An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function

This study was approved by Indiana University-Purdue University in Indianapolis institutional review board (1109006832). This procedure was performed on all patients requiring resection and resection of the distal intrathoracic esophagus for malignant or benign diseases since 2009 at Indiana University Hospital.

1. Pre-anesthesia phase

1. Place an epidural catheter.
2. Obtain standard central venous and radial arterial access.
3. Anesthetize and intubate using a double lumen left-sided endobronchial tube for selective lung ventilation during the thoracic phase of the operation.

2. Initial laparotomy phase

1. Perform an upper midline laparotomy including excision of the zyphoid process with electrocautery. Place a self-retaining abdominal wall retractor for peritoneal cavity exposure.
2. Perform a wide Kocher maneuver, which mobilizes the entire duodenum from the retroperitoneum. This maneuver not only straightens the gastric conduit, but also allows well-vascularized portions of the stomach conduit to be advanced above the azygos arch.
3. Temporarily place a standard size laparotomy sponge under the duodenum to elevate the conduit, which is removed in the final laparotomy phase.
4. Divide the gastrocolic ligament by cauterizing and dividing the omental blood vessels with a standard energy device. Avoid manipulation of the right gastroepiploic vessels by placing a nasogastric tube along the greater curvature, which is used as a “handle” retracting the stomach upward.
5. Score the peritoneum circumferentially around the diaphragmatic crus with electrocautery and temporarily place a Penrose drain around the intraabdominal esophagus.
6. Ligate the left gastroepiploic and short gastric vessels with a combination of suture and surgical clips. Then divide.
7. In cases of malignancy, mobilize the celiac lymph bearing tissues from the superior aspect of the pancreas, which includes ligation and division of both left gastric artery and vein.
8. Clear the lesser gastric curve of fat and blood vessels typically 3 to 5 cm distal to the gastroesophageal junction with vascular endostaplers. In cases of malignancy, plan the operations to achieve tumor free 3 to 5 cm distal stomach and 5 to 7 cm proximal esophageal surgical margins. As tumor locations range from the mid-esophagus to the gastric cardia, achieving adequate distal stomach and proximal esophageal margins results in conduits of varying lengths and associated lower or higher intrathoracic esophagogastric anastomoses. The specific site of the lesser curve clearing is therefore somewhat variable and dependent on exact tumor location.
9. Cleave the upper gastric fundus and cardia from the remainder of the stomach typically using anywhere from 3 to 5 60 mm endoscopic staplers beginning from the greater gastric curve into the cleared area on the lesser gastric curve.
10. Gastric conduit creation
    1. Debulk lesser omental fat around the right gastric vessels, which allows the conduit to be straightened as well as lengthened. Division of right gastric vessels as they insert onto the lesser curve at the incisura will provide further lengthening.
    2. Secure the stomach at three points and provide outward retraction (Figure 1).
    3. Create a narrow uniform diameter conduit (average 7-8 cm) with an initial fire of the 100 mm stapler, which delivers two rows of 4.8 mm staples aiming just beneath the previous staple line. Completion of the conduit construction usually requires 2 or 3 additional fires of the 60 mm endoscopic tri-stapler into the cleared area on the lesser gastric curve. In cases of malignancy, send the stomach defect as the “distal stomach margin” for frozen section pathologic analysis.
    4. Inspect the tip of the conduit. Within 3 to 5 min, punctate bright red bleeding is usually seen through the lesser curve staple line representing good conduit perfusion. If no punctate bright red oozing is present, slightly trim the conduit tip with another 100 mm stapler until punctate bleeding is seen. Tri-staplers are not used for conduit trimming as cutting through and restapling the conduit tip during the intrathoracic anastomosis may be difficult.
    5. Perform a standard Heineke-Mikulicz pyloroplasty in order to assure good conduit emptying.
    6. Initially estimate how high in the chest the conduit will reach by comfortably stretching the conduit towards the neck without undue tension.
    7. Open the right pleura through the diaphragmatic crus. Place the conduit tip into the right chest keeping the lesser curve staple line facing rightward.
    8. Temporarily close the abdomen with a few interrupted fascial sutures and skin staples.

3. Thoracic phase

1. Place the patient in the left lateral decubitus position.
2. Perform a serratus muscle sparing right thoracotomy through the 5^th intercostal space. Divide the intercostal muscle underneath the incision within 3 to 5 cm of the vertebral body posteriorly and the sternum anteriorly, allowing additional movement of the 5^th and 6^th ribs with minimal risk of fracture or bruising.
3. Excise the arch of the azygos vein and divide the inferior pulmonary ligament. In cases of malignancy, perform en bloc dissection by mobilizing the distal two-thirds of the intrathoracic esophagus with all surrounding soft tissues from the pericardium anteriorly to the aorta posteriorly esophageal blood vessels. Carefully occlude lymphatics with surgical clips before division during this dissection.
4. Deliver the conduit into the right chest until there is no redundancy, limiting tension on the right gastric and right gastroepiploic vascular pedicles to determine the superior extent of esophageal dissection needed.
5. At the level of the tracheal carina, dissect the esophageal wall from surrounding mediastinal soft tissues superiorly to a level where the tip of the conduit reaches without tension, which is usually 3 to 5 cm superior to the carina. Again however, given varying locations of tumors and length of stomach conduits created during the abdominal phase, establish anastomoses lower near the carina for gastric cardia tumors and higher at the thoracic inlet for tumors involving the middle intrathoracic esophagus.
6. Creation of the esophagogastric anastomosis
   1. Align the mid left lateral aspect of the upper third of the intrathoracic esophagus over the lesser curve staple line.
   2. Place four tacking sutures approximately 2 to 3 cm apart in order to maintain alignment (Figure 2).
   3. Transect the esophagus 1 cm distal to the inferior set of tacking sutures. In cases of malignancy, send a ring of esophagus at this level as the “proximal esophageal margin” for frozen section pathologic examination prior to proceeding.
   4. Create a corresponding 1 to 2 cm opening in the conduit across the lesser curve staple line.
   5. Place interrupted sutures within the common lumen, incorporating the adjacent conduit and esophageal walls beginning in the middle through the lesser curve staple line and progressing to either side (Figure 3).
   6. Place the narrow anvil of a 45 mm endoscopic stapler with a 4.1 mm staple height in the esophageal lumen and the large anvil in the conduit. To optimize the length of the side-to-side communication between the esophagus and the conduit, trim 5 mm from distal plastic tip of stapler cartridge with an oscillating saw.
   7. Fire the stapler, which cuts through and restaples the lesser curve staple line (Figure 4). The length of the cut end of the esophagus is usually somewhat longer than the edge of the gastric conduit, so remove an ellipse of the conduit over the lesser curve staple line rather than extending the rent laterally, preserving collateral blood supply (Figure 4 inset).
   8. Close the open common lumen in two layers of sutures beginning with an inner layer of inverted interrupted 3-0 polyglactin suture followed by a second layer of interrupted 3-0 silk using a Lembert technique (Figure 5).
   9. Over sew the upper aspect of the lesser curve conduit staple line with interrupted 3-0 silk sutures in a Lembert fashion extending inferiorly, until the right gastric vessels are encountered.
   10. Have the anesthesiologist place a nasogastric tube into the conduit to the level of the crus by palpation.
   11. For anastomoses created near the thoracic inlet, use a pleural flap to seal the anastomosis in the posterior mediastinum. For anastomoses in the middle aspect of the posterior mediastinum, mobilize a pericardial fat pat from anterior mediastinum and loosely wrapped to cover esophagogastric anastomosis (Figure 6 and Figure 7).
   12. Insert and position two 28-French chest tubes within the right hemithorax, one anterior and the other posterior, next to, but not abutting the conduit. Close the thoracotomy incision.

4. Re-laparotomy: “double flip” phase

1. Return patient to the supine position and reopen the midline laparotomy incision.
2. Inspect the right gastroepiploic fat and carefully push any excess fat upwards through the left diaphragm crus into the chest.
3. Secure the right gastroepiploic fat and conduit to the diaphragmatic crus with interrupted 2-0 silk sutures (Figure 8). Place a feeding jejunostomy tube in select patients, primarily in elderly patients or patients with preoperative nutritional deficits.
4. Formally close the midline laparotomy incision.
5. Keep patients intubated the evening of surgery with extubation planned the following morning.
6. Provide pain control with epidural catheters placed just prior to anesthetic induction for the first 3 to 4 days, which is supplemented by intravenous narcotics.
7. Obtain contrast upper gastrointestinal series 5 to 7 days postoperatively to assess for anastomotic integrity.
8. If no anastomotic leak is identified, remove the nasogastric tube.
9. Instruct patients to advance to a regular diet in 2 to 3 weeks after discharge as tolerated.