Esophago-jejunal anastomosis with open approach using the parachute technique to prioritize safety after resection of esophagogastric junction cancer

doi:10.21203/rs.3.rs-4371655/v1

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Esophago-jejunal anastomosis with open approach using the parachute technique to prioritize safety after resection of esophagogastric junction cancer

https://doi.org/10.21203/rs.3.rs-4371655/v1

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Background

The appropriate extent of resection for esophagogastric junction cancer and the method of surgical approach remain controversial. This study aimed to assess the safety and outcomes of the parachute technique, which is an open transhiatal reconstruction method that facilitates stable reconstruction.

Materials and methods

The surgical outcomes of 20 consecutive patients who underwent open lower- esophagogastrectomy for EGJ cancer at Kitasato University Hospital from June 2019 to July 2023 were retrospectively reviewed.

Surgical procedure (parachute technique):

The esophagus was transected, and a purse-string suture was placed at the stump. Then, a fixing string was placed. Hence, the mucosa, muscular layer, and adventitia, including the string of the purse-string suture, were not displaced. By placing approximately 10 stay sutures around the whole esophageal stump, the esophageal stump can be opened to the maximum diameter. Then, insert the anvil head into the esophagus lumen while laying it sideways, and it can be put on smoothly without stress.

Results

In total, there were 17 and 3, male and female patients, respectively. The median esophageal invasion length was 12.5 (0–30) mm. One patient presented with cStage I EGJ cancer, four with cStage II, 14 with cStage III, and one with cStage IV. In terms of postoperative complications, three (15%) patients developed grade II intra-abdominal fluid correction according to the Clavien–Dindo classification. However, none of the patients presented with anastomotic leakage.

Conclusions

The parachute technique can be a safe and effective reconstruction technique as it does not cause anastomotic leakage.

Esophagogastric junction cancers

Parachute technique

Anastomotic leakage

The incidence of Helicobacter pylori infection has decreased, and endoscopic submucosal dissection is widely applied for early-stage gastric cancer. Hence, in recent years the number of gastrectomy cases has significantly reduced in Japan. The incidence of esophagogastric junction (EGJ) cancer has increased worldwide over the last few decades [1, 2]. For treating EGJ cancer, multimodality treatment including perioperative chemotherapy and surgical resection, can be a therapeutic option. However, the appropriate extent of resection for EGJ cancer and the method of surgical approach (open vs laparoscopic surgery) remain controversial [3].

Lower- esophagogastrectomy can be the treatment of choice for esophagogastric junction carcinoma with an esophageal invasion length of ≤ 3 cm. Esophageal jejunal anastomosis is used for reconstruction after lower- esophagogastrectomy. However, the mediastinum is a narrow space. Therefore, anastomotic procedures can be challenging to perform. In addition, the increased difficulty of anastomotic procedures in cases of long esophageal invasion or large-size tumors can possibly cause anastomotic leakage [4].

Recently, a nationwide prospective multicenter study in Japan has evaluated the optimal extent of lymph node dissection in EGJ cancer [5]. However, the short-term surgical outcomes in this study revealed that incidence rate of anastomotic leakage is high. Moreover, the incidence rate of grade III or higher complications in patients who underwent transhiatal gastrectomy was 18.7%, and the incidence rate of grade II or higher anastomotic leakage was 12.0%. Anastomotic leakage in the mediastinum is associated with a high risk of important and fatal outcomes. In this trial, the surgery-related mortality rate due to anastomotic insufficiency was 0.4%.

The esophagus can be teared during insertion of the anvil head of the circular stapler during esophageal jejunal anastomosis. In addition, the esophagus has loose tissues between the mucosa and muscularis propria. Thus, full-layer anastomosis can be lacking. Thus, these factors can be the main causes of anastomotic leakage [6].

Previous research has demonstrated that parachute technique decreases anastomosis-related complications by preventing slippage of the esophageal mucosa and muscularis propria during anastomosis and esophageal injury during insertion of the anvil head of the circular stapler [7]. The current study assessed the safety of the parachute technique based on short-term surgical outcomes.

Patients

We retrospectively reviewed the surgical outcomes of patients (n = 20) who underwent open lower- esophagogastrectomy for EGJ cancers at Kitasato University Hospital from June 2019 to July 2023. The indications for lower- esophagogastrectomy as a case were EGJ cancer diagnosed using the Siewert classification and an esophageal invasion length of ≤ 3 cm. The EGJ location was the lower margin of the palisading small vessel on endoscopy according to the Japanese Classification of Esophageal Cancer, 11th Edition [8]. The clinical data collected from the medical records included sex, age, tumor diameter, length of esophageal invasion, Siewert classification [9], histological type, staging, surgery-related factors, and postoperative complications. Staging was assessed using the Union for International Cancer Control TNM Classification of Malignant Tumours, 8th Edition [10].

Parachute technique for anastomosis

The parachute technique is an anastomotic strategy that uses a circular stapler. It can facilitate minimal stress on the esophageal tissue during anvil head placement and ensure anastomosis in all layers of the esophageal wall.

In EGJ cancer, an adequate surgical field in the inferior mediastinum is useful for reconstruction. Therefore, the standard technique is used to widen the esophageal hiatus before lymph node dissection of the inferior mediastinum. The left hepatic coronary ligament and the left triangular ligament were dissected. The left lateral segment of the liver was mobilized. The diaphragm was then incised via the esophageal hiatus to the central tendon, thereby exposing the epicardium. When incising the diaphragm, the left branch of the right inferior phrenic vein was ligated and dissected to adequately widen the esophageal hiatus. Tumor location was confirmed on intraoperative endoscopy after inferior mediastinal lymph node dissection and esophageal mobilization. The esophagus was dissected using a purse-string suture with an appropriate margin from the tumor. Handling of the esophageal stump after the purse-string suture was performed without grasping with forceps to prevent mucosal damage. Then, approximately 10 stay sutures (4 − 0 PDS II® : polydioxane suture) were placed on the whole esophageal stump in all layers to ensure sufficient esophageal ring during reconstruction (Fig. 1). The stay sutures prevented the displacement of the mucosa, muscular layer, and adventitia of the esophagus, thereby ensuring the string of purse-string suture and all layers of the esophagus. The TMP suture ring® (Tokai Medical Products Inc.) was used to temporarily hold the string of stay sutures (Fig. 2). Then, the string of stay sutures was placed at regular intervals in a radial pattern by implanting it in the slit of the ring. Thus, the esophageal stump diameter was progressively expanded, and the maximum diameter was ensured if the stay sutures were completed. The esophageal stump was then extended to its maximum diameter. Hence, a 23- or 25-mm anvil head could be easily inserted into the esophageal lumen (Fig. 3). After inserting the anvil head into the esophageal lumen, the purse-string sutures were ligated, and the stay sutures was cut-off at a suitable length. When performing esophagojejunostomy, an auto-suture device was used to prevent shaking during reconstruction. The esophageal hiatus was sufficiently widened to allow direct visibility of the anastomotic site, and stable reconstructive procedures were performed. The ring on the esophageal side after esophagojejunostomy was identified as a thick and uniform ring (Fig. 4-a). After the reconstructive surgery was completed, intraoperative endoscopy confirmed the absence of anastomotic leakage and bleeding (Fig. 4-b).

Table 1 shows the characteristics of the patients with EGJ cancer (n = 20). Date on age, sex, American Society of Anesthesiologists physical status classification, Siewert classification, length of esophageal invasion, clinical stage, histological type, and chemotherapy status were evaluated.

In total, 17 (85%) patients were men and the median age was 70.5 years. Further, 16 (80%) had Siewert type II EGJ cancer, and the median length of esophageal invasion was 12.5 mm. Approximately 95% of patients presented with T2 or higher clinical status and 60% (n = 12) with cT4a. In all cases, organ invasion was found in the diaphragm. Eight (40%) patients presented with positive clinical N status and one (5%) with positive clinical M status, for which staging laparoscopy was performed and revealed a positive peritoneal lavage cytology. The histological type in all patients was adenocarcinoma. Among them, five (25%) were diagnosed with poorly differentiated adenocarcinoma (por) or signet-ring cell carcinoma (sig). In total, 12 (55%) patients received neoadjuvant chemotherapy. Seven (53.8%) patients had oxaliplatin plus S-1, and 5 (38.5%) patients received in 7 (53.8%) and docetaxel plus oxaliplatin plus S-1. One patient with a positive CY who was diagnosed with M1 received four courses of oxaliplatin plus S-1 plus and trastuzumab as induction chemotherapy. Then, the CY became negative. Next, conversion surgery was performed.

Table 2 shows the surgical outcomes. The median operation time was 427 min, and the median estimated blood loss was 555 mL. Three (15%) patients tested positive for cancer on the intraoperative frozen section of the proximal margin. Two patients underwent additional resection of the proximal margin. Thereafter, they had a negative margin. In one of three cases involving a positive proximal margin on the intraoperative frozen section, the length of the resected esophagus was 70 mm. Therefore, additional resection of the proximal margin using the transhiatal approach was challenging to perform. The median length of the resected esophagus during lower- esophagogastrectomy was 40 mm. In terms of postoperative complications, three (15%) patients developed grade II intra-abdominal fluid correction according to the Clavien–Dindo classification [11]. However, none of the patients presented with grade III or higher complications or anastomotic leakage. There was no postoperative mortality, and the median length of postoperative hospital stay was 10 days.

Table 3 presents the pathological findings. In total, 15 (75%) patients presented with T2 or higher pathological T status and 9 (45%) with positive pathological N status. Moreover, 15 (75%) patients had pathological stage II or higher cases. The median tumor size based on the pathology specimens was 42.5 mm, and the histology of the pathological specimen was similar to the preoperative diagnosis. The cases diagnosed as R1 with residual tumor were pPM1 cases with a positive proximal margin on the intraoperative frozen section. The median proximal margin based on the pathological diagnosis of all cases was 15 mm.

A stable anastomosis method, as characterized by a layer-by-layer anastomosis, is important to ensure a tight adhesion between layers. Dislocation of the layers and gaps between tissues may cause anastomotic leakage. The fragile esophageal tissue is more likely to tear easily. Hence, particular attention should be paid to the esophagojejunal anastomosis. The parachute technique, which addresses the abovementioned factors of anastomotic leakage, was developed for reconstruction [7]. Kurokawa et al. [5] reported that the incidence rate of anastomotic leakage with the transhiatal approach for EGJ cancer was approximately 10%. However, in this study, no anastomotic leakage was observed. The reasons for this are discussed below.

In an esophagojejunal anastomosis using an automatic suture, all layers of the esophagus and small intestine must be sutured to each other. However, the esophagus has loose tissues between the mucosa and muscular layers [12], and the esophageal stump layer may dissociate if the esophagus is dissected. In addition, using an automatic purse- string suture, the suture in the esophageal stump may fall out, and all layers of the esophagus may not be sutured. Therefore, checking all layers of the esophagus can reduce the incidence of anastomotic leakage. Therefore, the parachute technique of performing full-layer sutures around the whole esophageal stump reduced the incidence of anastomotic leakage.

Second, the esophageal stump should be handled gently during anvil head insertion. The esophagus is a tissue that can be easily teared and is often grasped at three points with forceps during insertion of the anvil head. Thus, the maximum esophageal stump diameter cannot be maintained. There is a risk of the esophageal wall tearing if the anvil head is inserted without sufficient dilatation of the esophageal stump diameter. The parachute technique can facilitate gradual maximization of the esophageal stump diameter and can prevent esophageal injury during anvil head insertion.

Third, tension on the anastomosis can cause anastomotic leakage. The jejunal limb in the esophagojejunal anastomosis was adequately elevated by dissecting the second jejunal artery. Assessment of blood flow in the jejunal limb was confirmed by interrupting blood flow and observing the color tone of the jejunal limb and beating of the marginal artery before the vessel in the second jejunal artery was dissected to ensure that there were no issues. If required, indocyanine green can also be used to assess blood flow in the jejunal limb.

Finally, it is important to ensure a safe field of vision during mediastinal anastomosis. Adequate visual field development of the inferior mediastinum requires mobilization of the left lateral segment of the liver, followed by incision from the central tendon to the diaphragm to completely expose the epicardium. If required, additional left crus of the diaphragm incision can be made to ensure an adequate field of view. Moreover, additional left crus of diaphragm dissection can facilitate stable anastomotic procedures under direct visualization in a wide surgical field.

Regarding complications, anastomotic leakage in the mediastinum can lead to mediastinitis, which can be severe [4]. Despite the large number of high position anastomosis cases in the current study, anastomotic leakage did not occur. The incidence of anastomotic leakage increases in cases of larger tumors and longer esophageal invasion lengths. However, it was performed safety in the current study. Recently, the safety of laparoscopic surgery has been identified based on the results of a large-scale clinical study. Minimally invasive surgery (MIS) is becoming the mainstream method [13–17]. MIS is superior in terms of lymph node dissection and operability in confined spaces. However, Mine et al reported that unlike open surgery, MIS is not associated with reduced anastomotic leakage rates. Even with MIS, anastomotic leakage can lead to mediastinitis, which can be extremely fatal. Therefore, MIS is truly minimally invasive if anastomotic leakage does not occur even with open surgery. At present, the parachute technique is challenging to replicate in MIS. However, the parachute technique in MIS should be developed in the future.

This study had several limitations. First, it was a single-center retrospective study, not a randomized controlled study. Second, the number of cases was small. Thus, further study should be performed, and prospective studies are more appropriate to validate the efficacy of this procedure.

In conclusion, transhiatal mediastinal esophagojejunal anastomosis using the parachute technique is a safe and reliable reconstruction method that decreases the risk of anastomotic leakage.

Disclosure

Acknowledgments

Conflict of interest

The authors declare that have no competing interests.

Ethics statement

This retrospective study was conducted with the approval of the Institution Review Board (B22-106). This study conforms to the provisions of the Declaration of Helsinki. Informed consent was obtained from all patients.

Author Contribution

NH supervised the entire study. Study conception and design, TH, MN and NH. All authors contributed to the analysis and interpretation of date.

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Table 1. Patient characteristics

Table 2. Surgical outcomes

Table 3. Pathological findings

No competing interests reported.

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You are reading this latest preprint version

Esophago-jejunal anastomosis with open approach using the parachute technique to prioritize safety after resection of esophagogastric junction cancer

Status:

Version 1

Abstract

Background

Materials and methods

Surgical procedure (parachute technique):

Results

Conclusions

Figures

Introduction

Patients and methods

Patients

Parachute technique for anastomosis

Results

Discussion

Declarations

Disclosure

Conflict of interest

Ethics statement

Author Contribution

References

Tables

Additional Declarations

Status:

Version 1