Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.

Abstract

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.
The PubMed electronic database was used for comprehensive literature search by two independent reviewers.
Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.
This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.

Full text

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REVIEWS
Minimally invasive intrathoracic anastomosis after Ivor Lewis
esophagectomy for cancer: a review of transoral or transthoracic
use of staplers
K. W. Maas•S. S. A. Y. Biere•J. J. G. Scheepers•
S. S. Gisbertz•V. Turrado Rodriguez•
D. L. van der Peet•M. A. Cuesta
Received: 23 May 2011/Accepted: 20 December 2011/Published online: 1 February 2012
? The Author(s) 2012. This article is published with open access at Springerlink.com
Abstract
Background
tomy is one of the approaches used worldwide for treating
esophageal cancer. Optimization of this approach and
especially identifying the ideal intrathoracic anastomosis
technique is needed. To date, different types of anasto-
mosis have been described. A literature search on the
current techniques and approaches for intrathoracic anas-
tomosis was held. The studies were evaluated on leakage
and stenosis rate of the anastomosis.
Methods
The PubMed electronic database was used for
comprehensive literature search by two independent
reviewers.
Results
Twelve studies were included in this review. The
most frequent applied technique was the stapled anasto-
mosis. Stapled anastomoses can be divided into a trans-
thoracic or a transoral introduction. This stapled approach
can be performed with a circular or linear stapler. The
reported anastomotic leakage rate ranges from 0 to 10%.
The reported anastomotic stenosis rate ranges from 0 to
27.5%.
Conclusions
This review has found no important differ-
ences between the two most frequently used stapled anas-
tomoses: the transoral introduction of the anvil and the
transthoracic. Clinical trials are needed to compare differ-
ent methods to improve the quality of the intrathoracic
anastomosis after esophagectomy.
Minimally invasive Ivor Lewis esophagec-
Keywords
Ivor Lewis ? Intrathoracic ? Anastomosis ? Minimally
invasive
Oesophageal ? Thoracoscopy ? Esophagus ?
Despite the important development of the minimally
invasive approach of esophageal cancer, esophagectomy is
still associated with a significant risk of perioperative
morbidity [1]. After a successfully performed esophageal
resection, the creation of a safe anastomosis is essential to
reduce the risk of leakage and related complications.
There is an important trend to anastomose the gastric
tube with the intrathoracic esophagus, the so-called Ivor
Lewis operation [2]. Risk for anastomotic leakage in the
thorax with possibly fatal consequences has resulted in the
development of the three-stage approach with a cervical
anastomosisby McKeown
approach with a cervical anastomosis by Orringer and
Sloan [4]. In case of anastomotic leakage in the neck, a
subsequent cervical fistula is a manageable complication
[5]. There is, however, some evidence that cervical anas-
tomosis could be related to more anastomotic leakage and
stenosis [6]. Currently, the increased numbers of gastro-
esophageal junction tumors form an ideal indication for an
Ivor Lewis procedure. This approach may reduce recurrent
nerve lesion and other complications associated with a
cervical dissection. Moreover, a shorter gastric conduit
will permit a more extended gastric resection and will,
because of a good vascular supply, lead to less anasto-
motic leakages. This transthoracic procedure may be
performed by a conventional or minimally invasive
approach.
The question is which type of intrathoracic anastomosis
is the ideal. According to the review of Blackmon et al. [7],
[3], and thetranshiatal
K. W. Maas ? S. S. A. Y. Biere ? J. J. G. Scheepers ?
S. S. Gisbertz ? V. Turrado Rodriguez ? D. L. van der Peet ?
M. A. Cuesta (&)
Department of Surgery, VU University Medical Center,
De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
e-mail: ma.cuesta@vumc.nl
123
Surg Endosc (2012) 26:1795–1802
DOI 10.1007/s00464-012-2149-z
and Other Interventional Techniques

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stapled anastomosis in conventional surgery will have less
leakages and stenosis than the manual anastomosis.
In this paper, all different techniques used for intratho-
racic anastomosis in minimally invasive Ivor Lewis
esophagectomy have been reviewed showing small differ-
ences concerning leakages and stenosis. Due to the
increased implementation of the use of minimally invasive
surgery for esophageal resection and the number of distal
adenocarcinomas and gastroesophageal junction tumors,
the ideal anastomosis has still to be found.
Methods
The PubMed electronic database was used for literature
search. A comprehensive search was performed using the
following terms: esophagus, esophagectomy, anastomosis,
intrathoracic, cancer, Ivor Lewis, minimally invasive, MIE,
laparoscopy, thoracoscopy, and esophagogastric. Related
terms and combinations also were used (e.g., thoracic,
esophagectomy).
Relevant titles were identified and abstracts were read to
decide eligibility. When the information in the title and
abstract met the objectives of this review, the full article
was read. A manual cross-reference search of the refer-
ences of the relevant articles was performed to identify
studies beside the computerized search. Furthermore, the
‘‘related articles’’ feature of PubMed was used. Two
reviewers (KWM and SSAYB) executed the search inde-
pendently of each other.
Results
Intrathoracic anastomoses can be accomplished by a
handsewn or stapler technique (Fig. 1). Twelve studies
were included in this review to analyze the different
techniques. Tables 1 and 2 depict the study characteristics,
anastomotic outcomes, and complications. The reported
anastomotic leakage rate ranges from 0 to 10% and the
anastomotic stenosis from 0 to 27.5%, showing no differ-
ences between the type of anastomosis. Compared with the
open Ivor Lewis operation, the range of complications were
0–4% for anastomotic leakage and 14.3–28.6% for anas-
tomotic stenosis [8, 9].
Handsewn technique
The first description of a totally endoscopic Ivor Lewis
esophagectomy with an intrathoracic anastomosis was
reported in 1999 by Watson et al. [10]. The thoracoscopic
phase of the operation was performed in the prone position.
They described two patients in which the intrathoracic
Fig. 1 Overview of minimally
invasive anastomosis techniques
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anastomosis was achieved with a handsewn single-layer
technique. Both patients recovered without complications
and with a short hospital stay.
Ten years later, Cadiere et al. [11] described a totally
minimally invasive Ivor Lewis esophagectomy with
handsewn anastomosis. The patient was operated through
right thoracoscopy in the prone position and laparoscopy.
No postoperative complications were reported in this case
report. An illustration of the handsewn intrathoracic anas-
tomosis technique is shown in Fig. 2.
Table 1 Study characteristics
Study No.
patients
Surgical approachPatients positiona
Anastomotic
technique
Type of
anastomosis
LayersFixation of anvil
Watson et al.
(1999) [10]
2 TransthoracicProne position HandsewnEnd-to-sideSingle
layer
NA
Cadiere et al.
(2010) [11]
1Transthoracic Prone positionHandsewn Side-to-endTwo
layers
NA
Lee et al. (1997)
[12]
8 Transhiatal and
transthoracic
45? Semilateral
position
Circular stapledEnd-to-sideNAPursestring
Nguyen et al.
(2001) [15]
1TransthoracicLeft lateral
decubitus position
Circular stapled End-to-side NAHandsewn
pursestring
Misawa et al.
(2005) [17]
5Transthoracic Left lateral
decubitus position
Circular stapledEnd-to-sideNAPursestring
Endo-stitch
Bizekis et al.
(2006) [18]
50 TransthoracicLeft lateral
decubitus position
Circular stapledEnd-to-sideNANR
Thairu et al.
(2007) [19]
18Transthoracic Prone position Circular stapledEnd-to-sideNA Linear staple gun
and Z-stitch
Sutton et al. (2002)
[21]
10Transhiatal Supine position Transorally
circular stapled
End-to-side NANR
Nguyen et al.
(2008) [22]
51TransthoracicLeft lateral
decubitus position
Transorally
circular stapled
End-to-side NANR
Campos et al.
(2010) [23]
37TransthoracicNR Transorally
circular stapled
End-to-sideNA NR
Ben-David et al.
(2010) [24]
6Transthoracic Left lateral
decubitus position
Linear stapledSide-to-side NANR
Gorenstein et al.
(2011) [25]
31Transthoracic Left lateral
decubitus position
Linear stapledSide-to-sideNA NR
aDuring performance of anastomosis
NA not applicable; NR not reported
Table 2 Anastomotic outcome
in minimally invasive and open
Ivor Lewis esophagectomy
aConventional open
esophagectomy
Study No. patientsAnastomotic leakAnastomotic stenosis
Watson et al. (1999) [10]200
Cadiere et al. (2010) [11]100
Lee et al. (1997) [12]801 (12.5%)
Nguyen et al. (2001) [15]100
Misawa et al. (2005) [17]500
Bizekis et al. (2006) [18] 503 (6%) 6 (12%)
Thairu et al. (2007) [19] 180Not reported
Sutton et al. (2002) [21]101 (10%)Not reported
Nguyen et al. (2008) [22]51 5 (9.8%)14 (27.5%)
Campos et al. (2010) [23]371 (2.7%) 5 (13.5%)
Ben-David et al. (2010) [24]6 Not reported0
Gorenstein et al. (2011) [25]
Chasseray et al. (1989)a[8]
Walther et al. (2003a) [9]
311 (3.2%)Not reported
492 (4%) 7 (14.3%)
42012 (28.6%)
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Stapled technique
Transthoracic circular stapled anastomosis
In 1997, Lee et al. [12] described a one-stage right lateral
thoracoscopic esophagectomy with intrathoracic stapled
anastomosis in a series of eight patients with carcinoma of
the lower esophagus. The operation was performed with a
double-lumen tracheal tube to enable collapse of the right
lung. The patient was placed in 45 position with the right
side up. A two-team synchronous approach was used: one
for the abdominal stage to perform the mobilization of the
stomach through a transverse incision laparotomy, and the
other team performed the thoracoscopic approach. Esoph-
agogastric anastomosis was fashioned by a stapling device
using the ligature method described by Allsop and Ng
[13, 14]. A right-angled clamp inserted by the abdominal
surgeon through the hiatus was applied onto the esophagus
just proximal to the lesion. A transverse incision in the
esophagus was placed, with adequate margin, above the
tumor. The abdominal surgeon inserted the anvil (28-mm
circular stapler) into the thoracic cavity through the hiatus
and introduced it into the lumen of the esophagus. A Vicryl
ligature was applied around the esophagus by means of
Roeder’s knot to fix the anvil in the proper position and the
esophagus divided as illustrated in Fig. 3. The cardio-
esophageal junction was transacted with a GIA linear sta-
pler and through a transverse gastrostomy the circular
stapler was inserted, the stomach introduced into the tho-
rax, and the anastomosis performed. The operation was
successful in seven patients, and the remaining patient
required conversion to thoracotomy. No leakages were
recorded. On short term, one patient developed a benign
stenosis that required dilatation.
The anastomosis technique described by Nguyen et al. in
2001 [15] in a case report was performed through a right
lateral thoracoscopy with lung block. After the laparoscopic
phase, the esophagus was dissected by thoracoscopy and
divided with the stapler 2 cm below the azygos vein. The
esophageal specimen was retrieved through an enlarged
(4 cm) posterior trocar site. Using this small incision, the
anvil of 21- or 25-mm circular stapler was placed into the
chest and inserted through the opening of the esophagus and
secured with a handsewn pursestring suture. The circular
Fig. 3 Fixation of the anvil by
a Roeder’s Knot (in line
illustrations by M.A. Cuesta)
Fig. 2 Handsewn intrathoracic
anastomosis (in line illustrations
by M.A. Cuesta)
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stapler was introduced into the chest and passed through an
anteriorgastrostomyofthegastricconduit.Astapledend-to-
side esophagogastric anastomosis was made. Most of the
techniques described for circular stapled anastomosis are
similar to this technique [16].
During the next years, new techniques have been
described to facilitate the placement of the anvil in the
proximal esophagus. Misawa et al. [17] approached the
esophagus, after the laparoscopic phase, through a lateral
right thoracoscopy in five patients with cancer of the
middle and lower thoracic esophagus. A 5-cm-long thora-
cotomy was made on the fifth intercostal space. After
mobilization of the esophagus, the level of transection was
decided and the distal esophagus tied with a 2-0 ligature.
The esophageal wall was anteriorly opened and two clamps
grasped the esophageal edges allowing the Endo-Stitch?
(US Surgical) device for achieving a pursestring suture.
After this, the anvil of a 25-mm circular stapler was
introduced into the proximal esophagus and the pursestring
tied. An Endoloop?ligature was placed over the purse-
string to reinforce it (Fig. 4). After retrieval of the distal
esophagus with the lesion, the proximal end of the gastric
tube was pulled out of the minithoracotomy and the cir-
cular stapler was introduced through it into a gastrostomy
incision. No leakage or other postoperative complications
were observed after this procedure.
Bizekis et al. [18] reported their experience with mini-
mallyinvasiveIvorLewisesophagectomyin50patients,the
majority with tumors with extension into the cardia or a
gastroesophageal junction tumor. Thirty-five patients
underwent a hybrid Ivor Lewis procedure, defined as lapa-
roscopic gastric mobilization combined with a 5-cm mini-
thoracotomy,andtheother15underwentthetotalminimally
invasive approach. In the total minimally invasive proce-
dure, after mobilization the esophagus was transacted
2–3 cm above the azygos vein, and an inferior intercostal
portsitewasenlargedtoallowtheintroductionofthecircular
staplerandforretrievalofthespecimen.A25-mm anvilwas
placed intothe proximalesophagusandsecured bymeansof
a pursestring suture (Endo-stitch, US Surgical). The stapler
was introduced into the gastric conduit and a circular anas-
tomosis was created in a side-to-end fashion. The redundant
gastric conduit was removed by using a linear stapler. In the
hybrid procedure, after the laparoscopic phase, the patient
was placed in the lateral position and a 5-cm minithoracot-
omy performed. A rib retractor was placed and the thoracic
esophagus mobilized under direct vision. A stapled esoph-
agogastric anastomosis was created in the same fashion.
There were three anastomotic leaks in the hybrid group: one
empyema not related to leak, one chylothorax, and one
pulmonary embolism. They observed 6% mortality. More-
over, six patients developed stenosis of the anastomosis,
being dilated postoperatively.
To obviate the necessity of the placement of a pursestring
sutureoramanuallytiedknottosecuretheanvil,Thairuetal.
[19]describedatechniqueinwhichtheheadoftheanvilwas
inserted through the anterior wall of the esophagus, opened
withdissectingscissors.Alinearstaplewasfiredat60?tothe
longitudinal axis first right and after left to the spike of the
anvil thus forming a V. Around this aperture a Z-stitch was
placed,whichsecuredtheanvilinplace,followedbyanend-
to-sideanastomosis.Usingthistechniquein18patients,they
observed no anastomotic leaks postoperatively. No midterm
results were reported (e.g., stenosis).
Transoral circular stapled anastomosis
An important development is the introduction of the anvil
transorally into the proximal esophagus, as described origi-
nally by Wittgrove et al. [20] for the gastrojejunostomy
Fig. 4 Fixation of the anvil by
purse-string using the
Endostitch (in line illustrations
by M.A. Cuesta)
Surg Endosc (2012) 26:1795–18021799
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construction of the gastric bypass in bariatric surgery after
the initial work of Sutton et al. in 2002 using a self-adopted
circular anvil system [21].
Nguyen et al. [22] described the transoral technique in a
series of ten patients to perform the intrathoracic anasto-
mosis after esophageal resection. A commercially available
prepared pretilted anvil’s head tip was attached to an oral-
gastric tube that was given to the anesthesiologist. The tilted
configuration of the anvil improved the ease of transoral
passage. After the transection of the esophagus by means of
linearstapler,thetubewaspassedtransorallyuntilitwasfelt
within the proximal esophageal stump. A small opening at
this level was made perpendicular to the staple line and the
tube was advanced through it and withdrawn until the anvil
was in the right position at the end of the esophageal stump.
The oral-gastric tube was removed after cutting the suture
that attached it to the anvil. The head of the anvil returned to
the flat position when attached to the spike of the 25-mm
circular stapler to perform the anastomosis (Fig. 5). The
authors applied the technique without passage problems in
ten patients. Moreover, tissue donuts were complete in all
cases and there were no postoperative leaks.
Campos et al. [23] confirmed the good results using the
transoral anvil technique in 37 patients with a distal esoph-
ageal cancer. After the laparoscopic approach in 81% of the
patients, the thoracic portionwas performed usinga muscle-
sparing minithoracotomy in 23 patients (62%) and total
thoracoscopic approach in 14 patients (37%). There were no
intraoperative technical failures of the anastomosis or
deaths. Five patients developed strictures (13.5%), and all
were successfully treated with endoscopic dilatations. One
patient had an anastomotic leak (2.7%) that was treated by
reoperation and endoscopic stenting of the anastomosis.
Side-to-side stapled anastomosis
Ben-David et al. [24] described in 2010 six patients with
gastroesophagealjunctioncancers inwhom after
laparoscopic dissection and formation of the gastric con-
duit, the thorax was approached through a lateral right
thoracoscopy. After dissection, the esophagus was divided
at the level of the azygos vein using a 60-mm stapler. The
transacted proximal esophagus and gastric conduit were
aligned with sutures. An esophagostomy was created at the
distal end of the transacted esophagus and a gastrostomy
performed proximal of the end of the gastric conduit. With
the aid of traction sutures, a side-to-side 6-cm linear sta-
pled esophagogastrostomy was performed. After this, the
common opening was closed with a running suture. There
were no leakages of anastomosis or other postoperative
complications. At a median follow-up of 9 months, no
postoperative strictures were reported.
Gorenstein et al. [25] described a slight different side-
to-side anastomosis technique in which the proximal
esophagus was not stapled, and used the whole lumen for
the construction of the side-to-side anastomosis by means
of a linear stapler. Once a 4-cm anastomosis was con-
structed, the anterior defect was closed. Of the 31 patients
operated on with this approach, one developed leakage that
required reoperation. There were no other anastomotic
complications. The side-to-side technique for stapled
intrathoracic anastomosis is illustrated in Fig. 6.
Discussion
Despite the new developments (e.g., minimally invasive
surgery), esophagectomy for cancer is still associated with
a significant risk of perioperative morbidity and mortality
[1, 4]. To reduce morbidity and mortality, it is important at
the end of the procedure to create a safe gastric conduit-
esophageal anastomosis with low risk of leakage.
With the increase of gastroesophageal junction tumors,
the Ivor Lewis type of resection with intrathoracic anas-
tomosis is increasingly being used. A shorter gastric con-
duit will permit an extended gastric resection and a
Fig. 5 Transoral introduction
of anvil by gastric tube (in line
illustrations by M.A. Cuesta)
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well-vascularized
invasive esophageal resection is increasingly implemented
with potential benefits of having less pain, less respiratory
infection, and reduced intensive care unit stay, preserving
the completeness of the resection. The combination of Ivor
Lewis esophagectomy with minimally invasive surgery has
the potential to improve the postoperative outcome.
There is more interest for stapler esophageal anasto-
mosis in literature than handsewn techniques [7, 26]. Sta-
pled anastomosis in the thoracic cavity has been supported
by Blackmon et al. [7] who analyzed three techniques of
intrathoracic esophagogastric anastomosis: handsewn, cir-
cular stapled, and side-to-side stapled anastomosis. In this
matched analysis, no significant differences were reported
concerning anastomotic leakage. However, a higher inci-
dence of dysphagia and a fourfold higher incidence of
stricture were seen after the handsewn technique. More-
over, no differences were reported for both circular stapled
and side-to-side stapled methods. This study suggests a
clearly superior role of the stapler technique for gastro-
esophageal anastomoses.
This review summarizes the different techniques used to
perform a safe intrathoracic anastomosis after an Ivor
Lewis thoracoscopic procedure. None of the techniques
described here are found superior to the others, but stapled
anastomosis offered a safe outcome with a low percentage
of anastomotic leakage and stenosis. Furthermore, no
important differences were found between the two most
used stapled anastomoses: the transoral introduction of the
anvil, and the transthoracic introduction. Clinical trials are
anastomosis.Moreover,minimally
needed to compare different methods to improve the
quality of the intrathoracic anastomosis after esophagec-
tomy for cancer.
Disclosures
Gisbertz, V. Turrado Rodriguez, D.L. van der Peet, and M.A. Cuesta
have no conflicts of interest or financial ties to disclose.
Drs. K.W. Maas, S.S.A.Y. Biere, J.J.G. Scheepers, S.S.
Open Access
Creative Commons Attribution License which permits any use, dis-
tribution, and reproduction in any medium, provided the original
author(s) and the source are credited.
This article is distributed under the terms of the
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