The Modified Ivor Lewis Esophagectomy Technique

  

The Ivor Lewis esophagectomy has remained the procedure of choice for localized middle or lower esophageal cancer since it was first introduced in 1946 [1,2]. Despite its widespread use, the rate of complications remains high. Anastomotic leak is still reported as high as 25% and esophageal strictures up to 40%. It is well known that ischemia of the anastomosis contributes to both of these outcomes, and we believe they may be largely avoidable [1,3,4].

In our recent manuscript, “Major modifications to minimize thoracic esophago‐gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy,” we introduce a novel technique for creating the thoracic esophago-gastric anastomosis [1]. The procedure reduces operative steps, preserves the right gastric artery, minimizes tissues trauma, obviates the need for routine feeding tubes, and relocates the anastomosis from the apex of the gastric conduit to the mid-posterior body. Both the esophagogastric and gastric staples lines are created closer to the remaining 2-vessel blood supply [1].  There were no postoperative deaths, no early re-admissions, no esophageal strictures on long term follow up, and the leak rate was 1.82% [1].

Following an upper midline laparotomy, a self‐retaining retractor is placed. The greater omentum and gastro‐colic ligament are divided with a LigaSureTM device (Medtronic). The stomach is manually retracted by holding the nasogastric tube as a handle. This minimizes contact with the gastro‐epiploic arcade and reduces the risk of vascular trauma. Mobilization of the greater curvature continues from the right gastric artery to the left crus, preserving the gastroepiploic arcade and peri‐gastric lymph nodes.

The gastro‐hepatic ligament is divided toward the right crus. The gastro‐esophageal junction is mobilized and a Penrose drain is placed, encircling the esophagus. The stomach is lifted to expose the lesser sac, and all posterior attachments are divided. The left gastric artery is identified and divided with an EndoGIATM stapler (Covidien‐Medtronic). The Penrose is then drawn inferiorly along the posterior aspect of the stomach toward the pylorus. As there are no further named structures, this maneuver identifies any remaining adhesions or attachments.

A pyloroplasty is completed with full thickness, interrupted 3‐0 vicryl. No Kocharization maneuver is performed, and no jejunostomy tube is placed. Gastric mobilization is confirmed by ensuring the pylorus can touch the esophageal hiatus. The abdomen is closed with size 1 looped PDS, 2‐0 vicryl sutures, and staples.

A lateral thoracotomy is performed in the right 5th intercostal space. The azygos vein is divided with an EndoGIATM stapler. A Penrose drain is placed around the esophagus and used to retract it toward the surgeon (laterally). Mobilization continues inferiorly, dividing the vascular and lymphatic branches with a combination of LigaSureTM and manual ligation. When possible, the thoracic duct is identified and ligated. After reaching the diaphragmatic hiatus, the stomach is gently delivered into the chest.

The nasogastric tube is withdrawn to the level of the neck. The esophagus is divided with Mayo scissors above the level of the azygos vein with a PurstringTM Auto SutureTM device (Covidien— Medtronic). The anvil of an EEA StaplerTM (Covidien—Medtronic) is placed in the proximal esophageal stump, and the pursestring is tied. Whenever possible, a 28‐mm EEATM anvil is used. If it does not fit in the proximal esophagus, a 25-mm is used instead.

A gastrotomy is created at the fundus in an area that will be resected with the specimen. The EEATM stapler is pointed inferiorly and posteriorly toward the origins of the RGEA and RGA. This intentionally expands the antero‐posterior diameter. The trocar of the EEATM stapler is advanced through the posterior wall of the antrum, “cheating” slightly laterally toward the gastroepiploic arcade, and as distal as possible while still allowing a tension‐free lock with the anvil. After the EEA is deployed, a linear Endo GIATM is used to remove the esophago‐gastric specimen parallel to the remaining esophagus [1].

References

1. Housman B, Lee DS, Wolf A, et al. Major modifications to minimize thoracic esophago-gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy. J Surg Oncol. 2021;124(4):529-539. doi:10.1002/jso.26550

2. Lewis I. The surgical treatment of carcinoma of the oesophagus. Br J Surg1946;18-31.

3. Jacobi CA, Zieren HU, Zieren J, Müller JM. Is tissue oxygen tension during esophagectomy a predictor of esophagogastric anastomotic healing? J Surg Res. 1998;74(2):161-4. doi:10.1006/jsre.1997.5239

4. 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 longterm survival in a high volume centre. Eur J Cardiothorac Surg. 2005;27(1):3-7. doi:10.1016/j.ejcts.2004.09.018