How I do it

A new technique for esophagojejunostomy after total gastrectomyfor gastric cancer

Jeffery Parker, M.D.a, Harry Sell, Jr., M.D.b, Kurt Stahlfeld, M.D.a

aDepartment of Surgery, Mercy Hospital of Pittsburgh, 1400 Locust St., Pittsburgh, PA 15219, USAbDivision of Gastrointestinal Surgery, Mercy Hospital of Pittsburgh, Pittsburgh, PA 15219, USA

Manuscript received January 12, 2001; revised manuscript March 30, 2001

Abstract

Background: The critical part of any operation involving a proximal gastric resection is the esophageal anastomosis. Leakage from thisanastomosis is one of the main reasons for postoperative morbidity and death after gastrectomy. Application of the double-stapling techniqueaffords many of the same advantages that it does for low rectal tumors, especially in obese patients with narrow costal margins.Methods: A new technique for esophagojejunostomy after total gastrectomy for gastric cancer is described.Results: This technique has been used in 3 patients. At a follow-up of 22 months, there have been no anastomotic leaks or evidence ofclinical stenoses.Conclusion: This technique minimizes manipulation and dissection around the distal esophagus. Not only does this make the operationeasier, but it also allows for a longer proximal resection margin. Possibly this will result in lower rates of esophageal breakdown. © 2001Excerpta Medica, Inc. All rights reserved.

Keywords:Esophagus; Anastamosis; Proximal; Stapling; Cancer

Gastric cancer is the second leading cause of cancer deathsworldwide. From being the most common cancer in 1930 toaccounting for 2% of all cancers in 1994, gastric carcinomahas steadily declined in incidence in the United States [1]. In1998 there were 22,600 new cases and 13,700 deaths attrib-uted to gastric cancer [2]. Over the past 40 years the locationof the primary tumor also has become more proximal [1,3].This has led to much debate over the best surgical approachand extent of resection for proximal gastric cancers [4,5].Supporters exist for a thoracoabdominal incision, trans-hiatal resection, left thoracotomy, and Ivor-Lewis approach[6–11]. Regardless of approach, surgical resection forboth early and advanced gastric carcinoma is the mosteffective treatment. Surgical resection requires reestablish-ing alimentary continuity once the cancer has been re-moved. Technically, the esophageal anastomosis is the mostcritical part of the operation. Here the authors describe a

novel technique for esophagojejunal anastomosis after gas-tric resection.

Surgical technique

Our technique is a modification of the standard methodsused in gastric surgery. Through a midline incision wecompletely mobilize the stomach and divide the esophagusand stomach or duodenum with a stapler. We then place theanvil of the end-to-end anastomotic (EEA) stapler in theflanged end of a no. 16 OG (oropharyngeal gastric) tube andsecure it with an 0-silk tie (Fig. 1). The OG tube is manuallyadvanced down the esophagus until the tip is seen protrud-ing on the distal esophagus. A small opening in the esoph-agus is made, and the OG tube is grasped and pulled untilthe anvil rests snugly against the staple line (Fig. 2). Thesilk tie is cut and the OG tube is detached from the anvil. Ifthe entire stomach is removed, the EEA stapler is introducedthrough the open end of a Roux-en-Y loop of jejunum, theanvil and stapler are approximated, and the instrument isfired (Fig. 3). The open Roux loop is then closed with a

* Corresponding author. Tel.: 1-412-232-8097; fax: 1-412-232-8096.E-mail address:kstahlfeld@mercy.pmhs.org

The American Journal of Surgery 182 (2001) 174–176

0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved.PII: S0002-9610(01)00671-7

linear stapler (Fig. 4). This same technique can also beapplied to the antrum if a proximal gastric resection isperformed.

Comments

Leakage from the esophageal anastomosis is one of themain reasons for postoperative morbidity and death aftergastrectomy [12]. Stapled and hand sewn esophagojejunalanastomoses have the same morbidity and mortality [13].The traditional stapling technique involves placing a pursestring suture around the transected esophagus. This can betechnically demanding especially in a large obese patientwith a narrow costal margin. Techniques avoiding the pursestring suture have been previously described [14–16]. Ourtechnique also avoids the placement of purse string stitchesin a tenuous esophagus that is retracting into the mediasti-num. This allows us to extend our resection more proxi-mally. It also reduces contamination at the time of surgeryas the distal esophagus is not open while performing theanastomosis. Because esophageal dissection is minimized,disruption of periesophageal tissue and blood supply isdecreased. We believe the double-stapling technique inproximal gastric tumors affords us the same advantages thatit does for low rectal tumors [17]. Intersecting staple linesdo not increase the rate of anastomotic failure [18].

We have used this technique in 3 patients. There havebeen no anastomotic leaks, and we have had no evidence ofclinical stenosis at a follow-up of 22 months. In our lastpatient, we encountered a problem when the anvil becameprematurely detached from the OG tube. It was retrievedusing an endoscope and external manipulation of the cervi-

Fig. 1. The anvil of the end-to-end anastomotic stapler is placed in theflanged end of no.16 oropharyngeal gastric tube and secured.

Fig. 2. After a small opening is made in the esophagus, the oropharyngealgastric tube is grasped and pulled until the anvil rests snugly against thestaple line.

Fig. 3. The end-to-end anastomotic stapler is introduced through a Roux-en-Y jejunal loop, anvil and stapler are approximated, and stapler is fired.

175J. Parker et al. / The American Journal of Surgery 182 (2001) 174–176

cal esophagus. We have since modified the technique byplacing a silk tie around the neck of the anvil and allowingthe string to exit through the mouth. In the event this wouldhappen again, we would be able to pull the anvil backthrough the oropharynx.

The method described involves techniques that havebeen used in resecting low rectal cancers, placing percuta-neous endoscopic gastrostomies, and performing laparo-scopic morbid-obesity procedures. We feel our modification

is safe, technically easier, and may allow for better resectionmargins with minimal tissue disruption.

References

[1] Cancer Statistics, 1998. CA Cancer J Clin 1998;48:10–11.[2] Sawyers J. Gastric carcinoma. Curr Prob Surg 1995;32:106–78.[3] Blot WJ, Devesa SS, Kneller RW, Fraumeni JF. Rising incidence of

adenocarcinoma of the esophagus and gastric cardia. JAMA 1991;265:1287–9.

[4] Jakl RJ, Miholic J, Koller R, et al. Prognostic factors in adenocarci-noma of the cardia. Am J Surg 1995;169:316–9.

[5] Harrison LE, Karpeh MS, Brennan MF. Total gastrectomy is notnecessary for proximal gasric cancer. Surgery 1998;123:127–30.

[6] Akiyama H, Miyazono H, Tsurumaru T, et al. Thoracoabdominalapproach for carcinoma of the cardia of the stomach. Am J Surg1979;137:345–52.

[7] Griffin SM, Chung SCS, Woods SDS, Li AKC. Adenocarcinoma ofthe cardia: treatment by thoracoabdominal R3 radical gastrectomy.Br J Surg 1990;77:937–39.

[8] Wayman J, Dresner SM, Raimes SA, Griffin SM. Transhiatal ap-proach to total gastrectomy for adenocarcinoma of the gastric cardia.Br J Surg 1999;86:536–40.

[9] Ellis HF, Gibb PS, Watkins E. Limited esophagogastrectomy forcarcinoma of the cardia. Indications, technique, and results. Ann Surg1988;208:354–61.

[10] King MR, Rairolero PC, Trastek VF, et al. Ivor Lewis esophagogas-trectomy for carcinoma of the esophagus: early and late functionalresults. Ann Thorac Surg 1987;44:119–22.

[11] Karl RC, Schreiber R, Boulware D, et al. Factors affecting morbidity,mortality, and survival in patients undergoing Ivor Lewis esophagec-tomy. Ann Surg 2000;231:635–43.

[12] Walther BS, Oscarson JEA, Graffner HOL, et al. Esoghagojejunos-tomy with the EEA stapler. Surgery 1986;99:598–603.

[13] Ikeda Y, Minagawa S, Koyanagi N, et al. Esophagojejunostomy withmanual single layer suturing after total gastrectomy for gastric cancer.J Surg Oncol 1997;66:127–9.

[14] Walther BS, Zilling T, Johnsson F, et al. Total gastrectomy andoesophagojejunostomy with linear stapling devices. Br J Surg 1989;76:909–12.

[15] Campion JP, Grossetti D, Launois B. Circular anastomosis stapler.Arch Surg 1984;119:232–3.

[16] Cebrian TE, Gimenez R, Fernandez FL, et al. Double stapling tech-nique for mechanical circular oesophagojejunal anastomosis aftertotal gastrectomy. Br J Surg 1994;81:408–9.

[17] Knight CD, Griffen FD. An improved technique for low anteriorresection of the rectum using the EEA stapler. Surgery 1980;88:710–14.

[18] Ravitch M. Intersecting staple lines in intestinal anastomoses. Sur-gery 1985;97:8–15.

Fig. 4. The open Roux-en-Y loop is stapled closed.

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