Clinical efficacy of modified Kamikawa anastomosis in patients with laparoscopic proximal gastrectomy

BACKGROUND With the increasing incidence of proximal gastric cancer,laparoscopic proximal gastrectomy has been applied.However,reflux esophagitis often occurs after traditional esophagogastric anastomosis.In order to solve this problem,several methods of digestive tract reconstruction have emerged,but the most satisfying method remains to be discussed.Therefore,we modified traditional Kamikawa anastomosis to investigate the appropriate digestive tract reconstruction in laparo-scopic proximal gastrectomy.All the patients were successfully operated on without conversion to laparotomy.The duration of operation and digestive tract reconstruction were 203.500(150-224)min and 87.500(73-111)min,respectively.The intraoperative amount of bleeding was 20.500 mL±0.696 mL.The time of postoperative first flatus,the first postoperative fluid intake,and the postoperative length of stay were 2(1-3)d,4(3-5)d,and 9(8-10)d,respectively.All the patients were followed up for 12-23 months.The body mass index at 6 and 12 months after surgery were 22.577 kg/m2±3.098 kg/m2 and 22.594 kg/m2±3.207 kg/m2,respectively.The nutrition risk screening 2002 score,the patient-generated subjective global assessment score,and the gastroesophageal reflux disease scale score were good at 6 and 12 months after surgery.Reflux esophagitis and anastomotic stenosis were not observed in any of the patients during their 12-month postoperative gastroscopy or upper gastrointestinal tract visits.All the patients exhibited no tumor recurrence or metastasis.CONCLUSION The modified Kamikawa anastomosis is safe and feasible for laparoscopic proximal gastrectomy and has good antireflux effects and nutritional status.

Double-tract reconstruction is superior to esophagogastrostomy in controlling reflux esophagitis and enhancing quality of life after proximal gastrectomy:Results from a prospective randomized controlled clinical trial in China

Objective:The aim of this study was to prospectively compare double-tract reconstruction(DTR)and esophagogastrostomy(EG)after proximal gastrectomy(PG)regarding the incidence of reflux esophagitis,quality of life(QOL),nutritional status and surgical safety.Methods:This study was a randomized controlled trial.Patients eligible for PG were enrolled and randomly assigned to the EG group and DTR group.The characteristics of patients,parameters for surgical safety,incidence of reflux esophagitis,nutrition status and QOL were collected and compared between the two groups.Univariate analysis and multivariate analysis were performed to determine the significant factors affecting the incidence of reflux esophagitis after PG.Results:Thirty-seven patients of the EG group and 36 patients of the DTR group were enrolled.The incidence of reflux esophagitis was significantly lower in the DTR group than in the EG group(8.3%vs.32.4%,P=0.019).The DTR group demonstrated a more favorable QOL than the EG group after PG.The nutritional status was balanced within the EG group and the DTR group.The operation time was longer in the DTR group than in the EG group(191 min vs.221 min,P=0.001),while surgical safety was similar in the two groups.Conclusions:Our research demonstrated that DTR is superior to EG after PG in terms of the incidence of reflux esophagitis and provides a more satisfactory QOL without increasing surgical complications or sacrificing nutritional status.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND Reflux esophagitis is a common postoperative complication of proximal gastrectomy.There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy.We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis(EGAA)can prevent postoperative reflux in a safe and feasible manner.To observe a novel method of EGAA to prevent postoperative reflux.METHODS Initially,we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis.This was done in order to better understand the anti-reflux function and mechanism.Next,we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy.Post-surgery,we monitored the structure and function of the reconstruction through imaging exams and gastroscopy.Finally,the patients were followed up to assess the efficacy of the anti-reflux effects.RESULTS Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma,providing a means to prevent the reverse flow of gastric fluids.Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy,with a mean operation time of 304.2±44.3 min.After the operation,the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux,three had mild reflux,and two had obvious reflux.The abdominal computed tomography examination showed a valve-like structure at the anastomosis.During followup,gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients.Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.CONCLUSION EGAA is a feasible and safe surgical method,with an excellent anti-reflux effect after proximal gastrectomy.

Efficacy analysis of Cheng's GIRAFFE reconstruction after proximal gastrectomy for adenocarcinoma of esophagogastric junction

Objective:Reconstruction of the digestive tract for adenocarcinoma of esophagogastric junction(AEG)is in dispute.This study evaluated Cheng’s gastric tube interposition esophagogastrostomy with reconstruction of His angle and fundus(Cheng’s GIRAFFE anastomosis)in laparoscopic/open proximal gastrectomy for Siewert typeⅡAEG,which was performed at Zhejiang Cancer Hospital and the First Affiliated Hospital of Zhejiang Chinese Medical University.Here,we discuss the preliminary results of gastric emptying and anti-reflux.Methods:From a retrospective database,74 patients with advanced Siewert typeⅡAEG underwent curative proximal gastrectomy with GIRAFFE anastomosis,and their gastric emptying and anti-reflux outcomes were evaluated by the Reflux Disease Questionnaire(RDQ)score,nuclide gastric emptying,24-h impedance-pH monitoring and gastroscopy.Results:Seventy-four patients successfully completed proximal partial gastrectomy with Cheng’s GIRAFFE esophagogastric anastomosis.RDQ score six months after the operation was 2.2±2.5.Results of nuclide gastric emptying examinations showed that the gastric half-emptying time was 67.0±21.5 min,the 1-h residual rate was(52.2±7.7)%,the 2-h residual rate was(36.4±5.1)%,and the 3-h residual rate was(28.8±3.6)%;24-h impedance-p H monitoring revealed that the mean De Meester score was 5.8±2.9.Reflux esophagitis was observed by gastroscopy in 7 patients six months after surgery.Conclusions:Cheng’s GIRAFFE anastomosis is safe and feasible for Siewert typeⅡAEG.

A modified double-tract reconstruction following laparoscopic proximal gastrectomy for Siewert Ⅱ adenocarcinoma of the esophagogastric junction (with video)

Objective:The incidence of adenocarcinoma of the esophagogastric junction(AEG)is increasing.For patients with resectable Siewert II AEG,there is still a lack of consensus with regards to which surgical procedure can well balance survival time and quality of life.This study aims to describe a modified double-tract reconstruction(DTR)method following laparoscopic proximal gastrectomy(LPG)and to evaluate the feasibility,safety,and effects of this novel method.Method:This study retrospectively reviewed 29 patients who received modified DTR after LPG for Siewert Ⅱ AEG at a single center between August 2015 and October 2020.Clinicopathological characteristics,surgical outcomes,nutritional status and dietary ability were analyzed.Result:The mean surgical time was 206.4±39.2 min,mean intraoperative blood loss was 175.9±41.4 mL,and median postoperative hospital stay was 11 d(range,9-70 d).The early complication rate was 13.8%(n=4),and the late complication rate was 6.9%(n=2).No reflux esophagitis or reflux symptom was recorded.There were no perioperative deaths within three months post-operatively.At the third follow-up month after surgery,most patients(25/29,86.2%)were experiencing sufficient oral food intake,with a median frequency of 5 meal/d(range,3-6 meal/d).The median total weight loss was 8 kg(range,0-15 kg)and there were no case of post-operative malnutrition.Conclusion:The modified DTR method following LPG represents a novel,safe,and feasible method that provides sufficient nutritional support with few diet-related discomforts.Prospective large-scale randomized trials are now needed to validate the clinical applicability of this method.

Esophagogastric Reconstruction in Cobra-Head Shape with Toupet-Like Partial Anti-Reflux Technique for Resection of Proximal Gastric Tumors. Experience with Three Cases from a Non-Asian Population

Background: Proximal gastrectomy is a rarely performed procedure but a feasible option in benign tumors and malignant neoplasms in the proximal third of the stomach since novel options of reconstructions are available nowadays with fewer long-term sequels. Methods: Report of three cases of proximal gastric gastrointestinal stromal tumors (GIST), with a description of its presentation, histological characteristics, and follow-up after being treated with proximal gastrectomy with cobra head reconstruction. Results: Case 1: A 62-year-old woman with epigastric pain of four months with endoscopic evidence of a cardia GIST. The surgery was performed without complications. The histopathological report confirmed a fusiform GIST of 3.2 × 3 × 2.5 cm, stage IA. No adjuvant treatment was considered. An esophagogram showed no evidence of reflux and no stenosis, and no disease recurrence after 40-months follow-up. Case 2: A 66-year-old woman with dyspepsia and a palpable tumor in the epigastrium. The surgery was performed without complications. The pathology report confirmed a proximal gastric GIST of 13 × 8 × 7 cm, staged II. She received adjuvant treatment with imatinib for 36 months without recurrence and no reflux or stenosis. Case 3: A 55-year-old woman with intermittent hematemesis and right subscapular pain. The surgery was performed without complications. The histopathological report concluded that a GIST tumor of the cardia, 1.4 × 1.2 cm, staged IA. She was left in observation. At a 6-month follow-up, she does not report dysphagia, reflux, or stenosis, and no locoregional recurrence. Conclusions: Open and laparoscopic proximal gastrectomy is a safe therapeutic option for GIST. Furthermore, the reconstruction of the esophagus-gastro anastomosis in the cobra head after proximal gastrectomy is feasible and secure in our population, with good functional results in a short follow-up.

Endoscopic retrograde cholangiopancretography in modified double tracks anastomosis with anastomotic stenosis

A 63-year-old man presented at our hospital with right upper abdomen pain and fever for 4 d.The patient's magnetic resonance cholangiopancreatography revealed dilated common bile duct and choledocholithiasis.In his past history,he received proximal gastrectomy and modified double tracks anastomosis.Endoscopic retrograde cholangiopancretography in modified double tracks anastomosis,especially accompanied with anastomotic stenosis,has been rarely reported.In the present case,the duodenoscope was successfully introduced over the guidewire and the stone taken out using a basket.The patient had good palliation of his symptoms after removal of the stone.