Reduced anastomotic complications with intracorporeal esophagojejunostomy using endoscopic linear staplers (overlap method) in laparoscopic total gastrectomy for gastric carcinoma

RESULTS OF MECHANIC VERSUS MOTORIZED STAPLER USED IN GASTRIC SURGERY: PROSPECTIVE STUDY

BACKGROUND

Mechanic sutures represent an enormous benefit for digestive surgery in decreasing postoperative complications. Currently, the advantages of motorized stapler are under evaluation.

AIMS

To compare the efficacy of mechanic versus motorized stapler in gastric surgery, analyzing rate of leaks, bleeding, time of stapling, and postoperative complications.

METHODS

Ninety-eight patients were submitted to gastric surgery, divided into three groups: laparoscopic sleeve gastrectomy (LSG) (n=47), Roux-en-Y gastric bypass (LRYGB) (n=30), and laparoscopic distal gastrectomy (LDG) (n=21). Motorized staplers were employed in 61 patients. The number of firings, number of clips, time of total firings, total time to complete the surgery, and postoperative outcome were recorded in a specific protocol.

RESULTS

Patients submitted to LSG, LRYGB, and LDG recorded a shorter time to complete the procedure and a smaller number of firings were observed using motorized stapler (p<0.0001). No differences were identified regarding the number of clips used in patients submitted to LSG. In the group that used mechanic stapler to complete gastrojejunostomy, jejuno-jejuno-anastomosis, and jejunal transection, it was observed more prolonged time of firing and total time for finishing the procedure (p=0.0001). No intraoperative complications were found comparing the two devices used. Very similar findings were noted in the group of patients undergoing LDG.

CONCLUSIONS

The motorized stapler offers safety and efficacy as demonstrated in prior reports and is relevant since less total time of surgical procedure without intraoperative or postoperative complications were confirmed.

Safety and Feasibility of Electro-Vaporization of Ligamentum Teres Hepatis in Totally Laparoscopic Gastrectomy

Introduction: The ligamentum teres hepatis may block the field of vision during totally laparoscopic gastrectomy (TLG), especially in patients with obesity. Aim: We used electrocautery to increase the visual field of TLG by shrinking the ligamentum teres hepatis. This procedure is termed electro-vaporization of the ligamentum teres hepatis (EVLTH). Methods: Patients with body mass index (BMI) ≥24 who underwent total laparoscopic distal gastrectomy (TLDG) or total laparoscopic total gastrectomy (TLTG) between January 2020 and December 2023 were retrospectively enrolled. According to the scope of gastrectomy and whether the patients underwent EVLTH, the patients were divided into the TLDG-EVLTH, TLDG-NEVLTH, TLTG-EVLTH, and TLTG-NEVLTH groups. The clinical characteristics, surgical outcomes, and pathological features were compared between the TLDG-EVLTH and TLDG-NEVLTH groups and the TLTG-EVLTH and TLTG-NEVLTH groups. Results: This study included 65 patients who underwent TLDG (EVLTH: NEVLTH = 29:36) and 32 patients who underwent TLTG (EVLTH:NEVLTH = 15:17). There were no significant differences in clinical characteristics, surgical outcomes, and pathological features between the TLDG-EVLTH and TLDG-NEVLTH groups. However, the operation time in the TLTG-EVLTH group was significantly shorter than that in the TLTG-NEVLTH group, and the difference was statistically significant, although differences in other data were not statistically significant. Conclusions: EVLTH is a simple and safe procedure that reduces the operation time of TLTG in patients who are overweight and enhances the field of vision of TLG.

Fully robotic side-to-side stapled anastomosis provides less anastomotic leakage than conventional minimally invasive approach in Ivor Lewis esophagectomy

INTRODUCTION

This study evaluates surgical outcomes of minimally invasive Ivor Lewis esophagectomy (ILE) for esophageal and esophagogastric cancer, with the comparison of the robotic approach (RA) and the conventional minimally invasive approach (CA).

METHODS

Selected patients who underwent minimally invasive ILE for esophageal cancer were included between January 2017 and December 2023. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes.

RESULTS

In this period, among a total of 840 esophagectomies, 81 patients (9.6%) underwent minimally invasive ILE, consisting of 24 cases with RA and 57 with CA. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction and patients with prior head and neck cancer treatment. Among these thoracic approaches, there were no significant differences in the patients' indications and characteristics, including age, histology, tumor location, clinical TNM stage, and preoperative therapy. Compared with the CA group, no anastomotic leakage was observed in the RA group (17.5% vs. 0, p = .035). Rates of total postoperative complications and length of hospital stay also tended to be reduced in the RA group but did not reach significance.

CONCLUSION

In the Ivor Lewis esophagectomy with a side-to-side linear-stapled anastomosis, the fully robotic approach has the potential to powerfully reduce anastomotic leakage compared to the conventional minimally invasive approach.

Safety and effectiveness of totally laparoscopic total gastrectomy vs laparoscopic-assisted total gastrectomy: a meta-analysis

BACKGROUND

For gastric cancer with total gastrectomy, the usual laparoscopic surgical approaches are totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG). Due to its difficult anastomotic technique, the adoption of TLTG is limited. Therefore, surgeons prefer using LATG, which also led to TLTG being somewhat overlooked, so there is no clear conclusion today as to which surgical procedure is more favorable to the patient's recovery. This article aimed to compare the safety and short-term outcomes of the two surgical approaches.

MATERIALS AND METHODS

Studies comparing TLTG and LATG, published up to December 2022, were searched in PubMed, Web of Science, and Embase databases. The study outcomes, including operative time, blood loss, anastomosis time, number of retrieved lymph nodes, proximal and distal resection margins, time to first fluid and soft diet, hospitalization duration, time to first flatus, and postsurgical and anastomotic complications, were compared between these two different surgical procedures. Statistics were analyzed with RevMan 5.4 and Stata 13.1.

RESULTS

Fifteen publications were included in this study. The total sample included 3023 cases. The meta-analysis revealed no significant difference in overall postoperative complications between the two surgical approaches ( P >0.05). Compared with LATG, TLTG led to reduced intraoperative blood loss ( P <0.0001), an increased number of lymphatic node dissections ( P <0.0001), and decreased hospitalization duration ( P =0.002). However, operative time, anastomosis time, pulmonary infection, resection margins, time to first fluid and soft diet, time to first flatus and anastomosis-related complications were no significant difference between TLTG and LATG groups ( P >0.05).

CONCLUSION

TLTG did not lead to an increase in overall postoperative complications, which is a reliable surgical approach for treatment of gastric cancer. Moreover, it may reduce harm to patients and enable them to obtain better surgical outcomes.

Different Methods of Minimally Invasive Esophagojejunostomy After Total Gastrectomy for Gastric Cancer: Outcomes from Two Experienced Centers

BACKGROUND

Esophagojejunostomy after minimally invasive total gastrectomy (MITG) for gastric cancer (GC) is technically challenging. Failure of the esophagojejunal anastomosis can lead to significant morbidity, leading to short- and long-term quality of life (QoL) impairment or mortality. The optimal reconstruction method following MITG remains controversial. We evaluated outcomes of minimally invasive esophagojejunostomy after laparoscopic or robotic total gastrectomies.

METHODS

We retrospectively reviewed MITG patients between 2015 and 2020 at two high-volume centers in China and the United States. Eligible patients were divided into groups by different reconstruction methods. We compared clinicopathologic characteristics, postoperative outcomes, including complication rates, overall survival rate (OS), disease-free survival rate (DFS), and patient-reported QoL.

RESULTS

GC patients (n = 105) were divided into intracorporeal esophagojejunostomy (IEJ, n = 60) and extracorporeal esophagojejunostomy (EEJ, n = 45) groups. EEJ had higher incidence of wound infection (8.3% vs 13.3%, P = 0.044) and pneumonia (21.7% vs 40.0%, P = 0.042) than IEJ. The linear stapler (LS) group was inferior to the circular stapler (CS) group in reflux [50.0 (11.1-77.8) vs 44.4 (0.0-66.7), P = 0.041] and diarrhea [33.3 (0.0-66.7) vs 0.0 (0.0-66.7), P = 0.045] while LS was better than CS for dysphagia [22.2 (0.0-33.3) vs 11.1 (0.0-33.3), P = 0.049] and eating restrictions [33.3 (16.7-58.3) vs 41.7 (16.7-66.7), P = 0.029] at 1 year. OS and DFS did not differ significantly between LS and CS.

CONCLUSIONS

IEJ anastomosis generated better results than EEJ. LS was associated with a better patient eating experience, but more diarrhea and reflux compared with CS. Clinical and patient-reported outcomes show the superiority of IEJ with the LS reconstruction method in MITG for GC.

Short-term outcomes of different esophagojejunal anastomotic techniques during laparoscopic total gastrectomy: a network meta-analysis

BACKGROUND

Different techniques have been described for esophagojejunostomy (EJ) during laparoscopic total gastrectomy (LTG) for gastric cancer. Linear stapled techniques include overlap (OL) and functional end-to-end anastomosis (FEEA) while single staple technique (SST), hemi-double staple technique (HDST), and OrVil® are circular stapled approaches. Nowadays, the choice among techniques for EJ depends on operating surgeon personal preference.

PURPOSE

To compare short-term outcomes of different EJ techniques during LTG.

METHODS

Systematic review and network meta-analysis. OL, FEEA, SST, HDST, and OrVil® were compared. Primary outcomes were anastomotic leak (AL) and stenosis (AS). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to measure relative inference.

RESULTS

Overall, 3177 patients (20 studies) were included. The technique for EJ was SST (n = 1026; 32.9%), OL (n = 826; 26.5%), FEEA (n = 752; 24.1%), OrVil® (n = 317; 10.1%), and HDST (n = 196; 6.4%). AL was comparable for OL vs. FEEA (RR = 0.82; 95% CrI 0.47-1.49), OL vs. SST (RR = 0.55; 95% CrI 0.27-1.21), OL vs. OrVil® (RR = 0.54; 95% CrI 0.32-1.22), and OL vs. HDST (RR = 0.65; 95% CrI 0.28-1.63). Similarly, AS was similar for OL vs. FEEA (RR = 0.46; 95% CrI 0.18-1.28), OL vs. SST (RR = 0.89; 95% CrI 0.39-2.15), OL vs. OrVil® (RR = 0.36; 95% CrI 0.14-1.02), and OL vs. HDST (RR = 0.61; 95% CrI 0.31-1.21). Anastomotic bleeding, time to soft diet resumption, pulmonary complications, hospital length of stay, and mortality were comparable while operative time was reduced for FEEA.

CONCLUSIONS

This network meta-analysis shows similar postoperative AL and AS risk when comparing OL, FEEA, SST, HDST, and OrVil® techniques. Similarly, no differences were found for anastomotic bleeding, operative time, soft diet resumption, pulmonary complications, hospital length of stay and 30-day mortality.

A novel, easier and safer alternative method for oesophagojejunal reconstruction after totally laparoscopic total gastrectomy

BACKGROUND

This study presents a novel laparoscopic modified overlapping oesophagojejunostomy anastomosis method which consists of self-pulling and latter transection to perform a safer anastomosis, describes the anastomosis technique in detail and reveals its short-term outcomes.

METHODS

Forty-five patients underwent totally laparoscopic total gastrectomy using the self-pulling and oesophagus latter-cut overlap method anastomosis for gastric cancer from January 2019-2022. During the self-pulling phase, the oesophagus was ligated at the level of the gastroesophageal junction or above and dragged down by a ligature rope to mobilise up to 5-6 cm. An entry hole was created on the right side of the oesophagus, and a nasogastric tube was taken out through the hole and tip of the tube was used as a guide for the endoscopic linear stapler to decrease the risk of entering the false lumen and creating a side-to-side anastomosis. The oesophagus was then latter-transected by a second endoscopic linear stapler. The common entry hole was closed using a hand-sewing method. Clinicopathological characteristics and surgical outcomes were collected and retrospectively evaluated.

RESULTS

The mean anastomosis duration was 27 min. The morbidity rate was 4.4%. Only two patients experienced postoperative complications but subsequently recovered conservatively. None of the patients suffered anastomotic leak or stricture.

CONCLUSIONS

Self-pulling and latter transection-based overlapping anastomosis is a simple and reliable approach that overcomes most of the limitations of standard overlap method and provides satisfactory surgical outcomes.

Study protocol for feasibility and safety of adopting early oral feeding in post total laparoscopic total gastrectomy (overlap esophagojejunostomy): A multicentre randomized controlled trial

Background

Total laparoscopic total gastrectomy (TLTG) for gastric cancer, especially with overlap esophagojejunostomy, has been verified that it has advantages of minimally invasion, less intraoperative bleeding, and faster recovery. Meanwhile, early oral feeding (EOF) after the operation has been demonstrated to significantly promote early rehabilitation in patients, particularly with distal gastrectomy. However, due to the limited application of TLTG, there is few related research proving whether it is credible or safe to adopt EOF after TLTG (overlap esophagojejunostomy). So, it is urgent to start a prospective, multicenter, randomized clinical trials to supply high level evidence.

Methods/design

This study is a prospective, multicenter, randomized controlled trial with 200 patients (100 in each group). These eligible participants are randomly allocated into two different groups, including EOF group and delay oral feeding (DOF) group after TLTG (overlap esophagojejunostomy). Anastomotic leakage will be carefully observed and recorded as the primary endpoints; the period of the first defecation and exhaust, postoperative length of stay and hospitalization expenses will be recorded as secondary endpoints to ascertain the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy).

Discussion

Recently, the adoption of TLTG was limited due to its difficult anastomotic procedure, especially in vivo esophagojejunostomy. With the innovation and improvement of operating techniques, overlap esophagojejunostomy with linear staplers simplified the anastomotic steps and reduced operational difficulties after TLTG. Meanwhile, EOF had received increasing attention from surgical clinicians as a nutrition part of enhanced recovery after surgery (ERAS), which had shown better results in patients after distal gastrectomy. Considering the above factors, we implemented EOF protocol to evaluate the feasibility and safety of adopting EOF after TLTG (overlap esophagojejunostomy), which provided additional evidence for the development of clinical nutrition guidelines.

Clinical trial registration

[www.chictr.org.cn], identifier [ChiECRCT20200440 and ChiCTR2000040692].

Modified -shaped esophagojejunostomy in totally laparoscopic total gastrectomy: a report of 40 consecutive cases from a single center

Objective

Intracorporeal esophagojejunostomy remains a challenging technique in totally laparoscopic total gastrectomy (TLTG) because of the lack of an established standard anastomosis method. However, π-shaped esophagojejunostomy in TLTG is reportedly safe and feasible. Therefore, we evaluated the short-term surgical outcomes of our modified π-shaped esophagojejunostomy in TLTG.

Methods

This study involved patients without neoadjuvant therapy diagnosed with gastric cancer who underwent TLTG by the same surgeon with modified π-shaped esophagojejunostomy from April 2018 to October 2019. Clinicopathologic data were collected and retrospectively analyzed.

Results

Forty patients diagnosed with gastric cancer were included. The mean operative time and estimated blood loss were 264.6 ± 56.9 minutes and 68.5 ± 53.3 mL, respectively. Postoperative flatus occurred at 4.6 ± 1.7 days. The mean time to resumption of diet was 7.4 ± 1.7 days postoperatively. One patient was diagnosed with anastomotic leakage and managed with conservative therapy. Pleural effusion was the most common complication, occurring in four (10%) patients. One patient developed intra-abdominal bleeding that required reoperation. Other complications were atrial fibrillation and wound infection. No mortality occurred during the 6-month follow-up.

Conclusions

Modified π-shaped esophagojejunostomy is safe and feasible for intracorporeal anastomosis in TLTG and showed favorable surgical outcomes in this study.

The Comparison of Short- and Long-Term Outcomes for Laparoscopic Versus Open Gastrectomy for Patients With Advanced Gastric Cancer: A Meta-Analysis of Randomized Controlled Trials

Objectives

The effect of laparoscopic gastrectomy (LG) for the treatment of advanced gastric cancer (AGC) is still controversial. The aim of this meta-analysis was to contrast the short- and long-term outcomes of laparoscopic versus conventional open gastrectomy (OG) for patients with AGC.

Methods

Databases including PubMed, Embase, Scopus, and Cochrane Library were systematically searched until December 2021 for randomized controlled trial-enrolled patients undergoing LG or OG for the treatment of AGC. Short-term outcomes were overall postoperative complications, anastomotic leakage, number of retrieved lymph node, surgical time, blood loss, length of hospital stay, and short-term mortality. Long-term outcomes were survival rates at 1, 3, and 5 years.

Results

A total of 12 trials involving 4,101 patients (2,059 in LG group, 2,042 in OG group) were included. No effect on overall postoperative complications (OR 0.84, 95% CI 0.67 to 1.05, p = 0.12, I² = 34%) and anastomotic leakage (OR 1.26, 95% CI 0.82 to 1.95, p = 0.30, I² = 0%) was found. Compared with the open approach, patients receiving LG had fewer blood loss (MD -54.38, 95% CI -78.09 to -30.67, p < 0.00001, I² = 90%) and shorter length of hospital stay (MD -1.25, 95% CI -2.08 to -0.42, p = 0.003, I² = 86%). However, the LG was associated with a lower number of retrieved lymph nodes (MD -1.02, 95% CI -1.77 to -0.27, p = 0.008, I² = 0%) and longer surgical time (MD 40.87, 95% CI 20.37 to 54.44, p < 0.00001, I² = 94%). Furthermore, there were no differences between LG and OG groups in short-term mortality and survival rate at 1, 3, and 5 years.

Conclusions

LG offers improved short-term outcomes including shorter hospital stays and fewer blood loss, with comparable postoperative complications, short-term mortality, and survival rate at 1, 3, and 5 years when compared to the open approach. Our results support the implementation of LG in patients with AGC.

Systematic Review Registration

PROSPERO (CRD 42021297141).

Alimentary tract obstruction attributed to use of barbed suture for double tract reconstruction after robot-assisted proximal gastrectomy: a case report

Background

Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery.

Case presentation

An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter.

Conclusion

This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery.

Circular versus linear stapling oesophagojejunostomy after laparoscopic total gastrectomy. A systematic review and meta-analysis

BACKGROUND

To assess which anastomosis technique is the most appropriate after laparoscopic total gastrectomy, a systematic review with meta-analysis has been performed to evaluate safety and efficacy of the linear versus circular stapler performing the oesophagojejunostomy.

METHODS

A systematic search was performed using the string: total AND gastrectomy AND (circular OR linear OR stapler). Extracted data were patients' number, gender, age, BMI, ASA Score, tumor stage. Outcomes were leakages, stenoses and bleedings, number of overall anastomotic complications, mortality, operative time, time to first flatus and diet resumption and length of stay of each group. A meta-analysis among the included studies was performed. A subgroup analysis, including the studies in which the Authors considered a single technique to perform each type of anastomosis (LS and CS), was performed. Meta-regression analyses were performed to assess if one or more demographic and clinical variables significantly impacted on the obtained results.

RESULTS

12 articles were included in the final analysis. A significant difference was observed in terms of "overall anastomotic complications" in favour of linear stapling (RD = 0.06, p = 0.01). No significant differences were observed in terms of postoperative complications anastomosis-related, even if a trend towards advantages of linear stapling have been found (stenosis: RD = 0.04, p = 0.06; bleeding: RD = 0.02, p = 0.05). However, all the study was retrospective and there was high heterogeneity among the studies.

CONCLUSION

Linear stapler seems to be related with lesser number of complication if compared with circular stapler. However, further high-quality studies are needed to obtain definitive conclusions.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Short-term outcomes after totally laparoscopic total gastrectomy with esophagojejunostomy constructed by π-shaped method versus overlap method

BACKGROUND

Regarding the overlap anastomosis and recently introduced π-shaped anastomosis, there is no consensus on which intracorporeal esophagojejunostomy (EJS) methods are preferred using linear stapler in totally laparoscopic total gastrectomy (TLTG). This study aims to evaluate the short-term outcomes using two methods.

METHODS

Patients with upper gastric cancer underwent TLTG with either π-shaped (n = 48) or the modified overlap method using knotless barbed sutures (MOBS) (n = 37) were included in our study. Intraoperative and perioperative outcomes were compared.

RESULTS

All patients achieved R0 resection margin. The overall esophagojejunal (E-J)-related complications rate was 7.06%. There was no significant difference between the two groups in terms of postoperative complications, margin distance, numbers of lymph nodes (LNs), length of stay. In the π-shaped group, anastomosis time (19.61 ± 7.17 min vs. 27.09 ± 3.59 min, p < 0.001) was significantly lower. The consumable costs for surgery were similar (44 507.74¥ [42 933.03-46 937.29] vs. 43 718.36¥ [42 743.25-47 256.06], p = 0.825). The first defection time was significantly longer in π-shaped group (131.00 h [93.75-171.25] vs. 100.00 h [85.00-120.00], p = 0.026), whereas the other postoperative recovery parameters were similar. No mortality was observed.

CONCLUSIONS

Both methods showed similar short-term postoperative outcomes. The π-shaped technique was faster than the MOBS method without significantly increasing the supplies costs. Large prospective studies are warranted.

Successful transition from open to minimally invasive approach in Ivor Lewis esophagectomy: a single-center experience in Japan

PURPOSE

This study evaluates surgical outcomes of Ivor Lewis esophagectomy (ILE) in our institution, with the transition from open ILE to hybrid or totally minimally invasive ILE (MI-ILE).

METHODS

Selected patients who underwent ILE for esophageal cancer between 2013 and 2020 were included. We retrospectively investigated the patients' background characteristics and the short-term surgical outcomes.

RESULTS

In this period, among a total of 858 esophagectomies, selected seventy-one patients (8.3%) underwent ILE, consisted of 17 cases with completely open procedures, 27 with hybrid MI-ILE, and 27 with total MI-ILE. The major indications for ILE were adenocarcinoma of the distal esophagus or esophagogastric junction (33.8%) and patients with prior treatment of head and neck cancer (31.0%). Among these approaches, there were no significant differences in the characteristics including age, body mass index (BMI), tumor location, preoperative therapy, and clinical TNM stage, except for histology. Compared to the completely open and hybrid groups, incidences of both total and severe complications in the total MI-ILE group were significantly lower (total 70.6 vs. 66.6 vs. 37.0%, p=0.036; severe 35.3 vs. 44.4 vs. 11.1%, p=0.023), and also, those of pneumonia (41.2 vs. 29.6 vs. 7.4%, p=0.026) and postoperative stricture (11.8 vs. 18.5 vs. 0%, p=0.001) were significantly fewer in the total MI-ILE group.

CONCLUSIONS

We have been able to achieve the transition from completely open to total MI-ILE with better short-term outcomes. Total MI-ILE with linear-stapled anastomosis can be a good alternative to open procedures for the selected patients with reducing the incidence of postoperative pneumonia and anastomotic stricture.

Esophagus two-step-cut overlap method in esophagojejunostomy after laparoscopic gastrectomy

PURPOSE

Esophagojejunostomy is a challenging step in laparoscopic gastrectomy. Although the overlap method is a safe and feasible approach for esophagojejunostomy, it has several technical limitations. We developed novel modifications for the overlap method to overcome these disadvantages.

METHODS

Forty-eight consecutive gastric cancer patients underwent totally laparoscopic total gastrectomy or laparoscopic proximal gastrectomy with double-tract reconstruction at our institution from January 2019 to April 2020 using the overlap method with the following modifications. The esophagus was initially rotated by 90° counterclockwise, followed by transection of two-thirds of the esophageal diameter. The unstapled esophagus was then transected with a harmonic ultrasonic scalpel to enable esophagostomy at the posterior side of the esophagus. A side-to-side esophagojejunostomy was then formed at the posterior side of the esophagus using an endoscopic linear stapler through the right lower trocar. The common entry hole was closed via hand sewing method using V-Loc suture. This procedure was termed "esophagus two-step-cut overlap method."

RESULTS

Only one patient suffered from esophagojejunal anastomotic leakage but subsequently recovered after conservative treatment. Patients did not experience anastomotic bleeding or stricture.

CONCLUSION

Our modified overlap method provides satisfactory surgical outcomes and overcomes several technical limitations, such as entering the false lumen of the esophagus, unnecessary pollution caused by nasogastric tube, and unintended left crus stapling during anastomosis.