Misbah Khan, MD, FCPS, Nimra Urooj, Dr, Aamir A Sayed, FRCS, Shahid Khattak, FRCS, Anam Muzaffar, Dr, Muhammad I Ashraf, Dr. Shaukat Khanum Memorial Cancer Hospital and Research Centre
Objectives: Purpose of study is to report our technique of use of excision biopsy wound of percutaneous endoscopic-gastrostomy (PEG) site for specimen retrieval and gastric conduit formation, in minimally invasive esophagectomy(MIE) for esophageal cancer.
Description: Technique involves a standard procedure of MIE with laparoscopic abdominal approach.
Following completion of laparoscopic gastric mobilization on right gastro-epiploic and right gastric pedicles, PEG site is disconnected close to the anterior abdominal wall with an Echelon stapler. Laparoscopic transhiatal or VATs mobilization of thoracic esophagus is done and ervical esophageal is mobilized via cervical approach. Cervical esophagus is divided. A soft Ryle’s tube French # 14/16 is tied to distal end of cervical esophagus with a silk stitch.
The outer PEG site is excised with an elliptical midline incision taking a 1 cm margin and sent for histopathology. The incision is much smaller than Hand assisted technique .Wound protector Alexis (small) is introduced into the resulting wound, stomach along with the esophagus over attached Ryle’s tube is brought into the wound (keeping other end of long Ryle’s tube still in cervical wound). Stomach tube is constructed with linear staplers and stapled line is secured with proline 4/0 suture. Proximal Gastric tube at proposed site of anastomosis is anchored to the distal end of Ryle’s tube with silk 2/0 stitch and is pulled up over Ryles tube into the cervical wound. Hand sewn gastro-esophageal anastomosis proceeds in the usual way after removal of Ryle’s tube. Pneumo-peritoneum can be re-achieved for remaining laparoscopic abdominal steps by gloving the Alexis retractor with a surgical glove.
Results: We present a data of our 100 resectable esophageal cancer patients who post neoadjuvant therapy underwent MIE from January 2012 till September 2015. All the patients had an initial staging EUS with PEG placement. The pre-study (conventional) approach i.e; laparoscopic gastric conduit formation along with specimen pull up from cervical /thoracic wound is compared to the present (Study) group. The two groups were similar(p>0.05) for basic demographics, tumor stage, morphology and nutritional status. The primary end points were operative time in minutes and any additional procedure specific complications (Abdominal excision wound complications or conduit failure). PEG site excision biopsy was positive in 2 cases,both were mid esophageal tumors not involving GE junction, one adeno and the other was squamous carcinoma, .
| Conventional Group | Study Group | Pvalue | |
|
Complications;N(%) No complications Class1,2 Class3 |
28(90.3%) 2(6.5%) 1(3.2%) |
59(85.5%) 9(13.0%) 1(1.4%) |
0.538 |
|
Operative time in minutes Mean(SD) Range |
396(90.5) 215-570 |
350(121) 195-750 |
0.06 |
SD = Standard deviation, N= number
Conclusions: Benefits of the approach are ease of gastric conduit formation in less time through the small wound,along with an additional 2nd layer, avoidance of specimen removal through the mediastinum from cervical incision, and excision of a potential site of esophageal cancer metastasis, without any added morbidity.