Esophageal anastomotic techniques

Transcription

1 Esophageal anastomotic techniques Raphael Bueno, MD, Brigham and Women s Hospital Slide 1 Good afternoon, I would like thank the association and Dr and Dr for inviting me to speak today. Slide 2 I am trying to get as many disclosures as I can, but none of them is relevant to this talk. Conflicts are good! Slide 3 Let s start with anastomotic techniques for esophagectomy and for esophageal reconstruction the first question is why are they relevant, why does this matter? A couple of reasons, one of them is functional results. As we improve the outcomes of patients with esophageal cancer and patients who otherwise undergo esophagectomy, the quality of longterm swallowing becomes more important. An anastomotic technique has something to do with that. More immediate is addressing the complications that may occur with an anastomotic problem, which includes strictures, either early or late, leaks, and I should point out here that it is important to categorize the severity of the leak when you compare one to another, but even minor ones can lead downstream to strictures. Dehiscence can be caused by a significant leak or conduit necrosis. Tracheal esophageal fistula can be caused by misadventure during anastomosis, infection because of a leak, or dilatation because of a stricture so it is all related. Slide 4 Briefly, this Table, as with many of the pictures and Tables in this talk, are extracted from Price et al, the group at the Mayo Clinic. In the booklet I have listed most of the references. The references not listed in the booklet will have a star. This is adopted from Tony Lerut s work and papers, demonstrating the definition of the different grades of leaks. I think it is important when you are calling something a leak, to define whether it is minor or major. Slide 5 Speaking of leaks, what is the incidence of leaks in the literature? Here are a number of relatively recent publications. When you sum it all up, you get 6%, but if you look at a study recently published using the STS database, in about 2300 patients, 11.3% had some sort of a leak. Slide 6

2 How about strictures? Post-operative strictures are defined by the need for dilatation at some point, and come at a very high percentage, 28% in these papers. Slide 7 How do we make things better? Tony Lerut (he reviewed this talk for me) made the point that our goal should be to have zero complications. How long it will take us to get there is questionable but that should be everybody s goal here. A lot of the complications are surgeons caused or surgeons controlled. The conduit (usually the stomach) must be well vascularized, adequately mobilized, not too tight, treated very gently, both when you create it and when you bring it up, and make sure to eliminate or resect any potentially ischemic portion of the conduit. Some of us believe that you should just cut the tip off. The anastomosis needs to be adequately wide to avoid stricture problems down the road, and it needs to be closed securely. Slide 8 There are many factors that have been previously proposed and logically might affect an anastomosis. Some have been looked at by multivariant analysis and some were positive and some were not. There are physical restraints when you do an anastomosis that relate to how much room you have to use a particular stapler; how much tension you are allowed to create, affecting how much conduit you are going to use; and the distance available, particularly of the proximal esophagus, but sometimes the tight distal conduit when you make an anastomosis. The type of operation is going to have some impact. The type of conduit, and if you use gastric conduit, whether you use the whole stomach or just the tube. Avoid trauma when handling the conduit. The technique it is important to incorporate the mucosa and not to put too many sutures or staples. It may be useful to place coverage over the anastomosis such as the omentum. Certainly, the surgeon s experience will have something to do with the outcome, as may be blood loss, hypertension. And a question of whether the type of sutures (if you are going to use sutures) will affect it. Slide 9 There are also patient factors: nutritional status of the patient, prior therapy, existence of comorbid diseases such as diabetes, coronary artery disease, vascular disease, obesity and body habitus, particularly if you can t find a neck (which can happen), hypotension, hypoxemia during the operation, the gender has been found to contribute to increased complications in some studies, as has smoking history and prior history of surgery on the esophagus or the stomach. Slide 10 The anastomotic methods I ll discuss today include hand-sewn, linear-stapled, circularstapled and hybrid. Slide 11 This is the point where I am going to bring in the question for the audience. So the question is (give the best answer): Which factor is most likely to be predisposing to a leak? a. Tension, b. location (ie chest versus neck), etc., c. preop chemoradiation, or d. technique used. Good, it is not all one answer! Yes, it is a trick question, just like the Boards! We ll keep talking, I am

3 not going to give you an answer yet; this way you have to be awake for the rest of the talk. Slide 12 Now we are going to the religious sphere, where I could be excommunicated by some people for what I am going to say, even though it is based on data. The hand-sewn anastomosis can be multi-layer, single-layer and so on. I am showing here a double-layer hand-sewn anastomosis. This is not exactly the one I learned, I learned a Sweet anastomosis, which takes the outside suture 3-0 silk muscle layers and inside making sure to definitely take the esophageal mucosa and then the stomach and that is a continuous chromic or vicryl suture. Including the mucosa is important. Remembering that the esophagus has longitudinal muscle, it can easily tear, so you shouldn t have them all in the same groove. Usually, an end esophagus to side stomach. There actually have been studies showing interrupted versus running do not matter and you can use different types of sutures to accomplish this. Slide 13 Linear-stapled anastomosis this is the one I now most commonly use for a three-hole esophagectomy. What you see here is a cervical incision, essentially a side-to-side esophageal stapled anastomosis, followed by a TA-stapled anastomosis. A couple of pointers: the distance on the first staple should be at least 5 cm to give you a nice wide anastomosis; sometimes you can incorporate, and I were talking about it yesterday, you can incorporate in the TA stapler the tip of the stomach if you are concerned about ischemia. Slide 14 Some tips: Usually side-to-side. Make sure the conduit orientation is correct otherwise if you are rotating the conduit when you bring it up 45, 90, 360 you may knock off the circulation and you will cause a postoperative long-term disaster that you will need to deal with later on. The tension on the conduit should be just right; whether you do it in the chest or neck, you have to remember that you eventually, in the neck, pop it back in, and also in the chest, pop it a little back in, so don t make it too tight but don t make it too loose. If you make it too loose you have too much stomach in the chest, and that can cause obstruction at the level of the diaphragm that will require surgery later on. Avoid the tip because it is most likely to be more ischemic. If you can use the omentum that will be great. Make sure the anastomosis is not too narrow, however you do it. If you leave the tip in, you can pop in an NG tube and bring it out thru the neck for drainage. I ll show you a picture in a few seconds, the side-to-side can either be double barreled up-stapled like I showed you, or it can be up and down. Slide 15 In my view, you need to see as many of these options as possible, and this is a plug for the AATS Learning Center, which is a new feature of this meeting. It is going to be at the Exhibit Hall from tonight till Tuesday and there are several esophagectomy movies- they are all 10 min movies. You re welcome to look at different people doing that. Slide 16 Back to the picture. This is what I meant about up and down stapled anastomosis, which I abstracted from Maas et al. Slide 17

4 A circular-stapler anastomosis is more popular now with the minimally invasive Ivor-Lewis but can be used by others, where you basically pop in the anvil in the proximal esophagus and then put in the EEA stapler thru an area in the stomach that will become the specimen. Make sure it evens/lines up well and secure it. Slide 18 A couple of pointers: The anvil can be placed either in an open position (as seen on your right-hand of the picture) with a pursestring before cutting it (as seen below) or trans-orally. There are a couple of small studies showing that the trans-oral and the trans-thoracic approaches are equivalent in early outcome. My view, and the view of the Mayo Clinic paper Price et al. (that I mentioned before), is that the bigger the EEA the better, if you can use something bigger than 25 it is better. Usually to put it in you have to be very careful, sometimes you have to dilate the esophagus; you really have to start being concerned when you tear the esophagus because the tear, particularly if you make your anastomosis way high up, may make it impossible for you to do the anastomosis in the chest. As shown in the Figures that I abstracted from Maas et al., the anvil can be fixed by a pursestring or a suture or a tie. Slide 19 Then, the hybrid anastomosis (Tony Lerut kindly contributed to these pictures). You will notice a couple of things: this is a cervical anastomosis, the stapled part is just like this linearstapled anastomosis picture I showed you before, but notice Tony left some omentum up there and he will close the front part with one layer of sutures and gently shove it back in. When you do this there is a little tension but you gain a couple of centimeters by pushing everything into the neck and the chest. Slide 20 This is the reverse cervical anastomosis that Orringer writes about, where you lay the stomach thru a cervical incision below the esophagus and put a stapler as shown in (B) and then close the front with sutures. Slide 21 So, what are the data? This is some of the data comparing hand-sewn anastomosis with modified or hybrid stapled anastomosis. In essentially every case, the hand-sewn anastomosis has a higher incidence of leak Slide 22 and stricture. You see there is a varying rate of strictures and that is based on who is reporting it because not infrequently the patient will have a dilatation by their gastroenterologist 3 months later and you ll never know about it. Slide 23 Now, what about the difference between an anastomosis in the neck and in the chest? There are some data out there. Luketich looked at this minimally invasive series and divided the anastomosis in the neck and chest looking at the major complications. Here we are looking at leak, and we are looking at major leak. This is Grade III (remember the Tables I showed you earlier), and for significant leak requiring surgery the outcome is the same, for very minor

5 leaks (Grade I or II), it appears to be higher in the cervical anastomosis. Slide 24 How about stricture formation? Pham et al. looked at MIEs with thoracic versus cervical anastomosis. When they looked at strictures they see pretty much the same rate and there was no significant difference between the leak rates in this series as well. Slide 25 Since we are in Minnesota, I wanted to make sure to bring up the Mayo Group great paper; they looked from 2004 to 2007/8 at their esophagectomies and they looked at the different anastomoses. It is a very careful paper looking at 432 patients. I abstracted several Tables from this looking at the distribution of the complications. If you look at the leak and the grade of the leak in Table 4, you will notice there are more minor leaks in the cervical anastomosis but equivalent major leaks. Slide 26 When you look at the technique, you are seeing that, at least in this paper, in addition to the one we have seen before, that the hand-sewn anastomosis is more problematic in terms of complications than the stapler anastomosis. They concluded, amongst other things, that the linear-stapled anastomosis gave them the best result in that paper. Slide 27 I also looked to see if there is anything else influencing strictures and there is a very nice trial from Johansen in the Annals of Surgery from His group did a prospective randomized trial taking esophagectomy patients and randomized them to a control group of no postoperative PPIs and another group who received PPIs. Then, they followed them for development of dilatation and followed them endoscopically for 12 months on the drug. Slide 28 Remarkably, if you look at the log-rank test here, the control group that did not receive PPIs had a much higher incidence of strictures. Slide 29 In conclusion, there are accumulating data that hand-sewn anastomosis is associated with more complications but not higher mortality. Linear-stapled or modified anastomoses have fewer cervical or chest complications related to the anastomosis. Clinically significant leaks Grades III and Grade IV occur with the same frequency in the chest and neck, and that should not be used as a rationale to do one operation over another one. Size does matter: the Mayo Group found some increase in strictures with an EEA particularly when it was 25 or smaller. How you do the anastomosis, it depends. I think all surgeons should have the ability to do all the anastomoses I have just shown you because there are some cases where you are going to have to do a different anastomosis; either because you have done a 3-hole and you have to resect some more stomach and you have to do an MIE, or because you have a very proximal tumor and you have very little esophagus to anastomose. PPIs post-operatively should be seriously considered by all of us for these patients not just the symptomatic ones. Hopefully, I am not going to be excommunicated because evolution continues, dogma is incorrect, and change is always going to happen.