Intracorporeal esophagojejunostomy after totally laparoscopic total gastrectomy: A single-center 7-year experience

AIM: To assess the efficacy and safety of intracorporeal esophagojejunostomy in patients undergoing laparoscopic total gastrectomy(LTG) for gastric cancer.METHODS: A retrospective review of 81 consecutive patients who underwent LTG with the same surgical team between November 2007 and July 2014 was performed. Four types of intracorporeal esophagojejunostomy using staplers or hand-sewn suturing were performed after LTG. Data on clinicopatholgoical characteristics, occurrence of complications, postoperative recovery, anastomotic time, and operation time among the surgical groups were obtained through medical records.RESULTS: The average operation time was 288.7 min, the average anastomotic time was 54.3 min, and the average estimated blood loss was 82.7 m L. There were no cases of conversion to open surgery. The first flatus was observed around 3.7 d, while the liquid diet was started, on average, from 4.9 d. The average postoperative hospital stay was 10.1 d. Postoperative complications occurred in 14 patients, nearly 17.3%.However, there were no cases of postoperative death.CONCLUSION: LTG performed with intracorporeal esophagojejunostomy using laparoscopic staplers or hand-sewn suturing is feasible and safe. The surgical results were acceptable from the perspective of minimal invasiveness.

Esophagojejunostomy after laparoscopic total gastrectomy by Or VilTM 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(Or VilTM), 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 comparedbetween 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). Intraoperative blood loss(96.4 ± 32.7 m L vs 88.2 ± 36.9 m L, 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 Or VilTM, and was more cost-effective. There was no significant difference in safety.

Disturbed passage of jejunal limb near esophageal hiatus after overlapped esophagojejunostomy following laparoscopic total gastrectomy

BACKGROUND Overlapped esophagojejunostomy(OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy(LTG). However, long-term surgical results have not been documented well.AIM In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.METHODS From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.RESULTS Five patients(2.4%) had unusual jejunal limb stricture after LTG and OEJ,occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia.Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.CONCLUSION Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.

Comparison of Intracorporeal and Extracorporeal Esophagojejunostomy after Laparoscopic Total Gastrectomy for Gastric Cancer： A Meta-Analysis Based on Short-Term

Background： Laparoscopic total gastrectomy （LTG） is increasingly performed in patients with gastric cancer. However, the usage of intracorporeal esophagojejunostomy （IEJ） following LTG is limited, as the safety and efficacy remain unclear. The present meta-analysis aimed to evaluate the feasibility and safety of IEJ following LTG. Methods： Studies published from January 1994 to January 2017 comparing the outcomes ofl EJ and extracorporeal esophagojejunostomy （EEJ） following LTG were reviewed and collected from the PubMed, EBSCO, Cochrane Library, Embase, and China National Knowledge lntemet （CNKI）. Operative results, postoperative recovery, and postoperative complications were compared and analyzed. The weighted mean difference （WMD） and odds ratio （OR） with a 95% confidence interval （CI） were calculated using the Review Manager 5.3. Results： Seven nonrandomized studies with 785 patients were included. Compared with EEJ, IEJ has less blood loss （WMD： -13.52 ml; 95% CI： -24.82-2.22; P = 0.02）, earlier time to first oral intake （WMD： -0.49 day; 95% CI： -0.83-0.14; P 〈 0.01 ）, and shorter length of hospitalization （WMD： -0.62 day; 95% CI： - 1.08-0.16; P 〈 0.01 ）. There was no significant difference between IEJ and EEJ regarding the operation time, anastomotic time, number of retrieved lymph nodes, time to first flatus, anastomosis leakage rate, anastomosis stenosis rate, and proximal resections （all P 〉 0.05）. Conclusions： Compared with EEJ, IEJ has better cosmesis, milder surgical trauma, and a faster postoperative recovery. IEJ can be performed as safely as EEJ. IEJ should be encouraged to surgeons with sufficient expertise.

Meta analysis of safety and effectiveness of anastomosis of esophagus and jejunum overlap in total laparoscopic total gastrectomy

Objective:To systematically evaluate and compare the safety and effectiveness of esophagojejunostomy and traditional esophagojejunostomy in total laparoscopic total gastrectomy in the treatment of gastric cancer,providing evidence-based medical evidence for clinical practice.Methods:PubMed,Embase,Cochrane Library,Web of Science,CNKI,Wanfang and VIP databases were searched by computer,and the retrieval time was up to December 2021.Relevant literatures were obtained,and eligible studies were gradually screened and included.Cochrane ROB bias risk assessment tool and NOS scale were used to evaluate the quality of the articles,and required data were extracted from high-quality literatures.Finally,meta-analysis was performed using Review Manager 5.3 software.Results:Eleven studies were finally included,including 1398 patients,including 566 patients receiving overlap anastomosis and 832 patients receiving traditional anastomosis.The results show that overlap anastomosis and traditional anastomosis had the advantages of operation time(MD=0.63,95%CI=7.22,8.48,P=0.88),postoperative first exhaust time(MD=-0.13,95%CI=0.43,0.18,P=0.42),postoperative first feeding time(MD=0.02,95%CI=0.33,0.37,P=0.91),anastomotic leakage(OR=1.38,95%CI=0.73,2.63,P=0.32),and postoperative hospital stay(MD=-0.16,95%CI=0.82,0.51,P=0.64)had no significant differences(all P>0.05).Compared with traditional anastomosis,overlap anastomosis had longer anastomosis time(MD=5.60,95%CI=0.59,10.62,P=0.03),higher incidence of anastomotic bleeding(OR=2.48,95%CI=1.08,5.69,P=0.03),less intraoperative bleeding(MD=-6.42,MD=-6.42,OR=2.48,95%CI=1.08,P=0.03).95%CI=10.28,-2.56,P=0.001)and anastomotic stenosis(OR=0.17,95%CI=0.06,0.46,P=0.0006).Conclusion:Overlap esophagojejunostomy is a safe,effective and prognostic surgical method,and is expected to become the standard esophagojejunostomy in total laparoscopic total gastrectomy.

Digestive tract reconstruction using isoperistaltic jejunumlater-cut overlap method after totally laparoscopic total gastrectomy for gastric cancer: Short-term outcomes and impact on quality of life

AIM To evaluate the short-term outcomes and quality of life(Qo L) in gastric cancer patients undergoing digestive tract construction using the isoperistaltic jejunum-latercut overlap method(IJOM) after totally laparoscopic total gastrectomy(TLTG).METHODS A total of 507 patients who underwent laparoscopic gastrectomy(D2) from January 2014 to March 2016 were originally included in the study. The patients were divided into two groups to undergo digestive tract construction using either IJOM after TLTG(group T, n = 51) or Roux-en-Y anastomosis after laparoscopic-assisted total gastrectomy(LATG)(group A, n = 456). The short-term outcomes and Qo L were compared between the two groups after 1:2 propensity-score matching(PSM). We used a questionnaire to assess Qo L.RESULTS Before matching, age, sex, tumor size, tumor location, preoperative albumin and blood loss were significantly different between the two groups(P < 0.05). After PSM, the patients were well balanced in terms of their clinicopathological characteristics, although both blood loss and in-hospital postoperative days in group T were significantly lower than those in group A(P < 0.05). After matching, group T reported better Qo L in the domains of pain and dysphagia. Among the items evaluating pain and dysphagia, group T tended to report better Qo L("Have you felt pain" and "Have you had difficulty eating solid food")(P < 0.05).CONCLUSION The IJOM for digestive tract reconstruction after TLTG is associated with reduced blood loss and less pain and dysphagia, thus improving Qo L after laparoscopic gastrectomy.

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

AIM:To investigate the feasibility of laparoscopyassisted total gastrectomy(LATG)using trans-orally inserted anvil(OrVilTM)in terms of operative characteristics and short term outcomes. RESULTS:Characteristics of 27 patients with gastric cancer who underwent LATG from October 2009 to October 2012 in the Foshan Affiliated Hospital of South Medical University were retrospectively reviewed. Among these patients,six were reconstructed by minilaparotomy and 21 by OrVilTM.The clinicopathological characteristics,total operation time,total blood loss, abdominal incision and complications of anastomosis including stenosis and leakage,were compared between the groups undergoing LATG with OrVilTM and the group undergoing minilaparotomy. RESULTS:The operations were successfully performed on all the patients without intraoperative complications or conversion to open surgery.Two(10%)patients received palliative procedure under laparoscope who were prepared for LATG preoperatively.One case had hepatic metastatic carcinoma and 1 case had tumor recurrence near the anastomosis 8 mo after surgery.The mean follow-up duration was 10 mo(range,2-24 mo). Operation time was significantly reduced by the use of OrVilTM(198.42±30.28 min vs 240.83±8.23 min). The postoperative course with regard to occurrence of stenosis and leakage was not different between the two groups.There were no significant differences in estimated blood loss.The upper abdominal incision was smaller in OrVilTM group than in minilaparotomy group (4.31±0.45 cm vs 6.43±0.38 cm). CONCLUSION:LATG using OrVil TM is a technically feasible surgical procedure with sufficient lymph node dissection,less operation time and acceptable morbidity.

Efficacy of totally laparoscopic compared with laparoscopic-assisted total gastrectomy for gastric cancer: A meta-analysis

BACKGROUND Laparoscopic radical gastrectomy is currently the most common surgical approach for gastric cancer.The main difference between totally laparoscopic total gastrectomy(TLTG)and laparoscopic-assisted total gastrectomy(LATG)is the route of digestive tract reconstruction.However,TLTG is currently not widespread as the safety and feasibility of intracorporeal esophagojejunostomy is uncertain.AIM To compare the short-term efficacy of TLTG and LATG for radical gastrectomy of gastric cancer,and to determine the safety and feasibility of intracorporeal esophagojejunostomy.METHODS PubMed,EMBASE,and Web of Science databases were searched for all relevant articles regarding TLTG vs LATG for gastric cancer published up to October 1,2019.Inclusion and exclusion criteria were established.All the basic conditions of patients and important clinical data related to surgery were extracted,and a meta-analysis was performed with RevMan 5.3 software.RESULTS Eight studies involving a total of 1883 cases(869 cases in the TLTG group and 1014 cases in the LATG group)were included.Compared with the LATG group,reduced intraoperative blood loss(weighted mean difference=-35.37,95%CI:-61.69--9.06,P=0.008)and a larger number of retrieved lymph nodes(weighted mean difference=3.11,95%CI:-2.60-12.00,P=0.01)were found in the TLTG group.There were no significant differences in operating time,anastomotic time,tumor size,proximal resection margin length,postoperative pain score,time to first flatus,time to first oral intake,postoperative hospital stay,postoperative anastomosis-related complication rate and overall complication rate between the two groups(P>0.05).CONCLUSION Intracorporeal esophagojejunostomy is safe and feasible.TLTG has the advantages of being minimally invasive,reduced intraoperative blood loss and easier access to lymph nodes compared with LATG.Totally laparoscopic gastrectomy is likely to be the surgical trend for gastric cancer in the future.

High yield reproducible rat model recapitulating human Barrett's carcinogenesis

AIM To efficiently replicate the biology and pathogenesis of human esophageal adenocarcinoma(EAC) using the modified Levrat model of end-to-side esophagojejunostomy. METHODS End-to-side esophagojejunostomy was performed on rats to induce gastroduodenoesophageal reflux to develop EAC. Animals were randomly selected and serially euthanized at 10(n = 6),17(n = 8),24(n = 9),31(n = 6),38(n = 6),and 40(n = 6) wk postoperatively. The esophagi were harvested for downstream histopathology and gene expression. Histological evaluation wascompleted to determine respective rates of carcinogenic development. Quantitative reverse transcriptionpolymerase chain reaction was performed to determine gene expression levels of MUC2,CK19,and CK20,and results were compared to determine significant differences throughout disease progression stages.RESULTS The overall study mortality was 15%. Causes of mortality included anastomotic leak,gastrointestinal hemorrhage,stomach ulcer perforation,respiratory infection secondary to aspiration,and obstruction due to tumor or late anastomotic stricture. 10 wk following surgery,100% of animals presented with esophagitis. Barrett's esophagus(BE) was first observed at 10 wk,and was present in 100% of animals by 17 wk. Dysplasia was confirmed in 87.5% of animals at 17 wk,and increased to 100% by 31 wk. EAC was first observed in 44.4% of animals at 24 wk and increased to 100% by 40 wk. In addition,two animals at 38-40 wk post-surgery had confirmed macro-metastases in the lung/liver and small intestine,respectively. MUC2 gene expression was progressively down-regulated from BE to dysplasia to EAC. Both CK19 and CK20 gene expression significantly increased in a stepwise manner from esophagitis to EAC. CONCLUSION Esophagojejunostomy was successfully replicated in rats with low mortality and a high tumor burden,which may facilitate broader adoption to study EAC development,progression,and therapeutics.

对比经口置入砥钉座方法进行食管空肠吻合与使用圆形吻合器进行腔外吻合应用于Siewert 2型食管胃结合部腺癌全胃切除后消化道重建的安全性

背景:对于近端胃癌全胃切除后消化道重建,采用经口置入砥钉座方法进行腔内食管空肠吻合已被证明是安全可行的。但尚未见到该方法用于Siewert 2型食管胃结合部腺癌(AEG)的评估报道。方法:2008年1月至2016年12月间,428例连续胃癌患者在广州南方医院接受腹腔镜全胃切除术,其中98例被归为Siewert 2型AEG。在98例AEG患者中,27例采用经口置入砥钉座方法进行腔内食管空肠吻合(经口组),71例采用圆形吻合器进行腔外食管空肠吻合(腔外组)。在基于吻合口漏危险因素进行1:1的倾向评分匹配后,26对匹配患者纳入分析。比较两组患者术后30天的安全性。结果:两组患者基线资料均衡。手术时间、消化道重建耗时、淋巴结清扫数量、近切缘长度、术中失血量、术中并发症发生率和术后恢复时间两组差异均无统计学意义。经口组相较腔外组,砥钉座置入时间更短(平均数:9.7 vs 13.4 min,P<0.001),手术切口更短(中位数:5.5 vs 7.0 cm,P<0.001)。术后并发症发生率两组差异无统计学意义(26.9%vs 23.1%,P¼0.749),并发症严重程度亦无显著差异(P¼0.939)。结论:采用经口置入砥钉座方法进行腔内食管空肠吻合,用以简化并优化Siewert 2型AEG患者全胃切除术后的消化道重建,是潜在安全的。