Page 16 - Read Online

Matto et al. Mini-invasive Surg. 2025;9:19 https://dx.doi.org/10.20517/2574-1225.2025.51 Page 7 of 11

After dividing the proximal esophagus, the specimen is sent for frozen section analysis to assess the surgical
margins. The conduit and proximal esophageal end are then prepared for anastomosis. If there is any
concern regarding the margins, we halt the procedure and wait for the frozen section results. If the margins
are confirmed to be negative, we proceed with the initial steps of the anastomosis. We begin by evaluating
the internal diameter and compliance of the proximal esophageal end. In most cases, this is located well
above the level of the azygous vein division, and the open esophageal lumen is wide enough to
accommodate a 28 mm anvil, which can be inserted and sutured without difficulty. If the proximal
esophagus is narrow, we may consider using a 25 mm anvil or performing a handsewn anastomosis. We
avoid using a 21 mm anvil in adults, as this has consistently led to refractory strictures and persistent
dysphagia. In many patients, distal obstruction caused by the tumor results in prestenotic dilation of the
proximal esophagus, facilitating the insertion of a 28 mm anvil. However, long-standing GERD or prior
radiation therapy can lead to a very stiff and narrowed mid-to-proximal esophagus. To assess the internal
diameter, the esophageal lumen is gently spread using an endoscopic sponge stick or a similar instrument.
Occasionally, a 30 cc Foley balloon may be inserted into the lumen for gentle dilation. If all attempts to
insert an anvil of the intended size fail, we either reduce the anvil size, opt for a handsewn anastomosis, or
consider a linear stapled technique. Once the anvil is in place, a purse-string suture with 2-0 Ethibond is
used to secure the esophageal edges around the anvil post. A second purse string is then placed to further
secure the tissue and create a flat esophageal surface for stapling. This step helps ensure the formation of
complete “rings” during the EEA stapling.

Once securing the anvil, we proceed with the insertion of the EEA stapler through the robotic arm 1 port
site. Since the EEA stapler is not compatible with the robotic system, the port must be temporarily removed
and the incision enlarged to accommodate the device. Previously, our technique involved inserting the EEA
shaft through the end of the open conduit, exiting through the posterior wall and along the greater
curvature, before docking with the anvil. The stapler would then be fired, and the remaining open end of
the conduit stapled closed. Over time, this approach has evolved into a stapled EEA, as described earlier
[Figures 1-3].

Most Ivor Lewis anastomoses are performed above the level of the azygous vein. Even in cases involving
small GE junction tumors, we rarely consider a low-lying gastroesophageal anastomosis, as this invariably
leads to severe and potentially recalcitrant bile and acid reflux. Such reflux carries an inherent risk of
developing Barrett’s esophagus and second malignancies. Therefore, to achieve optimal surgical margins
and functional outcomes that minimize reflux symptoms, we prefer a narrow gastric conduit with the
anastomosis placed above the azygous division point, avoiding any redundancy or spiraling.

After the anastomosis, a perianastomotic drain and a nasogastric tube (NGT) are placed. At this stage, the
chest is irrigated with several liters of warm antibiotic solution to remove any spillage of esophageal or
gastric contents. We then inject approximately 20 mL of 0.5% bupivacaine with epinephrine into the
intercostal spaces from the third down to the eleventh, administering approximately 2 cc per interspace.
Next, we carefully position the greater curvature fat and epiploic arcades between the conduit and the
mediastinal airways and pericardium. We prefer to orient the staple line away from the airway, with the
greater curvature fat and associated vessels facing the deeper mediastinum. The tip of the drain is then
loosely secured with a 4-0 absorbable suture to a delicate 1 mm edge of the mediastinal pleura. This suture
helps prevent malposition of the drain tip during lung expansion and postoperative mobilization. A flat
Jackson-Pratt drain is used and connected to either a bulb or bile bag for drainage.