Major modifications to minimize thoracic esophago‐gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy

Abstract

Background The Ivor Lewis esophagectomy (ILE) remains the procedure of choice for localized middle or lower esophageal carcinoma. Nevertheless, anastomotic leak remains a common complication with rates from 3% to 25% and a stricture rate as high as 40%. The frequency of these complications suggests that the procedure itself may have inherent limitations including the use of potentially ischemic tissue for the esophagogastric anastomosis. We introduce a modified technique that reduces operative steps, preserves blood supply, and uses a modified esophagogastric anastomosis. Methods All consecutive patients undergoing ILE with the described modified technique were identified. An esophagram was performed on postoperative day six or seven. To ensure that all cases were identified, anastomotic leaks were defined as any radiographic evidence of contrast extravasation. Results A total of 110 patients underwent the modified esophagectomy with 2 anastomotic leaks (1.82%) and zero strictures. There was 1 late death but no early deaths (<30 or 90 days) or early re‐admissions (<30 days). The average number of risk factors was 2.12, and 98 patients (90%) had at least 1 risk factor in their medical history. Conclusions The modifications proposed simplify procedural steps, limit unnecessary dissection and introduce a technique that ends the practice of connecting ischemic tissue. We believe this technique contributes to surgical durability and reduces the rate of postoperative leak and eliminates stricture.

A narrative review of anastomotic leak in the Ivor Lewis esophagectomy: expected, accepted, but preventable

“…In brief, the procedure involves an abdominal mobilization that typically sacrifices the left gastric (LGA), right gastric (RGA), left gastroepiploic (LGEA) and short gastric arteries. This is followed by Kocharization of the duodenum, a pyloric drainage procedure, and the placement of a feeding jejunostomy tube (J-Tube) ( 7 , 12 , 19 ). A tubularized gastric conduit is created by separating the gastro-esophageal junction (GEJ) from the fundus and greater curvature ( 2 , 19 , 20 ).…”

“…A second stage involves the mobilization and division of the esophagus in the chest. The anastomosis is created between the upper esophagus and the apex of the tubularized gastric fundus ( Figure 1 ) ( 12 , 19 , 20 ).…”

“…With tissue that is already anatomically vulnerable, medical risk factors that affect perfusion and oxygenation play a greater role in anastomotic healing ( 12 , 21 , 24 , 34 ). One of the most comprehensive lists was published by Ubels and colleagues ( 11 ).…”

“…One of the most comprehensive lists was published by Ubels and colleagues ( 11 ). It is organized by medical, oncologic, and perioperative conditions to which we add several additional risks and a section on surgical factors ( Table 3 ) ( 11 , 12 , 21 , 24 , 34 , 38 - 55 ).…”

“…Most studies investigating anastomotic outcomes have focused largely on operative techniques. The debates between minimally invasive vs. open, hand-sewn vs. staplers, circular vs. linear, end-to-end vs. end-to-side, reinforcement vs. two-layer closure, chest vs. neck, and Orringer vs. Collard continue in the literature and remain largely unresolved ( 12 , 22 , 26 , 37 , 59 - 63 ).…”