Laparoscopy-assisted total gastrectomy with trans-orally inserted anvil (OrVilTM): A single institution experience

Comparison of short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis in laparoscopic total gastrectomy

BACKGROUND

To compare short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis for laparoscopic total gastrectomy.

METHODS

This retrospective cohort study included patients with gastric cancer admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to March 2020. Quality of life, intraoperative and postoperative conditions were analyzed.

RESULTS

Compared with the conventional assisted group, the modified overlap group showed a shorter auxiliary incision, milder postoperative pain, shorter time to the first postoperative anal exhaust, shorter time to the first postoperative liquid food intake, and shorter postoperative stay. There were no differences between the two groups regarding operation time, esophagus-jejunum anastomosis time, intraoperative blood loss, number of lymph nodes dissected, and length of the upper incision margin. There were no differences between the two groups regarding postoperative early and late complications. There were no differences between the two groups regarding the QLQ-C30 scale three years after the operation. The scores of the QLQ-STO22 scale 3 years after the operation showed significantly lower scores for dysphagia and feeding limit in the modified overlap group than those in the conventional assisted anastomosis group. There was no recurrence in the modified overlap group but one patient in the conventional assisted group.

CONCLUSIONS

Patients undergoing totally laparoscopic total gastrectomy with modified overlap anastomosis have better minimal invasiveness and faster post-operative recovery than conventional incision-assisted anastomosis.

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.

Selection of two intrathoracic anastomosis methods for transabdominal radical surgery for Siewert type II adenocarcinoma of the esophagogastric junction

Introduction

The most common intrathoracic anastomosis techniques for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) are the overlap and transorally inserted anvil (OrVil) methods. However, the criteria for choosing between these two methods require further study.

Aim

This retrospective study aimed to compare the efficacy and safety of overlap versus OrVil anastomosis in transabdominal radical surgery for Siewert type II adenocarcinoma of the esophagogastric junction.

Material and methods

A total of 34 patients with Siewert type II AEG who underwent transabdominal radical surgery and intrathoracic anastomosis with the overlap or OrVil methods at our center from January 2018 to June 2019 were retrospectively analyzed. The relevant surgical and postoperative complication data of the two groups were collected and analyzed.

Results

Clinical characteristics: the mean tumor size was 7.5 ±2.4 cm in the OrVil group and 4.3 ±1.9 cm in the overlap group (p < 0.05). Surgery: the distance from the upper resection margin of the esophagus to the tumor was 3.2 ±0.84 cm in the OrVil group and 2.4 ±0.6 cm in the overlap group (p < 0.05). Postoperative complications: there were two cases of pleural effusion in the OrVil group and 18 cases of pleural effusion in the overlap group (p < 0.05).

Conclusions

There is no significant difference between the OrVil and overlap anastomosis in terms of the feasibility and safety; however, OrVil anastomosis can provide a higher margin of resection of the esophagus and is suitable for tumors with extensive esophageal invasion.

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.

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.

MATERIALS AND METHODS

We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).

RESULTS

A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).

CONCLUSIONS

Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

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.

Short-Term and Quality of Life Outcomes of Patients Using Linear or Circular Stapling in Esophagojejunostomy after Laparoscopic Total Gastrectomy

BACKGROUND

Studies comparing the incidence of reflux esophagitis (RE) and patients' quality of life (QoL) when using circular stapler (CS) and linear stapler (LS) in esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG) are rare, and certainly there are not enough to make a definitive decision on best practice. Presented herein is a study on the comparison of the short-term outcomes, QoL of the patients with the focus on the incidence of RE after both linear and circular stapling in LTG.

METHODS

From January 2014 to October 2018, 120 patients were analyzed; of these, 42 patients underwent laparoscopy-assisted total gastrectomy (LATG) with CS (CS group) and 78 patients who underwent totally laparoscopic total gastrectomy (TLTG) with LS (LS group). We examined the results obtained in terms of perioperative outcomes, reflux-related assessments (GerdQ questionnaire and endoscopy findings with all cases; 24-h pH monitoring with limited cases), and EORTC QLQ-C30 and QLQ-STO22. In addition, questionnaires were also supplied to patients and the results were recorded.

RESULTS

The incidence of anastomotic stenosis (7.1% vs. 0; P < 0.05) and the median intraoperative blood loss (180.0 vs. 100.0 mL; P < 0.05) of the CS group were higher than the LS group. The factor aside, no significant differences were observed between the two groups with regard to the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases) (P > 0.05). In the EORTC QLQ-C30 and QLQ-STO22, it was noted that the score of constipation [0 (0, 0) vs. 0 (0, 33.3); P = 0.028] and postoperative dysphagia [0 (0, 0) vs. 0 (0, 22.2); P = 0.046] of the LS group in a 1-year follow-up were lower than the CS group.

CONCLUSIONS

TLTG with LS generated better results than LATG with CS in terms of the incidence of anastomotic stenosis, intraoperative blood loss, and postoperative constipation and dysphagia. Furthermore, when compared with circular stapling, linear stapling in EJS did not increase the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases).

Laparoscopic mechanical latero-lateral oesophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results

BACKGROUND

The realization of a oesophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We here report our laparoscopic experience in intracorporeal oesophagojejunostomy.

METHODS

Adults who underwent laparoscopic total gastrectomy for cancer with laterolateral (functional termino-terminal) Roux en Y intracorporeal oesophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra and postoperative outcomes including 30-day readmissions and mortality were considered.

RESULTS

32 patients were included. Nodal dissection D1's were 16. Median operative time was 280'. median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent Non Operative Management. Median postoperative stay was 8.5 days.

CONCLUSIONS

This technique may improve the ergonomics of oesophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

Comparison of the short-term outcomes of laparoscopic and open total or proximal gastrectomy using the transorally inserted anvil (OrVilTM) for the proximal reconstruction: a propensity score matching analysis

PURPOSE

To compare the short-term surgical outcomes of laparoscopic and open total/proximal gastrectomy using transorally inserted anvil (OrVil^TM).

METHOD

Patients diagnosed with gastric cancer and underwent total or proximal gastrectomy using OrVil^TM for reconstruction were included. Clinical and pathological characteristics, as well as postoperative outcomes, were analyzed. Propensity score matching was used to balance baseline factors.

RESULTS

From April 2012 to April 2020, 199 patients at our center were included. A total of 166 underwent open total or proximal gastrectomy (OTG/OPG), and 33 underwent laparoscopic total or proximal gastrectomy (LTG/LPG). Twenty-seven patients from each group were paired with propensity score matching. The operation time was significantly shorter in the OTG/OPG group after matching. The overall complication rate and the incidence of each complication did not show significant differences between the two groups before and after matching.

CONCLUSION

LTG/LPG and OTG/OPG using OrVil^TM for the alimentary tract reconstruction are both feasible and can achieve similar short-term outcomes.

Hemi-double stapling technique performed with a transorally inserted anvil for esophagojejunostomy in the surgical treatment of gastric cancer

INTRODUCTION

A transorally inserted anvil has been developed to facilitate the creation of a stapled anastomosis without the need for a purse string to secure the anvil into place during laparoscopic total gastrectomy (LTG). We describe a hemi-double stapling technique and application of a transorally inserted anvil for esophagojejunostomy during LTG, and we report the results of a retrospective study in which we examined the feasibility and safety of this method. We also describe the key technical details of the method.

METHODS

Our anastomotic method has four chief features: (a) the esophagus is cut at a slant, and its left cut end is cut and punched for the hemi-double stapling technique; (b) the anvil and circular stapler are connected, placing the distal jejunum in cranial traction; (c) a single layer of sutures is used to correct dog-earing and overlapping, and these points are completely closed with Lembert sutures; and (d) the jejunal limb is fixed to the duodenal stump to prevent kinking of the jejunal limb and to decrease tension on the anastomosis.

RESULTS

This method has been used in 53 patients thus far. LTG with Roux-en-Y reconstruction was successful in all patients, and there was no need for conversion to open surgery. The mean operative time was 313 minutes, and the mean blood loss was 106 mL. The mean postoperative hospital stay was 18 days. There was no anastomotic leakage or stenosis.

CONCLUSION

Hemi-double stapling technique with a transorally inserted anvil for LTG can be performed safely and easily and safely. It can also product good outcomes.

Current status of laparoscopic total gastrectomy

In this article, the current state of laparoscopic total gastrectomy (LTG) was reviewed, focusing on lymph node dissection and reconstruction. Lymph node dissection in LTG is technically similar to that in laparoscopic distal gastrectomy for early gastric cancer; however, LTG for advanced gastric cancer requires extended lymph node dissections including splenic hilar lymph nodes. Although a recent randomized controlled trial clearly indicated no survival benefit in prophylactic splenectomy for lymph node dissection at the splenic hilum, some patients may receive prognostic benefit from adequate splenic hilar lymph node dissection. Considering reconstruction, there are two major esophagojejunostomy (EJS) techniques, using a circular stapler (CS) or using a linear stapler (LS). A few studies have shown that the LS method has fewer complications; however, almost all studies have reported that morbidity (such as anastomotic leakage and stricture) is not significantly different for the two methods. As for CS, we grouped various studies addressing complications in LTG into categories according to the insertion procedure of the anvil and the insertion site in the abdominal wall for the CS. We compared the rate of complications, particularly for leakage and stricture. The rate of anastomotic leakage and stricture was the lowest when inserting the CS from the upper left abdomen and was significantly the highest when inserting the CS from the midline umbilical. Scrupulous attention to EJS techniques is required by surgeons with a clear understanding of the advantages and disadvantages of each anastomotic device and approach.

Usefulness of the Transoral Anvil Delivery System for Esophagojejunostomy After Laparoscopic Total Gastrectomy: A Single-institution Comparative Study of Transoral Anvil Delivery System and the Overlap Method

PURPOSE

Many reconstruction techniques have been reported after laparoscopic total gastrectomy (LTG), but it is not clear which anastomosis technique is most useful, and no standard methods have been established. This study examined whether LTG using the transoral anvil delivery system (TOADS) is a feasible and safe procedure for gastric cancer.

MATERIALS AND METHODS

A series of 47 patients underwent the overlap method and 36 underwent the hemi-double-stapling technique with TOADS. Intraoperative and postoperative outcomes were compared between the 2 groups.

RESULTS

In the TOADS group, operation time for reconstruction was shorter (16±3 vs. 45±10 min, P=0.003), and blood loss was reduced (45±15 vs. 126±13 mL, P=0.0002). There were no significant differences in intraoperative complications, conversion to open surgery, and intraoperative anastomosis-related complications between the 2 groups. Furthermore, there were no significant differences in the incidence of complications, reoperation, mortality, and postoperative hospital stay.

CONCLUSION

LTG using TOADS for gastric cancer may be a technically feasible surgical procedure with acceptable morbidity.

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.

Anastomotic complications after laparoscopic total gastrectomy with esophagojejunostomy constructed by circular stapler (OrVil™) versus linear stapler (overlap method)

BACKGROUND

Esophagojejunostomy after laparoscopic total gastrectomy (LTG) is the most technically difficult type of anastomosis; thus, anastomotic complications such as leakage and stenosis sometimes occur. Identification of the safest anastomotic procedure is important for successful LTG. We have performed LTG since 2004 either with a circular stapler using an OrVil^™ anvil or via the overlap Orringer method with a linear stapler. This retrospective study aimed to determine which method results in a lower incidence of anastomotic complications in patients undergoing LTG.

METHODS

Data on 188 consecutive patients who underwent LTG between April 2004 and August 2016 were retrospectively reviewed. Patients were divided into those who underwent esophagojejunostomy performed via a circular stapler using an OrVil^™ anvil (group C, n = 49) or via the overlap method (group L, n = 139).

RESULTS

Anastomotic complications occurred in five of 188 esophagojejunostomies (2.7%). They comprised three cases of leakage (1.6%), and two of stenosis (1.1%). There was no significant difference in patient characteristics or hematological variables between groups C and L. There was no significant difference between groups in operation time, blood loss, lymph node dissection, and intraoperative anastomotic problems. The rate of anastomotic complications was significantly lower in group L (0.7%, 1/139) than in group C (8.2%, 4/49; p = 0.005). In particular, anastomotic leakage in group L tended to be lower (0.7% 1/139) than in group C (4.1% 2/49), although this difference was not significant. The rate of anastomotic stenosis in group L was significantly lower (0%, 0/139) than in group C (4.1%, 2/49; p = 0.017). Furthermore multivariate analysis showed anastomotic procedure was an independent factor for anastomotic complication.

CONCLUSIONS

There were fewer anastomotic complications after overlap esophagojejunostomy than after esophagojejunostomy via the OrVil^™ procedure, especially regarding anastomotic stenosis. We therefore recommend the overlap technique when performing esophagojejunostomy.

Comparison of OrVil™ and RPD in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Laparoscopic total gastrectomy (LTG) is frequently performed for treating patients with gastric cancer; however, the absence of anastomotic techniques with greater superiority has impaired its popularization. We have compared two types of anastomotic techniques with regard to technical perspectives and clinical outcomes.

METHODS

We reviewed 43 patients with gastric cancer who underwent LTG. Two types of anastomotic techniques have been applied after LTG-the trans-orally inserted anvil (OrVil™) and the reverse puncture device (RPD). Data on the type of anastomosis, blood loss, operation time, anastomosis time, location of tumors, distance between the top border of tumors and top resection margin, diameter of tumor, length of postoperative hospital stay, early and late postoperative complications, and total cost of surgical consumables were obtained by reviewing patient medical records and analyzed thereafter.

RESULTS

We included 32 men and 11 women (mean age 61 years). The loss to follow-up rate was 13.2%. The median survival time for the OrVil™ and RPD groups was 23 and 22 months, respectively. The total rate of complications was 9.3%. The difference in the anastomosis times between the groups was statistically significant. OrVil™ required more time than RPD and cost more than RPD.

CONCLUSIONS

Both the OrVil™ and RPD techniques showed good safety and applicability in LTG. RPD showed an advantage with regard to lesser operative complexity and lower cost.

Assessment of the Double-Staple Technique for Esophagoenteric Anastomosis in Gastric Cancer

INTRODUCTION

Reports on outcomes after double-staple technique (DST) for total and proximal gastrectomy are limited, originating mostly from Asian centers. Our objective was to examine anastomotic leak and stricture with DST for esophagoenteric anastomosis in gastric cancer patients.

METHODS

A single institution review was performed for patients who underwent total/proximal gastrectomy with DST between 2006 and 2015. DST was performed using transoral anvil delivery (OrVil) with end-to-end anastomosis. Clinical characteristics and outcomes, including anastomotic leak and stricture, were recorded.

RESULTS

Overall, DST was performed in 60 patients [total gastrectomy (81.7%, n = 49/60), proximal gastrectomy (10.0%, n = 6/60), and completion gastrectomy (8.3%, n = 5/60)]. Neoadjuvant chemotherapy was administered to 21 patients (35.0%), and 6 patients (10.0%) received external beam radiation therapy prior to completion gastrectomy. Operative approach was open (51.7%, n = 31/60), laparoscopic (43.3%, n = 26/60), or robotic (5.0%, n = 3/60). Anastomotic leak occurred in 6.7% (n = 4/60), while stricture independent of leak was identified in 19.0% (n = 11/58) of patients. Complications occurred in 38.3% (n = 23/60) of patients, of which 52% were classified as Clavien-Dindo grades III-V complications.

CONCLUSION

In the largest Western series of DST for esophagoenteric anastomoses in gastric cancer surgery, our experience demonstrates that DST is safe and effective with low rates of leak and stricture.

Technique of Roux-en-Y reconstruction using overlap method after laparoscopic total gastrectomy for gastric cancer: 100 consecutively successful cases

BACKGROUND

We have established a standard procedure for Roux-en-Y (RY) reconstruction in laparoscopic total gastrectomy (LTG) using esophagojejunostomy by the overlap method (OL). We report on our RY reconstruction technique and special approaches, and evaluate the usefulness of our reconstruction method based on the surgical results of 100 patients we have experienced to date.

METHODS

We performed LTG in 100 patients with gastric cancer. After total gastrectomy using five ports, the resected stomach was extracted through a small laparotomy. Through that, we performed sacrifice of the jejunum, Y limb anastomosis, creation of the lifted jejunum. As the OL, a side-to-side anastomosis of the lifted jejunum to the esophageal stump was laparoscopically performed using a linear stapler in an isoperistaltic direction, and the entry hole was closed with full-thickness suturing. The lifted jejunum was fixed with suture to the duodenal stump at a location where the esophagojejunostomy site was made linear, and the duodenal stump was buried. The mesenteric gap was laparoscopically closed with suture.

RESULTS

The median operative time in 100 patients undergoing LTG was 385 min, the median blood loss was 65 mL, and the median time required for the OL was 32 min. The mean hospitalization period was 10 days, and postoperative complications included bleeding requiring reoperation in one patient; other complications such as pancreatic fistula in five patients (5 %) were treated conservatively. No complication associated with anastomosis occurred.

CONCLUSION

In RY reconstruction using the OL, there were no complications associated with the anastomosis site in 100 consecutive patients, such as anastomotic leak or stenosis, indicating that it is a very useful and safe reconstruction method.

Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy

AIM: To investigate the anastomotic complications of esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG), we reviewed retrospective studies.

METHODS: A literature search was conducted in PubMed for studies published from January 1, 1994 through January 31, 2015. The search terms included “laparoscopic,”“total gastrectomy,” and “gastric cancer.” First, we selected 16 non-randomized controlled trials (RCTs) comparing LTG with open total gastrectomy (OTG) and conducted an updated meta-analysis of anastomotic complications after total gastrectomy. The Newcastle-Ottawa scoring system (NOS) was used to assess the quality of the non-RCTs included in this study. Next, we reviewed anastomotic complications in 46 case studies of LTG to compare the various procedures for EJS.

RESULTS: The overall incidence of anastomotic leakage associated with EJS was 3.0% (30 of 984 patients) among LTG procedures and 2.1% (31 of 1500 patients) among OTG procedures in the 16 non-RCTs. The incidence of anastomotic leakage did not differ significantly between LTG and OTG (odds OR = 1.42, 95%CI: 0.86-2.33, P = 0.17, I² = 0%). Anastomotic stenosis related to EJS was reported in 72 (2.9%) of 2484 patients, and the incidence was 3.2% among LTG procedures and 2.7% among OTG procedures. The incidence of anastomotic stenosis related to EJS was slightly, but not significantly, higher in LTG than in OTG (OR = 1.55, 95%CI: 0.94-2.54, P = 0.08, I² = 0%). The various procedures for LTG were classified into six categories in the review of case studies of LTG. The incidence of EJS leakage was similar (1.1% to 3.2%), although the incidence of EJS stenosis was relatively high when the OrVil^TM device was used (8.8%) compared with other procedures (1.0% to 3.6%).

CONCLUSION: The incidence of anastomotic complications associated with EJS was not different between LTG and OTG. Anastomotic stenosis was relatively common when the OrVil^TM device was used.

Short-term outcomes of intracorporeal esophagojejunostomy using the transorally inserted anvil versus extracorporeal circular anastomosis during laparoscopic total gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

To assess the short-term outcomes of intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil (OrVil) compared with extracorporeal circular Roux-en-Y anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer.

METHODS

From January 2011-April 2014, a total of 165 consecutive patients with gastric cancer underwent either intracorporeal Roux-en-Y esophagojejunostomy (n = 25) using the Orvil or extracorporeal circular anastomosis (n = 140) during LTG. After generating propensity scores with six covariates, including gender, age, body mass index (BMI), Eastern Cooperative Oncology Group performance status, tumor location, and tumor size, 25 patients undergoing the OrVil method (intracorporeal group) were one-to-one matched with 25 patients undergoing the extracorporeal method (extracorporeal group). The short-term outcomes were compared between the two groups.

RESULTS

Both groups were balanced regarding baseline variables. The total operative time was not significantly different between the two groups (216.5 ± 24.9 min versus 224.0 ± 30.5 min, P = 0.344), whereas either the duration of anvil insertion (9.9 ± 2.4 min versus 12.9 ± 2.0 min, P < 0.001) or reconstruction completion (44.4 ± 9.4 min versus 50.1 ± 5.4 min, P = 0.012) in the intracorporeal group was less. The mean length of minilaparotomy in the intracorporeal group was shorter (5.6 ± 0.4 cm versus 7.2 ± 1.7 cm, P < 0.001). No significant differences were observed in intraoperative complication rate, estimated blood loss, length of proximal margin, or postoperative recovery course (including the time to first flatus, liquid resumption, liquid, and soft diet) between the two groups. No patients suffered from anastomosis-related complications. The overall morbidity rates of 28.0% in the intracorporeal group and 32.0% in the extracorporeal group were comparable (P = 0.758).

CONCLUSIONS

Intracorporeal Roux-en-Y esophagojejunostomy using the transorally inserted anvil system may be a safe procedure during LTG for gastric cancer. However, a longer follow-up in a well-designed randomized controlled trial is necessary to more thoroughly evaluate this technique.

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.

An automatically contamination-avoiding technique for intracorporeal esophagojejunostomy using a transorally inserted anvil during laparoscopic total gastrectomy for gastric cancer

Background

Intracorporeal Roux-en-Y esophagojejunostomy during laparoscopic total gastrectomy for gastric cancer remains a challenging manipulation due to the uncontrolled direction of the jejunal side or unintended embedded tissues, although several methods have been introduced. In this study, we simplified the procedure based on a surgical string fixing technique using a transorally inserted anvil (OrVil™; Covidien Ltd., Mansfield, MA, USA).

Methods

From March 2012 to September 2013, 14 consecutive patients underwent simplified intracorporeal Roux-en-Y esophagojejunostomy using OrVil™ during laparoscopic total gastrectomy for gastric cancer at our hospital. Clinicopathologic characteristics and surgical outcomes of these patients were retrospectively analyzed.

Results

All of the procedures were successful completed with no complication or conversion to open surgery. The mean overall operative time was 193.8 ± 41.8 min, whereas the mean reconstruction time was 32.6 ± 4.6 min. The mean estimated blood loss was 105.7 ± 65.4 ml. The mean diameter of anastomosis measured by upper gastrointestinal contrast X-ray test at 1 month after operation was 2.3 cm. During a median follow-up period of 12 months, neither local recurrence nor anastomosis-related morbidity was observed.

Conclusions

Our preliminary results suggested that this automatically contamination-avoiding technique based on a surgical-string-fixing strategy using OrVil™ during laparoscopic total gastrectomy for gastric cancer might be feasible and safe and provide a simple solution for intracorporeal Roux-en-Y esophagojejunostomy.

Intrathoracic esophagojejunostomy using OrVil™ for gastric adenocarcinoma involving the esophagus

AIM: To demonstrate a new surgical technique of lower mediastinal lymphadenectomy and intrathoracic anastomosis of esophagojejunostomy using OrVil™.

METHODS: After a total median phrenotomy, the supradiaphragmatic and lower thoracic paraesophageal lymph nodes were transhiatally dissected. The esophagus was cut off using a liner stapler and OrVil™was inserted. Finally, end-to-side esophagojejunostomy was created by using a circular stapler. From July 2009, we adopted this surgical technique for five patients with gastric cancer involving the lower esophagus.

RESULTS: The median operation time was 314 min (range; 210-367 min), and median blood loss was 210 mL (range; 100-838 mL). The median numbers of dissected lower mediastinal nodes were 3 (range; 1-10). None of the patients had postoperative complications including anastomotic leakage and stenosis. The median hospital stay was 16 d (range: 15-20 d). The median length of esophageal involvement was 14 mm (range: 6-48 mm) and that of the resected esophagus was 40 mm (range: 35-55 mm); all resected specimens had tumor-free margins.

CONCLUSION: This surgical technique is easy and safe intrathoracic anastomosis for the patients with gastric adenocarcinoma involving the lower esophagus.

The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy

Background

Laparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature.

Methods

From October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data.

Results

Mean operation time, time to perform anastomosis, and estimated blood loss were 391.4 min, 36.3 min, and 146.9 ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4 days. Surgical outcomes did not differ significantly by body mass index.

Conclusions

First, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.

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

Laparoscopic total gastrectomy (LTG) is not a commonly performed procedure due to the difficulty associated with surgical reconstruction. We present our preliminary results after intracorporeal circular stapling esophagojejunostomy using the newly developed transorally inserted anvil (OrVil™, Covidien, MA, USA). Between 2008 and June 2013, 51 patients underwent laparoscopic gastrectomy with D2 lymph node dissection for gastric cancer. A total of 12 patients underwent LTG: of these, 5 received an intracorporeal linear side-to-side esophagojejunal anastomosis and the remaining 7 underwent intracorporeal circular stapling esophagojejunostomy using the OrVil™ system. Short-term outcomes were compared between the two groups. There were no intraoperative complications or conversions to open surgery in any patients. The mean operative time was significantly shorter in the OrVil™ than in the side-to-side group (261.4 ± 12.0 vs 333.0 ± 15.0 minutes, respectively, p = 0.005). Postoperative fluorography revealed no anastomosis leakage or stenosis in either groups. All patients resumed an oral liquid diet on postoperative day 5 and the mean postoperative hospital stay was 9 days. Intracorporeal circular stapling esophagojejunostomy using the OrVil™ system is technically feasible and safe in LTG. This technique may be considered a simple and time-saving alternative to the side-to-side linear esophagojejunostomy.

Laparoscopic approach to gastrointestinal malignancies: Toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.

Evaluation of the safety and efficacy of esophagojejunostomy after totally laparoscopic total gastrectomy using a trans-orally inserted anvil: a single-center comparative study

BACKGROUND

Although laparoscopic surgery is frequently performed for the treatment of gastric cancer, laparoscopic total gastrectomy is not widely performed because of its technical difficulty. Since December 2007 we have performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) in more than 110 cases in our institution by using a circular stapler with a trans-orally inserted anvil. We performed a single-center comparative study to evaluate the safety and efficacy of esophagojejunostomy using a trans-orally inserted anvil in patients who underwent TLTG for the treatment of gastric cancer.

METHODS

In the present study, we examined 329 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinicopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed.

RESULTS

Approximately 67% of the patients were men, and the average patient age was 64.0 years (range 26-93 years). In addition, 166 (50.5%) and 163 (49.5%) patients underwent open and laparoscopic surgery, respectively. Leakage following esophagojejunostomy was noted in 7 (4.2%) of 166 patients who underwent total gastrectomy with open laparotomy, and 0 of 46 patients who underwent laparoscopic-assisted total gastrectomy (LATG). However, only 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil exhibited leakage following esophagojejunostomy. Anastomotic stenosis of the esophagojejunostomy was observed in 5 (3.0%) of 166 patients who underwent total gastrectomy with open laparotomy, 2 (4.3%) of 46 patients who underwent LATG, and 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil.

CONCLUSIONS

We believe that esophagojejunostomy using a trans-orally inserted anvil after TLTG for gastric cancer is a safe and useful surgical procedure.

A safe anastomotic technique of using the transorally inserted anvil (OrVil) in Roux-en-Y reconstruction after laparoscopy-assisted total gastrectomy for proximal malignant tumors of the stomach

Background

To explore the safety and feasibility of the transorally inserted anvil (OrVil™) in laparoscopy-assisted total gastrectomy for gastric cancer.

Methods

From December 2010 to June 2011, a total of 28 patients underwent laparoscopy-assisted total gastrectomy with a Roux-en-Y-esophagojejunostomy anastomosis with OrVil™. Perioperative treatments, intraoperative data, postoperative complications and hospital length of stay were evaluated.

Results

There were no conversions to the open gastrectomy. The mean operation time was 143 minutes and the mean blood loss was 70 ml. Patients resumed an oral liquid diet on postoperative days 4 to 5. Two patients (7%) who suffered postoperative aspiration pneumonia were cured by conservative treatment. The median hospital length of stay was 9.6 days (8 to 11 days), with no inhospital mortalities. The median follow-up time was 14.8 months (12 to 18 months), and postoperative endoscopic examination revealed no anastomosis stenosis in patients who had dysphagia.

Conclusion

The use of the OrVil™ is technically feasible and relatively safe for Roux-en-Y reconstruction after laparoscopy-assisted total gastrectomy.

Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer

AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.

METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.

CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.

Systematic review and meta-analysis of laparoscopic and open gastrectomy for advanced gastric cancer

Background

The use of laparoscopic gastrectomy (LG) in advanced gastric cancer (AGC) remains a controversial topic, mainly because of doubts about its oncologic validity. This study is a systematic review and meta-analysis of the available evidence.

Methods

A comprehensive search was performed until June 2013 to identify comparative studies evaluating survival rates, recurrence rates, surgical outcomes and complications. Pooled risk ratios (RR) and weighted mean differences (WMD) with 95% confidence intervals (CI) were calculated using the random effects model. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.

Results

Fifteen trials were involved in this analysis. Compared to open gastrectomy (OG), LG involved a longer operating time (WMD = 48.67 min, 95% CI 34.09 to 63.26, P < 0.001); less blood loss (WMD = −139.01 ml, 95% CI −174.57 to −103.44, P < 0.001); earlier time to flatus (WMD = −0.79 days, 95% CI −1.14 to −0.44, P < 0.001); shorter hospital stay (WMD = −3.11 days, 95% CI −4.13 to −2.09, P < 0.001); and a decrease in complications (RR = 0.74, 95% CI 0.61 to 0.90, P = 0.003). There was no significant difference in the number of harvested lymph nodes, margin distance, mortality, cancer recurrence rate and long-term survival rate between the AGC patients treated with LG or OG (P > 0.05).

Conclusions

Despite a longer operation, LG is a safe technical alternative to OG for AGC with a lower complication rate and enhanced postoperative recovery. Moreover, there were similar outcomes between both approaches in terms of cancer recurrence and the long-term survival rate. Because of the limitation of this study, methodologically high-quality studies are needed for further evaluation.