J Gastric Cancer.  2019 Dec;19(4):473-483. 10.5230/jgc.2019.19.e35.

Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy

• Lehwald-Tywuschik N
• Steinfurth F
• Kröpil F
• Krieg A
• Sarikaya H
• Knoefel WT
• Krüger M
• Benhidjeb
• Beshay M
• Schulte am Esch J

• KMID: 2466035
• DOI: http://doi.org/10.5230/jgc.2019.19.e35

Abstract

Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The "˜dorsal track control' (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.

Keyword

AEG II; Esophagojejunostomy; Anastomosis, surgical; Gastric cancer; Surgical training

MeSH Terms

Adenocarcinoma
Anastomosis, Surgical
Esophagectomy
Esophagogastric Junction
Esophagus*
Stomach Neoplasms
Sutures
Traction

Figure

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  Fig. 1 Description of the DTC maneuver. (A) Transhiatal approach with lower mediastinal en-bloc lymphadenectomy. Ventral semi-circular incision in the esophagus at a level that provides a safety margin of minimum 5 cm cranial to the oral tumor. The posterior esophageal wall remains intact for traction control of the esophagus (naso-gastric tube in place). (B and C) Controlled positioning of the purse-string suture avoiding any manipulation of the remaining intrathoracic esophagus. One hand gently pulls down the esophagus by the posterior wall with DTC. (D) The dorsally-exposed epithelialized inner wall surface of the ventrally-opened esophagus serves as a guiding chute to ease the insertion of the anvil into the upper esophageal lumen; this is paralleled by preventing the retraction of the esophageal end towards the upper mediastinum. (E) Following the insertion of the circular stapler anvil into the upper esophageal lumen, the anvil attachment is tied by the purse string-suture. (F) Following the purse-string suture tie around the anvil attachment, the distal esophagus is cut just below. DTC = dorsal track control.

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  Fig. 2 Intraoperative pictures for extended gastrectomy. (A) Semi-circular opening of the ventral esophagus with a safety margin of minimum 5 cm cranial to the oral tumor (naso-gastric tube in place). (B) The purse-string suture is carefully placed, under observation, by avoiding any manipulation of the esophagus stump. (C) The anastomosis will be placed up to 10 cm intrathoracic in the mid mediastinum.

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  Fig. 3 Kaplan–Meier survival curve demonstrates similar OS and DFS rates in groups I (gastrectomy only, n=12) and II (gastrectomy + distal esophagectomy, n=8). OS = overall survival; DFS = disease free survival.

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  Fig. 4 Pre-(left panels) and post-(right panels) operative thoraco-abdominal computed tomography-scans of 1 patient operated with the dorsal track control technique (blue ovals—localization of the adenocarcinoma of the esophagogastric junction II; yellow arrows—position of the intrathoracic esophagojejunostomy after transhiatal extended gastrectomy). Pre-op = pre-operative; Post-op = post-operative.

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