EJSO 2002; 28: 46–48 doi:10.1053/ejso.2001.1183, available online at http://www.idealibrary.com on Endoscopic-assisted intrathoracic oesophagogastrostomy without thoracotomy for tumours of the lower oesophagus and cardia C. D. Sutton, S. A. White, L. J. Marshall, D. P. Berry and P. S. Veitch Department of Surgery, Leicester General Hospital, Leicester, UK Aims: This study aimed to evaluate the efficacy of a novel technique enabling a trans-hiatal oesophagectomy with intrathoracic anastomosis under direct vision, without thoracotomy. Methods: Trans-hiatal dissection of the oesophagus was performed using direct and laparoscopic visualization. The oesophagus was transected above the tumour with a linear endo-GIA-2 60 m stapler. The stomach was transected and a gastric tube fashioned. The anvil of an appropriately sized CEEA circular stapler was modified enabling it to flatten. It was attached to a novel delivery system introduced under direct vision along a guidewire into the stapled oesophagus. The anvil was realigned to its original position in the distal oesophagus, docked with the body of the stapler and an intrathoracic anastomosis performed. Results: Ten patients (female n=3, male n=7) aged from 39–77 years (mean age 65 years), ASA 2–3 with distal third tumours were treated. Duration of procedure ranged from 2–5 hours (mean 4 hours). One patient suffered a post-operative chest infection and an anastomotic leak treated successfully with a self-expanding metal stent. Hospital stay ranged from 6–28 days (mean 17 days). There was no mortality. Conclusion: This technique allows a safe intrathoracic anastomosis to be performed trans-hiatally under direct vision, avoiding the need for thoracotomy in patients with high comorbidity.  2002 Harcourt Publishers Ltd Key words: endoscopic; trans-hiatal; oesophagogastrostomy. the indications for potentially curative resection to be INTRODUCTION expanded. In recent years, the incidence of adenocarcinoma of the lower oesophagus and cardia has increased. 1 For patients SURGICAL TECHNIQUE with resectable disease, the Ivor Lewis procedure or a total gastrectomy plus lower oesophagectomy remain the The stomach, lower oesophagus and cardia were most common surgical options. Both of these procedures mobilized through an abdominal incision using fixed require an intra-thoracic oesophageal anastomosis, often sternal retraction to improve access to the posterior performed via a thoracotomy or thoracoscopy 2 assisted mediastinum. The trans-hiatal dissection was performed by one lung anaesthesia. However, the results of surgical initially under direct vision and thereafter with a zero resection remain poor, mainly because of late stage degree laparoscope to improve visualization of the disease, but also because of significant co-morbidity in posterior mediastinum. Once the tumour was fully elderly cohorts. 3 In addition, age and co-morbidity may mobilized and resection margins were defined, the preclude surgery for a number of patients, mainly because oesophagus was transected well above the tumour with of morbidity and mortality associated with thoracotomy. a linear endo-GIA-2 60 mm stapler (Autosuture, UK: The technique of endoscopic assisted intra-thoracic Fig. 1). The stomach was transected well below the anastomosis following oesophagus-gastrectomy. Which tumour and a gastric tube was fashioned from the does not rely upon the need for thoracotomy, may allow remaining stomach. The anvil of an appropriately sized CEEA circular stapler (Autosuture, UK) was then modified as follows. The spring was removed from the underside of the platform leaving a hook to which a length of suture Correspondence to: Mr C. D. Sutton, Department of Surgery, Leicester material was secured. The top of the anvil was then General Hospital, Gwendolen Road, Leicester LE5 4PW, UK. Tel: 0116 249 0490; Fax: 0116 258 4666; E-mail: crisdsutton@hotmail.com disengaged from the spike so that it fell into a ‘flip’ 0748–7983/02/010046+03 $35.00/0  2002 Harcourt Publishers Ltd