectomy during a seven year period, 75 via left thoracotomy. The overall peri-operative mortality was 7.9%. Complications occurred in 17% of patients with anastomotic leakage in 1.8% and anastomotic strictures in 9.7%. Mean hospital stay was 14 days. In the left thoracotomy sub-group mortality was 5%, the complication rate 23%, leak rate 3%, stricture rate 12% and mean hospital stay 13 days.     

Anastomotic narrowing after esophagogastrectomy with the EEA stapling device

We studied a series of 176 patients undergoing esophageal resection with the aid of the EEA surgical stapling device (Auto Suture U.K. Limited, Great Britain) during a period of 7 1/2 years. A total of 160 patients (91%) were operated on for malignant disease. Operative death occurred in 15 patients (8.5%), and there were three anastomotic leaks (1.7%). The prevalence of dysphagia caused by both benign and malignant strictures after esophageal resection in which the EEA stapler was used was 17.4%. The rate of benign anastomotic narrowing in discharged patients was 12.5%. Anastomotic stricture resulting from recurrent tumor caused dysphagia in 6.2% of the patients undergoing resection for malignant disease. The highest rate of benign anastomotic narrowing occurred in patients who had undergone esophageal resection for benign, nondilatable strictures. In these patients, the prevalence of benign anastomotic narrowing was 37.5%, compared with 9.6% in the patients undergoing resection for malignant disease (p less than 0.001). An additional trend was noted: The smaller the stapling head used to construct the anastomosis, the higher the prevalence of benign anastomotic narrowing; however, a statistically significant difference could not be documented. Ninety-five percent of patients with benign anastomotic narrowings complained of dysphagia within the first 6 months after the operation; 79% of these patients required two or fewer dilatations to relieve the dysphagia. Dysphagia after esophageal resection with the aid of EEA stapler occurred in just over one of six patients. The usual cause of the dysphagia was benign anastomotic narrowing, which responds well to dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications after double and single stapling in rectal surgery.

Stapled anterior resections were carried out in 131 patients between October 1980 and July 1990. Double stapling was used in 87 cases and single stapling in 44. Clinical leaks occurred in 20 patients (15%) and subclinical leaks in 10 (8%) giving a total leak rate of 30/131 (23%). This proportion was similar after double (19/87, 22%) and single (11/44, 25%) stapling. Three fistulas to adjacent organs developed (two after double and one after single stapling). Stenoses occurred in 27 patients (21%), 15/87 (17%) after double, and 12/44 (27%) after single stapling. A permanent stoma was the outcome of an anastomotic complication in 9/87 (10%) patients after double and in 4/44 (9%) after single stapling. The main risk factors were: the number of blood transfusions was related to the risk of dehiscence (p = 0.01), a small cartridge size increased the risk of stenosis (p = 0.002) and previous radiotherapy increased the probability of a permanent stoma (p = 0.0005).     

Chylothorax after esophagogastrectomy

In conclusion, chylothorax after esophagectomy is a devastating complication with high mortality rates if not corrected. A heightened awareness of this complication with early diagnosis and aggressive reoperation leads to excellent outcome. Reoperation is not indicated only when medical therapy significantly slows the daily loss of chyle and there are no metabolic consequences. The early decision to reoperate avoids the high morbidity of a persistently unchecked chylothorax. Reoperation should be based on the approach initially used for the esophagectomy, the location of the leak, and the side that has the chylothorax. The conduit should be handled carefully at the time of reoperation, the leak identified, the duct or the leaking nodal basin clipped and glued, and a pleurodesis performed. Following these principles minimizes the morbidity of a serious postoperative complication.     

The split-stomach fundoplication after esophagogastrectomy

Two complications associated with esophagogastrectomy are anastomotic leak and gastroesophageal re flux. We describe here a modification of an intrathoracic esophagogastrostomy using the gastric fundus to address these issues. After completion of the esophagogastrectomy, the fundus is divided to produce “wings.” After the esophagogastrostomy is performed, the wings are used to form a wrap around the anastomosis. This wrap is secured to the esophagus and to the stomach. All patients undergoing the split-stomach fundoplication were compared with all patients undergoing standard esophagogastrectomies. End points were in-hospital mortality, anastomotic leak, and postoperative endoscopic dilation. All living patients were contacted and questioned about refluxlike symptoms and completed the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) symptom severity questionnaire. Twenty-six patients underwent the split-stomach fundoplication (wrap group), compared to 54 patients undergoing standard resection (no wrap group). Occurrence of end points in the wrap vs. no wrap groups were, respectively, in-hospital mortality, 3.8% vs. 7.4% (P = NS); anastomotic leak, 0% vs. 17% (P = 0.03); reflux symptoms 20% vs. 60% (P = 0.001); postoperative dilation, 40% vs. 30% (P = NS). The median total GERD-HRQL score was 5 for the wrap group vs. 14 for the no wrap group (P = 0.03). The addition of the split-stomach fundoplication to esophagogastrectomy may decrease the incidence of anastomotic leak and postoperative refluxlike symptoms. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, {dy2005} (oral presentation).     

Percutaneous replacement jejunostomy after esophagogastrectomy

A surgically placed jejunostomy tube is a safe and effective means of delivering nutritional support for the postesophagogastrectomy patient. We have previously described a method that permits percutaneous replacement of surgically placed jejunostomy feeding tubes, and now present our results with the use of this technique in 350 consecutive esophagogastrectomy patients. Replacement jejunostomy was required in 17 patients (4.9%). M1 patients had successful percutaneous jejunostomy replacement. There were no procedural complications or deaths. The timing of feeding tube replacement following esophagogastrectomy was predictive of the indication. Before 16 weeks, the indication for feeding tube replacement was intubation and inability to eat (1 patient) or anorexia with weight loss and dehydration (7 patients). At or after 16 weeks, the indications for feeding tube replacement were all related to symptoms resulting from recurrent carcinoma. We conclude that the technique of percutaneous jejunostomy allows the surgeon tremendous flexibility in the management of the postesophagogastrectomy patient as it preserves the advantages of an adjuvant surgically placed feeding tube over the lifetime of the patient. The technique is safe, and the success rate is excellent. Supported by the Evelyn Glick Fund for Thoracic Surgery.     

The creation of autologous substitute organs with stapling instruments

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.     

The autosuture surgical stapling instruments: preliminary experience.

Stapling instruments for gastrointestinal surgery are relatively new in the surgical armamentarium of Australian surgeons. In an attempt to assess their safety and handling characteristics laboratory experience has been obtained in dogs. This has shown that these instruments are effective and easily handled, although costly in routine use. It seems likely that they will provide an appropriate alternative to certain conventional anastomotic techniques.     

Modern management of anastomotic leak after esophagogastrectomy

From 1970 to 1981, 167 patients, aged 35 to 84 years (mean 61), underwent resection for 94 adenocarcinomas and 73 squamous cell cancers. The operative mortality was 8.9 percent. Anastomotic leaks occurred in 19 patients (11.3 percent), including 18 of 72 (25 percent) after operations for palliation and 1 of 95 (1 percent) after procedures with curative potential (p <0.01). The leakage rate after esophagogastrostomy was 8.5 percent, compared with 43 percent after interposition operations. No leak is attributed to cancer in anastomotic margins. In contrast to previous reports of greater than 50 percent mortality from leaks, only 21 percent of our patients died in the past decade. Four of 19 contained leaks (sinus tract or upper gastrointestinal) were treated nonoperatively; esophagostomy was used only once. Factors responsible for improving results include early diagnosis with routine contrast studies on the fifth to seventh postoperative days, mandatory use of total parenteral nutrition, nonoperative management of contained leaks, accurate, aggressive use of adjuvant chest tubes, and selective esophagostomy for anastomotic disruption.     

Gastropericardial fistula-induced pyopneumopericardium after esophagectomy with esophagogastrectomy

Gastropericardial fistula is an acquired disorder presenting as an abnormal communication between the stomach and the pericardium, with a rare incidence and extremely high mortality rate. We recently experienced a case of life-threatening gastropericardial fistula occurring as an unusual complication after an esophagectomy with an esophagogastrostomy for esophageal cancer treatment. A 68-year-old man with a history of esophagectomy and esophagogastrostomy using the gastric pedicle for the esophageal cancer 13 years ago, visited the hospital with a complaint of dyspnea for 3 days. Chest roentgenogram, computed tomographic scan, and endoscopy showed a pneumopericardium and huge ulcer with central perforation in the posterior wall of the gastric pedicle.     

Coronary artery bypass graft after esophagogastrectomy.

A 71-year-old male with a history of retrosternal gastric bypass, after a resected esophageal carcinoma, developed angina pectoris due to stenosis of the left main trunk and the left anterior descending artery. The patient was treated with off-pump beating-heart coronary artery bypass approached via left thoracotomy. Two free conduits arising from the left internal mammary artery were utilized for this particular case, since the aortocoronary bypass was impossible due to the severely calcified aorta. Postoperative angiography confirmed good coronary flow and the patient has been symptom free for 6 months.     

Hepatic resection using stapling devices

BACKGROUND: The progress and development of stapling devices has been remarkable. They have become indispensable for gastrointestinal diseases and are increasingly utilized in laparoscopic operations. Liver surgery applications for this technique are continuing to emerge, and in this study, we introduced the use of stapling devices to hepatic surgery. METHODS: We examined the operative procedure and efficacy of hepatic resections using stapling devices as follows: transection of Glisson's pedicle and the hepatic vein using endolineal stapling devices in right and left lobectomies; bisegmentectomy II and III en masse using a stapling device; and application of endolineal stapling devices to vessel transections and dissections of the hepatic parenchyma in laparoscopic hepatectomies. RESULTS: It was considered useful to tactfully apply stapling devices to vessel transections and dissections of the hepatic parenchyma in order to simplify the operative procedures of right or left lobectomies and lateral segmentectomies. Furthermore, the use of endoscopic stapling devices was an acceptable alternative to vessel transactions and dissections of the hepatic parenchyma in laparoscopic hepatectomies. CONCLUSIONS: We believe that stapling devices will become utilized in liver surgery hereafter.     

Minimally invasive management of intrathoracic leaks after esophagogastrectomy

Enthusiasm for minimally invasive esophagectomy is increasing. When feasible, the laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy with construction of an intrathoracic anastomosis is favored. A potential catastrophic consequence of an intrathoracic anastomosis is a postoperative leak. In this review, the authors summarize the current understanding of the pathophysiology and the management of intrathoracic leak using minimally invasive surgical techniques.     

Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device

BACKGROUND Benign oesophageal strictures carry a significant level of morbidity, causing burdensome symptoms impacting on quality of life. Post-oesophagectomy anastomotic stricture rates as high as 41% have been reported in the literature.These can require endoscopic dilatation, often multiple times to relieve dysphagia. The aim of the present study was to determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.AIM To determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.METHODS We performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesophagectomy performed from 2004-2018 to determine the stricture rate. The database comprised a single-surgeon series of open, two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis. Tumour location, histology, neoadjuvant chemotherapy, stapler size, T-stage and R-status were analysed to see if they could predict stricture formation. Stricture was defined as dysphagia requiring endoscopic dilatation. Patients with anastomotic leaks were excluded on the basis they would develop an anastomotic stricture.RESULTS One hundred and seventy patients were collected in the database. Nineteen were excluded on the basis of anastomotic leak, perioperative death and early recurrence. One hundred and fifty-four patients(119 males, 35 females) with a mean age of 64 ± 10 years were eligible for analysis. A total of 15 patients developed strictures a median of 99 d(interquartile range: 84-133) after surgery,giving a Kaplan-Meier estimated stricture rate of 10% at one year. None of the factors considered were found to be significantly associated with strictures.CONCLUSION In this study the stricture rate was 10%, with the majority occurring in the first100 d after surgery. No significant independent factors were found in the development of strictures.