Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid "Lewis Santy"

Abstract

Background and study aims: Esophagogastric anastomosis (EGA) has a high risk of leakage. Based upon our experience in endoscopic gastrojejunal anastomosis using LAS, the aim of this study was to verify the technical feasibility and the safety of performing an EGA using a hybrid approach (endoscopic and surgical).

Materials and methods: A pilot prospective study was performed on 8 survival pigs. The procedure was carried out in 2 stages: (i) surgical step consisting of an esogastrectomy by laparotomy with separated suture of the esophagus and stomach; (ii) endoscopic esophagogastric anastomosis using the LAS. The first 2 pigs allowed for the setting of the 2 steps procedure, and 6 were included in the study for assessing the efficacy and safety of the procedure with a 3-week survival course. The primary endpoint was morbidity and mortality.

Results: All procedures were successfull. The mean operative time was 98 minutes, with a mean endoscopic time of 46 minutes. Three early deaths occurred within the first weeks, unrelated to the LAS anastomosis. At 3 weeks, endoscopic assessment followed by necropsy demonstrated the right position and the endoscopic removability of the stent with good patency of the esophagogastric anastomosis, without leakage of the endoscopic suture. Pathological examination confirmed the patency of the anastomosis with fusion of mucosal and muscle layers.

Conclusion: Endoscopic esophagogastric anastomosis with LAS is feasible and reproducible, without anastomotic leakage. It could be a new alternative to perform safe anastomoses, as part of a hybrid approach (surgical and endoscopic).

Fig. 1

Resection of the lower esophagus 2 to 3 cm above the cardia using a linear stapler.

Fig. 2

Puncture with a 19 G needle(Cook medical in Limerick, Ireland) above the aureastomosis esophagus.

Fig. 3

Access to the gastric lumen at the upper edge of the gastric suture using a cystostome 10 Fr (Cook Medical, Limerick, Ireland) by a section of current Pulse Cut Fast 80 W.

Fig. 4

With delivery of the catheter from the stent to the gastric position, expansion of the distal frange of the stent in the gastric cavity could be visualized.

Fig. 5

Pulling from the stomach into the mediastinum was achieved by using the endoscope to guide the catheter of the stent and also the Twin Grasper, plus assistance in the abdomen from a surgical aid.

Fig. 6

The proximal flange was deployed with correct positioning of the gastric cavity in the mediastinum and in contact with the esophagus had been confirmed.

Fig. 7

Correct positioning of the stent was confirmed by the appearance of gastric juice in the stent.

Fig. 8

The fistula was covered by the proximal flange on the line of esophageal surgical sutures.