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Journal of Minimally Invasive Surgery 2023; 26(2): 53-54

Published online June 15, 2023

https://doi.org/10.7602/jmis.2023.26.2.53

© The Korean Society of Endo-Laparoscopic & Robotic Surgery

Safe and convenient intrathoracic anastomosis in minimally invasive Ivor Lewis esophagectomy

Sang Hyun Kim

Department of Surgery,Soonchunhyang University Seoul Hospital, Seoul, Korea

Correspondence to : Sang Hyun Kim
Department of Surgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea
E-mail: ssan77@sch.ac.kr
https://orcid.org/0000-0002-0345-7044

Received: June 13, 2023; Revised: June 13, 2023; Accepted: June 13, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

To minimize cervical anastomosis complications, minimally invasive Ivor Lewis esophagectomy (MIILE) was introduced and it has lowered morbidity and mortality [1]. Owing to its safety and convenience, anastomosis technique using circular stapler is widely used for intrathoracic esophagogastric anastomosis in open esophagectomy [2]. The procedure involves the following steps: purse-string suturing of the esophagus, anvil placement in the proximal esophagus, and docking the anvil with the spike of stapler shaft. In particular, purse-string suturing and anvil insertion are very difficult under thoracoscopy. For this reason, some surgeons have modified the method to complete the procedure, however, they are technically demanding [3,4].

In the current study [5], the authors incorporated the double ligation method, which is successfully performed on esophagojejunostomy in gastric cancer surgery, into the esophagogastrostomy in MIILE. Relatively short purse-string suture time was required and a low anastomosis leakage rate was observed, and it is expected that the double ligation method provides a good approach to safely perform intrathoracic anastomosis using a circular stapler.

However, as the authors mentioned, a relatively high anastomotic stricture rate was observed. A study describing intrathoracic anastomoses using circular staplers showed similar stricture rates [3], whereas other studies showed relatively low anastomotic stricture rates [4,6]. Therefore, it may be necessary to consider other factors that may affect stricture rates, in addition to the fact that pulling the gastric tube may lead to stenosis.

Some anastomosis techniques that would be a better option during MIILE have been recently reported. One issue is a comparison between circular stapled anastomosis using a transorally inserted anvil (Orvil™, Medtronic) and circular stapled anastomosis using a transthoracically placed anvil (non-Orvil™). Another is a comparison between a linear stapled and a circular stapled anastomosis. Lin et al. [7] reported that the Orvil™ technique had a lower postoperative anastomotic leakage rate than the non-Orvil™ technique after propensity score-matched analysis. Regarding the stapler type, an open approach showed less anastomotic stricture after anastomosis using a linear stapler than using a circular stapler [8]. However, a recent comparative study in MIILE concluded that both techniques, linear and circular stapling, are safe and effective, producing comparably good clinical results [9]. In any case, the anastomosis technique using a linear stapler is gradually becoming the preferred choice during intraabdominal surgery, especially in gastric cancer surgery, and a recent long-term follow-up study has revealed the safety and effectiveness of esophagectomy using a linear stapler; attention is therefore needed [10].

Conflict of interest

The author has no conflicts of interest to declare.

Funding/support

None.

  1. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012;256:95-103.
    Pubmed KoreaMed CrossRef
  2. Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg 2007;83:1805-1813.
    Pubmed CrossRef
  3. Jeon HW, Park JK, Song KY, Sung SW. High intrathoracic anastomosis with thoracoscopy is safe and feasible for treatment of esophageal squamous cell carcinoma. PLoS One 2016;11:e0152151.
    Pubmed KoreaMed CrossRef
  4. Zhan B, Chen J, Du S, Xiong Y, Liu J. Using the hand-sewn purse-string stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy. Thorac Cardiovasc Surg 2019;67:578-584.
    Pubmed CrossRef
  5. Takahashi T, Kaneoka Y, Maeda A, et al. Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy. J Minim Invasive Surg 2023;26:64-71.
    Pubmed CrossRef
  6. Fabbi M, De Pascale S, Ascari F, Petz WL, Fumagalli Romario U. Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes. Updates Surg 2021;73:1837-1847.
    Pubmed KoreaMed CrossRef
  7. Lin H, Liang G, Chai H, Liao Y, Zhang C, Cheng Y. Comparison of two circular-stapled techniques for esophageal cancer: a propensity-matched analysis. Front Oncol 2021;11:759599.
    Pubmed KoreaMed CrossRef
  8. Price TN, Nichols FC, Harmsen WS, et al. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg 2013;95:1154-1161.
    Pubmed CrossRef
  9. Fabbi M, van Berge Henegouwen MI, Fumagalli Romario U, et al. End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes. Langenbecks Arch Surg 2022;407:2681-2692.
    Pubmed CrossRef
  10. Okabe H, Tsunoda S, Sunagawa H, et al. A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis. Surg Endosc 2022;36:1979-1988.
    Pubmed CrossRef

Article

Editorial

Journal of Minimally Invasive Surgery 2023; 26(2): 53-54

Published online June 15, 2023 https://doi.org/10.7602/jmis.2023.26.2.53

Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.

Safe and convenient intrathoracic anastomosis in minimally invasive Ivor Lewis esophagectomy

Sang Hyun Kim

Department of Surgery,Soonchunhyang University Seoul Hospital, Seoul, Korea

Correspondence to:Sang Hyun Kim
Department of Surgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 04401, Korea
E-mail: ssan77@sch.ac.kr
https://orcid.org/0000-0002-0345-7044

Received: June 13, 2023; Revised: June 13, 2023; Accepted: June 13, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

To minimize cervical anastomosis complications, minimally invasive Ivor Lewis esophagectomy (MIILE) was introduced and it has lowered morbidity and mortality [1]. Owing to its safety and convenience, anastomosis technique using circular stapler is widely used for intrathoracic esophagogastric anastomosis in open esophagectomy [2]. The procedure involves the following steps: purse-string suturing of the esophagus, anvil placement in the proximal esophagus, and docking the anvil with the spike of stapler shaft. In particular, purse-string suturing and anvil insertion are very difficult under thoracoscopy. For this reason, some surgeons have modified the method to complete the procedure, however, they are technically demanding [3,4].

In the current study [5], the authors incorporated the double ligation method, which is successfully performed on esophagojejunostomy in gastric cancer surgery, into the esophagogastrostomy in MIILE. Relatively short purse-string suture time was required and a low anastomosis leakage rate was observed, and it is expected that the double ligation method provides a good approach to safely perform intrathoracic anastomosis using a circular stapler.

However, as the authors mentioned, a relatively high anastomotic stricture rate was observed. A study describing intrathoracic anastomoses using circular staplers showed similar stricture rates [3], whereas other studies showed relatively low anastomotic stricture rates [4,6]. Therefore, it may be necessary to consider other factors that may affect stricture rates, in addition to the fact that pulling the gastric tube may lead to stenosis.

Some anastomosis techniques that would be a better option during MIILE have been recently reported. One issue is a comparison between circular stapled anastomosis using a transorally inserted anvil (Orvil™, Medtronic) and circular stapled anastomosis using a transthoracically placed anvil (non-Orvil™). Another is a comparison between a linear stapled and a circular stapled anastomosis. Lin et al. [7] reported that the Orvil™ technique had a lower postoperative anastomotic leakage rate than the non-Orvil™ technique after propensity score-matched analysis. Regarding the stapler type, an open approach showed less anastomotic stricture after anastomosis using a linear stapler than using a circular stapler [8]. However, a recent comparative study in MIILE concluded that both techniques, linear and circular stapling, are safe and effective, producing comparably good clinical results [9]. In any case, the anastomosis technique using a linear stapler is gradually becoming the preferred choice during intraabdominal surgery, especially in gastric cancer surgery, and a recent long-term follow-up study has revealed the safety and effectiveness of esophagectomy using a linear stapler; attention is therefore needed [10].

NOTES

Conflict of interest

The author has no conflicts of interest to declare.

Funding/support

None.

References

  1. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012;256:95-103.
    Pubmed KoreaMed CrossRef
  2. Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg 2007;83:1805-1813.
    Pubmed CrossRef
  3. Jeon HW, Park JK, Song KY, Sung SW. High intrathoracic anastomosis with thoracoscopy is safe and feasible for treatment of esophageal squamous cell carcinoma. PLoS One 2016;11:e0152151.
    Pubmed KoreaMed CrossRef
  4. Zhan B, Chen J, Du S, Xiong Y, Liu J. Using the hand-sewn purse-string stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy. Thorac Cardiovasc Surg 2019;67:578-584.
    Pubmed CrossRef
  5. Takahashi T, Kaneoka Y, Maeda A, et al. Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy. J Minim Invasive Surg 2023;26:64-71.
    Pubmed CrossRef
  6. Fabbi M, De Pascale S, Ascari F, Petz WL, Fumagalli Romario U. Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes. Updates Surg 2021;73:1837-1847.
    Pubmed KoreaMed CrossRef
  7. Lin H, Liang G, Chai H, Liao Y, Zhang C, Cheng Y. Comparison of two circular-stapled techniques for esophageal cancer: a propensity-matched analysis. Front Oncol 2021;11:759599.
    Pubmed KoreaMed CrossRef
  8. Price TN, Nichols FC, Harmsen WS, et al. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg 2013;95:1154-1161.
    Pubmed CrossRef
  9. Fabbi M, van Berge Henegouwen MI, Fumagalli Romario U, et al. End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes. Langenbecks Arch Surg 2022;407:2681-2692.
    Pubmed CrossRef
  10. Okabe H, Tsunoda S, Sunagawa H, et al. A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis. Surg Endosc 2022;36:1979-1988.
    Pubmed CrossRef

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Journal of Minimally Invasive Surgery

pISSN 2234-778X
eISSN 2234-5248