Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension

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.

Application value of continuous seromuscular layer sutures in the reinforcement of esophagojejunostomy in total gastrectomy for gastric cancer: a retrospective comparative cohort study

Background

The development process of gastrointestinal anastomosis is from complex to simple, from two layers to one layer, from extramucosal anastomosis to seromuscular anastomosis. With the rapid development of anastomosis instruments, the anastomosis process becomes more and more convenient. However, relevant studies have shown that related complications such as anastomotic leakage still occur. This study sought to investigate the feasibility and safety of seromuscular layer sutures in the reinforcement of esophagojejunostomy after open radical total gastrectomy.

Methods

This study retrospectively analyzed patients who underwent Roux-en-Y esophagojejunostomy after open radical total gastrectomy at The Third Department of Surgery, The Fourth Hospital of Hebei Medical University from April 2019 to May 2020. The inclusion criteria of patients were between 18 and 80 years old; pathology confirmed gastric adenocarcinoma; preoperative imaging showed no distant metastasis and did not receive neoadjuvant therapy; no complex infectious diseases; no blood transfusion was performed before operation. A total of 192 patients were included according to the inclusion criteria. They were divided into the following 2 groups based on whether seromuscular layer suturing of the anastomosis was performed: (I) group A (the simple anastomosis group, n=76); (II) and group B (the seromuscular layer suture group, n=116). The baseline data, surgical data and postoperative complications were compared between the two groups.

Results

All patients underwent esophagojejunostomy Roux-en-Y anastomosis after open radical total gastrectomy, and no perioperative deaths occurred. There was no significant difference in baseline data between the two groups. Group B had an earlier time to liquid diet than group A (4.23±0.76 vs. 4.57±0.58 days, P<0.001). The incidence of postoperative anastomotic leakage in group B (1.72%) was lower than that in group A (9.21%), and the difference was statistically significant (P=0.03). The incidence of pleural effusion was lower in group B (15.52%) than group A (32.89%), and the difference was statistically significant (P=0.005).

Conclusions

Compared to the simple anastomosis, seromuscular layer sutures after esophagojejunostomy may decrease the rates of postoperative anastomotic leakage and pleural effusion. This suture method is feasible and may provide a new option to increase surgical safety.

Risk Factors of Benign Stricture of Anastomotic Stoma after Esophagectomy and Therapeutic Effect of Stent Implantation

With the increase in the number of patients and prolongation of their lives after esophagectomy for esophageal cancer, the quality of life after surgery has attracted more and more attention. Although anastomotic stenosis is a common complication, it seriously affects the quality of life and psychological state of patients or even threatens their lives. At present, the exact independent influencing factors of anastomotic stenosis after esophageal cancer surgery have not been determined, and relevant treatment options are still controversial. Here, we analyzed the independent risk factors leading to good postoperative anastomotic stenosis, in order to provide a basis for late prevention. At the same time, we deeply discussed the advantages and safety of stent implantation in the treatment of anastomotic stenosis.