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• W2187202079 abstract "We used a reverse-puncture anastomotic technique in a total minimally invasive Ivor-Lewis esophagectomy. In the operation, a needle with a wire passed through the puncture head of the anvil of a circular stapler was used to make a fixed knot. In the proximal esophagus, the tissue was hemitransected, and the anvil was then inserted into the esophagus. The needle was then pulled from the inner to the anterior wall of the esophagus. After the wire was tightened, the center rod of the anvil was removed. After closure of the esophageal stump, the intrathoracic esophagogastrostomy was completed. We used a reverse-puncture anastomotic technique in a total minimally invasive Ivor-Lewis esophagectomy. In the operation, a needle with a wire passed through the puncture head of the anvil of a circular stapler was used to make a fixed knot. In the proximal esophagus, the tissue was hemitransected, and the anvil was then inserted into the esophagus. The needle was then pulled from the inner to the anterior wall of the esophagus. After the wire was tightened, the center rod of the anvil was removed. After closure of the esophageal stump, the intrathoracic esophagogastrostomy was completed. With the development and gradual maturity of minimally invasive surgical procedures, endoscopic esophageal operations have been used in more cases. For common cases of thoracic middle and lower esophageal cancer, an endoscopic Ivor-Lewis esophagectomy is an ideal surgical approach compared with the McKeown procedure [1Luketich J.D. Pennathur A. Awais O. et al.Outcomes after minimally invasive esophagectomy: review of over 1000 patients.Ann Surg. 2012; 256: 95-103Crossref PubMed Scopus (612) Google Scholar]. The technique of performing an endoscopic intrathoracic esophagogastrostomy is the main challenge affecting the extensive application of minimally invasive Ivor-Lewis esophagectomy. Developing an ideal anastomosis technique is important for thoracic surgeons worldwide [2Maas K.W. Biere S.S. Scheepers J.J. et al.Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.Surg Endosc. 2012; 26: 1795-1802Crossref PubMed Scopus (64) Google Scholar, 3Pennathur A. Awais O. Luketich J.D. Technique of minimally invasive Ivor Lewis esophagectomy.Ann Thorac Surg. 2010; 89: S2159-S2162Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar]. In recent years, endoscopic placement of the anvil has been reported in some countries, which allows completion of the endoscopic esophageal anastomosis by the use of a transorally inserted anvil system (OrVil) [4Nguyen N.T. Hinojosa M.W. Smith B.R. Gray J. Reavis K.M. Thoracoscopic construction of an intrathoracic esophagogastric anastomosis using a circular stapler: transoral placement of the anvil.Ann Thorac Surg. 2008; 86: 989-992Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar], a surgical stapling device (Endo-Stitch) [5Misawa K. Hachisuka T. Kuno Y. Mori T. Shinohara M. Miyauchi M. New procedure for purse-string suture in thoracoscopic esophagectomy with intrathoracic anastomosis.Surg Endosc. 2005; 19: 40-42Crossref PubMed Scopus (12) Google Scholar], or the continuous pursestring suture by hand [3Pennathur A. Awais O. Luketich J.D. Technique of minimally invasive Ivor Lewis esophagectomy.Ann Thorac Surg. 2010; 89: S2159-S2162Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar, 6Zhang R.Q. Xia W.L. Kang N.N. Che Y. Wan J. Yu Z. Purse-string stapled anastomotic technique for minimally invasive Ivor Lewis esophagectomy.Ann Thorac Surg. 2012; 94: 2133-2135Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. Here, our department applied the reverse-puncture anastomotic technique in 26 cases of total combined laparoscopic and thoracoscopic Ivor-Lewis esophagectomy from March to August 2014. In the laparoscopic phase, the patient was placed in a supine position. A total of five abdominal ports (two 5-mm, two 10-mm, and one 12-mm) were used. An injection of CO2 was used to establish a pneumoperitoneum. The stomach was transected with an endoscopic stapler to form a tubular stomach. Near the cardia, the gastric wall, with a width of approximately 3 cm, was retained for later pulling in the thoracic stage and to serve as the entrance of the stapler. In the thoracoscopic phase, the patient was repositioned to the left lateral decubitus position. Four operation ports were established on the right chest: port 1 (10 mm in diameter) at the seventh intercostal midaxillary line as the observation port, port 2 (10 mm) at the ninth intercostal anterior biased subscapularis, port 3 (40 mm) at the fourth intercostal anterior axillary line, and port 4 (5 mm) at the seventh intercostal posterior axillary line. The proximal esophagus was mobilized to approximately 6 to 7 cm from the top edge of the tumor. The needle with 2-0 wire was passed through the small hole at the tip of the puncture head, and a knot was tied (Fig 1). In the proximal esophagus, approximately 3 cm from the upper edge of the tumor, the esophagus was hemitransected. The anvil of a 23-mm or 25-mm circular stapler was then inserted into the esophagus (the depth of the insertion was adjusted to locate the tip of the puncture head on the plane 3 cm above the esophageal incision) (Fig 2A). The tissue was sewn from the inner to the anterior wall of the esophagus approximately 3 cm above the incision (Fig 2B). After the puller wire was tightened, the puncture head, along with the center rod of the anvil, was removed by the use of even force (Fig 2C), and the puncture head was then removed. The esophageal stump was closed with an endoscopic stapler (Fig 3). The tubular stomach was pulled into the chest through the enlarged hiatus. A full-thickness incision was made on the untransected stomach wall. A circular stapler was placed into the tubular stomach through port 3. After the center rod of the device pierced the greater curvature of the stomach and docked with the anvil (Fig 4A), the esophagogastrostomy was completed. Finally, an endoscopic stapler was used to close the incision of the tubular stomach (Fig 4B). The integrity of the anastomosis was evaluated (Fig 4C). After the placement of a transnasal gastric tube, the wall of the tubular stomach below the anastomosis and the mediastinal pleura were sutured with several stitches. Then the thoracic and mediastinal drainage tubes were placed in port 1 and port 2, respectively.Fig 2(A) The anvil is positioned under a thoracoscope. (B) The needle with a wire sewn into the inner esophagus. (C) The puncture head along with the center rod of the anvil is removed.View Large Image Figure ViewerDownload (PPT)Fig 3(A) The esophageal stump is closed with a stapler. (B) After closure of the esophageal stump.View Large Image Figure ViewerDownload (PPT)Fig 4(A) An esophagogastrostomy is conducted with use of a stapler. (B) The stomach stump is closed after the anastomosis. (C) Checking the anastomosis.View Large Image Figure ViewerDownload (PPT) Of all the patients, 1 patient (3.8%, 1/26) showed anastomotic leakage on the ninth day after the operation; the patient was discharged after treatment with mediastinal drainage, gastrointestinal decompression, and total parenteral nutrition therapy. Two patients (7.7%, 2/26) experienced pulmonary infections, which were cured with antiinfection treatment. No adverse events were observed involving anastomotic stricture, chylothorax, damage to the recurrent laryngeal nerve, or postoperative bleeding, and no perioperative deaths occurred. Because of the small operating area of an endoscopic surgical procedure, the technique for placing the anvil into the esophageal stump and completing the esophagogastrostomy has become the “bottleneck” that restricts the extensive application of the minimally invasive Ivor-Lewis esophagectomy [4Nguyen N.T. Hinojosa M.W. Smith B.R. Gray J. Reavis K.M. Thoracoscopic construction of an intrathoracic esophagogastric anastomosis using a circular stapler: transoral placement of the anvil.Ann Thorac Surg. 2008; 86: 989-992Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. The safety of the anastomosis is the key factor in evaluating the feasibility of a technique for esophageal resection and reconstruction. Some scholars have stated that the incidence of anastomotic leakage in minimally invasive Ivor-Lewis esophagectomy with different approaches of anastomosis ranges from 0% to 10% and that the incidence of anastomosis stricture ranges from 0% to 27.5%, with no statistically significant difference [2Maas K.W. Biere S.S. Scheepers J.J. et al.Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.Surg Endosc. 2012; 26: 1795-1802Crossref PubMed Scopus (64) Google Scholar]. In our study, the surgical procedures performed on all of the patients were successful. All patients have been postoperatively followed up for 4 to 9 months, and the incidences of anastomotic leakage and stricture are similar to those reported elsewhere in the literature. In addition, there is an issue of overlapping staple lines of the distal esophageal endoscopic stapler closure and the circular stapler in the esophagus–stomach anastomosis operation in the present cases. We noted that a similar issue was also present in the intrathoracic esophagus–stomach anastomosis technique, which uses the thoracoscopic transoral delivery of the anvil system (OrVil) that has been frequently reported in recent years. However, the reported results did not show significant differences in the incidences of anastomotic leakage and other adverse events compared with other anastomotic approaches [2Maas K.W. Biere S.S. Scheepers J.J. et al.Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers.Surg Endosc. 2012; 26: 1795-1802Crossref PubMed Scopus (64) Google Scholar, 4Nguyen N.T. Hinojosa M.W. Smith B.R. Gray J. Reavis K.M. Thoracoscopic construction of an intrathoracic esophagogastric anastomosis using a circular stapler: transoral placement of the anvil.Ann Thorac Surg. 2008; 86: 989-992Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. In the analysis of our results, we did not find any particular changes in the incidences of anastomotic leakage or any other adverse events. Therefore, we speculate that the overlapping staple line has no significant impact on anastomotic healing. We conclude that our approach has the following characteristics: (1) the anvil placement procedure is simple, does not include any endoscopic pursestring suture and knotting, and is fast and easy to learn; (2) as a fixed configuration for a conventional circular stapler, the puncture head can be used, which is economical; (3) for a small number of patients with a narrow esophagus, an appropriately sized stapler can be intraoperatively selected based on the diameter of the esophageal lumen to avoid tearing the esophageal mucosa and muscle during the anvil placement; (4) the center rod of the anvil can be removed with the puncture head, with the esophageal wall tightly attached with the center pole, to avoid the risk of the anvil slipping from the esophagus; (5) our approach can be used to best avoid potential damage to the mouth, throat, and normal esophageal mucosa, as is caused during transoral placement of the anvil; and (6) in the implementation of this approach, the anvil should be placed upward into the higher esophagus so that the puncture head is easy to pierce—if the intraoperative mediastinal pleural resection or mobilization during the mobilization of the esophagus is too high, it may cause difficulty in anvil placement. The integrity of the mediastinal pleura on the surface of the retained proximal esophagus should be confirmed, which will result in smoother placement of the anvil. The application of a reverse-puncture anastomotic technique in a minimally invasive Ivor-Lewis esophagectomy can achieve the combined goals of being safe, effective, minimally invasive, and economical. The operation is simple and easy to learn. We propose that this approach is worthy of further promotion in clinical practice." @default.
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• W2187202079 title "Reverse-Puncture Anastomotic Technique for Minimally Invasive Ivor-Lewis Esophagectomy" @default.
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