An improved technique for a stapled transabdominal esophagojejunostomy

Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy

Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The ‘dorsal track control’ (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.

Modified technique of stapled esophagojejunostomy without a purse-string suture

Placement of a purse-string suture during a stapled esophagojejunostomy following total gastrectomy is a technically demanding and time consuming procedure. Improper placement of the purse-string suture can lead to anastamotic breakdown with its associated complications. We describe a technique of stapled esophagojejunostomy without using a purse-string suture. We used this technique in 35 patients including 4 patients who underwent an extended total gastrectomy. We encountered a difficulty only in one patient due to malfunction of the stapler. None of the patients had an anastamotic leak. The modified technique of stapled esophagojejunostomy without a purse-string suture makes the procedure more easy, safe and simple.

New double-stapling technique for esophagojejunostomy and esophagogastrostomy in gastric cancer surgery, using a peroral intraluminal approach with a digital stapling system

In the abdominal-transhiatal approach for resection of adenocarcinoma of the cardia or subcardia, and in laparoscopy-assisted total gastrectomy (LATG), the use of a circular stapling device has potential problems with the placement of the purse-string suture and insertion of the anvil of the instrument. We describe a new double-stapling technique for esophagojejunostomy and esophagogastrostomy, using a peroral intraluminal approach with a digital stapling system, a flexible shaft remote-control stapler - the Surg-ASSIST and Power Circular Stapler 21 mm (PCS). The overtube of the flexible shaft of the PCS is prepared with a nylon tie and secured to a nasogastric (NG) tube. The flexible shaft is manually advanced down the esophagus with guidance by pulling the NG tube from the abdominal cavity side. The trocar of the flexible shaft is removed from the stump of the abdominal esophagus and connected to the anvil and they are approximated; the stapler device is then fired to form a double-stapled esophagojejunostomy and esophagogastrostomy. Our peroral intraluminal approach does not require a suturing technique, and it can make anastomosis after resection for carcinoma of the esophagogastric junction and after LATG safe and simple.

Linear stapling forms improved anastomoses during esophagojejunostomy after a total gastrectomy

BACKGROUND

Circular stapling devices are commonly used to form esophagojejunal anastomoses after total gastrectomy. However, the technique has potential problems with placement of the purse-string suture and insertion of the anvil of the instrument.

METHODS

We describe an improved technique for esophagojejunostomy by functional end-to-end anastomosis with linear stapling devices.

RESULTS

Three patients with gastric cancer underwent this procedure after total gastrectomy. No anastomotic leakage or clinical evidence of stenosis was encountered. The maximum diameters of the anastomoses, evaluated by radiography with barium at 6 months after surgery, were 3.5 cm and 4.0 cm in 2 patients. Endoscopic examination revealed clear lines of anastomosis with a straight continuity between the distal esophagus and the jejunum.

CONCLUSIONS

Our improved technique for esophagojejunostomy by functional end-to-end anastomosis with two linear staplers is a convenient, safe and reliable procedure that is independent of the width of the esophagus and the depth of the esophageal hiatus.