Hand-sewn Esophagogastric Anastomosis Research Articles

564. PRONE POSITION THORACOSCOPIC HAND-SEWN ESOPHAGO-GASTRIC ANASTOMOSIS DURING 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER. SURGICAL TECHNIQUE

Abstract Background Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of this approach is the construction of esophago-gastric anastomosis. Herein, we aim to present our anastomotic technique on hand-sewn esophago-gastric anastomosis in prone position, utilizing 3D-assisted thoracoscopy. Methods This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers from the same surgical team, over a period of 6 years and more than 250 consecutive esophagectomies. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. The anastomosis was hand-sewn in prone position, in 2-layers, using barbed sutures, with utilization of 3D-assisted thoracoscopy. Thorough technique and key steps of this anastomotic technique are provided. Results Median operative time was 280 minutes while median suturing time for the esophago-gastric anastomosis was 45 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=6 patients (2%); n=5 were type I anastomotic leaks, requiring no intervention and n=1 was type II, which was treated with thoracoscopic lavage and chest drains followed by endoVAC therapy. Conclusion Formation of the esophago-gastric anastomosis is the rate limiting step of 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction utilizing mechanical staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced safely and effectively, offering all the advantages of manual anastomosis and significant reduction of devastating post-operative anastomotic leakage. https://wetransfer.com/downloads/bdf3a3496197daf79ccf5b05f71ba64920240309175850/a4da3be742fd3199e102e553c8a4011e20240309175918/c14cc2

Impact of Minimally Invasive Intrathoracic Hand-sewn Esophago-gastric Anastomosis in Esophagectomy for Cancer.

Ivor Lewis esophagectomy is considered the gold standard approach for the treatment of distal esophageal and gastro-esophageal junction Siewert I-II tumors. Minimally invasive esophagectomy has provided improved outcomes compared to the open approach, offering reduced morbidity, and improved clinical and oncological outcomes. This is the largest study so far reporting the impact of hand-sewn esophago-gastric anastomosis in the prone position, during the 2-stage totally minimally invasive esophagectomy. A retrospective analysis of prospectively collected data regarding consecutive patients with distal-esophageal and gastroesophageal junction Siewert I-II tumors was conducted. All patients underwent 2-stage totally minimally invasive esophagectomy with thoracoscopic manual esophago-gastric anastomosis in the prone position. Clinical and oncological outcomes were examined and presented. One hundred and fifty consecutive patients were included in the study during a period of five years. Median operative time was 320 minutes, while median time for the construction of anastomosis was 45 minutes. We had no conversions to open esophagectomy. Anastomotic leakage was observed in 2% of the patients; anastomotic stricture rate reached up to 7.33%. Respiratory complications were seen in 18% and cardiac complications in 6.66% of the patients, respectively. Thirty-day mortality and 90-day mortality rates were 1.33% and 2.66%, accordingly. Intrathoracic hand-sewn esophago-gastric anastomosis in the prone position during totally minimally invasive esophagectomy has provided favorable outcomes in our cohort of patients, offering significantly reduced anastomotic-related complications, compared to other standardized techniques. Further prospective comparative studies are needed, to better interpret and amplify our results, that may lead to a paradigm shift regarding the preferred method of reconstruction from esophageal surgeons.

Comparison of Side to Side Staple Versus Hand Sewn Gastro Esophageal Anastomosis in Cases of Oesophagectomy in CA Esophagus

Objective: To compare outcomes of side to side staple versus hand-sewn esophago-gastric anastomosis in esophagectomy patients with carcinoma of esophagus after subtotal esophagectomy along with gastric tube reconstruction.
 Study Design: Retrospective cross-sectional study.
 Place and Duration of Study: Lady Reading Hospital, Peshawar Pakistan, from July 2019 to June 2020.
 Methodology: After ethical approval, medical records of patients that underwent stapled/hand sewn gastro esophageal anastomosis due to carcinoma esophagus were included. Inoperable Ca esophagus and with thoracic anastomosis were excluded. Each anastomotic technique was applied on 50 patients randomly. The variables of study included demographic,anastomotic leak, anastomotic stricture, operative time, and other complications. All the cases were followed up for 1 year.SPSS version 26.0 was used for data analysis.
 Result: From 100 patients, 56 were males and 34 females. Age ranged from 15 to 80 years with mean age of 48.5 and 51.1 respectively in two groups. In 42 cases tumor was present in lower end, middle third in 30 and middle lower third of gastro esophageal junction in 28 cases. Histo-pathologically 58 cases were adenocarcinoma, 31 squamous cell carcinoma and 11 adeno squamous carcinoma. The anastomosis time in group I was 6.8±.22 minutes while in group II was 13.2±1.71 minutes (p0.04). None of the patients in group I, having stapled anastomosis were found to have anastomotic leakage or stricture formation after 1 year of follow up while 04 patients in group II were reported to have anastomotic leakage and 06 patients had anastomotic stricture formation (p-<0.01).
 Conclusion: Side by side stapled anastomosis technique was far superior to hand-sewn technique in terms of the time taken for anastomosis to be completed and patient outcomes (anastomotic leakage and stricture formation).

Application of end-to-end double-layer hand-sewn esophagogastric anastomosis and gastric fundus embedding during minimally invasive esophagectomy for esophageal cancer

Application of end-to-end double-layer hand-sewn esophagogastric anastomosis and gastric fundus embedding during minimally invasive esophagectomy for esophageal cancer

594 HAND-SEWN CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS AFTER ESOPHAGECTOMY

Abstract Successful anastomosis is essential in esophagogastrectomy. Staplers are more popularly applied for the anastomosis. However, a hand-sewn anastomosis is a basic and cost-effective method. Herein, we introduce our technical tips of all hand-sewn cervical esophagogastric anastomosis. Methods Step 1: A 6 cm gastric tube is created and pulled up through the posterior mediastinal route. Step 2: A single layer Gambee sutures are used to approximate the cervical esophagus and the posterior wall of the gastric tube in end-to-side fashion. Step 3: The redundant part in the gastric tube apex is removed. Results We analyzed 199 consecutive patients who underwent this anastomosis in our institute from 2004 to 2019. There was no postoperative mortality. Anastomotic leak (Clavien-Dindo classification; Grade ≥ II) rate was 2.5%. Anastomotic stricture which required balloon dilation was 3.5%. Conclusion The anastomotic complication rates in the hand-sewn anastomosis were comparable to those of the mechanical stapled anastomosis in the previous reports. Video https://www.dropbox.com/s/sxnxs4962aj5n5k/anastomosis.mp4?dl=0.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BackgroundMinimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.MethodsFrom January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.ResultsThe post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.ConclusionDespite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-021-08715-4.

Study of completely linear stapled versus handsewn cervical esophagogastric anastomosis after esophagectomy at a tertiary hospital

Study of completely linear stapled versus handsewn cervical esophagogastric anastomosis after esophagectomy at a tertiary hospital

Study of completely linear stapled versus handsewn cervical esophagogastric anastomosis after esophagectomy at a tertiary hospital

Study of completely linear stapled versus handsewn cervical esophagogastric anastomosis after esophagectomy at a tertiary hospital

Intrathoracic hand-sewn esophagogastric anastomosis in prone position during totally minimally invasive two-stage esophagectomy for esophageal cancer.

Utilization of totally minimally invasive esophagectomy for cancer is on the rise. Esophagogastric anastomosis is mechanically or robotically performed routinely; little report exists of hand-sewn esophagogastric anastomosis. This is the largest so far study with thoracoscopic hand-sewn esophagogastric anastomosis during fully minimally invasive two-stage esophagectomy for esophageal cancer in prone position. Consecutive two-stage totally minimally invasive esophagectomies for cancer were performed by one surgical team, from September 2016 to March 2019. All operations were technically identical in terms of patient positioning, surgical approach, extend of lymphadenectomy and type of anastomosis formed. Primary end points were anastomotic leak and anastomotic stricture rate, while secondary end points were 30-day and 90-day mortality rates. From the overall n = 80 patients, n = 67 were males, while n = 13 were females. Mean age was 64.6years. Mean length of stay was n = 14days. There were no conversions to open. Mean operating time was 420minutes with no blood loss over 200 mL noted. Pulmonary and cardiac complication rate was 23.75% and 2.5%, respectively. Anastomotic leak rate was 2.5%. Anastomotic strictures were seen in 12.5% of cases. 30-day and 90-day mortality rate was 2.5% and 5%, respectively, with none accounted for ischemic conduit complications. Intrathoracic anastomosis in totally minimally invasive esophagectomy is challenging and accountable for most of the mortality associated with the procedure. In thoracoscopic two-stage esophagectomy, a mechanical anastomosis is usually preferred; this is believed to be due to the complexity of manual anastomosis associated with the thoracoscopic approach. We aim to present our series of completely hand-sewn intrathoracic anastomosis utilizing a totally minimally invasive approach with favorable outcomes. With this study, reproducibility of the anastomosis is shown that can potentially favor a change in the practice of esophageal surgeons worldwide.

Modified Double-Layer Anastomosis for Minimally Invasive Esophagectomy: An Effective Way to Prevent Leakage and Stricture.

Anastomotic leakage and stricture contribute to a large number of mortality and morbidity after esophagectomy. The aim of this work is to evaluate the outcome of modified double-layer hand-sewn esophagogastric anastomosis during minimally invasive esophagectomy for esophageal cancer. The clinicopathological data of 176 consecutive esophageal cancer patients who underwent cervical esophagogastric anastomosis using modified double-layer hand-sewn technique after radical esophagectomy were retrospectively reviewed. Total minimally invasive approach, including thoracoscopic surgery for thoracic procedure and laparoscopic approach for abdominal procedure, was implemented during the radical Mckeown esophagectomy. Patients were followed up for the assessment of postoperative anastomotic complications including anastomotic leakage and stricture, being the primary outcome measures for this study. Anastomotic leakage occurred in 2 of 176 patients (1.1%); both of the patients experienced only minor leakage and were treated conservatively. There was no significant difference in leakage between patients with and without major comorbidity (p=0.331). After a mean follow-up of 21.3months, four patients (4/176, 2.3%) developed benign anastomotic strictures, including those 2 patients experienced postoperative leakage. Symptoms for stricture were improved by endoscopic dilatations in all 4 patients. Besides, there was one case (1/176, 0.6%) of gastric necrosis in this cohort, who was also successfully managed by conservative therapy with no operative mortality. This modified double-layer hand-sewn anastomosis is a highly safe and stable technique for esophagogastrostomy, which is an effective way to prevent both anastomotic leakage and stricture.

Laparoscopy-Assisted Proximal Gastrectomy with the Hinged Double Flap Method.

No standard proximal gastrectomy method for gastric cancer of the upper third of the stomach (UGC) has been established because few of the current methods prevent gastro-esophageal reflux and allow easy postoperative endoscopic surveillance. In the present study, we describe laparoscopic proximal gastrectomy with the hinged double flap method (Kamikawa's method) in detail and examine the short- to medium-term outcomes of this approach, which resulted in excellent postoperative function. Between 2011 and 2015, 24 patients with early-stage primary UGC underwent laparoscopic proximal gastrectomy with the above-mentioned method. The celiac and hepatic nerves were preserved without pyloroplasty. A hand-sewn esophagogastric anastomosis was produced intracorporeally. There were no in-hospital deaths, and none of the patients were converted to open surgery. Complications occurred in two patients in the early part of this study (minor anastomotic leakage in one case and an abdominal abscess in the other). None of the patients exhibited symptoms of reflux. Regarding the patients' postoperative endoscopic classifications, 17, 2, and 1 patient were considered to have grade N or M, grade A, and grade B esophagitis, respectively. All of the patients remain alive, and no cases of postoperative bowel obstruction or recurrent cancer have been observed. This method can be performed safely and achieves excellent outcomes in terms of preventing gastro-esophageal reflux. It deserves further evaluation in a multi-center clinical study.

Is There No Significant Difference in the Incidence of Anastomotic Leakage Between the Hand-sewn and Mechanical Esophagogastric Anastomosis?

Is There No Significant Difference in the Incidence of Anastomotic Leakage Between the Hand-sewn and Mechanical Esophagogastric Anastomosis?

A Prospective Randomized Controlled Trial of Semi‐mechanical versus Hand‐sewn or Circular Stapled Esophagogastrostomy for Prevention of Anastomotic Stricture

Successful anastomosis is essential in esophagogastrectomy, and the application of the circular stapler effectively reduces the anastomotic leakage, although stricture formation has become more frequent. The present study, a randomized controlled trial, compared the recently developed semi-mechanical anastomosis with a hand-sewn or circular stapled esophagogastrostomy in prevention of anastomotic stricture. Between November 2007 and September 2008, 160 consecutive patients with esophageal carcinoma underwent surgical treatment our department. Five patients were excluded from this study, and the remaining 155 patients were completely randomized to receive either an everted plus side extension esophagogastrostomy (semi-mechanical [SM] group) or a conventional hand-sewn esophagogastric anastomosis ([HS] group) or a circular stapled ([CS] group) esophagogastric anastomosis, after dissection of the esophageal tumor and construction of a tubular stomach. The primary outcome was the incidence of an anastomotic stricture at 3 months after the operation (defined as the diameter of the anastomotic orifice ≤ 0.8 cm on esophagogram). Secondary outcomes were the dysphagia score and reflux score, as well as the anastomotic diameter. The anastomotic stricture rate was 0 % (0/45) in the SM group, 9.6 % (5/52) in the HS group, and 19.1 % (9/47) in the CS group (p < 0.001). The mean diameter of the anastomotic orifice was 18.2 ± 4.7 mm in the SM group, 11.5 ± 2.4 mm in the HS group, and 9.5 ± 3.0 mm in the CS group (p < 0.001). The reflux/regurgitation score among the three groups was similar. Semi-mechanical esophagogastric anastomosis could prevent stricture formation more effectively than hand-sewn or circular stapler esophagogastrostomy, without increasing gastroesophageal reflux.

Laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis using a knifeless endoscopic linear stapler

Proximal gastrectomy has been applied for selected patients with early upper gastric cancer, because of its potential advantages over total gastrectomy, such as preserving gastric capacity and entailing fewer hormonal and nutritional deficiencies. Esophago-gastric anastomosis is a simple reconstruction method with an excellent postoperative outcome provided that gastroesophageal reflux is properly prevented. Following open surgery, the esophagus is anastomosed to the anterior stomach wall with partial fundoplication to prevent esophageal reflux. We developed a novel laparoscopic hand-sewn method to reproduce the anti-reflux procedure that is used in open surgery. The esophagus is first fixed to the anterior stomach wall with a knifeless endoscopic linear stapler. This fixation contributes to maintaining a stable field for easier hand-sewn anastomosis, and allows us to complete the left side of the fundoplication at the same time. This novel technique was used to successfully perform complete laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis in ten patients, without any postoperative complications. No patient had symptoms of gastroesophageal reflux during a median follow-up period of 19.9 months. One patient developed anastomotic stenosis, and this was resolved with endoscopic dilatation. The mean percent body weight loss at 12 months after surgery, in comparison to the preoperative weight, was 10.4 %. Laparoscopic proximal gastrectomy with an esophago-gastric anastomosis using our novel technique would be a feasible choice would be a feasible choice and would show benefit for selected patients with early upper gastric cancer.

Randomized Trial Comparing Side-to-Side Stapled and Hand-Sewn Esophagogastric Anastomosis in Neck

BackgroundLeak from cervical esophagogastric anastomosis (CEGA) following esophagectomy is associated with morbidity and poor functional outcome. To address this issue, we conducted a randomized trial comparing “hand-sewn” with “stapled side-to-side” CEGA. MethodsOf 174 patients who underwent esophageal resection and CEGA between 2004 and 2010, 87 each were randomized to “hand-sewn” and “stapled side-to-side” CEGA [www.ClinicalTrials.gov: NCT00497549]. The primary outcome measure was anastomotic leak rate. The secondary outcome measures included CEGA construction time and occurrence of anastomotic stricture during follow up. ResultsThe overall anastomotic leak rate was 17.2 % (major leaks: 8 %). The leak rate was similar among the two groups (hand-sewn: 14/87, stapled: 16/87; p = 0.33). The stapled anastomotic technique was faster (25 ± 6.5 min vs. 27 ± 5.5 min; p = 0.02). The overall operative mortality and morbidity rates were 6.3 % and 40.8 %, respectively. At a median follow up of 12 (6–42) months, anastomotic stricture occurred in 24 (14.7 %) patients and was significantly more common in the “hand-sewn” group (17/82 vs. 7/81; p = 0.045). ConclusionThere were no differences in the leak rates and postoperative outcome between the two CEGA techniques. At follow up, anastomotic strictures occurred less frequently following stapled CEGA. The ideal CEGA technique remains elusive.

Endoscopic Evaluation of the Quality of the Anastomosis After Esophagectomy with Gastric Tube Reconstruction

The morbidity and mortality of anastomotic complications after esophagectomy have gradually decreased in recent years. However, swallowing difficulties and reflux continue to burden patients jeopardizing their quality of life. In the present study we performed endoscopic evaluation of the outcomes of esophagogastrostomy by analyzing the presence of anastomotic stenosis and reflux esophagitis. A retrospective analysis was carried out on 74 patients who underwent esophagogastrostomy after esophagectomy by one surgeon between January 1995 and December 2004. Fifty-three patients had an endoscopic examination during follow-up (29 +/- 23.6 months, range = 5-111 months). Reflux esophagitis and stenosis at the anastomostic site were analyzed according to the surgical technique used and the location of the esophagogastrostomy. The mean age at the time of repair was 60.3 +/- 8.87 (range = 39-81) years. Cervical anastomosis was performed in 26 patients and intrathoracic anastomosis in 27 patients. No significant statistical difference in the frequency of anastomotic stenosis was observed between the two groups (p = 0.829); reflux esophagitis was noted in three patients in the cervical anastomosis group and in 14 patients in the intrathoracic anastomosis group (p = 0.041). For all patients, 23 received a hand-sewn esophagogastric anastomosis and 30 a circular stapled one. There was no significant statistical difference in anastomotic stenosis (p = 0.689) and reflux esophagitis (p = 0.879) in comparisons between the two groups. Cervical anastomosis resulted in a better outcome for esophagogastrostomy by lowering the risk of reflux esophagitis; this outcome might improve the patient's quality of life.

Esophageal mucosal stripping for palliation of dysphagia in advanced carcinoma of lower third esophagus diagnosed at laparotomy

We report our novel technique, as a palliative procedure for carcinoma of the lower third esophagus, of stripping the mucosa of the esophagus with enbloc resection of cancer of the lower third esophagus with gastric pull up and cervical hand sewn esophagogastric anastomosis. This was undertaken primarily for the relief of dysphagia in locally advanced/metastatic cancer diagnosed at laparotomy. The technique has distinct advantages of being simpler, economical with minimal morbidity.