Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer

Surgical Technique

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Technique of esophagojejunostomyusing transoral placement of thepretilted anvil head after laparoscopicgastrectomy for gastric cancerShinichi Sakuramoto, MD, PhD, Shiro Kikuchi, MD, PhD, Nobue Futawatari, MD, PhD,Hiromitsu Moriya, MD, Natsuya Katada, MD, PhD, Keishi Yamashita, MD, PhD, and MasahikoWatanabe, MD, PhD, FACS, Kanagawa, Japan

Background. During esophagojejunostomy using a circular stapler after laparoscopy-assisted gastrec-tomy, placement of the anvil head via the transabdominal approach proved difficult. The authors reporton a method modified for laparoscopy-assisted, esophagojejunostomy performed by placing the pretiltedanvil head via the transoral approach.Methods. Between November 2007 and December 2008, esophagojejunostomy was performed using thetransoral, pretilted anvil head in 27 patients after laparoscopy-assisted gastrectomy. The anesthesiologistintroduced the anvil while observing its passage through the pharynx. During the anastomosis, we keptthe jejunum fixed in position with a silicone band Lig-A-Loops, thereby preventing the intestine fromslipping off the shaft of the stapler.Results. Esophagojejunal anastomosis using the transoral anvil head was achieved successfully in 26patients; for 1 patient, passage of the anvil head was difficult owing to esophageal stenosis. No othercomplications, such as hypopharyngeal perforation and/or esophageal mucosal injury, occurred duringpassage. No postoperative complications occurred, except for 1 patient who developed anastomoticstenosis, in whom mild relief was achieved using a bougie.Conclusion. Esophagojejunostomy using the transoral pretilted anvil head is a simple and safetechnique. (Surgery 2010;147:742-7.)

From the Department of Surgery, Kitasato University School of Medicine, Kanagawa, Japan

ESOPHAGOJEJUNOSTOMY USING A CIRCULAR STAPLING DE-

VICE AFTER OPEN TOTAL GASTRECTOMY is a safe and widelyused method for anastomosis. After laparoscopy-as-sisted total gastrectomy,1,2 instrumental anastomosishas also been performed using a circular stapler;however, placement of the anvil head via the transab-dominal approach was difficult, because the left lobeof the liver and the jejunum prevented the operatorfrom clear visualization, often requiring a larger lap-arotomy to obtain adequate vision for placing the an-vil head safely. When performed by an open

d for publication June 11, 2009.

requests: Shinichi Sakuramoto, MD, PhD, Departmentry, Kitasato University School of Medicine, 2-1-1 Asami-

agamihara, Kanagawa 228-8520, Japan. E-mail: [email protected].

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016/j.surg.2009.06.016

URGERY

technique, the jejunum is pulled toward the cartridgeof the stapler to prevent too much of the jejunal wallfrom being sandwiched inside the circular stapler. Incontrast, during laparoscopic total gastrectomy, itcan be difficult to prevent the jejunum from beingcaught up into the anastomotic site.

The authors performed esophagojejunostomyusing a pretilted anvil (Orvil; Covidien, Norwalk,CT) developed specifically for the purpose oftransoral delivery in bariatric surgery.3 Describedin this report is the authors� initial clinical experi-ence with this technique for transoral placementof the anvil for construction of a circularly stapledesophagojejunostomy during laparoscopic proxi-mal or total gastrectomy for gastric cancer.

PATIENTS AND METHODS

Between November 2007 and December 2008,the authors performed esophagojejunostomy

Table. Demographic characteristics of the patients

Trans oral LATG (n = 24) Trans abdominal LATG (n = 30)

Age (yr) 62 64Gender, male/female 19/5 18/12Body mass index (kg/m2)*,y 24 ± 4 22 ± 3Tumor location (upper/middle third

of the stomach)16/8 18/12

Operative findings lymph node dissectionD1 + b 17 25D2 7 5

Operative time (min)* 328 ± 64 313 ± 81Blood loss (g)* 135 ± 128 134 ± 98Number of dissected lymph nodes* 42 ± 20 43 ± 17Postoperative hospital stay (days)*,y 12 ± 2 14 ± 3Cost (yen) 105,000 74,000

*Mean value ± standard deviation.yP < .05.

D1 +b, Limited lymph-node dissection plus dissection of nodes along the left gastric artery and common hepatic artery, around the celiac artery; D2,extended lymph-node dissection; LATG, laparoscopy-assisted total gastrectomy.

Fig 1. A pretilted anvil and a detachable orogastric tubeare shown. A scale is attached to the tube marking thedistance at 5-cm intervals.

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using a transoral circular stapling technique in 27patients for upper (n = 18) and/or middle (n = 8)gastric cancers, and for 1 patient with a gastrointes-tinal stromal tumor. The technique included lapa-roscopy-assisted pancreas- and spleen-preservingtotal gastrectomy (LATG) with D1 + b or D2 lymphnode dissection, with Roux-en-Y reconstruction(25 patients) or laparoscopy-assisted proximal gas-trectomy with D1 + b lymph node dissection anddouble tract anastomosis (2 patients). Operativeindications included gastric cancers with wall inva-sion T1 (mucosa, submucosa; n = 19) or T2(proper muscular layer, subserosa; n = 7). Includedalso in indicated cases were patients who receivedadditional treatment (salvage) for endoscopic

submucosal dissection,4 submucosal invasion, orvascular or lymphatic invasion.

Postoperative managements. A nasogastric tubewas in place and removed on postoperative day1 in all 27 patients. Upper gastrointestinal swallowtest was obtained to confirm whether there wereany leaks, stenosis, or other abnormal conditionsin all patients. Water intake began on postopera-tive day 1 and oral feeding on postoperative day 2.The median follow-up was 12 months. Demograph-ics of LATG are use (Table) include comparativedata from the control group (LATG with circularstapling method) as disclosed in our recent publi-cation.5 Transoral esophagojejunostomy includedmore patients with greater body mass index(P < .05) and a shorter hospital stay (P < .05).These findings may be related to difference oftreatment; transoral esophagojejunostomy wasstarted after sufficient experience of the operatingsurgeons with LATG and laparoscopic distal gas-trectomy (LADGs). Moreover, the clinical pathwayrecently was also updated for earlier discharge.

OPERATIVE PROCEDURES

Laparoscopic resections were performed as fol-lows. A camera port was introduced into theumbilicus, and 2 12-mm trocars were introducedinto the left and right lateral quadrants using aflexible fiberscope with a 10-mm tip (OlympusOptical, Ltd., Tokyo, Japan). A 5- to 6-cm trans-verse laparotomy of the upper left quadrant wasconstructed for removal of the resected stomach.The esophagojejunostomy was performed using anOrvil package (Covidien) consisting of the 25-mm

Fig 2. (A) Total gastrectomy is performed. (B) A small hole is made with scissors along the center of the staple line atthe esophageal stump. (C, D) The orogastric tube is removed through the small hole.

Fig 3. (A) The center rod of the transoral anvil is held with grasp forceps for the anvil. (B) The orogastric tube isretrieved by cutting the grasp suture with scissors.

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anvil with the head pretilted and the tip attachedto an 18-Fr orogastric tube (Fig 1) after the enter-oenterostomy for Roux-en-Y reconstruction wascreated under direct vision through a minilaparot-omy at a site 20 cm distal to the Treitz ligament. Wedid not attempt to use a stapler of other than thatwith a 25-mm anvil. In preparation for transoralplacement of the anvil head, the esophagus wastransected using the Endo-GIA Universal Roticula-tor 60-3.5 (Covidien) after dissecting a 3- to 4-cmlength of distal esophagus (Fig 2, A). The

orogastric tube attached to the anvil head waspassed carefully transorally under vision by ananesthesiologist. Passage of the anvil headthrough the hypopharynx was observed carefullywith a laryngoscope, and the cuff of the endotra-cheal tube was deflated during its passage. A smallhole was made at the center of the staple line whenthe tip of the tube had reached the esophagealstump (Fig 2, B and C). The orogastric tube wasthen extracted from the trocar in the left lateralquadrant (Fig 2, D). After the anvil reached the

Fig 4. The jejunum is advanced around the main bodyof the anvil to prevent separation of the jejunum duringanastomosis and penetration of the anvil into the jeju-num at the time of firing.

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esophageal stump, the ‘‘grasp notch’’ was graspedwith the anvil holder that had been introducedthrough the trocar positioned in the right upperquadrant (Fig 3, A). Sutures attaching the anvilto the orogastric tube were then cut and the tubewas retrieved from the body (Fig 3, B). We per-formed a completion endoscopy for all the 26cases done by this procedure to ensure that therewas no esophageal injury made by the anvil. Mini-laparotomy was made for size of 5--6 cm in length.Through the minilaparotomy, the cartridge of thecircular stapler was introduced through the cut-end of the Roux limb jejunum, allowing the‘‘spike’’ to exit the side of the jejunum and thusdock with the end of the anvil.

Using the Lig-A-Loops (Cardinal Health Japan,Tokyo, Japan), the small intestine was pulledtoward the main body of the cartridge to preventthe jejunum from slipping off and being acciden-tally caught up inside the approximation of theanvil and the cartridge when closing the circularstapler (Fig 4). Appropriate approximation wasconfirmed by introducing a fiberscope throughthe right lateral quadrant to ensure that the tiltedanvil head had tilted back automatically into theflat position when it was attached to the mainbody of the stapler. Esophagojejunostomy wasperformed (Fig 5, A and B) by firing; the cartridgewas removed after the Lig-A-Loops was cut. Thecut-end of the jejunum was closed using theEndo-GIA Universal Roticulator 60-2.5 (Covidien),completing the anastomosis (Fig 5, C and D).

RESULTS

The transoral technique for placement of the25-mm anvil head was used in 26 patients who under-went laparoscopy-assisted proximal gastrectomy

(n = 2) or LATG (n = 24). Esophagojejunalanastomosis was performed successfully in 26 of27 patients. In 1 patient, placement of the anvilhead was not possible because of esophageal ste-nosis, and, therefore, a side-to-side anastomosisusing a linear stapler was performed. No compli-cations, such as hypopharyngeal perforation and/or esophageal mucosal injury, were observedduring the passage of the anvil head.

Placement of the transoral Orvil at the esoph-ageal stump was technically easy, except in 1 case.The Orvil gastric tube scale of 25--30 cm read at theesophageal stump shows the passage of the anvilhead through the pharynx, whereas that of 15 to20 cm shows its passage through the cuff of theendotracheal tube. In the initial several cases, theanvil was often partially obstructed during itspassage through the pharynx; passage was madepossible by evading the tongue or spreading thepharynx. Resistance felt during removal of theorogastric tube at the site where the scale ofthe esophageal stump shows below 10 cm suggeststhe presence of esophageal stenosis caused byulceration. In such cases, the Orvil was removedfrom the esophagus using a snare guided byesophageal endoscopy during operation.

In the patients in whom a small hole forextracting the oral tube was made at the centerof the linear stapler of the esophageal stump, nolaceration of the esophageal tissue occurred dur-ing retrieval of the tube. In the 5 patients in whoma small hole was made in the anterior or posteriorside of the linear stapler, lacerations of the esoph-ageal tissue occurred in 2; in these patients, apurse-string suture was placed to obtain a tight sealof the esophageal tissue around the anvil. Thetissue ‘‘doughnuts’’ were complete in 25 of the 26patients. In the 1 patient with an incompletedoughnut, the anastomosis was secured with addi-tional interrupted sutures. No postoperative anas-tomotic leaks were observed. No complicationssuch as anastomotic stenosis and/or passage prob-lems occurred, although an anastomotic stenosisdeveloped in 1 patient 2 months postoperatively,and was treated successfully by dilatation.

DISCUSSION

To construct an esophagojejunostomy duringlaparoscopy-assisted gastrectomy, a few attemptshad been made at developing instruments anddevices for placing circular staplers.6 There havebeen reports on side-to-side anastomoses using lin-ear staplers under good visualization.7,8 The pre-sent paper reports on the authors� initial clinicalexperience of circular stapling technique in

Fig 5. (A) The tilted anvil head tilts back automatically into the flat position when the circular stapler is approximatedto the anvil. (B) Care is taken to prevent the jejunum from being caught up into the anastomotic site during firing.(C) The jejunal stump is closed using a linear stapler. (D) The final image of esophagojejunostomy is shown. No torsionof the small intestine is observed.

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esophagojejunostomy using an Orvil developedspecifically for the use of transoral delivery of theanvil head in bariatric surgery.3 In 1 patient, place-ment of the 25-mm Orvil at the esophageal stumpwas difficult because of esophageal stenosis causedby ulceration.

The authors suggest that the best site forcreating a small esophagotomy for retrieving theorogastric tube is at the center of the linearstapler on the esophageal stump. When the tubewas extracted through the central part, placementof the anvil head was achieved without causingany lacerations in the esophageal wall. This tech-nique resulted in successful anastomosis andcomplete esophageal tissue doughnut. In theinitial several cases, attempts were made to makea small hole for retrieving the tube at the anteriorwall and/or the posterior wall of the linear staplerapplied to the esophageal stump. In such cases,the opening became slightly loose because of thelaceration at the esophageal wall as has beenreported in the bariatric surgery, where 5 out of the23 patients were loose, and a purse-string suture wasneeded.3 Creating an anastomosis without fixing thelaceration may result in an incomplete esophagealtissue doughnut; therefore, oversewing was added

to the anastomosis with interrupted sutures. Thesedrawbacks were able to be corrected by adding apurse-string suture to the tissue around the anvil.

Entanglement of too much jejunal wall into theanastomosis can result in postoperative delay in thepassage of food. In open total gastrectomy, care istaken to prevent such entanglement from occurringby supporting the jejunum slightly with the opera-tor’s left hand. In the case of LATG, it is impossibleto support the jejunum with the left hand, so theanastomosis was achieved by a novel application ofLig-A-Loops by bringing the opposite side of themesentery close to the main body of the stapler.Good visualization was obtained during anastomosisby advancing the main body of the stapler throughthe small transverse laparotomy of the left upperquadrant and by introducing a camera through theright lower quadrant. Until now, neither anasto-motic leakage nor functional obstruction at theanastomosis has occurred owing to torsion and/orentanglement of the jejunum. The Lig-A-Loops ismade of silicon, so it is atraumatic to the jejunum.Fixing the jejunum to the cartridge of the staplerwith the Lig-A-Loops prevents the jejunum fromslipping off from the circular stapler and/or itsbeing caught up into the anastomosis.

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In conclusion, esophagojejunostomy uses thetransoral technique for placing the 25-mm anvilhead enables its smooth passage through the oro-pharynx and esophagus, owing to its pretilted head.Compared with the transabdominal approach,placement of the anvil at the esophagus using thetransoral method was achieved under good visionindependent of the patient’s physique, so thetransoral approach was considered to be a feasibleand safe technique for construction of an esoph-agojejunostomy in LAPG or LATG.

REFERENCES

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2. Tanimura S, Higashino M, Fukunaga Y, Kishida S, Ogata A,Fujiwara Y, et al. Laparoscopic gastrectomy with regionallymph node dissection for upper gastric cancer. Br J Surg2007;94:204-7.

3. Nguyen NT, Hinojosa MW, Smith BR, Reavis KM, Wilson SE.Advances in circular stapling technique for gastric bypass:transoral placement of the Anvil. Obese Surg 2008;18:611-4.

4. Gotoda T, Yanagisawa A, Sasako M, Ono H, Nakanishi Y, Shi-moda T, et al. Incidence of lymph node metastasis from earlygastric cancer: estimation with a large number of cases at twolarge centers. Gastric Cancer 2000;3:219-25.

5. Sakuramoto S, Kikuchi S, Futawatari N, Katada N, Moriya H,Hirai K, et al. Laparoscopy-assisted pancreas- and spleen-preserving total gastrectomy for gastric cancer as comparedwith open total gastrectomy. Surg Endosc 2009 Mar 6 [Epubahead of print].

6. Usui S, Ito K, Hiranuma S, Takiguchi N, Matsumoto A, Iwai T.Hand-assisted laparoscopic esophagojejunostomy using newlydeveloped purse-string suture instrument Endo-PSI. SurgLaparosc Endosc Percutan Tech 2007;17:107-10.

7. Uyama I, Sugioka A, Fujita J, Komori Y, Matsui H, Hasumi A.Laparoscopic total gastrectomy with distal pancreatosplenec-tomy and D2 lymphadenectomy for advanced gastric cancer.Gastric Cancer 1999;2:230-4.

8. Okabe H, Obama K, Tanaka E, Nomura A, Kawamura J,Nagayama S, et al. Intracorporeal esophagojejunal anastomo-sis after laparoscopic total gastrectomy for patients with gas-tric cancer. Surg Endosc 2008 Jun 14 [Epub ahead of print].