Comparison of single-stapling and hemi-double-stapling methods for intracorporeal esophagojejunostomy using a circular stapler after totally laparoscopic total gastrectomy

A Modified Purse-String Stapling Technique for Intracorporeal Circular Stapled Esophagojejunostomy During Laparoscopic Total Gastrectomy: Comparison with Extracorporeal Reconstruction Technique

Background: Intracorporeal esophagojejunostomy (EJ) in the context of laparoscopic total gastrectomy remains a complex and technically demanding procedure. We have previously introduced a novel method of intracorporeal circular stapled EJ utilizing a conventional purse-string suture instrument. Since May 2018, we have refined this technique, and the aim of this study was to assess its safety and efficacy. Methods: Between May 2018 and June 2022, we enrolled 92 patients who underwent laparoscopic total gastrectomy with the modified intracorporeal reconstruction method. In addition, between March 2014 and June 2022, we enrolled 121 patients who underwent the procedure with the extracorporeal reconstruction method. We retrospectively collected and compared the clinical data of these 2 patient cohorts. Results: Intracorporeal reconstruction group experienced lower postoperative pain scores (2.7 ± 1.3 versus 4.5 ± 1.4, P = .032), reduced administration of analgesics (3.1 ± 2.2 versus 5.0 ± 3.5, P = .041), and shorter postoperative hospital stays (4.9 ± 2.3 versus 6.3 ± 3.5, P = .045) compared with the extracorporeal reconstruction group. In addition, anastomotic time and postoperative pain score were not increased in the overweight patients in the intracorporeal reconstruction group. Anastomotic leakage occurred in 2 (2.2%) patients in the intracorporeal reconstruction group and 4 (3.3%) patients in the extracorporeal reconstruction group. Anastomotic stricture occurred in 1 (1.1% and 0.8%) patient in each group. There was no significant difference in the overall postoperative complication rate between the 2 groups. Conclusions: The modified intracorporeal purse-string stapling technique for EJ during laparoscopic total gastrectomy is a safe and viable option, exhibiting less invasiveness and comparable outcomes to the extracorporeal reconstruction method, especially suitable for obese patients.

Effectiveness and safety of self-pulling and latter transected reconstruction in totally laparoscopic total gastrectomy: a comparison with laparoscopic-assisted total gastrectomy

BACKGROUND

In some earlier studies, self-pulling and later transection (SPLT) esophagojejunostomy (E-J) was incorporated into total laparoscopic total gastrectomy (TLTG) procedures. Its effectiveness and safety, however, remain unknown. This study compared (SPLT)-E-J in TLTG with conventional E-J in laparoscopic-assisted total gastrectomy (LATG) in order to assess the short-term safety and efficacy of (SPLT)-E-J in TLTG.

METHODS

This research analyzed patients with gastric cancer who received SPLT-TLTG or LATG between January 2019 and December 2021 in the First Affiliated Hospital of Chongqing Medical University. Baseline data and postoperative short-term surgical outcomes were obtained retrospectively and compared between the two groups.

RESULTS

A total of 83 patients who underwent SPLT-TLTG (n = 40, 48.2%) or LATG (n = 43, 51.8%) were included in this study. There were no differences between the two groups in terms of patient demographics or tumor characteristics. No statistically significant differences were observed between the two groups in terms of operation time, intraoperative blood loss, harvested lymph nodes, postoperative complications, postoperative decrease in hemoglobin and albumin levels, or postoperative hospital stay. Five and seven patients experienced short-term postoperative complications in the SPLT-TLTG and LATG groups, respectively.

CONCLUSIONS

SPLT-TLTG is a dependable and safe surgical method for the treatment of gastric cancer. Its short-term outcomes were similar to those of conventional E-J in LATG and had advantages regarding surgical incision and simplification of reconstruction.

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.

Clinical Evaluation of Laparoscopic Surgery for Hirschsprung Disease Combined with Colorectal Anastomosis with a Stapling Technique in Infants

Aim: To evaluate the effect of laparoscopic-assisted resection and colorectal anastomosis with a stapling technique in the treatment of Hirschsprung disease (HSCR) in infants. Methods: From June 2018 to January 2019, 25 cases of HSCR diagnosed by clinical examination and pathology were selected at the Children's Hospital, School of Medicine, Zhejiang University, China. All children were treated with standard laparoscopic-assisted transanal endorectal pull-through surgery (the modified Swenson technique). The short segment type and the typical type with a descending colon-rectum anastomosis were both included. The long segment type had an ascending colon-rectal anastomosis after ascending colon turnover. The colorectal anastomosis was divided into traditional manual anastomosis and straight intraluminal stapler (SIS) anastomosis. According to the different methods of anastomosis, the patients were divided into a traditional group and a SIS group. Age, gender, body weight, operation time, blood loss, postoperative anal exhaust and defecation time, postoperative hospitalization time, and postoperative short-term complications were analyzed retrospectively. Results: A total of 25 children were diagnosed with HSCR. There were 17 boys and 8 girls, and their average age was 10.20 months (interquartile range, 8.60-11.30). Their average body weight was 7.90 kg (interquartile range, 7.50-8.40). There were 17 cases of the typical type, 5 cases of the short segment type, and 3 cases of the long segment type. The different colorectal anastomosis methods were divided into 10 cases in the traditional group and 15 cases in the SIS group. There were no intraoperative complications, wound infections, or anastomotic fistula. Compared with the SIS group, children in the traditional group had an increased operative time (129.5 versus 103.00 minutes; P < .0001), increased intraoperative blood loss (20.00 versus 7.00 mL; P < .0001), increased postoperative hospitalization time (12.00 versus 9.00 days; P = .0003), and increased postoperative defecation time (18.40 versus 13.20 hours; P < .0001). After 6-12 months of follow-up, there was no anastomotic stenosis or enterocolitis in the SIS group. In the traditional group, 1 child had anastomotic stenosis, which improved 6 months after anal dilatation. One case of enterocolitis occurred 4 months after the operation and was cured after enema and infusion. Conclusion: Laparoscopic-assisted resection combined with colorectal anastomosis with the stapling technique in the treatment of HSCR in infants is feasible. It had a short operation time, less bleeding, less trauma, and a rapid recovery of postoperative intestinal function. The anastomosis was smooth, wide, and reliable, and anastomotic fistula and stenosis did not occur.

Postoperative morbidity and quality of life between totally laparoscopic total gastrectomy and laparoscopy-assisted total gastrectomy: a propensity-score matched analysis

BACKGROUND

This study aimed to evaluate the surgical outcome and quality of life (QoL) of totally laparoscopic total gastrectomy (TLTG) compared with laparoscopy-assisted total gastrectomy (LATG) in patients with clinical stage I gastric cancer.

METHODS

From 2012 to 2018, EGC patients who underwent TLTG (n = 223), including the first case with intracorporeal hemi-double stapling, were matched to those who underwent LATG (n = 114) with extracorporeal circular stapling, using 2:1 propensity score matching (PSM). Prospectively collected morbidity was compared between the TLTG and LATG groups in conjunction with the learning curve. The European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30, STO22, and OG25 were prospectively surveyed during postoperative 1 year for patient subgroups.

RESULTS

After PSM, grade I pulmonary complication rate was lower in the TLTG group (n = 213) than in the LATG group (n = 111) (0.5% vs. 5.4%, P = 0.007). Other complications were not different between the groups. The learning curve of TLTG was overcome at the 26th case in terms of the comprehensive complication index. The TLTG group after learning curve showed lower grade I pulmonary complication rate than the matched LATG group (0.5% vs. 4.7%, P = 0.024). Regarding postoperative QoL, the TLTG group (n = 63) revealed less dysphagia (P = 0.028), pain (P = 0.028), eating restriction (P = 0.006), eating (P = 0.004), odynophagia (P = 0.023) than the LATG group (n = 21). Multivariate analyses for each QoL item demonstrated that TLTG was the only common independent factor for better QoL.

CONCLUSIONS

TLTG reduced grade I pulmonary complications and provided better QoL in dysphagia, pain, eating, odynophagia than LATG for patients with clinical stage I gastric cancer.

Bracket-like suture method: a novel, circular marked, simplest sided purse-string suture technique for intracorporeal circular-stapled oesophagojejunostomy during laparoscopic total gastrectomy

PURPOSE

Total laparoscopic total gastrectomy (TLTG) has been limited in application because of the difficulty of intracorporeal oesophagojejunostomy. Theoretically, an intracorporeal single-stapling oesophagojejunostomy using a circular stapler could be commonly used and provide favourable outcomes for TLTG, as in open total gastrectomy(OTG), in which the use of circular staplers in oesophagojejunostomy is common and the standard procedure. This could be possible if use of a laparoscopic purse-string suture along the distal oesophagus were made easy and simple. However, the simple and optimal use of this procedure remains to be developed.

METHODS

Between October 2018 and March 2020, 21 consecutive patients with gastric cancer underwent TLTG using the bracket-like suture method (BLSM) for intracorporeal circular-stapled oesophagojejunostomy in our institution. The surgical details and postoperative outcomes were analysed to evaluate this method.

RESULTS

The mean operation time was 227.6 ± 13.6 min. The median time for the two-sided purse-string suture was 4 min (range, 3-5 min). It took an average of 11.5 min for the completion of purse-string suture and anvil placement. Tumour-free margins were achieved in 21 patients with a median length of 2.5 cm (range, 2-6 cm) proximal margin. Three patients developed postoperative complications. There was no mortality. During the median follow-up period of 12 months, no anastomosis-related complications were observed.

CONCLUSION

The results suggest that the method cannot only facilitate safe and easy purse-string creation, using the simplest two-sided suture in a short amount of time by circular marking of the intended transection level for intracorporeal circular-stapled oesophagojejunostomy, but can also be completed by laparoscopic surgeons with basic laparoscopic suturing skills.

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.

Natural orifice specimen extraction with a modified reverse puncture device technique for total laparoscopic colorectal resection: feasibility and efficacy

Objective: To evaluate the feasibility and efficacy of the modified reverse puncture device (mRPD) technique for transanal anastomosis in total laparoscopic colorectal resection with natural orifice specimen extraction surgery (NOSES).Methods: From August 2015 to September 2017, 34 patients underwent laparoscopic colorectal resection using the mRPD technique to place the anvil in the abdominal cavity and complete transanal anastomosis.Results: All patients who underwent total laparoscopic colorectal resection with NOSES were analyzed. The anvil placement time was 5-14 min, with an average of 6.7 min. The postoperative pain visual analogue scale (VAS) score was 1-4 points, with an average of 2.2 points. The postoperative hospital stay was 7-13 days, with an average of 8.7 days. No complications, such as anastomotic bleeding or stenosis, occurred. During a 14- to 28-month follow-up period (average, 19.5 months), no cases of long-term complications were observed.Conclusion: Total laparoscopic colorectal resection using mRPD is a technically feasible and safe procedure with satisfactory short-term efficacy.

Reverse puncture device technique: an innovation of esophagojejunostomy in radical laparoscopic total gastrectomy

Aim: To evaluate the feasibility, safety, short- and long-term efficacy of a reverse puncture device (RPD) technique for esophagojejunostomy in laparoscopic-assisted total gastrectomy. Patients & methods: This retrospective study analyzed outcome data of 104 patients in propensity score matching whom were divided into the RPD and the purse-string suture technique group. Results: The RPD group had a shorter anvil placement time, shorter operative time, longer resected esophageal length, shorter incision length, shorter postoperative drainage time, shorter postoperative hospital stay and anastomotic complications than the purse-string suture technique group (p < 0.05). Multivariate analysis showed that BMI (odds ratio: 6.285, 1.446-27.322) and anvil placement time (odds ratio: 5.645, 1.089-29.321) were independent risk factors for anastomotic complications (p < 0.05). Conclusion: Laparoscopic-assisted total gastrectomy using an RPD technique is feasible, safe and effective.

Comparison of the safety and efficacy between linear stapler and circular stapler in totally laparoscopic total gastrectomy: protocol for a systematic review and meta-analysis

INTRODUCTION

Total gastrectomy is often recommended for upper body gastric cancer, and totally laparoscopic total gastrectomy (TLTG) is deemed to be a promising surgical method with the well-known advantages such as less invasion and fast recovery. However, the anastomosis between oesophagus and jejunum is the difficulty of TLTG. Although staplers have promoted the development of TLTG, the choice of suitable staplers to complete oesophagojejunostomy is controversial and unclear. Therefore, a higher level of research evidence is needed to compare the two types of staplers in terms of safety and efficacy for oesophagojejunostomy in TLTG among patients with gastric cancer.

METHODS AND ANALYSIS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI) and Wanfang Databases will be comprehensively searched from January 1990 to July 2019. All eligible randomised controlled trials (RCTs), non-RCTs or observational studies comparing the two types of staplers will be included. A meta-analysis will be performed using Review Manager V.5.3 software to compare the safety and efficacy of linear and circular staplers for oesophagojejunostomy in TLTG. The primary outcomes are anastomotic leakage, anastomotic stricture, anastomotic haemorrhage. The secondary outcomes include time to first instance of passing gas after surgery, first feeding time, total operation time, reconstruction time, estimated blood loss. The heterogeneity of this study will be assessed by p values and I² statistic. Subgroup analyses and sensitivity analyses will be used to explore and explain the heterogeneity. The risk of bias will be assessed using the Cochrane tool or the Newcastle-Ottawa Quality Assessment Scale.

ETHICS AND DISSEMINATION

Ethical approval will not be required because this proposed systematic review and meta-analysis is based on previously published data, which does not include intervention data on patients. The findings of this study will be submitted to a peer-reviewed journal and will be presented at a relevant congress.

PROSPERO REGISTRATION NUMBER

CRD42018111680.

Intracorporeal Esophagojejunostomy Using a Circular or a Linear Stapler in Totally Laparoscopic Total Gastrectomy: a Propensity-Matched Analysis

Purpose

There is no consensus on the optimal method for intracorporeal esophagojejunostomy (EJ) in laparoscopic total gastrectomy (LTG). This study aims to compare 2 established methods of EJ anastomosis in LTG.

Materials and Methods

A total of 314 patients diagnosed with gastric cancer that underwent LTG in the period from January 2013 to October 2016 were enrolled in the study. In 254 patients, the circular stapler with purse-string "Lap-Jack" method was used, and in the other 60 patients the linear stapling method was used for EJ anastomosis. After propensity score matching, 58 were matched 1:1, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed.

Results

The 2 groups showed no significant difference in age, body mass index, or other clinicopathological characteristics. After propensity score matching analysis, the linear group had shorter operating time than the circular group (200.3±62.0 vs. 244.0±65.5, P≤0.001). Early postoperative complications in the circular and linear groups occurred in 12 (20.7%) and 15 (25.9%, P=0.660) patients, respectively. EJ leakage occurred in 3 (5.2%) patients from each group, with 1 patient from each group needing intervention of Clavien-Dindo grade III or more. Late complications were observed in 3 (5.1%) patients from the linear group only, including 1 EJ anastomosis stricture, but there was no statistical significance.

Conclusions

Both circular and linear stapling techniques are feasible and safe in performing intracorporeal EJ anastomosis during LTG. The linear group had shorter operative time, but there was no difference in anastomosis complications.

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.

Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy

BACKGROUND

The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments.

METHODS

From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy.

RESULTS

In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series.

CONCLUSIONS

Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.

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.

Intracorporeal Circular Stapled Esophagojejunostomy Using Conventional Purse-String Suture Instrument After Laparoscopic Total Gastrectomy

BACKGROUND

An optimal alimentary tract reconstruction technique after laparoscopic total gastrectomy (LTG) remains controversial. The authors developed a new simple technique for intracorporeal esophagojejunal anastomosis that employs a conventional purse-string suture instrument (PSI) and circular stapler.

METHODS

From May 2014 to April 2016, 41 consecutive patients with gastric cancer underwent LTG in the author's institution. Intracorporeal esophagojejunal anastomosis using the following method was attempted for all patients. After total gastrectomy was completed laparoscopically, a small vertical incision (about 40 mm) was created at the left midclavicular line and retracted by a wound retractor. An anvil of a 25 mm circular stapler was introduced into the abdominal cavity. Then a previously prepared surgical glove, which was cut open at the thumb and the little finger through which the two hand shafts of the PSI were passed separately and sealed by ties, was attached to the wound retractor to maintain airtightness, and the PSI was introduced into the abdominal cavity. The following procedure was similar to conventional open surgery except that it was performed under laparoscopic vision.

RESULTS

Intracorporeal esophagojejunal anastomosis was performed successfully for all 41 patients. No case required extension of the initial incision for difficulties during anastomosis. The mean operation time was 245 minutes, and the mean time for the purse-string suture and anvil placement was 15 minutes. Tumor-free margins were achieved in all 41 patients. There were no anastomosis-related complications or other major surgical complications.

CONCLUSIONS

With the described method, intracorporeal esophagojejunal anastomosis can be performed easily and safely.