Laparoscopic total gastrectomy using the transorally inserted anvil (OrVil™): a preliminary, single institution experience

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.

Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial

BACKGROUND

The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance.

METHODS

A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications.

RESULTS

Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8 min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different.

CONCLUSIONS

No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.

Analysis of outcomes of a transoral circular stapled anastomosis following major upper gastrointestinal cancer resection

BACKGROUND

Esophageal anastomoses performed following esophagectomy and total gastrectomy are technically challenging with a significant risk of anastomotic leak. A safe, reliable, and easy anastomotic technique is required to improve patient outcomes and reduce morbidity.

METHOD

This paper analyses 328 consecutive patients who underwent transoral circular stapled esophageal anastomosis (ORVIL™) from a prospectively collected single-center database between December 2011 and February 2019.

RESULTS

Two hundred and twenty-seven esophagectomies and 101 gastrectomies were performed using OrVil™ anastomoses. The mean patient age was 63.7 years. Of 328 consecutive OrVil™-based anastomoses, there were 10 clinically significant anastomotic leaks requiring radiological or operative intervention (3.05%). Twenty-eight (8.54%) patients developed anastomotic stricture, all of which were successfully treated with endoscopic balloon dilatation (a median of 1 dilatation was required per patient).

CONCLUSION

The OrVil™ anastomotic technique is reliable and safe to perform. This is the largest reported series of the OrVil™ anastomotic technique to date. Leak rates and anastomotic dilations were similar to other reported series. Based on our experience, we consider the use of the OrVil™ device for reconstruction after major upper GI resection to be safe and reliable.

Technical details of and prognosis for the "China stitch", a novel technique for totally laparoscopic hand-sewn esophagojejunostomy

The current study describes the technical details of and the clinical prognosis for the "China stitch", a novel technique for hand-sewn esophagojejunostomy in totally laparoscopic total gastrectomy. This study also explores the feasibility and safety of the technique. Clinical data of 20 patients with esophagogastric junction cancer in Beijing Shijitan Hospital, Capital Medical University from January 2017 to April 2018 were retrospectively analyzed. All 20 patients underwent esophagojejunostomy via a novel hand-sewn technique that uses traction to turn the left or right wall of the esophagus into an anterior wall. This avoids the difficulty of suturing the posterior wall. All patients were followed until June 2019. All 20 patients successfully underwent the procedure. The mean operating time was 216.5 ± 24.9 (176-254) min, the mean hand-sewn reconstruction time was 44.4 ± 9.4 (26-61) min, intraoperative bleeding was 141.2 ± 24.9 (130-160) mL, and the number of resected lymph nodes was 23 ± 8 (14-33). After surgery, there was one case of anastomotic leakage and one case of anastomotic stenosis, but both were alleviated with conservative treatment. The mean duration of follow-up was 15 (4-33) months. There was no significant difference in postoperative complications of and short-term oncologic prognosis for the 20 patients who underwent hand-sewn esophagojejunostomy and the 21 patients who underwent mechanical esophagojejunostomy during the same period. In conclusion, the "China stitch", a novel hand-sewn technique, is a cost-effective, safe, and reliable method for esophagojejunostomy in totally laparoscopic total gastrectomy.

Comparison of the short-term outcomes between totally laparoscopic total gastrectomy and laparoscopic-assisted total gastrectomy for gastric cancer: a meta-analysis

BACKGROUND

Totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) are two common surgical approaches for upper and middle gastric cancer. Which surgical approach offers more advantages is still controversial due to a lack of evidence from randomized controlled trials (RCTs). This meta-analysis was conducted to compare the short-term outcomes between the two surgical approaches.

METHODS

A systematic literature search was performed to evaluate short-term outcomes between TLTG and LATG, including overall postoperative complications, anastomosis-related complications, time for anastomosis, operation time, intraoperative blood loss, harvested lymph nodes, proximal margin, distal margin, time to first flatus, time to first diet, and postoperative hospital stay. Short-term outcomes were pooled and compared by meta-analysis using RevMan 5.3. Mean differences (MDs) or risk ratios (RRs) were calculated with 95% confidence intervals (CIs). P < .05 was considered statistically significant.

RESULTS

A total of 9 cohort studies fulfilled the selection criteria. The total sample included 1671 cases. The meta-analysis showed no significant difference between the two surgical approaches in overall postoperative complications (RR = 1.02, 95% CI = 0.82 to 1.26, P = .87),anastomosis-related complications (RR = 0.64, 95%CI = 0.39 to 1.03, P = .06),time for anastomosis (MD = -5.13, 95% CI = -10.54 to 0.27, P = .06),operation time (MD = -10.68, 95% CI = -23.62 to 2.26, P = .11), intraoperative blood loss (MD = -25.58, 95% CI = -61.71 to 10.54, P = .17), harvested lymph nodes (MD = 1.61, 95% CI = -2.09 to 5.31, P = .39), proximal margin (MD = -0.37, 95% CI = -0.78 to 0.05, P = .09), distal margin (MD = 0.79, 95% CI = -0.57 to 2.14, P = .25), time to first flatus (MD = 0.01, 95% CI = -0.13 to 0.15, P = .87), time to first diet (MD = -0.22, 95% CI = -0.45 to 0.02, P = .07), and postoperative hospital stay (MD = -0.51, 95% CI = -1.10 to 0.07, P = .09).

CONCLUSIONS

TLTG is a safe and feasible surgical approach for upper and middle gastric cancer, with short-term outcomes that are similar to LATG. Nevertheless, high-quality, large-sample and multicenter RCTs are still required to further verify our conclusions.

Comparison of the safety and efficacy between linear stapler and circular stapler in totally laparoscopic total gastrectomy: protocol for a systematic review and meta-analysis

INTRODUCTION

Total gastrectomy is often recommended for upper body gastric cancer, and totally laparoscopic total gastrectomy (TLTG) is deemed to be a promising surgical method with the well-known advantages such as less invasion and fast recovery. However, the anastomosis between oesophagus and jejunum is the difficulty of TLTG. Although staplers have promoted the development of TLTG, the choice of suitable staplers to complete oesophagojejunostomy is controversial and unclear. Therefore, a higher level of research evidence is needed to compare the two types of staplers in terms of safety and efficacy for oesophagojejunostomy in TLTG among patients with gastric cancer.

METHODS AND ANALYSIS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) and Wanfang Databases will be comprehensively searched from January 1990 to July 2019. All eligible randomised controlled trials (RCTs), non-RCTs or observational studies comparing the two types of staplers will be included. A meta-analysis will be performed using Review Manager V.5.3 software to compare the safety and efficacy of linear and circular staplers for oesophagojejunostomy in TLTG. The primary outcomes are anastomotic leakage, anastomotic stricture, anastomotic haemorrhage. The secondary outcomes include time to first instance of passing gas after surgery, first feeding time, total operation time, reconstruction time, estimated blood loss. The heterogeneity of this study will be assessed by p values and I² statistic. Subgroup analyses and sensitivity analyses will be used to explore and explain the heterogeneity. The risk of bias will be assessed using the Cochrane tool or the Newcastle-Ottawa Quality Assessment Scale.

ETHICS AND DISSEMINATION

Ethical approval will not be required because this proposed systematic review and meta-analysis is based on previously published data, which does not include intervention data on patients. The findings of this study will be submitted to a peer-reviewed journal and will be presented at a relevant congress.

PROSPERO REGISTRATION NUMBER

CRD42018111680.

Impact of stepwise introduction of esophagojejunostomy during laparoscopic total gastrectomy: a single-center experience in Japan

Background

The number of laparoscopic gastrectomies performed in Japan is increasing with the development of laparoscopic and surgical instruments. However, laparoscopic total gastrectomy is developing relatively slowly because of technical difficulties, particularly in esophagojejunostomy.

Methods

We retrospectively reviewed 83 patients with early gastric cancer in the upper portion of the stomach who underwent laparoscopic total gastrectomy between April 2007 and March 2016. We classified the patients into three periods, mainly on the basis of the esophagojejunostomy procedures performed: first period, various conventional procedures based on the physicians’ choice (n=14); second period, transoral method (n=51); and third period, fully intracorporeal technique (n=18). We evaluated the clinical impact of a stepwise introduction of unfamiliar new methods during laparoscopic total gastrectomy.

Results

Between the first and second periods, there were significant differences in the blood loss volume, number of harvested lymph nodes, frequency of conversion to open surgery, and postoperative hospital stay. The number of harvested lymph nodes was significantly higher in the third than in the second period, with no detriment to other intraoperative or postoperative factors.

Conclusion

The use of a unified surgical method for esophagojejunostomy seems to be the key to a successful and advantageous laparoscopic total gastrectomy. Stepwise introduction of a well-established technique of esophagojejunostomy during laparoscopic total gastrectomy will benefit patients, as shown, for example, by the higher number of dissected lymph nodes in the present study. However, a protracted learning curve is required.

Esophagojejunostomy after laparoscopic total gastrectomy by OrVilTM or hemi-double stapling technique

AIM: To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.

METHODS: This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group I underwent esophagojejunostomy using a transorally-inserted anvil (OrVil^TM), while patients in Group II underwent esophagojejunostomy using the hemi-double stapling technique (HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients’ baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were compared between the two groups. The primary endpoint was evaluation of the surgical outcome (operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation (operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared.

RESULTS: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups (287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group II compared with Group I (47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intra-operative blood loss (96.4 ± 32.7 mL vs 88.2 ± 36.9 mL, P = 0.28), time to defecation (3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation (3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet (7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization (10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups (73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group II (32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P < 0.001).

CONCLUSION: Anvil insertion was faster and easier using the HDST technique compared with OrVil^TM, and was more cost-effective. There was no significant difference in safety.