Esophagojejunostomy Using the Purse-String Suturing Device After Laparoscopic Total or Proximal Gastrectomy for Gastric Cancer. World J Surg. 2017;41:2605-2610. [PMID: 28447165 DOI: 10.1007/s00268-017-4033-4]

New purse-string suture clamp and multi-functional seal cap: a simple intracorporeal circular-stapled oesophagojejunostomy after laparoscopic total gastrectomy

BACKGROUND

Laparoscopic total gastrectomy (LTG) is still limited because intracorporeal oesophagojejunostomy is technically demanding and difficult in laparoscopic gastrectomy. Circular-stapled anastomosis is considered the "gold standard" method for oesophagojejunostomy in open total gastrectomy. A purse-string suture instrument is used to create a purse-string suture along the distal oesophagus as a standard technique for classic circular-stapled oesophagojejunostomy in the open total gastrectomy. However, a simple and optimal laparoscopic purse-string suture device or instrument with an appropriate and optimal tube in the abdomen remains to be developed as a standard procedure for simple intracorporeal oesophagojejunostomy.

STUDY DESIGN

Between May 2023 and October 2023, a new laparoscopic purse-string suture clamp (Lap-PSC) and multi-functional seal cap (MSC) were applied to obtain a simple intracorporeal circular-stapled oesophagojejunostomy after laparoscopic total gastrectomy in 21 patients with gastric cancer in our hospital. The surgical details and postoperative outcomes were analyzed to evaluate this method.

RESULTS

The mean operation time was 203.8 ± 39.1 min. The mean time for the purse-string suture was 6.6 ± 2.8 min. An average of 13 min was required for purse-string creation and anvil placement. Tumor-free margins were obtained in 21 patients, with a median proximal margin length of 2 cm (range, 1.5-5 cm). Four postoperative complications occurred in this study. There was no mortality. During the median follow-up periods of 11 months, no anastomosis-related complications were observed.

CONCLUSIONS

The standardized single-stapling end-to-side oesophagojejunostomy in open surgery can be easily and safely performed during LTG using both Lap-PSC and MSC. The procedure using Lap-PSC with MSC may be considered as a better procedure to option in LTG.

Esophageal Suspension Method for Hand-Sewn Esophagojejunostomy After Totally Laparoscopic Total Gastrectomy: A Simple, Safe, and Feasible Suturing Technique

Background: Totally laparoscopic total gastrectomy (TLTG) not only is difficult to operate but also has high technical requirements and a long learning curve. Therefore, it has not been widely carried out yet, and esophagojejunostomy is one of its difficulties. Relevant studies have shown that intracorporeal hand-sewn esophagojejunostomy is safe, feasible and low-cost, but it is complicated and time-consuming and requires a high-suture technique. This study introduces a simple, safe and feasible hand-sewn technique. Methods: The clinical data of 32 patients with the esophageal suspension method for hand-sewn esophagojejunostomy (suspension group) after TLTG were collected from February 2018 to June 2019. During the same period, 32 patients with traditional hand-sewn esophagojejunostomy (traditional group) after TLTG were used as the control group. Results: The operative time, anastomosis time, exhaust time and hospitalization time of the suspension group were shorter than those of the traditional group. The intraoperative blood loss in the suspension group was less than that in the traditional group. There were no postoperative complications associated with the suspension group. Conclusion: For those who have some experience in laparoscopic suture technique, the esophageal suspension method for hand-sewn esophagojejunostomy after TLTG is a simple, safe, and feasible suture technique.

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.

Feasibility of laparoscopic total gastrectomy in overweight patients: Implications of less impact of overweight on laparoscopic versus open approach

AIM

To investigate safety and oncological feasibility of laparoscopic total gastrectomy (LTG) in overweight (OW) patients.

METHODS

Patients who underwent total gastrectomy (110 laparoscopic, 211 open) for gastric cancer between January 1999 and July 2016 were included. Propensity score matching selected 152 patients (76 laparoscopic, 76 open), which were subsequently divided into the OW (≥ 25) or non-OW (< 25) group by body mass index. Postoperative outcomes of laparoscopic versus open approaches were compared between OW and non-OW groups.

RESULTS

In the propensity-matched population, baseline characteristics were comparable between the OW and non-OW groups for the laparoscopy and open groups. In the laparoscopy group, operative time was longer (P = 0.01) in the OW group, however, other perioperative results including complication rates were comparable between the non-OW and OW groups. In the open group, number of retrieved lymph nodes were less (P = 0.03) and local complication rate was more frequent (P = 0.03) in the OW group.

CONCLUSION

LTG in OW patients remains technically challenging but can be performed safely. Our findings imply that OW has a lesser effect on the laparoscopic versus open approach to total gastrectomy.