Experience of 15 years using the 25-mm flexed end to end anastomosis anvil for safe transoral passage during intracorporeal circular-stapling gastrojejunostomy, esophagogastrostomy, and esophagojejunostomy

Abstract

I read with interest the article entitled Intracorporeal Circular Stapling Esophagojejunostomy Using the Transorally Inserted OrVilTM After Laparoscopic Total Gastrectomy. The article stated that ‘‘an optimal procedure has yet to be established,’’ referring to the use of a flip-top end to end anastomosis (EEA) for reconstruction after major gastric resections [1]. The authors did not report that this technique has been described since 1995, first for the use of gastrojejunostomy during Roux-en-Y gastric bypass and then for esophagogastrostomies and esophagojejunostomies after proximal or total gastrectomies and various esophagectomies. The OrVilTM product by Covidien (Norwalk, CT) is a commercialization of the concept and method I designed in 1995 and used clinically in 1996, applying a conventional 25-mm curved end to end anastomosis (CEEA) anvil from which the spring was removed, the cutting plate depressed to allow free movement, and the anvil shaft invaginated into a cut no. 18 nasogastric tube. A prolene suture was passed through the tube and orifice at the tip of the shaft and into the circular metal plate to maintain the anvil in a flexed position for an easy transoral passage in the oropharynx and to prevent accidental deployment (Fig. 1A, B) [2]. This was an improvement over the transoral passage of a 21-mm EEA described by Wittgrove et al. [3] because the 21-mm EEA was not inserted in a flexed position, which despite the smaller EEA diameter could result in disruption or damage to the integrity of the esophageal wall or lodging of the EEA along its passage. It has subsequently been demonstrated that the 21-mm EEA results in a much higher stricture rate [4] and probably is associated with a higher leak rate due to the smaller staple line surface area, which may not cover the perforated tube site if stapling is performed excentrically. I have used the technique described in 1996 very safely in more than 3,000 cases, and others have used it in probably more than 100,000 procedures worldwide for the aforementioned indications, including complex esophagogastric revisions and repair of strictures [5–7]. Moreover, this technique has been used for duodenoileostomy anastomosis in laparoscopic biliopancreatic diversion with a duodenal switch when the ileum is wide enough to accommodate a 25-mm EEA, as well as for duodenojejunal or jejunojejunal bypass and transanally for reversed coloanal or colorectal anastomosis [8].