Robotic Totally Endoscopic Retrosternal Gastric Pullup
Abbas E. Abbas.
Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA.
OBJECTIVE: It is sometimes necessary to use the retrosternal route for gastric or colonic esophageal replacement. This is often indicated for patients who have had an esophageal diversion procedure either for severe esophageal injury or as an anastomotic complication from esophagectomy. Less commonly it is employed to bypass an unresectable esophageal malignancy. Patients who require this operation have usually experienced significant sepsis and malnutrition. Unfortunately, this operation routinely requires an open laparotomy. This may add to the surgical morbidity in these high risk patients. We have developed a novel robotic totally endoscopic technique for this operation which requires only laparoscopic ports.
METHODS: Three patients required retrosternal gastric pull-up (RSGP) in our institution from 2013 to 2016. One had unresectable squamous cell carcinoma of the esophagus invading into the left main stem bronchus. Another had a delayed presentation of spontaneous esophageal perforation that could not be primarily repaired. The third patient had a severe esophageal iatrogenic injury from dilation of a chronic ischemic stricture. A retrospective review of the patient charts was performed with IRB approval. Standard robotic assisted laparoscopy is performed. After creating the gastric conduit, the substernal plane is entered by dividing the phrenosternal attachments. A simultaneous cervicotomy is performed and the left sternoclavicular junction is resected. The transabdominal retrosternal space is then connected to the cervicotomy and the conduit is passed to the neck where it is anastomosed to the cervical esophageal.
RESULTS: We have performed this procedure in 3 patients. No operative mortalities were encountered. One patient had a minor anastomotic leak with spontaneous resolution. There were no incidents of vocal cord paralysis or delayed gastric emptying. Average postoperative length of stay was 10.3 days (7, 10, 14). All 3 patients were able to resume normal diet within 1 month of the operation.
CONCLUSIONS: Retrosternal gastric pull-up is not a common operation. However, it is usually required in sick patients who have needed esophageal diversion. Our small series illustrates the possibility of performing this operation which has always required laparotomy in a minimally invasive fashion.
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