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J Thorac Cardiovasc Surg 2006;132:1491-1492
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Received for publication July 5, 2006; accepted for publication August 8, 2006. * Address for reprints: Richard van Hillegersberg, MD, PhD, University Medical Center Utrecht, Department of Surgery, G04.228, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. (Email: r.vanhillegersberg{at}umcutrecht.nl).
After esophagectomy, continuity is frequently restored by means of gastric replacement. The staple line of this gastric conduit is generally oversewn to prevent leakage and erosion of adjacent tissue. This last step is often omitted during minimally invasive esophagectomy (MIE) because technical difficulties make it time consuming.1
Moreover, there is little evidence that supports the need for oversewing staple lines in gastrointestinal surgery. We describe two major complications that occurred after abandoning oversewing the staple line of the gastric conduit after esophagectomy.
Patient 1
A 66-year-old woman with a squamous cell carcinoma of the midesophagus underwent robot-assisted thoracoscopic esophagectomy. Through a laparotomy, the resected specimen and abdominal lymph nodes were removed. By using the GIA-stapler (GIA 80, 3.8 mm; Tyco Healthcare, Norwalk, Conn), a 3-cm-wide gastric conduit was created.2 The staple line was not oversewn.
On the first postoperative day, the left thoracic drain produced bile. Methylene blue was injected into the nasogastric tube, which was detected in the thoracic drain soon afterward. A contrast-enhanced radiographic examination of the gastric conduit showed leakage at the distal staple line at the level of the diaphragm (Figure 1).
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Patient 2
A 69-year-old man with an adenocarcinoma of the esophagus underwent robot-assisted thoracoscopic esophagectomy with gastric conduit formation through a laparotomy. The staple line was not oversewn.
At day 9, his condition deteriorated, and he had to be reintubated. Because the bronchoalveolar aspirate contained bile, a bronchoscopy was performed, showing a fistula between the right bronchus and the gastric conduit.
Thoracotomy revealed a defect of 4 cm in the right main bronchus communicating with the neo-esophagus. Given the size of the bronchial defect and the condition of the lung with massive infiltrate, a pneumonectomy was performed. The gastric conduit was well perfused, and the defect was closed with stitches. Despite this intervention, the patient died from ongoing sepsis.
Gastric conduit staple lines are routinely oversewn to prevent local complications. Nevertheless, evidence about the value of this step is scarce. No randomized controlled trials are available comparing complication rates of oversewn versus nonoversewn (gastric) staple lines. In MIE, oversewing the gastric conduit staple line is often omitted because of technical difficulties in laparoscopic suturing. To our knowledge, this is the first report describing the possible consequences of abandoning this step.
In our hospital from 1995 until 2003, 126 consecutive patients underwent esophagectomy for malignancy either through a transthoracic or transhiatal approach. Conduit staple lines were routinely oversewn. No leakage at the staple line has occurred in any of the patients. In contrast, in the first 13 minimally invasive cases, staple lines were not oversewn, resulting in leakage in 2 (15%) patients.2 After these 2 events, we reintroduced this step, and no staple line leakage was encountered in the following 20 patients.
The incidence of dehiscent gastrotomy staple lines is not precisely described in the literature. Several factors can contribute to staple line leaks.3 Technical inadequacies of stapling material can lead to staple line disruptions, as probably occurred in our first case.3 Moreover, surrounding organs can be injured by protruding staples, resulting in fistula, as found in our second case. Third, ischemia in the region of the staple line can cause leakage. Also, staples can be caught in the posterior mediastinum during the conduit pull-up procedure, causing damage to adjacent structures and to the conduit itself. Gastrotomy leaks can lead to severe sepsis, mediastinitis, and respiratory-neo-esophageal or aorto-neo-esophageal fistulas.4
Respiratory neo-esophageal fistula is a rare but dangerous complication of esophagectomy. Although several cases are described of fistulas located at the esophagogastric anastomosis,4 few cases are depicted at the staple line of the gastric conduit.4,5 In these cases oversewing of the staple line is not reported.
Remarkably, the largest reported series of MIE has not reported any complications at the nonoversewn staple lines in 222 patients.1 Nevertheless, because the consequences of a possible leakage are severe and carry a high mortality rate, oversewing the gastric conduit staple line should be performed routinely, even in MIE. In MIE extracorporeally the gastric tube can be created and conventionally oversewn through a 7-cm transverse incision.
References
This article has been cited by other articles:
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