Gastro-Esophageal-Anastomosis-Using-the-Automatic-Pursestringer-and-Circular-Stapling-Device_2008_Operative-Techniques-in-General-Surgery.pdf...

8/17/2019 Gastro-Esophageal-Anastomosis-Using-the-Automatic-Pursestringer-and-Circular-Stapling-Device_2008_Operative-Te…

http:///reader/full/gastro-esophageal-anastomosis-using-the-automatic-pursestringer-and-circular-stapling-device200… 1/4

Gastro-Esophageal Anastomosis Using the

Automatic Pursestringer and Circular Stapling DeviceWalter A. Koltun, MD

One of the more difficult components of a subtotal ortotal gastrectomy is the esophageal anastomosis. This isbecause of the frequently difficult exposure at the hiatus of the diaphragm or posterior mediastinum, making a hand-sewn anastomosis problematic. The useof thecircular staplerand the automatic pursestringer facilitates the creation of thisanastomosis from the abdominal approach. This techniquenot only eases the difficulty of anastomosis creation, but also

provides for improved control of the transected esophagus,especially when additional tissue needs to be resected to in-crease a proximal resection margin.

Operative Technique

Once the major part of the gastrectomy has been per-formed, including the peri-esophageal dissection to theproximal extent desired, the automatic pursestringer isplaced across the esophagus at the planned point of transec-tion. Theinstrumentis fired andleft locked. Theesophagus istransected below the instrument (Fig 1). The handle of theautomatic pursestringer now provides excellent control of

the transected esophagus and inhibits its retraction up intothe posterior mediastinum. The specimen is passed off and if necessary, frozen sections are done of the proximal resectionmargin. If additional resection is necessary, the automaticpursestringer allows uniform traction on the esophagus asmore proximal dissection is done. If the resection of addi-tional esophagus is necessary, a right angle bowel clamp isplaced just above the pursestringer that is then removed.Further dissection is performed and then a second purse-

stringer is placed higher up at the new resection margin and

once again fired. The additional esophageal tissue caudad to

this second pursestringer is then resected for added margin.

If the operator is satisfied with the level of proximal resec-tion, a long Babcock clamp is then placed on the esophagus 2

to 4 cm above the pursestringer to provide control while the

pursestringer is removed, leaving the pursestring suture inposition on the cut end of the esophagus. The anvil from the

appropriately sized circular stapler is then placed within the

esophagus using Allis clamps to control and spread the cut

edges of the esophagus (Fig 2). If desired, the circular staplersizers can first be used to define or dilate the size of the

esophagus to allow the largest reasonable circular stapling

instrument to be used. After placement of the anvil, thepursestring is tied down and the long Babcock clamp re-

moved. The esophagus with its anvil will typically retract

several centimeters upward, but will be easily retrieved bygrasping the pin of the anvil when the anastomosis is to be

subsequently created.

The distal half of the anastomosis is then prepared by

ensuring adequate mobility of either the remaining stomach

or other intestinal structure. An enterotomy is created in theside of the downstream viscus, several centimeters from the

planned anastomosis. This allows the entry of the hand-heldportion of the circular stapling instrument and the end of the

instrument is positioned to have the spike exit the viscus at

theplanned, distal half of theanastomosis. The anvil contain-ing esophagus is retrieved from the posterior mediastinum

and is engaged with the hand held portion of the instrument

(Fig 3). The circular stapler is closed and fired, creating the

anastomosis. If reinforcing sutures are desired, placing themin four quadrants across the anastomosis can be done while

the EEA is still closed and in place but not tying them down

until the stapler is removed. The instrument is opened and

removed through the defect in the downstream viscera that isthen closed with either a TA stapler or suture.

Department of Surgery, Division of Colon and Rectal Surgery, Penn State

College of Medicine, Milton S. Hershey Medical Center, Hershey, PA.

Address reprint requests to Walter A. Koltun, MD, Professor of Surgery,

Division of Colon and Rectal Surgery, Penn State College of Medicine,

Milton S. Hershey Medical Center, 500University Drive,MCH137, Her-shey, PA 17033-0850. E-mail: [email protected]

190 1524-153X/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.

doi:10.1053/j.optechgensurg.2008.10.002

mailto:[email protected]:[email protected]



Figure 1 The automatic pursestringer is placed at site of planned resection, fired and left locked. The esophagus is

transected below the instrument, which is left on to control the esophagus until further dissection is unnecessary andanvil is to be placed.

Gastro-esophageal anastomosis 191



Figure 2 Placementof theanvilis facilitated by using a Babcock to grasp theesophagus several centimeters proximal andone or two Allis clamps to open the cut end of the esophagus.

192 W.A. Koltun



Results and Pitfalls

The described technique using the circular stapling deviceand automatic pursestringer instruments provides an im-proved ability to perform a safe esophago-gastric anastomosisin the tight quarters of the upper abdomen or lower posteriormediastinum. Various studies and operators have suggestedan improved anastomotic leak rate using the circular stapler,but this has not been consistent between all studies.1,2 Theuse of reinforcing sutures, especially in the context of incom-plete donuts found on removal of the instrument is recom-mended.3,4 The most common postoperative complication isdysphagia because of anastomotic stricture that is most com-monly encountered when the smaller diameter circular sta-pling instruments, especially 25 mm diameter or smaller areused. When such occurs, it is usually within a few monthsafter surgery. However, such strictures are very effectivelymanaged by postoperative bougenage, often requiring two orless dilatations.5,6 Some advocate the preferential use of asmaller sized circular stapler accepting the more easily man-

aged complication of anastomotic stricture postoperatively,

rather than using too large an instrument and dealing withthe potentially lethal complication of anastomotic leak be-

cause of esophageal disruption or tearing during surgery.

References1. Wong J, CheungH, Lui R, et al: Esophagogastricanastomosisperformed

with a stapler: The occurrenceof leakage and stricture.Surgery 101:408-

415, 1987

2. Takeyoshi I, Ohwada S, Ogawa T, et al: Esophageal anastomosis follow-

ing gastrectomy for gastric cancer: Comparison of hand-sewn and sta-

pling technique. Hepatogastroenterology 47:1026-1029, 2000

3. Muehrcke DD, Donnelly RJ: Complications after esophagogastrectomy

using stapling instruments. Ann Thorac Surg 48:257-262, 1989

4. West PN, Marbarger JP, Martz MN, et al: Esophagogastrostomy with the

EEA stapler. Ann Surg 193:76-81, 19815. Muehrcke DD, Kaplan DK, Donnelly RJ: Anastomotic narrowing after

esophagogastrectomy with the EEA stapling device. J Thorac Cardiovasc

Surg 97:434-438, 1989

6. Ferguson CM: Esophagogastrostomyusing the EEA stapling instrument.

Am Surg 51:223-225, 1985

Figure 3 The esophagus is easily retrieved from posterior mediastinum using the secured anvil shaft. It is engaged with

the handheld portion of the circular instrument, having been placed through a gastrotomy downstream of the anas-tomosis.

Gastro-esophageal anastomosis 193

Gastro-Esophageal-Anastomosis-Using-the-Automatic-Pursestringer-and-Circular-Stapling-Device_2008_Operative-Techniques-in-General-Surgery.pdf...

Documents

Transcript of Gastro-Esophageal-Anastomosis-Using-the-Automatic-Pursestringer-and-Circular-Stapling-Device_2008_Operative-Techniques-in-General-Surgery.pdf...