Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia

Abstract

Aims: This study aimed to evaluate the efficacy of a novel technique enabling a trans-hiatal oesophagectomy with intrathoracic anastomosis under direct vision, without thoracotomy.

Methods: Trans-hiatal dissection of the oesophagus was performed using direct and laparoscopic visualization. The oesophagus was transected above the tumour with a linear endo-GIA-2 60 mum stapler. The stomach was transected and a gastric tube fashioned. The anvil of an appropriately sized CEEA circular stapler was modified enabling it to flatten. It was attached to a novel delivery system introduced under direct vision along a guidewire into the stapled oesophagus. The anvil was realigned to its original position in the distal oesophagus, docked with the body of the stapler and an intrathoracic anastomosis performed.

Results: Ten patients (female n=3, male n=7) aged from 39--77 years (mean age 65 years), ASA 2--3 with distal third tumours were treated. Duration of procedure ranged from 2--5 hours (mean 4 hours). One patient suffered a post-operative chest infection and an anastomotic leak treated successfully with a self-expanding metal stent. Hospital stay ranged from 6--28 days (mean 17 days). There was no mortality.

Conclusion: This technique allows a safe intrathoracic anastomosis to be performed trans-hiatally under direct vision, avoiding the need for thoracotomy in patients with high comorbidity.