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Review
. 2019 Apr;11(Suppl 5):S743-S749.
doi: 10.21037/jtd.2019.01.28.

Optimal mobilization of the stomach and the best place in the gastric tube for intrathoracic anastomosis

Wytze Laméris  1 , Wietse J Eshuis  1 , Miguel A Cuesta  1 , Suzanne S Gisbertz  1 , Mark I van Berge Henegouwen  1
Affiliations
Review

Optimal mobilization of the stomach and the best place in the gastric tube for intrathoracic anastomosis

Wytze Laméris et al. J Thorac Dis. 2019 Apr.

Abstract

Esophagectomy with gastric tube reconstruction is a highly complex surgical procedure. With regard to mobilization of the stomach and optimal gastric tube preparation and anastomosis, there are several important intraoperative steps that can influence the outcome of the operation. This study aims to describe the optimal mobilization of the stomach for gastric tube reconstruction and explore the best place in the gastric tube for intrathoracic anastomosis after esophagectomy. A search of the literature was performed and results are described in a descriptive review. Based on literature and our own experience we describe important operating steps for laparoscopic stomach mobilisation for gastric tube reconstruction. Steps to create additional length include preserving the left gastroepiploic artery, transecting the right gastric artery, extended duodenal mobilization, and duodenal diversion with roux-Y reconstruction. Several techniques for intrathoracic anastomosis are described in literature. Several imaging techniques, of which fluorescence imaging is the most commonly used, are available to assess the vascularization of the gastric tube and to assist in determining the best place in the gastric tube for intra thoracic anastomosis. Although there is little evidence of exact technique on stomach mobilization and location for an intrathoracic anastomosis, many techniques are used by different authors with varying results.

Keywords: Esophagectomy; gastric tube; intrathoracic anastomosis.

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Conflict of interest statement

Conflicts of Interest: MI van Berge Henegouwen—Educational grant Stryker, Research grant Olympus, Consultant for Medtronic; SS Gisbertz—Research grant Olympus, Consultant for Medtronic. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Anatomical structures of the omental bursa.
Figure 2
Figure 2
The specimen is brought extracorporeal through a mini-thoracotomy, after which the gastric tube is completed and a circular stapler can be introduced.
Figure 3
Figure 3
End-to-side technique for intrathoracic anastomosis in Ivor Lewis esophagectomy.
Figure 4
Figure 4
Anastomosis is buried under a pleural flap.
Figure 5
Figure 5
Anastomosis is covered by omental wrap.
Figure 6
Figure 6
Side-to-side technique for intrathoracic anastomosis in Ivor Lewis esophagectomy.
Figure 7
Figure 7
Stapling on the mesenterial side of the gastric tube (left) and on the antimesenterial side (right).
See this image and copyright information in PMC

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