DARMARAJAH VEERAMOOTOO, MB BS MRCS MD, ANGELA C SHORE, PhD, SHAHJEHAN A WAJED, MA BMBCh MChir FRCS. Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom. Institute of Biomedical and Clinical Sciences, University of Exeter, Exeter, United Kingdom.
Minimally invasive esophagectomy (MIE) offers a novel strategy for the management of resectable esophago-gastric cancer. However, success of this surgery is highly reliant on fate of the gastric conduit fashioned to restore gastrointestinal continuity. Failure of the conduit is believed to result from ischemia which can be potentially limited by technical modifications. The purpose of this study is to explore the impact of technical refinements on conduit perfusion.
A prospective study was designed to evaluate the MIE technique in our Unit. This is a three-stage procedure consisting of a thoracoscopic esophageal mobilisation and lymphadenectomy, laparoscopic gastric mobilisation, lymphadenectomy and extra-corporeal fashioning of the gastric conduit with a cervical anastomosis. Delivery of the stomach to the outside can be facilitated by use of a hand-port. The conduit can then be carefully constructed to a measured width of 5cm, followed by laparoscopic assisted trans-mediastinal delivery to the neck. Perfusion, in tissue perfusion unit, was recorded from the serosal surface of the fundus of the stomach by laser Doppler fluximetry. Measurements were taken at every stage of an MIE (Laparoscopy = baseline, exteriorisation of stomach, conduit formation and delivery at neck). A perfusion coefficient measured as: ratio of perfusion at neck over baseline perfusion was used for statistical analysis.
Sixteen patients were considered for this study. Hand-port and measured conduit technique were used in 8 (cohort A), but not used in the other 8 (cohort B). For the whole cohort at MIE, a significant drop in fundus perfusion is noted once stomach is mobilised and exteriorised (Laparoscopy 539.7±161.6 v outside 207.5±73.7, p=0.0001; Wilcoxon matched-pairs test). Once the conduit is fashioned perfusion drops further (180.7±63.4), but improves at neck level (193.9±66.6). This trend holds true for both cohorts. The mean perfusion coefficient at the neck was 38.0% (range 18.1 to 67.4), i.e. average 62% drop in stomach perfusion. For cohort A, the perfusion coefficient was 45.0±12.6 v 31.1±12.5 for cohort B (p=0.028 – Mann Whitney U Test). There were two cases of simple anastomotic leak (managed conservatively) in this series, one in each cohort, and perfusion coefficient were 41.0 and 41.1 for the two cases respectively.
Perfusion of the stomach suffers a significant fall once it is fashioned into a conduit. Technical modifications can optimise conduit perfusion. However, a low perfusion coefficient does not always lead to failure of the conduit and optimisation techniques may not prevent simple anastomotic leaks.
Program Number: S117