Outcomes Using Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer
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Outcomes Using Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer. Presentation given at Academic Surgical Congress, Las Vegas NV, February 2015.
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Outcomes Using Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer
- 1. Ann Falor, MD1, Audrey H. Choi, MD1, Michael Lew, MD2, Byrne Lee, MD1, I. Benjamin Paz, MD1, Rebecca A. Nelson, PhD3, Joseph Kim, MD1 1Department of Surgery, 2Department of Anesthesia, 3Department of Biostatistics City of Hope National Medical Center, Duarte, CA Outcomes Using Double-Stapled Technique for Esophagoenteric Anastomosis in Gastric Cancer
- 3. Introduction • Slow adoption of minimally-invasive proximal and total gastrectomy for gastric cancer – Technically challenging to create the esophagoenteric anastomosis (requires advanced suturing techniques) • Double-stapled technique (DST) is one method of overcoming this challenge – Can be used in both minimally-invasive and open approaches • Series describing the outcomes after DST for gastric cancer are limited
- 4. Introduction • Transoral anvil delivery system (EEATM OrvilTM device, Covidien) • Esophagus transected with linear stapler, esophagotomy created next to staple line for the device’s valve tip • OrvilTM inserted orally, tube is pulled through the esophagotomy • The string is cut to release anvil head from the OG tube, then anvil is seated at the staple line Kelly KJ, Strong VE (2014). Minimally Invasive Total Gastrectomy. In Kim J and Garcia-Aguilar J (Eds), Surgery for Cancers of the Gastrointestinal Tract.
- 5. Introduction End-to-side anastomosis created by passing a 25 mm EEA stapler into the Roux limb Remainder of jejunum closed with linear stapler fire Kelly KJ, Strong VE (2014). Minimally Invasive Total Gastrectomy. In Kim J and Garcia-Aguilar J (Eds), Surgery for Cancers of the Gastrointestinal Tract.
- 6. Introduction
- 7. Objective • To evaluate the anastomotic leak and stricture rates after DST for esophagoenteric anastomosis in gastric cancer patients
- 8. Methods • Single institution review • 2006-2015 • All patients underwent proximal or total gastrectomy with DST for gastric carcinoma • Anastomotic leak – Perianastomotic contrast extravasation on imaging – Anastomotic disruption visualized by endoscopy • Anastomotic stricture – Symptomatic narrowing requiring dilation
- 9. Patient Characteristics DST (N=60) Age (years)* 64 (20-89) Sex (male) 37/60 (61.7%) Prior gastric or esophageal surgery 8/60 (13.3%) Diabetic 12/60 (20.0%) Pre-operative albumin (g/dL)† 4.1 ± 0.4 Neoadj chemo 21/60 (35.0%) Prior radiation therapy 6/60 (10.0%) DST (N=60) Pathology Adenocarcinoma Other 55/60 (91.7%) 5/60 (8.3%) Path stage 0 I II III IV 2/60 (3.3%) 16/60 (26.7%) 18/60 (30.0%) 19/60 (31.7%) 5/60 (8.3%) *Median (range); †Mean ± Std Dev
- 10. Operative Characteristics DST (N=60) Procedure Completion gastrectomy Total gastrectomy Proximal gastrectomy 5/60 (8.3%) 49/60 (81.7%) 6/60 (10.0%) Approach Open Laparoscopic Robotic 31/60 (51.7%) 26/60 (43.3%) 3/60 (5.0%) Operative time (min)† 366 ± 111 EBL (ml)† 281 ± 234 †Mean ± Std Dev
- 11. Leak and stricture rates 7.1% 17.9% Anastomotic Leak Anastomotic Stricture 6.7% 20.0% Median time to leak (days): 14 (5-20) Median time to stricture (days): 86 (40-405) N=4 N=56 N=12 N=48
- 12. 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 2006-2011 2012-2015 0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00% 2006-2011 2012-2015 Outcomes improved over time Anastomotic Leak Anastomotic Stricture 11.1% N=4/36 0% N=0/24 25.0% N=9/36 12.5% N=3/24
- 13. Post-Operative Outcomes DST (N=60) Length of stay (days)* 9 (5-67) Complications† Grade I Grade II Grade III Grade IV Grade V 23/60 (38.3%) 2/60 (3.3%) 9/60 (15.0%) 10/60 (16.7%) 0/60 (0%) 2/60 (3.3%) *Median (range); †Clavien-Dindo Classification
- 14. Factors associated with anastomotic stricture N (%) Univariate OR (95% CI) P-value Multivariate OR (95% CI) P- value Time period 2006-2011 2012-2014 36 (60.0%) 24 (40.0%) Reference 0.45 (0.11-1.88) 0.27 Reference 0.49 (0.06-3.70) 0.48 Operation Total Completion Proximal 49 (81.7%) 5 (8.3%) 6 (10.0%) Reference 1.08 (0.11-10.89) 2.17 (0.34-13.72) 0.95 0.41 Reference 2.24 (0.13-37.34) 1.54 (0.13-17.67) 0.72 0.98 Approach Laparoscopic Open Robotic 26 (43.3%) 31 (51.7%) 3 (5.0%) Reference 0.54 (0.15-1.98) *** 0.35 0.97 Reference 0.64 (0.09-4.57) *** 0.96 0.96 *** insufficient sample size
- 15. Conclusion • Largest Western series of DST for gastric cancer • DST can facilitate esophagoenteric anastomoses during proximal and total gastrectomy without advanced suturing techniques – Safe and effective with low leak and stricture rates – Both leak and stricture rates declined over time with increasing experience with DST
- 16. Thank You
Editor's Notes
- What are the other methods? Hand-sewn Linear stapler method – transect the esophagus with linear stapler, make esophagotomy to put another linear stapler into that and the roux limb, then you sew the staple line all the way up to the top. Problem is that this can be hard to sew all the way up to the top and the very top corner can retract into the chest
- OrVil: commercially available device, anvil head is either 21 mm or 25 mm, attached to a 18F OG tube Pros: makes intracorporeal anastomosis for prox and total gastrectomy easier, can make the procedure totally laparoscopic Cons: need an assistant to pass the OG orally, concerns about potential esophageal injury from the anvil head passage, concerns about leak and stricture rates
- This example shows creation of a EJ, but this can also be done with an esophagogastric anastomosis in the case of a proximal gastrectomy
- “Prior radiation therapy” patients – 5 were adj CRT from initial gastric cancer resection, one received palliative radiation for severe abd pain for newly diagnosed gastric cancer while being treated for liver mets from colon cancer Path notes: Stage 0: one pCR, one prophylactic Stage IV: 1 was palliative, 2 HIPEC, 2 mets to omentum
- Jung 2013: N=40, leak rate 5%, stricture rate 2.5% Shim 2013: N=12, leak rate 16%, stricture rate 33% Zuiki 2013: N=52, leak rate 1.9%, stricture rate 21% Their MVA showed that DST and 21 mm EEA were risk factors for stenosis For comparison, they also looked at a historic group of open TG, stenosis rate was 1%
- Leaks (N=4): all dx by CT CT-guided drainage, NPO/abx for one Endoscopic stent placement for two ROR to repair anastomotic dehiscence for one, later needed a stent for persistent anastomotic defect Strictures (N=12) Median number of dilations: 1.5 (1-17), people who needed most dilations (5 times, 17 times) also had leaks Mean number dilations: 3.7
- Apart from the leaks and strictures, the most common type of complication was GI (Oglivie’s, duod stump leak, DGE, FT volvulus, SBO, ischemic anastomosis; the last 3 were RORs), followed by pulmonary complications. Cardiac, infectious, thrombotic, endocrine all had N=2. There were two deaths: (1) septic shock, withdrawl of care, (2) major bleed
- Not possible to run a MVA on leak because the event rate was too low. There were no variables significantly associated with leak or stricture
- Works both open and minimally invasive In more recent patients, we use a single stitch at the esophagotomy, gets better donuts