Method for forming single-row continuous esophagogastroanastomosis on neck
The 'Four-String Method' addresses high failure rates in esophagogastrostomy by using seromuscular sutures and strategic monofilament sutures to align tissues securely, reducing complications and hospital stay in esophageal cancer surgery.
Patent Information
- Authority / Receiving Office
- RU · RU
- Patent Type
- Patents
- Current Assignee / Owner
- ПРОКОПЬЕВ СЕРГЕЙ АНАТОЛЬЕВИЧ
- Filing Date
- 2025-07-28
- Publication Date
- 2026-07-02
AI Technical Summary
Existing methods for forming esophagogastrostomy face high failure rates due to ischemia and tension in the anastomotic area, leading to complications such as anastomotic leakage and salivary fistulas, particularly in esophageal cancer surgery requiring esophagectomy and esophagogastrostomy on the neck.
A single-layer continuous esophagogastrostomy method, known as the 'Four-String Method', involving circular transection of the esophageal adventitial layer without mucosal opening, fixation of the graft with seromuscular sutures, and a strategic monofilament suture to minimize tissue tension and ensure secure alignment, combined with a narrow gastric stalk for blood supply from the right gastroepiploic artery and preventive feeding enterostomy.
Significantly reduces the risk of anastomotic leakage and salivary fistulas to 0% in 17 surgical procedures, ensuring technical simplicity and reproducibility, with minimal material costs and reduced hospitalization duration.
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Abstract
Description
[0001] FIELD OF TECHNOLOGY
[0002] The invention relates to medicine and can be used in surgery and oncology, in particular in the surgical treatment of esophageal cancer, which requires esophagectomy and the formation of an esophagogastrostomy on the neck.
[0003] STATE OF THE ART
[0004] A new method for forming an esophagogastrostomy in conditions of insufficient plastic material by modifying the posterior lip is known [Patent No. 2248185 C2 Russian Federation, IPC A61B 17 / 00, A61B17 / 11. A new method for forming an esophagogastrostomy in conditions of insufficient plastic material by modifying the posterior lip: No. 2000129298: declared 22.11.2000: published 10.10.2002 / Khvastunov R.A., Chukhnin A.G.; applicant VolgSMU. – 12 p.]. The method involves the application of an isoperistaltic esophagogastrostomy with two rows of sutures, the posterior lip is dissected between the central sutures in the sagittal direction, and two interrupted sutures are applied to the resulting defect on each side.
[0005] The disadvantage of the anastomosis is that the proposed method, according to the authors, allows for a fundamental "unloading" of the anterior lip of the anastomosis by "switching" the pressure of the chyme to the posterior wall of the graft, which is the least vulnerable, and does not take into account that the most common generally recognized cause of failure is the resulting ischemia and tension of the graft, and the opinion about the influence of the pressure of the chyme on the anterior lip of the anastomosis on the frequency of failure has not been confirmed in scientific studies.
[0006] An end-to-end esophagogastrostomy is also known, which has been used in the Hong Kong Medical Center since 1996 and was published in 2005 by Simon Law et. al. [Law S, Suen DTK, Wong K, Kwok K, Wong J. A Single-Layer, Continuous, Hand-Sewn Method for Esophageal Anastomosis: Prospective Evaluation in 218 Patients. [Journal] / / Arch Surg. - 1 January 2005. - 140: T. 1. - pp. 33-39. - doi: 10.1001 / archsurg.140.1.33]. The stomach was mainly used to form the anastomosis. It was crossed using linear staplers. In most patients, the entire stomach was used for reconstruction, with the gastric dissection line extending from a selected point on the lesser curvature to the fundus. The distal stomach was used for reconstruction when the proximal stomach was removed along with the esophagus.This was indicated either because the gastric fundus was redundant (regardless of the location of the primary tumor) or because the esophageal tumor was close to the gastroesophageal junction. If the entire stomach was used, a disk of gastric wall (the size of the stump of the anastomosed esophagus) was removed from the end of the gastric fundus, and the anastomosis was created at this location. When using the distal stomach, the tip of the gastric tube with the upper part of the linear stapled suture was removed, thus incorporating the stapled suture into the gastroesophageal anastomosis. Pyloroplasty was typically performed for all anastomoses. All anastomoses were created with a single-layer running suture using absorbable monofilament suture material (Maxon, 4-0 polyglyconate). This anastomotic technique required two unidirectional sutures, securely tied at the ends.The posterior anastomotic suture involved the full thickness of both the esophagus and the graft, while the anterior layer was formed only from the seromuscular wall of the graft, but covered the full thickness of the esophagus with minimal mucosal involvement. Each stitch was evenly spaced (approximately 5 mm apart at a depth of 5 mm) without excessive tension to avoid tissue compression.
[0007] The disadvantage of this method is that the failure rate is 3.2%, and the anastomotic stricture rate is 17.5%. The use of the end-to-end anastomosis method on the neck can potentially be accompanied by an increase in anastomotic tension and the occurrence of ischemia.
[0008] The closest to the proposed method for restoring the continuity of the esophageal-intestinal tract is the “Method for forming an esophagogastric anastomosis on the neck” [Patent No. 2 737 585 C1 Russian Federation, IPC A61B 17 / 00, A61B 17 / 11. Method for forming an esophagogastric anastomosis on the neck: No. 2020119333: declared 10.06.2020: published 01.12.2020 / Pikin O.V., Ryabov A.B., Glushko V.A., Alexandrov O.A., Bagrov V.A. [Patent holder: Federal State Budgetary Institution "National Medical Research Center of Radiology" of the Ministry of Health of the Russian Federation (Federal State Budgetary Institution "National Medical Research Center of Radiology" of the Ministry of Health of the Russian Federation)]. A method for forming an esophagogastric anastomosis on the neck, including mobilization of the thoracic esophagus and formation of a gastric graft with blood supply from the right gastroepiploic vessels, cervicotomy is performed along the inner edge of the left sternocleidomastoid muscle with the patient in a supine position with a cushion under the shoulder blades,the head end in the extension position, characterized in that access is gained to the cervical esophagus, it is isolated to the limit of mobilization from the pleural cavity and brought out into the neck wound, the gastric graft is passed through the posterior mediastinum to the neck, the cervical esophagus is crossed at a distance of 2-3 cm from the pharynx with preliminary dissection of the muscular layer to the submucosa, the esophagus is clamped along the edge of the dissected muscular layer, the thoracic esophagus together with the lesser curvature of the stomach is removed, then an esophagogastric anastomosis is formed on the neck according to the "end to side" type: the stump of the cervical esophagus is anastomosed to the posterior wall of the gastric graft, and the stump of the esophagus is fixed with three separate interrupted sutures to the posterior wall of the gastric graft, forming the outer row of the posterior lip of the anastomosis,then, 5 mm proximal to the formed outer row and parallel to it, a 10 mm long opening is made in the posterior wall of the gastric graft and the inner row of the posterior lip of the esophagogastric anastomosis is formed with five separate interrupted sutures, after which the gastric graft is sutured with a stapler in the transverse direction 10 mm proximal to the previously formed opening for the anastomosis, the apical fragment of the gastric graft is cut off and removed, the mechanical suture line on the gastric stalk is not covered, then a nasogastric tube is inserted into the distal part of the gastric graft and the inner row of the anterior lip of the anastomosis is formed with five separate interrupted sutures with the capture of the mucous membrane of the anastomosed organs, the threads are tied, the knots are placed inside the lumen or outside the lumen, then the outer row of the anterior lip of the anastomosis is formed, the inner row of sutures is covered with three U-shaped sutures: the first needle puncture is performed,starting at one of the edges of the line of the mechanical suture of the gastric transplant from the side of its anterior wall under the line of the mechanical suture, the needle is punctured from the side of the posterior wall, then the needle is passed through the muscular layer of the cervical esophagus in the transverse direction at a distance of 5 mm from the line of sutures of the internal row of the anastomosis and in the opposite direction the needle is passed under the mechanical suture of the gastric transplant in the direction from the posterior wall to the anterior, the puncture on the anterior wall of the gastric stalk is made 5 mm from the previous puncture, the thread is taken on the handle and a suture is similarly formed from the opposite edge of the gastric transplant and the third suture is passed between the two previously formed ones, each suture is taken on the handle and upon completion of the formation of the U-shaped sutures, all three threads are outside the anterior wall of the gastric transplant, passed under the line of the mechanical suture, then they are tied one by one so thatIn order for the top of the gastric transplant to completely cover the first row of the anterior lip of the anastomosis with its posterior surface, after completion of the anastomosis, the wound on the neck is drained with one drain and sutured layer by layer.
[0009] The disadvantage is that the proposed technique is difficult to reproduce and minimizes the incidence of leakage and salivary fistulas, but does not eliminate the possibility of their occurrence.
[0010] DISCLOSURE OF THE INVENTION
[0011] The proposed method for creating a single-layer continuous esophagogastrostomy in the neck, known as the "Four-String Method," pertains to esophageal reconstructive surgery and is intended to minimize postoperative complications, such as anastomotic leakage and salivary fistula, during McKeown esophagectomy. The essence of the invention lies in a unique combination of surgical techniques.The key elements are: preliminary preparation of the esophagus by circular transection of the adventitial muscular layer without opening the mucosa, which creates its excess after contraction of the muscular layer to ensure a secure seal; fixation of the graft with two seromuscular sutures of 3-0 absorbable polyfilament suture (Vicryl or Polysorb), connecting the gastric stalk to the lateral and medial walls of the esophagus to eliminate tension; and formation of the anastomosis itself using two strategically placed sutures of 4-0 absorbable monofilament suture (PDS or Maxon). The first suture serves as a traction stay suture at the medial angle, facilitating tissue alignment.A second thread with two needles at opposite ends is placed at the lateral angle as a through-and-through suture through all layers of the stomach and esophagus, providing primary fixation after tying. One half of this thread is used to form a continuous suture of the posterior lip of the anastomosis, passing the thread overlapping after passing the point of the traction suture. The second half of the same thread is used to create a continuous serous-muscular-submucosal suture of the anterior lip of the anastomosis, immersing the excess esophageal mucosa and finally tying the threads. Essential accompanying elements of the method include the formation of a narrow gastric stalk 5–6 cm wide with a blood supply exclusively from the right gastroepiploic artery; retromediastinal positioning of the graft; mandatory placement of a preventive feeding enterostomy according to Witzel-Eiselsberg at the laparotomy stage; and categorical refusal to use a nasogastric tube.The technical result consists of a significant reduction in the risk of anastomotic leakage and salivary fistulas (0% based on the results of 17 surgical procedures). This is achieved by eliminating ischemia in the anastomotic area thanks to an end-to-side connection using a single-row continuous monofilament suture, minimizing tissue tension by fixing the narrow gastric stalk to the esophagus, and ensuring optimal alignment of homogeneous layers of sutured tissue using excess mucosa and traction suture. The advantage of this method of creating an esophagogastrostomy in the neck is its technical simplicity and minimal material costs.
[0012] BRIEF DESCRIPTION OF DRAWINGS
[0013] The invention is illustrated by the drawings presented in Figures 1–9.
[0014] In Fig. 1: View of the esophagus after circular intersection of the adventitial-muscular layer of the esophagus to the submucosal layer, without opening the mucosa.
[0015] In Fig. 2: View of the esophagus (diagram and photo) with a Fedorov clamp applied 1-1.5 cm proximal to the intersection of the muscular-adventitial layer of the esophagus with the branches closed on one rack.
[0016] Fig. 3: The diagram shows the application of two seromuscular sutures on the gastric transplant at a distance of 1.5-2 cm from each other at the same level with absorbable polyfilament threads 3-0 (Vicryl or Polysorb), which are used to stitch the lateral side wall of the esophagus (Thread 1) and the medial side wall of the esophagus (Thread 2) under a Fedorov clamp.
[0017] Fig. 4: Shows the diagram and photo of the fixed gastric graft to the esophagus after tightening the polyfilament threads (Thread 1 and Thread 2) and performing a gastrotomy parallel to the transected esophagus.
[0018] Fig. 5: A diagram and 2 photographs are shown with a view of sutures applied through all layers at the lateral (Thread 3) and medial (Thread 4) corners of the gastrotomy opening and the esophagus using absorbable monofilament 4-0 threads with two needles (PDS or Maxon) over the branches of the Fedorov clamp.
[0019] Fig. 6: shows the diagram and photo after removing the Fedorov clamp and tying the monofilament thread (Thread 3) in the area of the lateral angle.
[0020] Fig. 7: Shows the diagram and photo of the formation of the posterior lip of the anastomosis by continuous suture covering the entire wall of the stomach and esophagus, using a 4-0 monofilament absorbable thread (Thread 3).
[0021] Fig. 8 shows a diagram and photo after tying and cutting the ends of the traction suture (Thread 4) and completing the formation of the posterior lip of the anastomosis with a self-tightening knot (Thread 3 is passed with an overlap).
[0022] Fig. 9: A diagram and 2 photos of the completed anastomosis are shown.
[0023] The numbers on the figures indicate:
[0024] 1 - thread 1,
[0025] 2 - thread 2,
[0026] 3 - thread 3,
[0027] 4 - thread 4.
[0028] IMPLEMENTATION OF THE INVENTION
[0029] The proposed method begins with a laparotomy, during which a Kocher mobilization of the stomach and duodenum is performed, as well as a pyloric digitalis. Using a linear stapler, a 5-6 cm wide gastric stalk is formed by resecting the cardiac region and the lesser curvature of the stomach. The blood supply to the formed graft is provided exclusively by the right gastroepiploic artery. The mechanical suture is inserted with interrupted seromuscular sutures. Next, the greater omentum is resected, D2 lymph node dissection is performed, and a sagittal diaphragmotomy is performed. The laparotomy stage is completed with the formation of a feeding enterostomy using the Witzel-Eiselsberg technique. At the next, thoracic stage, performed either openly through a right-sided thoracotomy in the 5th intercostal space, or thoracoscopically, the esophagus is mobilized with lymph node dissection in a volume of 2F to a level above the chest aperture.The gastric transplant is placed retromediastinally in the bed of the mobilized esophagus.
[0030] Formation of an esophagogastrostomy in the neck is performed in a strict sequence. After cervicotomy on the left along the anterior edge of the sternocleidomastoid muscle, the cervical esophagus is mobilized, ensuring a 4-5 cm aboral length, and a circular transection of the adventitial-muscular layer to the submucosal layer is performed without opening the mucosa (see Fig. 1). After contraction of the muscular layer, 1-1.5 cm proximal to the transection line, a Fedorov clamp is applied to the esophagus, closing its branches on one ratchet. Then, the mucosa is transected 0.5 cm distal to the line of the transected and contracted muscular-adventitial layer, thereby creating its excess (see Fig. 2). The next step is fixation of the gastric graft to the esophagus. To do this, two serous-muscular sutures with a 3-0 polyfilament absorbable thread (Vicryl or Polysorb) are placed on the gastric stalk, parallel to its feeding vessels.The first suture (Thread 1) is placed through the lateral wall of the esophagus under a Fedorov clamp, securing the suture with a clamp. The second suture (Thread 2) is placed 1.5-2 cm from the first (proportionate to the diameter of the esophageal lumen) at the same level, suturing the medial lateral wall of the esophagus also under a Fedorov clamp. Both sutures are tied sequentially, securely fixing the graft (see Fig. 3). Opposite the esophageal lumen, a gastrotomy is performed using monopolar coagulation, 0.5-0.7 mm in length, followed by careful separation of the edges of the opening with scissors to the diameter of the transected esophagus (see Fig. 4).
[0031] Next, the key sutures of the anastomosis are placed. A 4-0 monofilament absorbable suture (PDS or Maxon) with two needles at the ends (Thread 3) is placed at the lateral angle of the gastrotomy opening, passing it through all layers of the stomach (injection from the serosa side, injection from the gastric mucosa side), and then through all layers of the esophagus (injection from the esophageal mucosa side through the muscular layer and adventitia above the branches of the Fedorov clamp). These sutures are not tied, and the ends of the suture with needles are fixed with an atraumatic clamp. A second suture (Thread 4) is placed at the medial angle of the gastrotomy opening using the same principle (through all layers of the stomach and esophagus), serving as a traction stay. This suture is not tightened, and both ends are secured with a clamp (see Fig. 5). After these sutures are placed, the Fedorov clamp is removed from the esophagus, and the thread in the lateral angle area (Thread 3) is tied (see Fig. 6).
[0032] Next, a continuous suture of the posterior lip of the anastomosis (Thread 3) is formed with a 4-0 absorbable monofilament suture (PDS or Maxon), from the lateral corner of the anastomosis to the medial corner. The suture covers all layers of the wall of both the esophagus and the gastric graft, applying 4-5 ties at a distance of 5 mm from each other and at a depth of 5 mm (see Fig. 7). When the suture reaches the medial corner area, where the loose traction stay suture (Thread 4) is located, this traction suture is tightened and cut. The thread of the posterior continuous suture (Thread 3) is passed overlapping and fixed with a stay clamp (see Fig. 8).
[0033] The next step is to form a continuous anterior anastomotic suture (Thread 3) using a second needle, also from the lateral angle of the anastomosis to the medial. The anterior lip of the anastomosis is formed by suturing the seromuscular-submucosal wall of the gastric graft. Next, using the tip of the needle, minimally grasping excess esophageal mucosa (1-2 mm), which is immersed into the lumen of the esophagus, the entire esophageal wall is sutured. The ties are applied evenly, approximately 5 mm apart and 5-7 mm deep, avoiding excessive tension to prevent tissue compression. Upon reaching the previously overlapped thread (from the posterior suture) and secured with a clamp, the stomach and esophageal walls are sutured through all layers, once immediately before this secured thread and once immediately after it. Then the ends of the working thread of the front suture and the thread fixed in the overlap are tied together, which completes the formation of the anastomosis (see Fig. 9).
[0034] Critically important conditions for the successful implementation of the invention are the fixation of the graft with two seromuscular sutures of absorbable polyfilament thread 3-0 (Vicryl or Polysorb), connecting the gastric stalk with the lateral and medial walls of the esophagus to eliminate tension and the formation of the anastomosis itself using two strategically important threads of absorbable monofilament thread 4-0 (PDS or Maxon), one of which, due to traction, facilitates the comparison of single-row tissues during the formation of the posterior row of the anastomosis and a categorical refusal to use a nasogastric tube in the postoperative period, as well as the formation of a preventive feeding enterostomy according to Witzel-Eiselsberg at the laparotomy stage for the implementation of early enteral nutrition.The use of the described method ensures technical simplicity and reproducibility, contributes to achieving a low incidence of anastomotic failure (0% based on the results of 17 surgical interventions) and, as a result, reduces the duration of hospitalization of patients and contributes to improving the quality of life of operated patients.
Claims
1. A method for forming a single-row continuous esophagogastrostomy on the neck, including mobilization of the thoracic esophagus, formation of a gastric stalk 5–6 cm wide with blood supply from the right gastroepiploic artery, retromediastinal positioning of the graft, cervicotomy on the left along the anterior edge of the sternocleidomastoid muscle and mobilization of the cervical esophagus 4–5 cm long, characterized in that the adventitial-muscular layer of the esophagus is circularly crossed to the submucosal layer without opening the mucous membrane, a Fedorov clamp is applied to the esophagus 1–1.5 cm proximal to the intersection line, the mucous membrane is crossed 0.5 cm distal to the line of the contracted muscular layer, the gastric stalk is fixed to the esophagus with two seromuscular sutures of absorbable polyfilament thread 3-0, wherein the first suture connects the gastric stalk with the lateral wall of the esophagus, and the second with the medial wall of the esophagus at a distance of 1.5–2 cm,a 0.5–0.7 mm long gastrotomy is performed opposite the esophageal incision, and an end-to-side esophagogastrostomy is formed: a 4-0 monofilament absorbable suture with two needles at the ends is applied to the lateral angle of the gastrotomy opening, passing it through all layers of the stomach, then through all layers of the esophagus; the sutures are not tied, and the ends of the suture with needles are fixed with an atraumatic clamp; then a traction stay suture is applied to the medial angle of the esophagogastrostomy with a similar thread through all layers of the stomach and esophagus; the stay suture is not tightened, both ends of it are fixed with a clamp; after applying the sutures, the Fedorov clamp is removed from the esophagus, the suture in the area of the lateral angle of the esophagogastrostomy is tied; then a continuous suture of the posterior lip of the anastomosis is formed with 4-0 absorbable monofilament thread from the lateral corner of the anastomosis to the medial corner, capturing all layers of the esophageal wall and gastric graft, upon reaching the continuous suture of the medial corner of the esophagogastroanastomosis,where the loose traction stay suture is located, the traction suture is tightened and cut; the thread of the continuous suture of the posterior lip of the anastomosis is passed in an overlapping manner and fixed with a clamp; then a continuous suture of the anterior lip of the anastomosis is formed with a second needle, also from the lateral angle of the anastomosis to the medial; the anterior lip of the anastomosis is formed by suturing the serous-muscular-submucosal wall of the gastric graft; then the excess esophageal mucosa is grasped with the tip of the needle and immersed into the lumen of the esophagus, suturing its entire wall; upon reaching the thread previously passed in an overlapping manner from the continuous suture of the posterior lip of the anastomosis and fixed with a clamp, the wall of the stomach and esophagus is sutured through all layers once in front of this fixed thread and once immediately after it; then the ends of the working thread of the continuous suture of the anterior lip of the anastomosis and the thread fixed in an overlapping manner,tied together; a nasogastric tube is not used in the postoperative period; a preventive enterostomy according to Witzel-Eiselsberg is applied at the laparotomy stage.
2. The method according to paragraph 1, characterized in that the stitches of the continuous seam are applied to a depth of 5–7 mm with an interval of 5 mm.