A safe and reproducible anastomotic technique for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with the trans-oral anvil

Abstract

Objectives: In expert hands, the intrathoracic oesophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardised 25 mm/4.8mm circular-stapled anastomosis using a trans-orally placed anvil.

Materials and methods: We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis oesophagectomy at a tertiary referral centre. The oesophago-gastric anastomosis was created using a 25-mm anvil (Orvil, Autosuture, Norwalk, CT, USA) passed trans-orally, in a tilted position, and connected to a 90-cm long polyvinyl chloride delivery tube through an opening in the oesophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (end-to-end anastomosis stapler (EEA XL) 25 mm with 4.8-mm staples, Autosuture, Norwalk, CT, USA) inserted into the gastric conduit. Primary outcomes were leak and stricture rates.

Results: Thirty-seven patients (mean age 65 years) with distal oesophageal adenocarcinoma (n=29), squamous cell cancer (n=5) or high-grade dysplasia in Barrett's oesophagus (n=3) underwent an Ivor Lewis oesophagectomy between October 2007 and August 2009. The abdominal portion was operated laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle-sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis.

Discussion: The circular-stapled anastomosis with the trans-oral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis oesophagectomy.

Figure 1

Laparoscopic Gastric Conduit preparation

Figure 2

Tran-oral introduction of the 25mm anvil in the esophageal stump (Orvil, Autosuture, Norwalk, CT). Small opening of the esophageal stump (A), initial delivery of the 90cm long PVC tube through the small opening in the stapled esophageal stump (B), and 254m anvil in the esophageal stump (C).

Figure 3

Joining the anvil to a circular stapler (EEA XL 25mm with 4.8mm Staples, Autosuture, Norwalk, CT) (A) and final aspect of the anastomosis (B).

Figure 4

Endoscopic view of an esophago-gastric anastomosis with a stricture (A), with the balloon dilation in place (B) and after successful dilation (C).