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Transthoracic, Extracorporeal Gastric Conduit Preparation: A Simple Alternative to Mini-laparotomy in Minimally invasive, Ivor-Lewis Esophagectomy
Anna McGuire, Sebastien Gilbert.
University of Ottawa, Ottawa, ON, Canada.
OBJECTIVE: During totally minimally invasive esophagectomy (MIE), the gastric conduit is typically constructed via laparoscopy. Trauma from laparoscopic instruments, inability to palpate the gastroepiploic arcade, and challenges in optimal positioning the stomach for intra-abdominal stapling have led to widespread use of laparotomy as part of hybrid MIE procedures. Our objective was to evaluate the safety of transthoracic, extracorporeal gastric conduit preparation. We hypothesize that this alternative technique is equivalent to the laparoscopic approach.
METHODS: The gastric conduit was fashioned through the intercostal access incision (6-8 cm) normally used to retrieve the surgical specimen and insert the EEA stapler during Ivor-Lewis MIE. Retrospective comparison with laparoscopic gastric conduit preparation was performed with emphasis on anastomotic and respiratory outcomes.
RESULTS: From June 2010 to May 2013, there were 30 MIEs (extracorporeal conduit = 15; laparoscopic conduit = 15) (Table 1). Mean age, tumor location and histology were similar between groups (Table 1). Anastomotic technique and location, and operating surgeon were the same for all patients. Patients in the laparoscopic gastric conduit group were slightly more likely to have undergone induction chemoradiotherapy (Table 1). There was no significant difference between groups with respect to anastomotic complications, including anastomotic leak and anastomotic stricture (Table 1). There was a trend toward fewer respiratory complications in the transthoracic conduit preparation group (Table 1).
CONCLUSIONS: Transthoracic, minimally invasive gastric conduit preparation is a safe alternative to hybrid esophagectomy with laparotomy. It overcomes shortcomings of the laparoscopic approach. This technique allows the surgeon to commit to Ivor-Lewis esophagectomy only once resectability of the thoracic esophagus has been confirmed.
Outcome | Extracorpeal Transthoracic Conduit (n=15)* | Intracorporeal Laparoscopic Conduit (n=15)* | p value |
Mean age (years) | 58.6 | 67.0 | 0.59 |
Gender • Female • Male | 3 (20.0) 12 (80.0) | 2 (13.3) 13 (86.7) | 1.0 |
Tumor Location • Gastroesophageal junction • Middle or distal esophagus | 5 (33.3) 10 (66.7) | 6 (40.0) 9 (60.0) | 0.27 |
Histology • Adenocarcinoma • Other | 10 (66.7) 5 (33.3) | 12 (80.0) 3 (20.0) | 0.68 |
Pre-operative chemoradiation | 6 (40.0) | 12 (80.0) | 0.030 |
Anastomotic complications • Leak • Stricture | 2 (13.3) 1 (6.7) | 1 (6.7) 1 (6.7) | 0.70 |
Respiratory complications | 8 (53.3) | 12 (80.0) | 0.09 |
*Numbers in parentheses represent percentages. |
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