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

Stapled vs handsewn anastomosis and anastomotic leaks in gastric cancer surgery-a population-based nationwide study in Finland

BACKGROUND

There is a lack of evidence regarding anastomotic technique and postoperative complications in gastric cancer surgery. This study aimed to evaluate whether there are differences between stapled and handsewn anastomosis and anastomotic leaks.

METHODS

This was a population-based, retrospective, nationwide cohort study in Finland using the Finnish National Esophago-Gastric Cancer Cohort. Patients undergoing gastrectomy with available postoperative complication data were included. Logistic regression analysis was used to calculate the odds ratios with 95% CIs, adjusted for calendar period of surgery, age at surgery, sex, comorbidity, tumor stage, neoadjuvant therapy, minimally invasive surgery, type of gastrectomy, radical resection, and type of anastomosis.

RESULTS

Of the 2164 patients, 472 of all patients (21.8%) had handsewn anastomosis and 1692 of all patients (78.2%) had stapled anastomosis. In the unadjusted analysis, anastomotic leaks were significantly lower in the handsewn group (hazard ratio [HR], 0.42; 95% CI, 0.22-0.79) than the stapled group, but after adjustment for known prognostic factors, this association was no longer significant (HR, 0.57; 95% CI, 0.27-1.21). In the analysis stratified by gastrectomy type (distal or total), no differences in anastomotic leaks were observed between anastomotic techniques.

CONCLUSION

In this population-based nationwide study, anastomotic technique (stapled or handsewn) was not associated with anastomotic leaks in any, distal or total, gastrectomy.

Hand-sewn esophagojejunostomy in transthoracic single-port assisted laparoscopic esophagogastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction with esophageal invasion > 3 cm

BACKGROUND

An optimal method for digestive tract reconstruction (DTR) in laparoscopic radical resection of Siewert type II adenocarcinoma of esophagogastric junction (AEG) has not yet been standardized. The aim of this study was to evaluate the safety and feasibility of a hand-sewn esophagojejunostomy (EJ) technique during transthoracic single-port assisted laparoscopic esophagogastrectomy (TSLE) for Siewert type II AEG with esophageal invasion > 3 cm.

METHODS

The perioperative clinical data and short-term outcomes for patients who underwent TSLE using hand-sewn EJ for Siewert type II AEG with esophageal invasion > 3 cm between March 2019 and April 2022 have been retrospectively reviewed.

RESULTS

A total of 25 patients were eligible. All 25 patients were successfully operated. None was converted to open surgery or mortality. 84.00% of patients were male and 16.00% were female. The mean age, body mass index (BMI), and the American Society of Anesthesiologists (ASA) score were 67.88 ± 8.10 years, 21.30 ± 2.80 kg/m², and 2.08, respectively. The average incorporated operative and hand-sewn EJ procedural times were 274.92 ± 57.46 and 23.36 ± 3.00 min, respectively. The length of extracorporeal esophageal involvement and proximal margin was 3.31 ± 0.26 cm and 3.12 ± 0.12 cm, respectively. The average time for the first oral feeding and hospital stay were 6 (3-14) and 7 (3-18) days, respectively. Two patients (8.00%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pleural effusion and 1 case of anastomotic leakage, both of whom were cured by puncture drainage.

CONCLUSION

Hand-sewn EJ in TSLE is safe and feasible for Siewert type II AEG. This method can ensure safe proximal margins and could be a good option with an advanced endoscopic suture technique for type II tumor with esophageal invasion > 3 cm.

Role of minimally invasive techniques in gastrointestinal surgery: Current status and future perspectives

In recent years, the incidence of gastrointestinal cancer has remained high. Currently, surgical resection is still the most effective method for treating gastrointestinal cancer. Traditionally, radical surgery depends on open surgery. However, traditional open surgery inflicts great trauma and is associated with a slow recovery. Minimally invasive surgery, which aims to reduce postoperative complications and accelerate postoperative recovery, has been rapidly developed in the last two decades; it is increasingly used in the field of gastrointestinal surgery and widely used in early-stage gastrointestinal cancer. Nevertheless, many operations for gastrointestinal cancer treatment are still performed by open surgery. One reason for this may be the challenges of minimally invasive technology, especially when operating in narrow spaces, such as within the pelvis or near the upper edge of the pancreas. Moreover, some of the current literature has questioned oncologic outcomes after minimally invasive surgery for gastrointestinal cancer. Overall, the current evidence suggests that minimally invasive techniques are safe and feasible in gastrointestinal cancer surgery, but most of the studies published in this field are retrospective studies and case-matched studies. Large-scale randomized prospective studies are needed to further support the application of minimally invasive surgery. In this review, we summarize several common minimally invasive methods used to treat gastrointestinal cancer and discuss the advances in the minimally invasive treatment of gastrointestinal cancer in detail.

Application value of hand-sewn anastomosis in totally laparoscopic total gastrectomy for gastric cancer

Background

Digestive tract reconstruction in totally laparoscopic total gastrectomy can be divided into two types: instrument anastomosis and hand-sewn anastomosis. This study explored the feasibility and safety of hand-sewn sutures in esophagojejunostomy of totally laparoscopic total gastrectomy, compared with instrument anastomosis using an overlap linear cutter.

Methods

This retrospective cohort study was conducted from January 2017 to January 2020 at one institution. The clinical data of 50 patients who underwent totally laparoscopic total gastrectomy, with an average follow-up time of 12 months, were collected. The clinicopathologic data, short-term survival prognosis, and results of patients in the hand-sewn anastomosis (n=20) and the overlap anastomosis (n=30) groups were analyzed.

Results

There were no significant differences between the groups in sex, age, body mass index, American Society of Anesthesiologists score, tumor location, preoperative complications, abdominal operation history, tumor size, pTNM stage, blood loss, first postoperative liquid diet, exhaust time, or postoperative length of hospital stay. The hand-sewn anastomosis group had a significantly prolonged operation time (204±26.72min versus 190±20.90min, p=0.04) and anastomosis time (58±22.0min versus 46±15.97min, p=0.029), and a decreased operation cost (CNY 77,100±1700 versus CNY 71,900±1300, p<0.0001). Postoperative complications (dynamic ileus, abdominal infection, and pancreatic leakage) occurred in three patients (15%) in the hand-sewn anastomosis group and in four patients (13.3%) in the overlap anastomosis group (anastomotic leakage, anastomotic bleeding, dynamic ileus, and duodenal stump leakage).

Conclusion

The hand-sewn anastomosis method of esophagojejunostomy under totally laparoscopic total gastrectomy is safe and feasible and is an important supplement to linear and circular stapler anastomosis. It may be more convenient regarding obesity, a relatively high position of the anastomosis, edema of the esophageal wall, and short jejunal mesentery.

Digestive tract reconstruction of laparoscopic total gastrectomy for gastric cancer: a comparison of the intracorporeal overlap, intracorporeal hand-sewn anastomosis, and extracorporeal anastomosis

Background

The application of esophagojejunostomy has certain difficulties in totally laparoscopic total gastrectomy (TLTG). This is due to the higher requirement for surgical techniques and the lack of any unified standards. This study aim to explore the practicability and safety of intracorporeal overlap and intracorporeal hand-sewn anastomosis compared with extracorporeal anastomosis.

Methods

The clinical pathological data of 56 patients who underwent TLTG from March 2016 to December 2020 in the Harbin Medical University Cancer Hospital were retrospectively analyzed. According to the method of anastomosis, the patients were divided into the overlap (n=36) and the hand-sewn anastomosis (n=20). Patients who receive laparoscopic-assisted total gastrectomy (LATG; n=74) formed the control group. The basic clinical data, and intraoperative and postoperative results of the patients were assessed.

Results

Compared with the control group, the overlap anastomosis and hand-sewn anastomosis groups showed no significant differences in clinicopathological data and short-term postoperative recovery. There were no significant differences between the overlap and the control group in operation time nor anastomosis time. However, the anastomosis time of the hand-sewn anastomosis group was significantly prolonged compared to the control group (53.20±14.14 vs. 43.01±12.53 minutes, P=0.002). Compared with the control group, the operation cost was significantly higher in the overlap group (CNY 81,300±6,100 vs. CNY 76,600±6,800, P=0.001), but significantly lower in the hand-sewn anastomosis group (CNY 71,900±1,700 vs. CNY 76,600±6,800, P=0.003). Early postoperative complications occurred in 5 cases (13.9%) in the overlap group, 3 cases (15.0%) in the hand-sewn anastomosis group, and 11 cases (14.9%) in the control group. There were 3 cases (8.3%) of postoperative anastomotic-related complications in the overlap group. No anastomotic-related complications were observed in the hand-sewn anastomosis group.

Conclusions

The overlap anastomosis and hand-sewn anastomosis are practical and safe. Furthermore, the overlap anastomosis may be more suitable for patients with lower cardia and fundic lesions. The hand-sewn method has a wider range of indications pending advanced surgical skills, and is an effective supplementary technique for instrument anastomosis.