The Modified Ivor Lewis Esophagectomy Technique

The Ivor Lewis esophagectomy has remained the procedure of choice for localized middle or lower esophageal cancer since it was first introduced in 1946 (1,2). Despite its widespread use, the rate of complications remains high. Anastomotic leak is still reported as high as 25 percent, and esophageal strictures can be up to 40 percent. It is well known that ischemia of the anastomosis contributes to both of these outcomes, and the authors believe they may be largely avoidable (1,3,4). 

In the authors’ recent manuscript, “Major modifications to minimize thoracic esophago‐gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy,” they introduced a novel technique for creating the thoracic esophagogastric anastomosis (1). The procedure reduces operative steps, preserves the right gastric artery, minimizes tissues trauma, obviates the need for routine feeding tubes, and relocates the anastomosis from the apex of the gastric conduit to the midposterior body. Both the esophagogastric and gastric staples lines are created closer to the remaining two-vessel blood supply (1).  There were no postoperative deaths, no early readmissions, no esophageal strictures on long-term follow-up, and the leak rate was 1.82 percent (1). 

The Modified Technique 

Following an upper midline laparotomy, a self‐retaining retractor is placed. The greater omentum and gastrocolic ligament are then divided with a LigaSure device (Medtronic). Next, the stomach is manually retracted by holding the nasogastric tube as a handle. This minimizes contact with the gastroepiploic arcade and reduces the risk of vascular trauma. Mobilization of the greater curvature continues from the right gastric artery to the left crus, preserving the gastroepiploic arcade and perigastric lymph nodes. 

The gastrohepatic ligament is divided toward the right crus. The gastroesophageal junction is mobilized, and a Penrose drain is placed, encircling the esophagus. The stomach is lifted to expose the lesser sac, and all posterior attachments are divided. Then, the left gastric artery is identified and divided with an Endo GIA stapler (Covidien‐Medtronic). The Penrose is then drawn inferiorly along the posterior aspect of the stomach toward the pylorus. As there are no further named structures, this maneuver identifies any remaining adhesions or attachments. 

After this, a pyloroplasty is completed with full thickness, interrupted 3‐0 Vicryl sutures. No Kocher maneuver is performed, and no jejunostomy tube is placed. Gastric mobilization is confirmed by ensuring the pylorus can touch the esophageal hiatus. The abdomen is closed with size 1 looped PDS, 2‐0 Vicryl sutures, and staples. 

A lateral thoracotomy is performed in the right fifth intercostal space. The azygos vein is divided with an Endo GIA stapler. A Penrose drain is placed around the esophagus and used to retract it toward the surgeon (laterally). Mobilization continues inferiorly, dividing the vascular and lymphatic branches with a combination of LigaSure and manual ligation. When possible, the thoracic duct is identified and ligated. After reaching the diaphragmatic hiatus, the stomach is gently delivered into the chest. 

The nasogastric tube is withdrawn to the level of the neck. Then the esophagus is divided with Mayo scissors above the level of the azygos vein with a Purstring Auto Suture device (Covidien-Medtronic). The anvil of an EEA Stapler (Covidien-Medtronic) is placed in the proximal esophageal stump, and the purse string is tied. Whenever possible, a 28‐mm EEA anvil is used. If it does not fit in the proximal esophagus, a 25-mm is used instead. 

Then, a gastrotomy is created at the fundus in an area that will be resected with the specimen. The EEA stapler is pointed inferiorly and posteriorly toward the origins of the right gastroepiploic artery (RGEA) and right gastric artery (RGA). This intentionally expands the antero‐posterior diameter. The trocar of the EEA stapler is advanced through the posterior wall of the antrum, “cheating” slightly laterally toward the gastroepiploic arcade, and as distal as possible while still allowing a tension‐free lock with the anvil. After the EEA is deployed, a linear Endo GIA is used to remove the esophago‐gastric specimen parallel to the remaining esophagus (1). 

References

1. Housman B, Lee DS, Wolf A, et al. Major modifications to minimize thoracic esophago-gastric leak and eradicate esophageal stricture after Ivor Lewis esophagectomy. J Surg Oncol. 2021;124(4):529-539. doi:10.1002/jso.26550
2. Lewis I. The surgical treatment of carcinoma of the oesophagus. Br J Surg1946;18-31.
3. Jacobi CA, Zieren HU, Zieren J, Müller JM. Is tissue oxygen tension during esophagectomy a predictor of esophagogastric anastomotic healing? J Surg Res. 1998;74(2):161-4. doi:10.1006/jsre.1997.5239
4. Junemann-Ramirez M, Awan MY, Khan ZM, Rahamim JS. Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre. Eur J Cardiothorac Surg. 2005;27(1):3-7. doi:10.1016/j.ejcts.2004.09.018

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