TY - JOUR
AU - Ruurda, Jelle, P
AB - SUMMARY The circular mechanical and hand-sewn intrathoracic anastomosis are most often used in robot-assisted minimally invasive esophagectomy (RAMIE). The aim of this study was to describe the technical details of both techniques that were pioneered in two high volume centers for RAMIE. A prospectively maintained database was used to identify patients with esophageal cancer who underwent RAMIE with intrathoracic anastomosis. The primary outcome was anastomotic leakage, which was analyzed using a moving average curve. For the hand-sewn anastomosis, video recordings were reviewed to evaluate number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Between 2016 and 2019, a total of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis were included in the study. For the hand-sewn anastomosis, the moving average curve for anastomotic leakage (including grade 1–3) started at a rate of 40% (cases 1–10) and ended at 10% (cases 59–68). For the circular-stapled anastomosis, the moving average started at 10% (cases 1–10) and ended at 20% (cases 51–60). This study showed the technical details and refinements that were applied in developing two different anastomotic techniques for RAMIE. Results markedly improved during the period of development with specific changes in technique for the hand-sewn anastomosis. The circular-stapled anastomosis showed a more stable rate of performance. INTRODUCTION Esophagectomy is the cornerstone of curative treatment for esophageal cancer and achieves a 5-year survival rate of ~50% when combined with neoadjuvant therapy.1 Although the postoperative morbidity after esophagectomy has decreased over the recent decades, complications are still common and anastomotic leakage occurs in 10% to 30%.2,3 As an intrathoracic anastomosis appears to be associated with the lowest leakage rates, a shift toward two-stage transthoracic esophagectomy is seen over the last decades.4–7 Robot-assisted approaches for the surgical treatment of esophageal and junctional cancer gained considerably importance over the last years.8 Initially, the robotic resection was combined with a neck anastomosis.9 More recently, the robotic intrathoracic anastomosis was developed. The two intrathoracic techniques that are most commonly applied are the circular-stapled and hand-sewn anastomosis.10 Most reports, so far, describe the robotic-assisted hand-sewn anastomosis, that takes optimal advantage of the robotic suturing capacity.11–14 The circular-stapled anastomosis is used mainly by groups that also used this technique in open surgery.15–17 This study aimed to describe the technical details of the circular-stapled and hand-sewn robotic intrathoracic anastomosis, analyzed in two high-volume centers for robotic-assisted minimally invasive esophagectomy (RAMIE). PATIENTS AND METHODS Patient population Patients were selected from prospectively maintained databases of two high-volume centers for RAMIE. Patients who underwent RAMIE with gastric conduit reconstruction and an intrathoracic anastomosis were included. In the University Medical Center Utrecht (UMCU), a robotic intrathoracic, hand-sewn anastomosis was routinely performed since September 2016. All RAMIE procedures were routinely recorded and stored on the hospital server. The University Hospital Schleswig Holstein, Campus Kiel (UKSH) started with the robot-assisted circular-stapled technique from October 2017. Patients who underwent RAMIE with gastric conduit reconstruction and a circular-stapled intrathoracic anastomosis were included. The institutional review board of both hospitals approved this study. Hand-sewn anastomosis surgical technique After performing two-field lymphadenectomy and creation of the gastric conduit as was previously reported in detail,18 an intrathoracic esophagogastric anastomosis was constructed above the level of the azygos arc. A robot-assisted, single-layer running, hand-sewn technique was applied to first close the posterior wall and then the anterior wall by two separate suturing wires that were placed in identical direction to end at the same site (i.e. from 9 to 3 o’clock). If possible, the tip of the gastric conduit was removed, and an omental wrap was positioned around the anastomosis. The surgical technique was refined during the inclusion period. The first 13 cases were end-to-end (E-T-E) anastomoses. After consecutive case 13, a transit was made to an end-to-side (E-T-S) anastomosis in order to be able to better tailor the level of the anastomosis at the level of the gastric tube. Furthermore, at consecutive case 18, the surgical team switched from using V-Loc 3.0 barbed suture wires (Medtronic) to Stratafix 3.0 (Ethicon) barbed suture wires. The reason for the change was that the more rigid v-lock suture could damage the esophageal wall at the level of the stiches. Starting with consecutive case 21, four supportive stitches were placed in the esophagus (i.e. at 12, 3, 6 and 9 o’clock) before initiating the suturing. Finally, to avoid traction on the anastomosis, four tension-release stitches (i.e. at 12, 3, 6 and 9 o’clock) were placed in the serosa of the esophagus and gastric conduit from consecutive case 47 onward. Consequently, the final anastomotic technique involved an E-T-S intrathoracic anastomosis that was created by the successive placement of four supportive stitches, single layer continuous suturing of the posterior and anterior wall with two separate Stratafix wires, four tension release stiches and an omental wrap. The incision in the gastric conduit for creating the anastomosis was made as far as possible from the longitudinal staple line and near the omentum. Circular-stapled anastomosis surgical technique The approach is fully robotic—meaning the abdominal part of the operation is performed robotic-assisted as well. Our established technique is characterized by the only partial formation of the gastric tube abdominally and an intrathoracic E-T-S anastomosis with a circular stapling device. The creation of the gastric tube is deliberately incomplete. The small gastric curvature later serves to introduce the circular stapling device in the thoracic part of the operation and is resected afterward. From our point of view, the main advantage of this method is the possibility to determine the needed length of the gastric tube in the thoracic part of the operation. The anastomosis begins with the introduction of the circular stapler anvil in the transected esophageal stump. The fixation of the anvil is secured by a purse-string suture (Stratafix 3.0). For this fixation, we use a barbed suture, which delivers a very good result especially with the robot.19 For this purpose, the bougie (24Ch) that was introduced to prevent an esophageal spasm is withdrawn. The minor curvature is now brought to the thoracic wall and incised through the assistant port. A circular stapling device with a diameter of 29 mm can now be inserted. Now, a suitable location for anastomosis can be selected near the greater curvature. Here, particular attention should be paid to the correct length of the gastric tube: the anastomosis should not be under tension, but a gastric tube that is too long can lead to emptying disorders postoperatively due to the formation of a siphon and might be not well perfused. For that reason, routinely fluorescence angiography with indocyanine green is performed to ensure adequate perfusion of the gastric tube. After selecting the appropriate location, the mandrel is extended and connected to the anvil. An assistant puts the gastric tube under slight tension and completes the anastomosis. After insertion of a bougie past the anastomosis, the minor curvature is transected with a linear stapling device, and the specimen is salvaged via the assistant port. This is followed by the circular stitch over of the anastomosis and the proximal row of the gastric staple line. It can be helpful to change the camera to arm 2, resulting in a superior overview and improved freedom of movement for the bedside surgeon. Outcomes Patient characteristics were assessed (Table 1). The primary outcome measure was anastomotic leakage defined according to the Esophageal Complications Consensus Group.20 For the hand-sewn anastomosis, additional technical details were collected by reviewing surgical videos of all the patients. Table 1 Patient characteristics of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis during robot-assisted minimally invasive esophagectomy . Hand-sewn N (%) . Circular-stapled N (%) . Gender  Male 56 (82) 51 (85)  Female 12 (18) 9 (15) Age, years [mean, (±SD)] 64 (±9.3) 64 (±8.6) Clinical T stage  T1 6 (9) 2 (3)  T2 13(19) 13 (22)  T3 48 (71) 35 (58)  T4 1 (1) 10 (17) Clinical N stage  N0 32 (47) 13 (22)  N1 27 (40) 18 (30)  N2 7 (10) 20 (33)  N3 2 (3) 9 (15) Neoadjuvant treatment  None 5 (7) 11 (18)  Chemoradiotherapy 62 (91) 10 (17)  Chemotherapy 1 (2) 39 (65) . Hand-sewn N (%) . Circular-stapled N (%) . Gender  Male 56 (82) 51 (85)  Female 12 (18) 9 (15) Age, years [mean, (±SD)] 64 (±9.3) 64 (±8.6) Clinical T stage  T1 6 (9) 2 (3)  T2 13(19) 13 (22)  T3 48 (71) 35 (58)  T4 1 (1) 10 (17) Clinical N stage  N0 32 (47) 13 (22)  N1 27 (40) 18 (30)  N2 7 (10) 20 (33)  N3 2 (3) 9 (15) Neoadjuvant treatment  None 5 (7) 11 (18)  Chemoradiotherapy 62 (91) 10 (17)  Chemotherapy 1 (2) 39 (65) Open in new tab Table 1 Patient characteristics of 68 patients with a hand-sewn anastomosis and 60 patients with a circular-stapled anastomosis during robot-assisted minimally invasive esophagectomy . Hand-sewn N (%) . Circular-stapled N (%) . Gender  Male 56 (82) 51 (85)  Female 12 (18) 9 (15) Age, years [mean, (±SD)] 64 (±9.3) 64 (±8.6) Clinical T stage  T1 6 (9) 2 (3)  T2 13(19) 13 (22)  T3 48 (71) 35 (58)  T4 1 (1) 10 (17) Clinical N stage  N0 32 (47) 13 (22)  N1 27 (40) 18 (30)  N2 7 (10) 20 (33)  N3 2 (3) 9 (15) Neoadjuvant treatment  None 5 (7) 11 (18)  Chemoradiotherapy 62 (91) 10 (17)  Chemotherapy 1 (2) 39 (65) . Hand-sewn N (%) . Circular-stapled N (%) . Gender  Male 56 (82) 51 (85)  Female 12 (18) 9 (15) Age, years [mean, (±SD)] 64 (±9.3) 64 (±8.6) Clinical T stage  T1 6 (9) 2 (3)  T2 13(19) 13 (22)  T3 48 (71) 35 (58)  T4 1 (1) 10 (17) Clinical N stage  N0 32 (47) 13 (22)  N1 27 (40) 18 (30)  N2 7 (10) 20 (33)  N3 2 (3) 9 (15) Neoadjuvant treatment  None 5 (7) 11 (18)  Chemoradiotherapy 62 (91) 10 (17)  Chemotherapy 1 (2) 39 (65) Open in new tab Video evaluation All videos of the hand-sewn anastomosis were evaluated by the same investigator (EdG) who was blinded for patient characteristics and postoperative outcomes. Manual scoring and counting was performed to collect data regarding all outcomes (shown in Tables 2,3), except for measuring distances, which are specified and defined in Table 4. Image J-software (National Institutes of Health and LOCI, University of Wisconsin, Madison, WI, USA) was used to measure distances within the video material by using the known sizes of surgical instruments in the recordings as references. Distances were only measured in case a surgical instrument was positioned in the same direction and at the same depth as the distance to be measured. When these conditions were met, a snapshot was made and imported in Image J-software to scale and measure the distance. Distances were measured in multiple directions and the mean distance was reported. In case, an adequate snapshot could not be created, the corresponding distances was reported as missing outcomes. Table 2 Characteristics of the hand-sewn anastomosis that was created in 68 patients who underwent robot-assisted minimally invasive esophagectomy Variable . Total cohort (N = 68) . N (%) Supportive stitches  Yes 48 (71)  No 20 (29) Tension release stitches  Yes 22 (32)  No 46 (68) Tension on the gastric tube  No tension 40 (59)  Tension 20 (29)  Severe tension 8 (12) Type of stitch  V-Loc 17 (25)  Stratafix 51 (75) Omental wrap  Yes 64 (94)  No 4 (6) Knot tying  None 13 (19)  Tied 9 (13)  Fixed with another suture 5 (8)  Sewed backward 41 (60) Type of anastomosis  End-to-end 13 (19)  End-to-side 55 (81) Tip of the gastric conduit  Not stapled 24 (35)  Stapled before anastomosis 13 (19)  Stapled after anastomosis 31 (46) Variable . Total cohort (N = 68) . N (%) Supportive stitches  Yes 48 (71)  No 20 (29) Tension release stitches  Yes 22 (32)  No 46 (68) Tension on the gastric tube  No tension 40 (59)  Tension 20 (29)  Severe tension 8 (12) Type of stitch  V-Loc 17 (25)  Stratafix 51 (75) Omental wrap  Yes 64 (94)  No 4 (6) Knot tying  None 13 (19)  Tied 9 (13)  Fixed with another suture 5 (8)  Sewed backward 41 (60) Type of anastomosis  End-to-end 13 (19)  End-to-side 55 (81) Tip of the gastric conduit  Not stapled 24 (35)  Stapled before anastomosis 13 (19)  Stapled after anastomosis 31 (46) Open in new tab Table 2 Characteristics of the hand-sewn anastomosis that was created in 68 patients who underwent robot-assisted minimally invasive esophagectomy Variable . Total cohort (N = 68) . N (%) Supportive stitches  Yes 48 (71)  No 20 (29) Tension release stitches  Yes 22 (32)  No 46 (68) Tension on the gastric tube  No tension 40 (59)  Tension 20 (29)  Severe tension 8 (12) Type of stitch  V-Loc 17 (25)  Stratafix 51 (75) Omental wrap  Yes 64 (94)  No 4 (6) Knot tying  None 13 (19)  Tied 9 (13)  Fixed with another suture 5 (8)  Sewed backward 41 (60) Type of anastomosis  End-to-end 13 (19)  End-to-side 55 (81) Tip of the gastric conduit  Not stapled 24 (35)  Stapled before anastomosis 13 (19)  Stapled after anastomosis 31 (46) Variable . Total cohort (N = 68) . N (%) Supportive stitches  Yes 48 (71)  No 20 (29) Tension release stitches  Yes 22 (32)  No 46 (68) Tension on the gastric tube  No tension 40 (59)  Tension 20 (29)  Severe tension 8 (12) Type of stitch  V-Loc 17 (25)  Stratafix 51 (75) Omental wrap  Yes 64 (94)  No 4 (6) Knot tying  None 13 (19)  Tied 9 (13)  Fixed with another suture 5 (8)  Sewed backward 41 (60) Type of anastomosis  End-to-end 13 (19)  End-to-side 55 (81) Tip of the gastric conduit  Not stapled 24 (35)  Stapled before anastomosis 13 (19)  Stapled after anastomosis 31 (46) Open in new tab Table 3 Suturing details in patients with a hand-sewn anastomosis who underwent robot-assisted minimally invasive esophagectomy Variable . Patients . Outcome . Median [range] Time supportive stitches (minutes) n = 46 5 [4–7] Time running suture (minutes)  Total n = 68 26 [14–45]  Posterior wall 11 [7–28]  Anterior wall 12 [6–22] Time tension releasing sutures (minutes) n = 22 10 [7–15] Time omental wrap (minutes) n = 64 3 [1–14] Time final anastomotic technique n = 21 40 [31–48] Number of sews in running suture  Total n = 68 27 [20–38]  Posterior 13 [7–25]  Anterior 13 [9–21] Revisions n = 68 0 [0–5] Variable . Patients . Outcome . Median [range] Time supportive stitches (minutes) n = 46 5 [4–7] Time running suture (minutes)  Total n = 68 26 [14–45]  Posterior wall 11 [7–28]  Anterior wall 12 [6–22] Time tension releasing sutures (minutes) n = 22 10 [7–15] Time omental wrap (minutes) n = 64 3 [1–14] Time final anastomotic technique n = 21 40 [31–48] Number of sews in running suture  Total n = 68 27 [20–38]  Posterior 13 [7–25]  Anterior 13 [9–21] Revisions n = 68 0 [0–5] Open in new tab Table 3 Suturing details in patients with a hand-sewn anastomosis who underwent robot-assisted minimally invasive esophagectomy Variable . Patients . Outcome . Median [range] Time supportive stitches (minutes) n = 46 5 [4–7] Time running suture (minutes)  Total n = 68 26 [14–45]  Posterior wall 11 [7–28]  Anterior wall 12 [6–22] Time tension releasing sutures (minutes) n = 22 10 [7–15] Time omental wrap (minutes) n = 64 3 [1–14] Time final anastomotic technique n = 21 40 [31–48] Number of sews in running suture  Total n = 68 27 [20–38]  Posterior 13 [7–25]  Anterior 13 [9–21] Revisions n = 68 0 [0–5] Variable . Patients . Outcome . Median [range] Time supportive stitches (minutes) n = 46 5 [4–7] Time running suture (minutes)  Total n = 68 26 [14–45]  Posterior wall 11 [7–28]  Anterior wall 12 [6–22] Time tension releasing sutures (minutes) n = 22 10 [7–15] Time omental wrap (minutes) n = 64 3 [1–14] Time final anastomotic technique n = 21 40 [31–48] Number of sews in running suture  Total n = 68 27 [20–38]  Posterior 13 [7–25]  Anterior 13 [9–21] Revisions n = 68 0 [0–5] Open in new tab Table 4 Measurements in patients with a hand-sewn anastomosis who underwent robot-assisted minimally invasive esophagectomy Outcome . Patients . Distance (mm) . Median [range] Diameter esophagus n = 63 17 [12–22] Length incision gastric conduit n = 44 14 [10–18] Distance incision gastric conduit to stapler sideline for end-to-side anastomosis n = 43 10 [5–25] Distance incision gastric conduit to the tip of the gastric conduit for end-to-side anastomosis n = 49 22 [5–66] Gastric conduit stump n = 56 14 [0–35] Outcome . Patients . Distance (mm) . Median [range] Diameter esophagus n = 63 17 [12–22] Length incision gastric conduit n = 44 14 [10–18] Distance incision gastric conduit to stapler sideline for end-to-side anastomosis n = 43 10 [5–25] Distance incision gastric conduit to the tip of the gastric conduit for end-to-side anastomosis n = 49 22 [5–66] Gastric conduit stump n = 56 14 [0–35] Open in new tab Table 4 Measurements in patients with a hand-sewn anastomosis who underwent robot-assisted minimally invasive esophagectomy Outcome . Patients . Distance (mm) . Median [range] Diameter esophagus n = 63 17 [12–22] Length incision gastric conduit n = 44 14 [10–18] Distance incision gastric conduit to stapler sideline for end-to-side anastomosis n = 43 10 [5–25] Distance incision gastric conduit to the tip of the gastric conduit for end-to-side anastomosis n = 49 22 [5–66] Gastric conduit stump n = 56 14 [0–35] Outcome . Patients . Distance (mm) . Median [range] Diameter esophagus n = 63 17 [12–22] Length incision gastric conduit n = 44 14 [10–18] Distance incision gastric conduit to stapler sideline for end-to-side anastomosis n = 43 10 [5–25] Distance incision gastric conduit to the tip of the gastric conduit for end-to-side anastomosis n = 49 22 [5–66] Gastric conduit stump n = 56 14 [0–35] Open in new tab Statistics All statistical analyses were performed using SPSS 25.0 (IBM) and Microsoft Excel 2018. Descriptive analyses were performed according to the type of data. Categorical variables were shown as a count with percentage. Continuous data were reported as mean (with standard deviation) or median (with range), depending on data distribution. Moving average analyses for anastomotic leakage (percentage) were performed by repeatedly taking windows of 10 previous cases, thereby visualizing the trend in performance regarding these outcomes. RESULTS Study population Between September 2016 and November 2018, 68 patients who underwent RAMIE with a hand-sewn anastomosis were included in the UMCU. Between October 2017 and December 2019, 60 patients underwent RAMIE with a circular-stapled anastomosis in the UKSH. The patient characteristics are shown in Table 1. Technical parameters The technical parameters of the hand-sewn anastomoses are demonstrated in Tables 2–4. The anastomotic steps are visualized in Figures 1,2. An E-T-S anastomosis was created in the majority of patients (n = 55, 81%) and Stratafix suturing wires were used most often (n = 51, 75%). Prior to suturing of the anastomosis, supportive stitches were placed in 48 of these patients (71%), which took a median of 5 minutes (range 4–7 minutes). The posterior wall was closed by a median of 13 stitches (range 7–25 stitches) in 11 minutes (range 7–28 minutes). Closure of the anterior wall required a median of 13 stitches (range 9–21 stitches) in 12 minutes (range 6–22 minutes). The median time between the first stitch in the posterior layer and the last stitch in the anterior layer was 26 minutes (range 14–45 minutes). Most running sutures were fixed by sewing the last stitch backward (n = 41, 60%). In other cases, the stitch was not fixed (n = 13, 19%), tied (n = 9, 13%) or fixed with an extra Vicryl wire which was necessary to fix the wire because the end of the leftover wire was too short (n = 5, 8%). Tension releasing stitches were placed in 22 patients (32%), which was achieved in a median of 11 minutes (range 8–15 minutes). An omental wrap was positioned to cover the anastomosis in 64 patients (94%) in a median of 3 minutes (range 1–14 minutes). The steps of the final technique—successively consisting of1 placing supportive stitches,2 sewing the posterior wall,3 sewing the anterior wall,4 placing tension-release stitches and5 omentoplasty—were measured in 21 patients. The cumulative median duration of this final technique was 40 minutes (range 31–48 minutes). Tension on the anastomosis was observed in 28 patients (41%), which was considered to be severe in eight of these patients. The tip of the gastric conduit was removed by a stapler in the majority of patients (n = 44, 65%), either before (n = 13, 19%) or after sewing the anastomosis (n = 31, 46%). Fig. 1 Open in new tabDownload slide Steps of the hand-sewn anastomosis. Eso = esophagus, GC = gastric conduit, SS = stapler sideline. Fig. 1 Open in new tabDownload slide Steps of the hand-sewn anastomosis. Eso = esophagus, GC = gastric conduit, SS = stapler sideline. Fig. 2 Open in new tabDownload slide Steps of the intrathoracic circular-stapled anastomosis. Eso = esophagus, GC = gastric conduit. Fig. 2 Open in new tabDownload slide Steps of the intrathoracic circular-stapled anastomosis. Eso = esophagus, GC = gastric conduit. Measurements The measurements that were performed in video material of the hand-sewn anastomoses are shown in Table 4. The median diameter of the esophagus was 17 millimeters (range 12–22 mm). The incision in the gastric conduit was median 14 mm (range 10–18 mm). For E-T-S anastomosis, the distance between the incision in the gastric conduit and the vertical conduit stapler-line was median 10 mm (range 5–25 mm) and the distance between the incision in the gastric conduit and the tip of the gastric conduit was median 22 mm (range 5–66 mm). Anastomotic leakage In patients with hand-sewn anastomosis, anastomotic leakage rate was observed in a total of 22 patients (32%). This involved a grade 1 leak in five patients (7%), a grade 2 leak in seven patients (10%) and grade 3 leak in 10 patients (15%).17 Figure 3a demonstrates the moving average regarding anastomotic leakage over the consecutive cases in relation to changes in technique that were made at certain points in time, which started for the hand-sewn anastomosis at 40% (consecutive cases 1–10) and ended at 10% (consecutive cases 59–68). In patients with a circular-stapled anastomosis, anastomotic leakage occurred in 10 patients, 17% of the patients. No grade 1 leakage occurred, whereas in 10 patients (12%), a grade 2 leakage was observed and in three patients (5%), a grade 3 leakage was observed. Figure 3b shows the moving average analysis regarding anastomotic leakage for the circular-stapled anastomosis, the leakage rate started with 10% (consecutive cases 1–10) and ended at 20% (consecutive cases 51–60). Fig. 3 Open in new tabDownload slide Moving average analysis of anastomotic leakage in 68 patients with a hand-sewn anastomosis (a) and 61 patients with a circular-stapled anastomosis (b). Fig. 3 Open in new tabDownload slide Moving average analysis of anastomotic leakage in 68 patients with a hand-sewn anastomosis (a) and 61 patients with a circular-stapled anastomosis (b). DISCUSSION This study described the technical details and initial results of a hand-sewn and circular-stapled, intrathoracic anastomosis for RAMIE in two high-volume centers. In case of the hand-sewn anastomosis, moving average analyses for anastomotic leakage showed a decrease from 40% in cases 1–10 to 10% in cases 59 to 68. In case of a circular-stapled anastomosis, moving average analysis was between 10% and 30% from the beginning of the technique on until the last cases. The optimal technique for a robot-assisted intrathoracic anastomosis is still unclear, as evidence to support superiority of either one is lacking. The hand-sewn technique is the most commonly used technique during RAMIE. This technique, however, may carry a longer learning curve compared to the circular-stapled technique as was demonstrated in this paper. In contrast to the moving average of the hand-sewn anastomosis, the circular anastomosis shows a more stable curve regarding anastomotic leakage with less outliers. Both anastomotic techniques can be standardized as was shown by the analysis of the hand-sewn method, showing that the distances and number of stitches were very consistent during the inclusion period for both patients and surgeons. Although improvement in anastomotic leakage was observed in the hand-sewn anastomosis, the overall anastomotic leakage rate was relatively high.2 It must be noted, however, that this study described the initial experience of RAMIE with a pioneered hand-sewn anastomosis, which means that a learning curve effect is to be expected.9,21 Several refinements were made to improve the technique, including the switch from an E-T-E to an E-T-S anastomosis, the switch from V-Loc to Stratafix and the placement of tension release stitches for the final 23 patients. These refinements may have resulted in the decreasing anastomotic leakage rate during the last part of the inclusion period. Especially, the introduction of tension releasing stitches appears to be beneficial, although the numbers are too small for any definite conclusions. Nonetheless, it cannot be concluded with certainty that the learning curve has been completed as a previous study found that the learning curve of an intrathoracic anastomosis might take as much as 119 cases.9 That retrospective multicenter study, evaluating 646 patients from four centers, considered the learning curve to be completed once an anastomotic leakage rate of 8% was achieved. Multiple ups and downs were observed in the average anastomotic leakage rate over time, with peaks of up to 37%. In this context, the findings in the current study might still represent early learning curve results. Continued evaluation of postoperative outcomes is warranted to monitor the safety of the technique. Furthermore, it should be mentioned that before adopting the RAMIE circular anastomosis, this technique was already used in open esophagectomy. Therefore, it is possible that the learning curve was already partially completed. A disadvantage of the circular anastomosis is the fact that a mini-thoracotomy is necessary to introduce the stapler, due to the nonexistence of a robot-circular stapler. The head of the stapler is relatively large in respect to the intercostal space that requires spreading the ribs, potentially causing pain. Also, the surgeon needs to scrub in at the operating table. The new robotic linear stapler can be fully controlled from the robotic console without the need of a mini-thoracotomy. An additional advantage of the linear stapled anastomosis is the possibility of creating a wider anastomosis, which might cause less strictures. On the other hand, the linear-stapled anastomosis is only mechanical for the posterior layer of the anastomosis. To close the anastomosis, the anterior layer must still be closed by manual suturing, which consequently requests the technical expertise of the surgeon for robotic hand-sewing. A possible advantage of a full hand-sewn technique is the preciseness of construction in a difficult to assess part of the thorax. Moreover, the surgeon can develop a highly controlled anastomosis. In contrary to the circular technique, the surgeon can complete the anastomosis without leaving the robotic console to the bedside. On the other hand, a hand-sewn anastomosis may be more technically challenging and requires a learning curve.22,23 Four previous studies11–14 have reported on widely varying techniques to construct a hand-sewn, intrathoracic anastomosis during RAMIE. Two studies mentioned the importance of the distance between the incision in the gastric conduit and the gastric stapler line when creating the anastomosis. This was the main reason for the increasing distances in our series. One study maintained a distance of at least 20 mm from the gastric stapler line.11 Another study made the incision as far away as possible from the lesser curve stapler line and 3 to 4 cm below the most superior gastric stapler line.13 However, if and how these distances were measured, which was not reported in those papers. The assumed importance of these distances is based on the hypothesis that the tissue in proximity of the gastric conduit tip is relatively ischemic, which implies that an anastomosis at that site would be more prone to developing anastomotic leakage. Therefore, increasing distances might contribute to a decreasing anastomotic leakage rate. Also the added value of omentoplasty around the anastomosis has been described in the literature, which might contribute to a decrease in incidence of anastomotic leakage.24 To date, no prospective studies have compared a hand-sewn versus stapled technique for an intrathoracic anastomosis during minimally invasive esophagectomy. However, literature on open esophagectomy suggests that a mechanical anastomosis might be superior in terms of leakage and strictures.25,26 Prospective studies may be warranted to adequately compare these techniques regarding anastomotic leakage, benign strictures and functional outcome during RAMIE. When constructing such a prospective comparative study, it is important to pay attention to the learning curve. The major strength of this study is its unique design that provides the first detailed technical parameters of a robot-assisted hand-sewn intrathoracic anastomosis in two high-volume RAMIE centers. This information provides insights in the development of this technique and could be helpful when training other surgeons. Furthermore, prospectively maintained databases were used to register anastomotic leakage. A limitation of this study may be the requirement of adequate still images to estimate distances in the video material. However, the risk of observer bias was minimalized by using predefined definitions and measurement criteria and by blinding the investigator responsible for video review for patient characteristics and postoperative outcomes. In addition, all distances were measured multiple times and in various directions, thereby maximizing the accuracy of the estimations. Only one other study used video review for identifying technical variables and performing measurements.27 In that study, the investigators also used surgical instruments as references to measure the length of the gastrojejunal anastomosis, the flow angle and the distance from the pylorus to the gastric division from video material taken during Whipple procedures. This study stated that video review is a powerful tool to assess technical factors. In conclusion, this study provides insight into technical details and refinements of a robot-assisted, hand-sewn and circular-stapled, intrathoracic anastomosis during RAMIE. ACKNOWLEDGEMENTS Figure 1 and Figure 2 are created with BioRender.com. Conflicts of interest J.P.R., R.v H. and JH.E. are proctors for Intuitive Surgical Inc., Sunnyvale, CA, USA. Funding JHE and TB received the da Vinci Xi robotic surgical system from Intuitive Surgical Sarl for the purpose of clinical research. REFERENCES 1 Shapiro J , van Lanschot J J B, Hulshof M C C M et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial . Lancet Oncol 2015 ; 16 : 1090 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Low D E , Kuppusamy M K, Alderson D et al. Benchmarking complications associated with esophagectomy . Ann Surg 2017 ; 1 . [ Internet : . http://insights.ovid.com/crossref?an=00000658-900000000-95806. Available from Google Scholar OpenURL Placeholder Text WorldCat 3 Biere S S A Y , Maas K W, Cuesta M A, Van Der Peet D L. 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World J Gastroenterol 2015 ; 21: 4757–64. Google Scholar OpenURL Placeholder Text WorldCat 27 Jung J P , Zenati M S, Dhir M et al. Use of video review to investigate technical factors that may be associated with delayed gastric emptying after pancreaticoduodenectomy . JAMA Surg 2018 ; 153: 918–27. Google Scholar OpenURL Placeholder Text WorldCat Author notes Eline M. de Groot, Thorben Möller, Jan-Hendrik Egberts and Jelle P. Ruurda contributed equally to this work. © The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Technical details of the hand-sewn and circular-stapled anastomosis in robot-assisted minimally invasive esophagectomy
JF - Diseases of the Esophagus
DO - 10.1093/dote/doaa055
DA - 2020-11-26
UR - https://www.deepdyve.com/lp/oxford-university-press/technical-details-of-the-hand-sewn-and-circular-stapled-anastomosis-in-NP0J1j86Fd
VL - 33
IS - Supplement_2
DP - DeepDyve
ER -