Ann Thorac Surg 2007;84:1780-1782. doi:10.1016/j.athoracsur.2007.08.019
© 2007 The Society of Thoracic Surgeons
How To Do It
Modified Nissen Fundoplication Combined With Ivor Lewis Esophagogastrectomy
Maria C. Russell, MD*,
Vinod H. Thourani, MD,
Joseph I. Miller, Jr, MD
Subsection of General Thoracic Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
Accepted for publication August 9, 2007.
* Address correspondence to Dr Russell, Department of Surgery, Emory University Hospital, Rm B206, 1364 Clifton Road, NE, Atlanta, GA 30322 (Email: maria.russell{at}emoryhealthcare.org).
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Abstract
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Esophageal carcinoma is a difficult neoplasm to treat, with a reported overall 5-year survival of about 15%. The role of chemotherapy and radiation has yet to be defined, making surgical resection the standard treatment. Postoperative esophageal leak remains a significant contributor to morbidity and mortality, especially after an intrathoracic anastomosis. We propose a modification of the Ivor Lewis esophagogastrectomy that has resulted in two anastomotic leaks in a series of more than 500 patients.
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Introduction
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The most significant complication after esophagogastrectomy is the potential for leak. Causes of postoperative anastomotic leak include local factors such as arterial ischemia, venous insufficiency, tension, gastric distention, and infection, as well as systemic factors such as malnutrition, diabetes mellitus, cirrhosis, and hypotension. Finally, technical factors such as the inherent difficulty of sewing mucosa and longitudinal muscle without serosa contribute to anastomotic leaks [1, 2]. Each factor plays a part in the 3% to 25% incidence of leak for intrathoracic anastomosis [3, 4]. Our experience with a standard Ivor Lewis anastomosis, followed by a modified Nissen fundoplication, used in more than 500 patients in the last 21 years by a single surgeon and his surgical residents, has resulted in only two anastomotic leaks and three 30-day mortalities, none of which was related to leak.
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Technique
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The abdominal portion of the operation is done in routine fashion with gastric mobilization preserving the right gastroepiploic and right gastric artery, combined with a pyloroplasty and feeding jejunostomy. Recently, the harmonic scalpel has greatly facilitated mobilization of the greater curve. The esophageal hiatus is dilated with an opening to the right pleural space of 4 to 5 fingerbreadths. In only one case in the series, the small bowel herniated through the hiatus in the early postoperative period and required replacement into the abdomen.
Once the abdominal phase of the operation is completed, the patient is placed in the left lateral decubitus position with an indwelling double lumen endotracheal tube. The right pleural space is entered by standard posterior lateral thoracotomy position through the fourth or fifth intercostal space, depending on the level of the primary tumor. The inferior pulmonary ligament is divided and swept to the level of the inferior pulmonary vein. The azygous vein is clamped and ligated with 0-0 silk suture. The mediastinal pleura is opened over the esophagus starting at 20 cm from the incisors, or approximately 5 cm above the aortic arch, to the level of the esophageal hiatus. Penrose drains are placed around the esophagus at the carina and the gastroesophageal junction. The esophagus is then mobilized out of the bed from the aorta to the pericardium, taking all of the lymph nodes with it. The stomach is brought into the thoracic cavity and appropriate orientation is confirmed.
Regardless of the tumor location, the anastomosis is made at 25 cm or above the aortic arch, whenever possible, in an attempt to decrease reflux. We try to obtain a 10-cm esophageal true margin. Approximately 20% to 30% of the stomach is resected to create a gastric tube from the greater curve to the lesser curve. The staple line is then oversewn with a running 3-0 Prolene (Ethicon, Somerville, NJ) suture. Gastric margins are checked by pathology.
We use several important technical points when we determine the location for the anastomosis that others have emphasized as well. First, we mobilize the esophagus no more than 1.5 cm above the level at which the anastomosis will be performed to preserve the blood supply to the esophagus. Next, the anastomosis is placed 1 to 1.5 cm off the greater curve of the stomach to avoid interrupting the gastric vasculature. Finally, we preserve 3 to 5 cm of upper gastric tube to be later used as the Nissen wrap after the anastomosis is completed.
We then perform an end-to-side esophagogastric anastomosis using 3-0 silk suture. The initial posterior layer of suture goes through the esophageal musculature and the gastric seromuscular layer with a total of 7 stitches placed. The anterior wall of the stomach and posterior wall of the esophagus are opened, and the second layer of inverting interrupted stitches with 3-0 silk suture are placed, taking full thickness bites through all layers of the esophagus and the stomach. These stitches are placed 1 mm apart and 3 mm in depth. The esophagus is then severed and margins are checked by frozen section. An anterior inner layer of interrupted inverting 3-0 silk suture is passed through all layers to complete the anterior wall anastomosis.
The remainder of the gastric tube is then folded over the anastomosis in typical Nissen fashion, with the exception that it covers only 270° of the anastomosis. This is tacked into position with several interrupted stitches of 3-0 silk suture in the fashion of the original Nissen fundoplication (Fig 1
and inset). All patients routinely undergo a gastrograffin-barium swallow (Gastroview;Tyco Healthcare, St. Louis, MO; barium; EZEM Inc, Westbury, NY) on postoperative day 7 to assess the anastomosis (Fig 2).
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Fig 1. The completed anastomosis with the initial layer of anterior sutures placed. A second layer of anterior sutures from the muscular wall of the esophagus to the seromuscular layer of the stomach are taken through part of the upper gastric tube and brought over as the second anterior covering of the anastomosis. (Inset) The completed anastomosis. This is a 270° wrap and is a modification of the Nissen fundoplication.
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Fig 2. The postoperative barium swallow will generally identify the area of anastomosis. There will be air (arrows) in the gastric wrap, as demonstrated on this patient’s roentgenogram, as the wrap comes around the anastomosis. Rarely will barium fill the gastric wrap.
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Comment
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The recently published 5-year survival rate for esophageal carcinoma of 15% is likely affected by early tumor dissemination and advanced disease progression at diagnosis [5]. Neoadjuvant chemotherapy increases the likelihood of achieving a complete resection, but survival benefit has not been shown. For this reason, surgery remains the standard treatment [6].
The two most common operations for esophageal carcinoma are the transhiatal esophagectomy and the Ivor Lewis transthoracic approach. Although disadvantages of the transhiatal approach include lack of thoracic lymphadenectomy and absence of visualization of the midthoracic dissection, the transthoracic esophagectomy has a limited proximal resection margin and an intrathoracic anastomosis. Leaks from a cervical anastomosis, although more frequent, are usually treated with simple drainage. Leaks from the transthoracic anastomosis are associated with substantial morbidity and mortality. Published guidelines recommend a leak rate less than 5% [7]. Given the already low 5-year survival rate, it is essential to minimize the risk for complications such as anastomotic leak.
Several factors in our technique contribute to a low leak rate:
- • care is taken to ensure appropriate orientation of the stomach, thus preserving a healthy arterial supply and preventing venous obstruction; a gastric emptying procedure prevents gastric distention;
- • mobilization of the proximal esophagus is limited to preserve the blood supply to the esophagus;
- • the anastomosis is placed off of the greater curve of the stomach to avoid interruption of the gastric blood supply; and
- • finally, the gastric tube is folded over the anastomosis, adding additional reinforcement to the anastomosis.
Although we are not the first to describe the use of a fundoplication after esophagogastrectomy, our results present the modified Nissen fundoplication technique as an option to significantly decrease the leak rate after esophagogastrectomy [8]. The technique described here has been used in more than 500 cases between 1984 and 2005, resulting in only two anastomotic leaks.
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Acknowledgments
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Figure 1 was illustrated by Charles Boyter.
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References
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- Urschel J. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review Am J Surg 1995;169:634-640.
- Peracchia A, Bardini R, Ruol A, Asolati M, Scibetta D. Esophagovisceral anastomotic leak J Thorac Cardiovasc Surg 1988;95:685-691.
- Junemann-Ramirez M, Awan MY, Khan ZM, Rahamim JS. Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on long-term survival in a high volume center Eur J Cardiovasc Surg 2005;27:3-7.
- Whooley BP, Law S, Alexandrou A, Murthy SC, Wong J. Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer Am J Surg 2001;181:198-203.
- Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2006 CA Cancer J Clin 2006;56:106.
- Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrectomy for esophageal carcinoma Ann Thorac Surg 2001;72:1918-1924.
- Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer Gut 2002;50(suppl 5):v1-v23.
- Velanovich V, Mohlberg N. The split-stomach fundoplication after esophagogastrectomy J Gastrointest Surg 2006;10:178-183.
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Abstract
Introduction
