HOW TO DO IT Laparoscopic and Thoracoscopic Ivor Lewis Esophagectomy With Colonic Interposition Ninh T. Nguyen, MD, FACS, Marcelo Hinojosa, MD, Christine Fayad, BS, James Gray, BS, Zuri Murrell, MD, and Michael Stamos, MD Department of Surgery, University of California Irvine Medical Center, Orange, California Minimally invasive esophagectomy is a feasible and safe alternative to open esophagectomy. The stomach is the preferred conduit for gastrointestinal reconstruction after esophagogastrectomy; however, if the stomach is not usable, the colon can be interposed as an alternative conduit. We describe the technique of minimally invasive Ivor Lewis esophagogastrectomy in a patient with a gastric cardia cancer involving the gastric body and distal esophagus. Laparoscopic colonic interposition using the right colon based on the middle colic vessels was used to restore gastrointestinal continuity. (Ann Thorac Surg 2007;84:2120 4) 2007 by The Society of Thoracic Surgeons Surgical treatment of the proximal stomach cancer is complex. The surgical options for treatment are tailored according to the proximal and distal extent of the cancer. Patients with gastric cardia cancer without involvement of the esophagus who have significant involvement of the gastric body may be a candidate for total gastrectomy with Roux-en-Y esophageal-jejunal reconstruction. Patients with isolated gastric cardia cancer without involvement of the esophagus or the gastric body may be a candidate for an Ivor Lewis esophagogastrectomy with the use of a gastric tube for reconstruction [1]. If feasible, the stomach is always the preferred conduit to obtain gastrointestinal continuity [2]. In patients who have gastric cardia cancer with involvement of the gastric body and distal esophagus in which the stomach will not be usable for restoring esophageal continuity, the colon may be used as an alternative conduit. Minimally invasive esophagectomy has been introduced at selected institutions. At first, minimally invasive esophagectomy was done by a laparoscopic transhiatal technique with construction of a cervical anastomosis. Subsequently the laparoscopic and thoracoscopic esophagectomy technique with construction of a cervical anastomosis and the laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy were described [1, 3, 4]. The preferred conduit in these series continues to be the gastric tube. Colonic interposition poses a challenging operation, particularly if the esophagogastrectomy is performed using laparoscopic techniques. In this report, we describe our technique of a minimally invasive Ivor Lewis esophagogastrectomy with colonic interposition for the treatment of gastric cardia cancer with involvement of the distal esophagus. Accepted for publication March 26, 2007. Address correspondence to Dr Nguyen, Department of Surgery, 333 City Bldg West, Suite 850, Orange, CA 92868; e-mail: ninhn@uci.edu. Technique A 43-year-old Hispanic male presented with dysphagia caused by a malignancy extension from the gastric cardia into the esophagus approximately 39 cm from the incisors. The retroflex endoscopic view showed a large circumferential mass involving the gastric cardia with extension to the gastric fundus and gastric body. An endoscopic biopsy showed poorly differentiated adenocarcinoma. Work-up included an endoscopic esophageal ultrasound, which showed a T3N1 lesion at the distal esophagus, and a computed tomography of the chest and abdomen showed a large gastric cardia mass without liver metastasis. The need for an esophagogastrectomy for restoration of swallowing and possible cure was discussed with the patient. Because there is cancer involvement of the distal esophagus, a total gastrectomy with Roux-en-Y jejunal reconstruction will not be able to obtain a clear proximal margin without excessive tension on the reconstructed anastomosis. We planned a laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy with colon interposition to establish esophageal continuity to ensure clear proximal and distal margins from the carcinoma (Fig 1). A preoperative colonoscopy and computed tomographic angiogram were performed to evaluate the colon and patency of the middle colic vessels. The patient underwent a Nichols bowel preparation with anaerobic coverage the day prior to the operation. Abdominal Phase of Minimally Invasive Ivor Lewis Esophagogastrectomy The patient was intubated with a double-lumen tube for single lung ventilation. The procedure began laparoscopically with the patient in the supine position. Five abdominal trocars were introduced (Fig 2). The hepatogastric ligament was divided and the left gastric vessels leading to the gastric pouch were exposed. A celiac lymphadenectomy was performed en bloc, and the gas- 2007 by The Society of Thoracic Surgeons 0003-4975/07/$32.00 Published by Elsevier Inc doi:10.1016/j.athoracsur.2007.03.091
Ann Thorac Surg HOW TO DO IT NGUYEN ET AL 2007;84:2120 4 MINIMALLY INVASIVE IVOR LEWIS ESOPHAGOGASTRECTOMY 2121 vessels. The transverse colon was divided proximal to the splenic flexure. The transected terminal ileum was reanastomosed to the transverse colon proximal to the colonic splenic flexure. An enterotomy was made in both the transverse colon and terminal ileum. A side-to-side anastomosis was performed using a 60-mm linear stapler. The remaining enterotomy was closed with a running suture in two layers, and the mesenteric defect was closed (Fig 3). Esophageal continuity was established first by construction of a colonic gastric anastomosis. The distal aspect of the transverse colon conduit was anastomosed to the residual prepyloric gastric remnant. An enterotomy was made in both the gastric remnant and the colonic conduit. A side-to-side anastomosis was constructed using a 60-mm linear stapler. The remaining enterotomy was closed with a running suture in two layers. The distal esophagus was mobilized circumferentially for a segment of 6 cm into the mediastinum. Due to the large size of the gastric mass, the tumor mass was removed transabdominally rather than transthoracically. The esophagus was divided at 4 cm proximal to the gastroesophageal junction. The tip of the cecum was Fig 1. Laparoscopic esophagogastric cancer with planned level of distal resection and colonic interposition. tric vessels were divided at their origin from the celiac trunk with a linear stapler. The greater curvature of the stomach was mobilized by dividing the gastrocolic omentum. The mobilization continued toward the gastric fundus by dividing the short gastric vessels and also toward the first portion of the duodenum. The right gastroepiploic vessels were divided and the stomach was divided distally leaving a small gastric remnant above the pylorus. An intraoperative frozen section of the distal margin was obtained and was clear of carcinoma. A partial omentectomy was also performed. The right colon was mobilized by dividing the white line of Tolt and the hepatic flexure. The entire transverse colon and splenic flexure were also mobilized. The terminal ileum was divided 4 cm proximal to the ileocecal valve. The ileocolic vessels were divided with the linear stapler. The mesentery of the right colon was divided with bipolar cautery. The blood supply for the right and transverse colon segment was based on the middle colic Fig 2. Laparoscopic port position for minimally invasive extended esophagogastrectomy with colonic interposition.
2122 HOW TO DO IT NGUYEN ET AL Ann Thorac Surg MINIMALLY INVASIVE IVOR LEWIS ESOPHAGOGASTRECTOMY 2007;84:2120 4 Fig 3. Laparoscopic mobilization of right and transverse colon with construction of an ileocolic anastomosis. Thoracic Phase of Minimally Invasive Ivor Lewis Esophagogastrectomy With Colonic Interposition The patient was then repositioned in a left lateral decubitus position. Under single-lung ventilation, four thoracic trocars were introduced in the right thoracic cavity. A wound protector was placed at one of the thoracic trocars in preparation for introducing the circular stapler. The inferior pulmonary ligament was divided. The mediastinal pleura overlying the distal esophagus were divided until the Penrose drain was visualized. The Penrose drain around the distal esophagus was identified and used for esophageal retraction during mobilization of the thoracic esophagus up to the level of the azygous vein. The remaining distal esophagus and the attached right colon were pulled through the esophageal hiatus into the right chest. The esophagus was divided immediately below the level of the azygous vein. The esophageal surgical specimen was separated from the colonic conduit and removed through the 2.5-cm trocar site. A 25-mm anvil was inserted transthoracically and placed into the esophageal stump. The anvil was secured with a pursestring suture. An enterotomy was created at the terminal ileum. The ileocecal valve was dilated with a 10-mm instrument. A 25-mm circular stapler was placed transthoracically through the 2.5-cm trocar incision and positioned through the terminal ileum into the side wall of the cecum in preparation for construction of the esophagocolonic anastomosis. The anvil from the esophageal stump was connected to the circular stapler and an esophagocolonic anastomosis was performed. The stapled anastomosis was reinforced with a second layer of interrupted Lembert sutures. A nasogastric tube was inserted into the colonic conduit. The enterotomy at the terminal ileum was closed with a linear stapler and oversewn with a second layer of running Lembert suture (Fig 5). An appendectomy was also performed using the linear staplers. A 28-French chest tube and a 10-French Blake drain (Johnson & Johnson Gateway, Livingston, UK) were inserted for postoperative drainage. The operative time was 4 hours for the laparoscopic portion of the procedure and 2 hours for the thoracoscopic portion. The estimate blood loss was 100 ml. No intraoperative or postoperative blood transfusion was required. Grossly, the esophagus has adenocarcinoma sutured to the esophageal stump in preparation for a colonic pull-up (Fig 4). A Penrose drain was placed circumferentially around the distal esophagus and left in the mediastinum for retrieval in the chest. The 12-mm trocar incision was extended to 4 cm to accommodate the gastric mass. A plastic wound protector was placed to protect the wound from direct contact with the tumor. The large esophagogastric mass was removed and the fascia layer was closed with interrupted sutures. A needle catheter jejunostomy tube was placed at the proximal jejunum. Fig 4. Laparoscopic construction of the gastrocolic anastomosis. The cecum is attached to the esophageal stump in preparation of thoracic colonic pull-up.
Ann Thorac Surg HOW TO DO IT NGUYEN ET AL 2007;84:2120 4 MINIMALLY INVASIVE IVOR LEWIS ESOPHAGOGASTRECTOMY 2123 Fig 5. Schematic diagram of the extended esophagogastrectomy with colonic interposition. There are three anastomoses: (1) ileocolic anastomosis, (2) gastrocolic anastomosis, and (3) esophagocolic anastomosis. An appendectomy was performed in the right chest. Inset represents construction of the esophagocolic anastomosis using a circular stapler. involvement to 3 cm above the gastroesophageal junction. Histologic findings confirmed poorly differentiated carcinoma with esophageal involvement. The proximal and distal margins were negative for carcinoma. Sixteen of 18 lymph nodes had cancer involvement. Fig 7. Postoperative abdominal x-ray film showing the descending colon on the left with the entire small bowel on the right side of the abdomen. The patient was extubated in the operating room and transferred to the intensive care unit. Patient-controlled analgesia with morphine infusion was used for pain control. The patient was transferred to the surgical floor on postoperative day 2 when an enteral tube feeding was started. A gastrograffin contrast study was performed on postoperative day 5 and demonstrated no leak or obstruction (Figs 6, 7). Both the nasogastric and chest tubes were removed and the patient was discharged home on postoperative day 7. The patient was readmitted 5 weeks postoperatively for nausea and fever to 38 C. Chest computed tomographic scan showed a 3-cm intrathoracic collection without any evidence of anastomotic leak. The patient underwent percutaneous drainage of purulent fluid with pigtail catheter placement with successful resolution, and the patient was discharged. The patient is now doing well and receiving adjuvant chemoradiation therapy. Fig 6. Postoperative upper gastrointestinal contrast study showing the colonic interposition in the right chest cavity. Comment We describe our technique of laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy with colonic interposition for the treatment of a large esophagogastric cancer involving the gastric body, rendering the stomach unusable as a conduit for reconstruction. The need for colon interposition is uncommon, but the colon is a time-tested alternative option if the stomach cannot be used for gastrointestinal continuity [5].
2124 HOW TO DO IT NGUYEN ET AL Ann Thorac Surg MINIMALLY INVASIVE IVOR LEWIS ESOPHAGOGASTRECTOMY 2007;84:2120 4 Some of the advantages of a colonic interposition compared with gastric pull-up are the lack of regurgitation and reflux esophagitis [6]. However, an esophagogastrectomy with colonic interposition is a technically demanding operation and can be associated with higher morbidity and mortality compared with the use of the stomach as the conduit [7, 8]. Isolauri and colleagues [8] reported one of the largest experiences with open colonic interposition with 248 patients in whom the mortality rate was 16% and the incidence of colon graft necrosis was 3%. We believe there has been no previous report of colonic interposition performed by using a laparoscopy. Building on our experience with minimally invasive esophagectomy and laparoscopic colon resection, we devised our technique of minimally invasive Ivor Lewis esophagogastrectomy with colonic interposition. Minimally invasive esophagogastrectomy with colonic interposition may reduce the morbidity and mortality associated with this complex operation. In our patient, the initial approach was the use of laparoscopy for evaluation of the gastric cardia cancer, particularly the proximal and distal extent of the cancer. Endoscopy was also intraoperatively performed to localize the site of the tumor and its extension. Once we determined that the stomach could not be used as a conduit for reconstruction, a wide resection of the stomach was performed to obtain good distal margins. In our case, the decision to keep the pylorus was based on the fact that there is a lower risk for anastomotic disruption with construction of a gastrocolic anastomosis compared with construction of a duodenal-colic anastomosis. The right colon was chosen to be the conduit with the vascular supply based on the middle colic vessels. One of the disadvantages of using the right colon as the conduit is the size discrepancy between the esophagus and cecum; however, an advantage of using the right colon is the long length of the conduit and dependable blood supply [8, 9]. A postoperative intrathoracic abscess that likely resulted from spillage of colon contents during construction of the esophago-colic anastomosis developed in this patient. In retrospect, copious antibiotic irrigation of the thoracic cavity may have prevented this complication. In summary, minimally invasive Ivor Lewis esophagogastrectomy with colonic interposition is technically feasible and safe. In this report we describe the technique of extended esophagogastrectomy with gastrointestinal reconstruction using the right colon based on the middle colic vessels. This minimally invasive procedure is technically demanding, requiring extensive experience in minimally invasive esophageal surgery and laparoscopic colon surgery that can be obtained at centers with a high volume of esophageal and colon operations. References 1. Nguyen NT, Follette DM, Lemoine PH, et al. Minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg 2001; 72:593 6. 2. Cense HA, Visser MR, van Sandick JW, et al. Quality of life after colon interposition by necessity for esophageal cancer replacement. J Surg Oncol 2004;88:32 8. 3. Luketich JD, Alvelo-Rivera M, Buenaventura PO, et al. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Thorac Surg 2003;238:486 95. 4. Nguyen NT, Roberts P, Follette DM, et al. Thoracoscopic and laparoscopic esophagectomy for benign and malignant disease: lessons learned from 46 consecutive procedures. J Am Coll Surg 2003;197:902 13. 5. Renzulli P, Joeris A, Strobel O, et al. Colon interposition for esophageal replacement: a single-center experience. Langenbecks Arch Surg 2004;389:128 33. 6. Yildirim S, Koksal H, Celayir F, et al. Colonic interposition vs. gastric pull-up after total esophagectomy. J Gastrointest Surg 2004;8:675 8. 7. Cerfolio RJ, Allen MS, Deschamps C, et al. Esophageal replacement by colon interposition. Ann Thorac Surg 1995;59: 1382 4. 8. Isolauri J, Markkula H, Autio V. Colon interposition in the treatment of carcinoma of the esophagus and gastric cardia. Ann Thorac Surg 1987;43:420 4. 9. Furst H, Hartl WH, Lohe F, et al. Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. Ann Surg 2000;231:173 8.