Article
Atraumatic handling of the distal esophagus via dorsal track control – a novel technical modification prior to circular stapler esophago-jejunostomy following open transhiatal esophago-gastrectomy for AEG II
Search Medline for
Authors
-
Jan Schulte am Esch
- Universitätsklinikum der Heinrich Heine Universität Düsseldorf, Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Düsseldorf, Deutschland
-
Feride Kröpil
- Universitätsklinikum der Heinrich Heine Universität Düsseldorf, Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Düsseldorf, Deutschland
-
Matthias Schauer
- Universitätsklinikum der Heinrich Heine Universität Düsseldorf, Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Düsseldorf, Deutschland
-
Daniel Vallböhmer
- Klinikum Niederrhein, Chirurgische Klinik, Duisburg, Deutschland
-
Wolfram Trudo Knoefel
- Universitätsklinikum der Heinrich Heine Universität Düsseldorf, Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Düsseldorf, Deutschland
| Published: | April 21, 2016 |
|---|
Outline
Text
Background: Adeno carcinoma of the esophageal gastric junction (AEG) demonstrates an increasing incidence. Surgical therapy for AEG type II requires distal esophagectomy. To fulfill the requirements of minimum oral safety margins and adequate lymphadenectomy of the distal mediastinum the transhiatal management of the distal esophagus is crucial. It is mandatory to avoid retraction of the esophageal stump toward the mediastinum on one hand and to assure minimal manipulation of the remaining esophagus stump for optimal perfusion and to prevent trauma on the other in order to minimize the risk of anastomotic dehiscence and leakage.
Materials and methods: Here we present a non-traumatic novel technique to handle the distal esophagus in preparation for a circular stapler esophago-jejunostomy. This as ‘dorsal track control’ entitled technique is based on a ventral semi-circular incision of the esophagus on the level that is providing a safety margin of minimum 2 cm cranial of the oral tumor end leaving the dorsal esophageal wall intact for traction control of the esophagus. Hereby controlled positioning of the purse-string suture up to the time point of its completed tie around the circular stapler anvil attachment is possible avoiding any manipulation of the remaining, intrathoracic esophagus e. g. due to retracting sutures, clamps etc. Further the dorsally exposed epithelialized inner wall surface of the ventrally opened esophagus serves as a guiding chute to ease the insertion of the anvil into the upper esophageal lumen paralleled by the prevention of pushing the esophagus end towards the upper mediastinum in the process of that move.
Results: We performed this technique in four cases enabling a safe anastomoses between 6 and 10 cm proximal of the Z-line with en-bloc lymphadenectomy of the lower mediastinum all without development of anastomotic leakage. In one case, an additional esophagus resection of 3 cm was mandatory due to a positive oral resection margin on immediate frozen section. Second purse string suture was again safely placed utilizing the dorsal track control -technique with an overholt clamp on the lower end of the esophagus as handle.
Conclusion: We introduce here the ‘dorsal track control’ manover as technical improvement of open transhiatal lower mediastinal reconstruction following esophago-gastrectomy for AEG II. In addition this technique may increase the safety of surgical training for total or esophageally extended gastrectomy. Safety and feasibility as observed in our initial experience needs to be validated in a larger series of patients.
Figure 1 [Fig. 1]
