EAES Academy

Introduction

At the present stage of the development of esophageal surgery in the leading healthcare institutions in the World, esophagectomy is routinely performed by minimally invasive technology. There is no significant difference in the safety of many types of minimally invasive esophagectomy compared with open esophagectomy. Esophagogastric anastomosis reconstruction is an unresolved issue. Anastomosis formation is a technically complex manipulation and it has a high risk of postoperative complications, such as anastomotic leak or stricture [1]. They lead to a decrease in quality of life and death. The rate of the anastomotic leak remains extremely high (5–10%) and the mortality rate can reach up to 30% [2; 3; 4; 5]. Stricture of the esophageal-gastric anastomosis in the world literature on average occurs in 42% of cases and ranges from 3% to 72%. A newly systematic review and meta-analysis of comparison of different anastomotic techniques (hand-sewn [HS], circular stapled [CS], triangulating stapled [TS], or linear stapled/semimechanical [LSSM] techniques) demonstrated advantages of LSSM and recommended using this technic as the preferred one. However, the optimum technique is still disputable [6].
We developed a new LSSM anastomosis with invagination, implemented it in routine practice. Up to day, we have applied it in 26 patients treated by minimally invasive esophagectomy for esophageal carcinoma and benign esophageal strictures. We have recently conducted a retrospective evaluation of the surgical safety and feasibility of our technique of esophagogastric anastomosis. Therefore, this article describes the procedure and results of our study.
Aim
In our article we are pleased to present a new method of forming the esophagogastric anastomosis. According to our experience and literature data, the use of different techniques for the formation of esophageal-gastric anastomosis does not give a statistically desirable result. High rates of anastomosis laek, stricture and mortality against the background of severe complications encourage further optimization of existing techniques and the development of new ones. The developed anastomosis should improve the postoperative results of esophagectomy, reduce the frequency of anastomosis laek and stricture due to the use of a linear suturing apparatus, and intussusception of the anastomosis into the lumen of the gastric graft.
Material and methods
26 minimally invasive esophagostomies with invagination LSSM anastomosis were performed. In 20 patients (77%) of them, MIE was performed for esophageal carcinoma and six (23%) for benign esophageal diseases. In the study group, there were 21 (80%) men and 5 (20 %) women. The average age was 53 (47–64) years.
There were 14 patients (70%) patients with squamous cell carcinoma and six (30%) patients with adenocarcinoma. There were 11 patients (55%) with localization in the middle third and nine (45%) patients with localization in the lower third. Neoadjuvant chemoradiation was performed in nine (45%) patients. The inclusion criteria were the following: non-metastatic disease, the absence of signs of tracheobronchial invasion, and the absence of end-stage disease (Table 1).
All of the oncological patients were examined in the preoperative stage according to NCCN (National Comprehensive Cancer Network) [7]. Physical laboratory examination, ECG, ultrasound of the heart, esophagogastroscopy, EUS, chest CT and esophagogastric X-ray was performed in patients with benign esophageal diseases. The inclusion criteria were the following: no concomitant pathology, which could be a contraindication to major surgery, clinically insignificant previous endoscopic treatment, persistent dysphagia stage III–IV.
All patients underwent minimally invasive Ivor Lewis esophagectomy (laparoscopy+VATS). All surgeries were performed by the same surgeon. The following intraoperative and postoperative data were evaluated: time of intervention, blood loss volume, postoperative length of stay, anastomosis scar stricture. In the postoperative period, patients underwent a survey, endoscopic monitoring for the presence of the anastomosis scar stricture after one, three, and six months and the manifestations of reflux esophagitis. Evaluation of dysphagia degree was performed according to the Bown scale [8; 9].
Method of anastomosis:

A gastric isoperistaltic graft up to 4 cm wide is formed, which is supplied with blood through the right gastric, gastroepiploic, and intramural vessels. The graft is pulled up into the pleural cavity through the esophageal hiatus. Three seromuscular stitches are applied over 4 cm on both sides to the lateral surfaces of the esophagus posterior wall and gastric graft posterior wall, towards their edges, forming anastomosis “Side suture” (Fig. 1, 2). The formed sutures are tied so that the esophageal stump and the gastric graft are adjacent to each other for 4–5 cm with their posterior walls (Fig. 3).
The excess of the proximal part of the gastric graft is cut off at the level of the esophageal stump lumen. Two holding stitches are imposed on the distance of 1.5 cm from each other through all layers of the posterior wall of an anastomosis from the lumen (Fig. 4). Then holding stitches on a posterior wall are pulled up to place the linear stapler 30–40 mm deep (Fig. 5), stitch, and cut so that the posterior inner layer of sutures is formed (Fig. 6). The first layer of the anterior wall is sutured with a stapler (Fig. 7, 8). The next layer of sutures on the anastomosis anterior wall invaginates the esophageal stump into the gastric graft. Starting from the left edge of the anastomosis, the needle is inserted 2–2.5 cm from the inner layer capturing the seromuscular layer of the stomach and the adventitia with esophagus muscular layers. Normally 4–5 of such sutures are applied (Fig. 9). As a result, the esophagus is immersed in the gastric graft formed, up to 4–5 cm deep with no tension of the external sutures (Fig. 10).
The proposed method aims to form an invagination anastomosis with a depth of 30–40 mm. “Side suture” of the anastomosis applied to eliminate uneven immersion of the esophageal stump and strengthens the anastomosis. Holding stitches facilitate the stapler introduction. Due to the stapler use, a reliable three-layer line of the inner layer of the posterior and the anterior walls is swiftly formed. The invagination introduction allows the formation of a broad comparison of the esophageal adventitia and the stomach serous membrane. This provides greater reliability and tightness of the anastomosis, creates conditions for better healing, and prevents infection.
Extensive invagination anastomosis not only prevents anastomotic leak due to the wide area of comparison of the walls of the esophagus and stomach, but also reduces the likelihood of anastomotic stricture development due to edema or hypertrophic scarring, and has antireflux mechanisms that play an important role in reflux prevention.
To show the clinical effectiveness of the invagination semimechanical esophagogastric anastomosis, we present the following example.