A novel method of delta-shaped intracorporeal double-tract reconstruction in totally laparoscopic proximal gastrectomy. Surg Endosc. 2016;30:2396-2403. [PMID: 26416371 DOI: 10.1007/s00464-015-4490-5]

Anastomotic stenosis following proximal gastrectomy with single flap valvulopasty successfully managed with endoscopic stricturotomy: a case report

Background

Due to its nutritional advantages over total gastrectomy, proximal gastrectomy (PG) with anti-reflux techniques has gained significant attention in East Asian countries in recent years. The double flap technique (DFT) and modified side overlap and fundoplication by Yamashita (mSOFY) are two promising anti-reflux interventions following PG. However, anastomotic stenosis after DFT and gastroesophageal reflux after mSOFY have been reported in several patients. To address these concerns, a hybrid reconstruction procedure was designed, namely, right-sided overlap with single flap valvulopasty (ROSF), for proximal gastrectomy, with the aim of reducing anastomotic stricture and reflux. Among the 38 patients who underwent ROSF at our hospital, one developed Stooler grade II anastomotic stenosis. Herein, we present the successful management of this patient through endoscopic stricturotomy (ES).

Case summary

A 72-year-old female complaining of "epigastric pain and discomfort for more than 1 month" was diagnosed with adenocarcinoma of the esophagogastric junction (Siewert type II). She underwent laparoscopic-assisted PG and ROSF procedures at our hospital and recovered well after surgery. However, she started experiencing progressive difficulty in eating and vomiting approximately 3 weeks after the intervention. Endoscopy revealed Stooler grade II esophagogastric anastomotic stenosis. ES with insulated tip (IT) Knife nano was eventually performed, and the patient was able to resume a normal diet without experiencing any discomfort during the 5-month follow-up period.

Conclusion

Endoscopic stricturotomy using IT Knife nano successfully treated anastomotic stenosis following ROSF with no associated complications. Thus, ES to treat anastomotic stenosis after PG with valvulopasty can be considered a safe option and should be performed in centers with the required expertise.

Is single tract jejunal interposition better than double tract reconstruction after proximal gastrectomy?

Double tract reconstruction (DTR) is the main digestive tract reconstruction method after proximal gastrectomy (PG). Single tract jejunal interposition (STJI) derived from the double tract reconstruction is also increasingly used in clinical practice. However, there is still a great controversy as to which of the two reconstruction methods can achieve better results. In this study, we systematically reviewed studies on DTR and STJI after PG and performed a meta-analysis. We searched PubMed, Embase, and Cochrane Library databases for clinical studies comparing DTR and STJI after PG to December 2021 without language restriction. Review Manager (version5.4) software was used to perform meta-analysis on operative outcomes, postoperative complications and nutritional outcomes. The protocol for this meta-analysis was registered with PROSPERO (CRD42022301455). Five randomized controlled trials involving 453 patients were included in the meta-analysis. There were no significant differences between DTR and STJI in terms of intraoperative blood loss, postoperative hospital stay, incidence of reflux esophagitis, anastomotic complications and total complications. The operation time of STJI group was longer than that of DTR group [WMD - 0.79; 95% CI (- 1.55, - 0.03)] [heterogeneity: χ² = 4.94, df = 3 (P = 0.18); I² = 39%, test for overall effect: Z = 2.04 (P = 0.04)]. The body weight of STJI group was significantly higher than that of DTR group at 6 months after surgery [WMD 3.90; 95% CI (0.56, 7.23)] [heterogeneity: τ² = 7.67, χ² = 19.76, df = 2 (P < 0.0001); I² = 90%, test for overall effect: Z = 2.29 (P = 0.02)]. To the best of our knowledge, this is the first systematic review and meta-analysis to compare the outcomes of DTR and STJI after PG. There were no significant differences in operative outcomes and postoperative complications between DTR and STJI after PG. Although STJI prolonged the operation time compared to DTR, postoperative nutritional outcomes of patients in the STJI group was significantly better than that in the DTR group. Therefore, compared to DTR, STJI may be more suitable for the vast majority of patients undergoing PG due to its better postoperative nutritional status.

Effect of different oesophagojejunostomy methods on the quality of life of gastric cancer patients after totally laparoscopic total gastrectomy with self-pulling and latter transected technique: study protocol for a randomised trial

INTRODUCTION

Gastric cancer is the fifth most common cancer worldwide and the detection rate of proximal gastric cancer has been increasing. Currently, surgical resection using gastrectomy and proper perigastric lymphadenectomy is the only treatment option to enhance the survival rate of patients with gastric cancer. Laparoscopic total gastrectomy (LTG) is increasingly performed for adenocarcinoma of the oesophagogastric junction. However, totally LTG (TLTG) is only performed by a few surgeons due to difficulty associated with oesophagojejunostomy (OJ), in which there is no consensus on a standardised anastomosis technique. We propose a randomised trial to compare functional end-to-end anastomosis (FETE) and side-to-side anastomosis (Overlap) for OJ.

METHODS AND ANALYSIS

A prospective, randomised, open-label, single-centre, interventional trial has been designed to evaluate the quality of life (QoL) outcomes and safety of FETE and Overlap, with a 1-year follow-up as the primary endpoint. The trial began in 2020 and is scheduled to enrol 96 patients according to a previous sample size calculation. Patients were randomly allocated to the FETE or Overlap groups with a follow-up of 1 year to assess QoL after the procedure. All relevant clinical data including biological markers were collected. The primary indicator is the D-value between the postoperative and preoperative QoL. Student's t-tests will be used to compare continuous variables, while χ² tests or Fisher's exact tests will be used to compare categorical variables. Statistical analysis will be performed with SPSS V.23.0 statistical software. A p<0.05 will be considered statistically significant.

ETHICS AND DISSEMINATION

This study has been approved by the Hospital Institutional Review Board of Huashan Hospital, Fudan University (2020-1055). The results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2000035583.

Various Kinds of Functional Digestive Tract Reconstruction Methods After Proximal Gastrectomy

The incidence of proximal gastric cancer has shown a rising trend in recent years. Surgery is still the main way to cure proximal gastric cancer. Total gastrectomy with D2 lymph node dissection was considered to be the standard procedure for proximal gastric cancer in the past several decades. However, in recent years, many studies have confirmed that proximal gastrectomy can preserve part of the stomach function and can result in a better quality of life of the patient than total gastrectomy. Therefore, proximal gastrectomy is increasingly used in patients with proximal gastric cancer. Unfortunately, there are some concerns after proximal gastrectomy with traditional esophagogastrostomy. For example, the incidence of reflux esophagitis in patients who underwent proximal gastrectomy with traditional esophagogastrostomy is significantly higher than those patients who underwent total gastrectomy. To solve those problems, various functional digestive tract reconstruction methods after proximal gastrectomy have been proposed gradually. In order to provide some help for clinical treatment, in this article, we reviewed relevant literature and new clinical developments to compare various kinds of functional digestive tract reconstruction methods after proximal gastrectomy mainly from perioperative outcomes, postoperative quality of life and survival outcomes aspects. After comparison and discussion, we drew the conclusion that various functional reconstruction methods have their own advantages and disadvantages; large scale high-level clinical studies are needed to choose an ideal reconstruction method in the future. Besides, in clinical practice, surgeons should consider the condition of the patient for individualized selection of the most appropriate reconstruction method.

Double-tract reconstruction for oesofagocardial gastric cancer: A systematic review

The number of people with gastric cardia and distal oesophageal cancers has increased in the last five years. The surgical treatment method of choice is proximal gastrectomy, with an option being reconstruction of the gastrointestinal tract. There are many reconstruction techniques for anastomosis of the oesophagus and distal parts of the digestive tract. However, all can result in complications. This systematic review aims to identify the efficacy of the double-tract reconstruction method after gastric resection. Different operative techniques for gastric reconstruction have been included in this review. The double-tract reconstruction method, which is gaining popularity among surgeons in Asia and Europe, is a promising technique that improves the early and late results of surgical treatment. This method is associated with low complications related to gastroesophageal reflux disease and dysphagia. Double-tract reconstruction is a promising method for the treatment of patients with esofagocardial gastric cancer. However, further studies are required on the long-term complications and side effects.

Initial Results of Laparoscopic Proximal Gastrectomy With Double-tract Reconstruction Using Oblique Jejunogastrostomy Method on the Long-term Outcome of Postoperative Nutritional Status: A Propensity Score-matched Study

BACKGROUND

The aim of this study was to evaluate the long-term nutritional state of patients with gastric cancer who underwent laparoscopic proximal gastrectomy with double-tract reconstruction (LPG-DTR) using oblique jejunogastrostomy method (OJG).

METHODS

Medical records of 38 patients who underwent LPG-DTR using OJG (21 patients) or laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG-RY) (17 patients) between October 2011 and March 2018 were retrospectively reviewed. In these patients, clinicopathologic variables were analyzed using propensity score matching for age, sex, body mass index, American Society of Anesthesiologists physical state, clinical stage, and lymph node dissection. Operative outcomes and postoperative nutritional status were compared between the 2 groups.

RESULTS

A total of 16 patients were matched to analyze the LPG-DTR and LTG-RY groups. The serum hemoglobin, total protein, and albumin levels at 12 months postoperatively (P=0.008, 0.034, and 0.049) and serum hemoglobin level at 24 months (P=0.025) in the LPG-DTR group was significantly superior to those in the LTG-RY group.

CONCLUSIONS

The postoperative nutritional status as long-term outcomes of patients who underwent LPG-DTR using OJG was significantly superior to those who underwent LTG-RY. The results hereby presented suggest that LPG-DTR using OJG for gastric cancer produces better postoperative nutritional status.

A novel method for π-shaped esophagojejunostomy and double-tract reconstruction (DTR) as an alternative in totally laparoscopic or robotic proximal gastrectomy for treating upper third proximal early gastric cancer

This study evaluated the impact of a new intracorporeal π-shaped esophagojejunostomy (EJS) and double-tract reconstruction (DTR) in totally laparoscopic and totally robotic proximal gastrectomy (TLPG or TRPG) for treating upper third early gastric cancer (U-EGC) in terms of intraoperative and short-term postoperative outcomes. Early proximal gastric cancer patients were identified based on a prospectively established database. From January 2017 to December 2018, these patients underwent intracorporeal π-shaped EJS and DTR after totally laparoscopic (n = 8) or robotic (n = 4) proximal gastrectomy (PG). We recorded and analyzed the baseline characteristics and surgical outcomes, including postoperative complications for these patients. No severe postoperative complications were observed following the operational procedures. Twelve patients (seven male and five female) diagnosed with cardia cancer (Siewert II and III) were enrolled, of which eight underwent the totally laparoscopic proximal gastrectomy (TLPG), and four underwent the totally robotic proximal gastrectomy (TRPG). The mean operative time, blood loss, day of the start of the diet, and postoperative hospital stay was 235.54 ± 20.79 min, 50.65 ± 35.44 mL, 3.85 ± 0.65 days, and 12.45 ± 3.24 days, respectively. All patients presented with a diagnosis of stage I gastric cancer. The mean number of lymph node dissections and the maximum tumor diameter was 13.91 ± 4.63 and 2.18 ± 0.73 cm, respectively. After the operational procedure, using the iodoethylene contrast reagent, we observed that a large proportion of iodoethylene contrast agents entered the jejunum directly, and a small proportion entered the jejunum through the duodenum. Surgeons followed up with ten patients for more than 12 months and the remaining two patients for more than 24 months. None of the patients showed any signs of anastomotic stenosis or reflux esophagitis or anemia symptoms. This study presents a novel method for π-shaped EJS and DTR as an alternative in TLPG or TRPG for treating proximal early gastric cancer, and it offers better short-term postoperative and intraoperative surgical outcomes.

Laparoscopic Double-Tract Esophago-Jejunostomy Reconstruction for Iatrogenic Esophageal Perforation After Endoscopic Pneumatic Dilatation for Achalasia: A Case Report

Patient: Male, 73-year-old

Final Diagnosis: Achalasia

Symptoms: Dysphagia

Medication:—

Clinical Procedure: Laparoscopic surgery

Specialty: Surgery

Predominant classic circular-stapled double-tract reconstruction after totally laparoscopic proximal gastrectomy: safe, feasible, time-saving anastomoses by technical tie-up

BACKGROUND

The double-tract reconstruction (DTR) could be a preferable option in avoiding the postoperative esophageal reflux and anastomotic stenosis during totally laparoscopic proximal gastrectomy (TLPG). An optimal procedure to achieve the DTR in TLPG remains to be established.

METHODS

During March 2018 to April 2019, 15 consecutive patients with gastric cancer in the upper third of the stomach underwent intracorporeal DTR after TLPG at our hospital. The intracorporeal esophagojejunostomy (E-J), gastrojejunostomy (G-J) and jejunojejunostomy (J-J) were, respectively, performed using circular staplers by the Self-Pulling and Holding Purse-String Suture Technique, Intraluminal Poke Technique and U-shaped Parallel Purse-string Suture Technique (Technical Tie-Up). Demographic and clinicopathologic characteristics, perioperative details and postoperative outcomes were analyzed.

RESULTS

The mean operating time was 216.1 ± 18.2 min. Total time for three anastomoses was 49.8 ± 6.1 min, and the time for E-J, G-J, J-J was 22.4 ± 5.0 min, 13 (range 11-16) min, 14.2 ± 2.8 min, respectively. The median proximal and distal resection margins were 2.5 (range 2-4) cm and 6 (range 5-7) cm, respectively, which were all tumor-free in 15 patients. No major complications and mortality occurred. During the median follow-up period of 14 months (range 7 to 20.5 months), there were no postoperative anastomosis-related complications observed, such as anastomotic bleeding, leakage or stenosis. No patients complained the symptoms indicating esophageal reflux and remnant gastritis.

CONCLUSIONS

Predominant classic circular-stapled double-tract reconstruction is safe, feasible and time-saving in TLPG by the technical tie-up.

Effects of reconstruction techniques after proximal gastrectomy: a systematic review and meta-analysis

BACKGROUND

Additional studies comparing several reconstruction methods after proximal gastrectomy have been published; of note, it is necessary to update systematic reviews and meta-analysis from the current evidence-based literature.

AIM

To expand the current knowledge on feasibility and safety, and also to analyze postoperative outcomes of several reconstructive techniques after proximal gastrectomy.

METHODS

PubMed, Google Scholar, and Medline databases were searched for original studies, and relevant literature published between the years 1966 and 2019 concerning various reconstructive techniques on proximal gastrectomy were selected. The postoperative outcomes and complications of the reconstructive techniques were assessed. Meta-analyses were performed using Rev-Man 5.0. A total of 29 studies investigating postoperative outcomes of double tract reconstruction, jejunal pouch interposition, jejunal interposition, esophagogastrostomy, and double flap reconstruction were finally selected in the quantitative analysis.

RESULT

Pooled incidences of reflux esophagitis for double tract reconstruction, jejunal pouch interposition, jejunal interposition esophagogastrostomy, and double flap reconstruction were 8.6%, 13.8%, 13.8%, 19.3%, and 8.9% respectively. Meta-analysis showed a decreased length of hospital in the JI group as compared to the JPI group (heterogeneity: Chi2 = 1.34, df = 1 (P = 0.25); I2 = 26%, test for overall effect: Z = 2.22 (P = 0.03). There was also a significant difference between JI and EG in length of hospital stay with heterogeneity: Chi2 = 1.40, df = 3 (P = 0.71); I2 = 0%, test for overall effect: Z = 5.04 (P < 0.00001). Operative time was less in the EG group as compared to the JI group (heterogeneity: Chi2 = 31.09, df = 5 (P < 0.00001); I2 = 84%, test for overall effect: Z = 32.35 (P < 0.00001).

CONCLUSION

Although current reconstructive techniques present excellent anti-reflux efficacy, the optimal reconstructive method remains to be determined. The double flap reconstruction proved to lower the rate of complication, but the DTR, JI, JPI, and EG groups showed higher incidence of complications in anastomotic leakage, anastomotic stricture, and residual food. In the meta-analysis result, the complications between the JI, JPI, and EG were comparable but the EG group showed to have better postoperative outcomes concerning the operative time, blood loss, and length of hospital stay.

Double-Tract Reconstruction Designed to Allow More Food Flow to the Remnant Stomach After Laparoscopic Proximal Gastrectomy

PURPOSE

Laparoscopic proximal gastrectomy (LPG) is a function-preserving surgery performed on patients with cancer of the upper third of the stomach. However, if much of the ingested food passes through the jejunum, LPG might function broadly like a total gastrectomy. We devised a jejunogastrostomy with double-tract reconstruction (DTR) to ensure that most food flows easily to the remnant stomach.

METHODS

A side-to-side jejunogastrostomy was created between the remnant stomach's posterior wall and the jejunum 10 cm below the esophagojejunostomy, and the common stab incision was also closed with a linear stapler. The jejunogastrostomy was created as a delta-shaped anastomosis by using only linear staplers. The 15 patients who underwent delta-shaped anastomosis from 2017 to 2018 were retrospectively reviewed to collect and analyze their surgical and postoperative outcomes, including nutritive conditions, in comparison to the reconstruction that was performed before then.

RESULTS

Operative times and postoperative complications were not significantly different compared to the previous reconstruction. We confirmed significant differences in operative bleeding and passage of food through the remnant stomach. The level of nutritional indicators at the end of postoperative year one did not tend to be lower, but total weight loss (TWL) and %TWL were significantly lower. As expected, there was a correlation between differences in jejunogastrostomy type and postoperative malnutrition.

CONCLUSIONS

This method devised for intracorporeal DTR provided patients with improved postoperative nutritional status by directing more food through the remnant stomach after LPG.

Digestive tract reconstruction options after laparoscopic gastrectomy for gastric cancer

In addition to the popularity of laparoscopic gastrectomy (LG), many reconstructive procedures after LG have been reported. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer (GC). Presently, no consensus exists regarding the optimal reconstructive procedure. In this review, the current state of digestive tract reconstruction after LG is reviewed. According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction, we divide these reconstruction procedures into three categories consistent with the resection procedures. We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes (length of surgery and blood loss) and postoperative complications (anastomotic leakage and stricture) to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

Comparison of laparoscopic proximal gastrectomy with double-tract reconstruction and laparoscopic total gastrectomy in terms of nutritional status or quality of life in early gastric cancer patients

BACKGROUND

This study aimed to evaluate the surgical outcomes of laparoscopic proximal gastrectomy (LPG) reconstructed by the double-tract method in comparison to those of laparoscopic total gastrectomy (LTG).

METHODS

A retrospective review of the prospectively established database identified early gastric cancer patients who underwent LPG (n = 34) or LTG (n = 46) between January 2011 and December 2015. Baseline characteristics and surgical outcomes including postoperative complications, changes in body composition, nutritional status, and quality of life (QOL) after surgery were compared between the LPG and LTG patients.

RESULTS

Operating time was significantly longer in the LTG group (240.7 ± 43.9 vs. 211.7 ± 32.8 min, p = 0.007). The incidence of grade II or more complications and the hospital stay were comparable between the groups. There was no significant difference between the groups in terms of body composition using a bioelectrical impedance method in 1 year postoperatively. Nutritional status assessed by serum hemoglobin, iron, vitamin B12, albumin, total protein, and total cholesterol levels and postoperative changes in quality of life up to 2 years after surgery were also similar between the groups. Vitamin B12 supplementation was required in 75.4% of the patients in the LTG group and 46.5% in the LPG group within 2 years after surgery (p = 0.005).

CONCLUSION

LPG with double-tract reconstruction appears superior in preventing vitamin B12 deficiency compared to LTG, particularly after 1 year after the surgery, although it offered little benefit in terms of postoperative body composition changes and QOL.

Proximal Gastrectomy with Double Tract Reconstruction Is an Alternative Revision Surgery for Intractable Complications After Sleeve Gastrectomy

Gastric leakage and stricture are challenging complications of sleeve gastrectomy (SG). Failure of endoscopic intervention necessitates revision surgery. We describe two cases in which proximal gastrectomy with double tract reconstruction (PG with DTR) was performed in patients with chronic gastric fistula and twisted gastric tube after SG. Following resection of the affected part of the proximal stomach, reconstruction was achieved with three anastomoses [esophagojejunostomy (EJ), gastrojejunostomy (GJ), and jejunojejunostomy]. DTR provides two exit routes, the remnant stomach and the distal jejunum. The GJ was created 15 cm below the EJ with a stoma 10 mm in diameter, which can pass a standard endoscope. Both cases were a success without any short-term complications. PG with DTR could be an alternative option for refractory complications of SG.

Laparoscopic double-tract reconstruction after total gastrectomy for postoperative duodenal surveillance: Case series

Introduction

When gastric cancer or carcinoid patients have coexisting diseases such as duodenal adenoma, FAP, or Crohn's disease, periodic observation of the duodenum is necessary.

Methods

Between August 2013 and April 2015, we performed four consecutive laparoscopic total gastrectomies with double tract reconstruction for duodenal surveillance. Three of the patients were diagnosed with gastric cancer, while the remaining patient was diagnosed with gastric carcinoid.

Results

No deaths occurred, and three of the patients showed no early complications. One patient with Crohn's disease developed anastomotic leakage, but it was successfully managed conservatively. On endoscopy three to seven months later, we were able to observe the duodenum via jejunal anastomosis in all of the patients.

Discussion

Roux-en-Y reconstruction is one of the options after laparoscopic total gastrectomy. However, given that periodical endoscopic examinations of the duodenum are strongly recommended after surgery, double-tract reconstruction may be preferable in these patients.

Conclusion

Although more detailed data are required, double-tract reconstruction may be the best choice for patients requiring total gastrectomy with regular check-up of the duodenum.

•

When gastric cancer patients have coexisting duodenal diseases, periodic observation of the duodenum is necessary.

•

Given that postoperative endoscopic examinations of the duodenum are needed after total gastrectomy, double-tract reconstruction may be preferable.

•

This is the first report of total gastrectomy with double-tract reconstruction in gastric cancer patients with FAP.

•

Double-tract reconstruction following total gastrectomy may be technically feasible for duodenal surveillance.

Laparoscopic proximal gastrectomy with oblique jejunogastrostomy

BACKGROUND

Proximal early gastric cancer is a good indication for totally laparoscopic proximal gastrectomy (TLPG) with double-tract reconstruction (DTR). However, when most of the dietary intake passes through the escape route of the jejunum, the functional benefits of proximal gastrectomy might be similar to those after total gastrectomy. Our DTR procedure was improved for easy passage through the remnant stomach. The purposes of this study were to present a novel technique for intracorporeal DTR using linear staplers after TLPG and to investigate surgical outcomes.

METHODS

DTR was performed using linear staplers only. A side-to-side jejunogastrostomy with twisting of both the remnant stomach and the anal jejunum was performed for the purpose of passing meals through the remnant stomach (an oblique jejunogastrostomy technique). The ten patients who underwent TLPG with DTR from January 2011 to August 2016 in Hokkaido University Hospital were retrospectively reviewed. Their clinicopathological characteristics and surgical and postoperative outcomes were collected and analyzed.

RESULTS

The median duration of operation was 285 (range 146-440) min. No patients required blood transfusions. The number of dissected lymph nodes was 32 (range 22-56). There were no intraoperative complications, and no cases were converted to open surgery. All the patients were pT1N0M0 stage IA. No anastomotic leakage or complications were detected. Postoperative gastrography after reconstruction showed that contrast medium flowed mainly to the remnant stomach. The average percentage body weight loss was 14.0 ± 7.1% at 10 months. The average percentage decrease in serum hemoglobin was 5.4 ± 10.4% at 12 months.

CONCLUSIONS

This novel technique for intracorporeal DTR provided a considerable advantage by the passage of dietary intake to the remnant stomach after LPG.