Healing of esophagojejunal anastomoses after experimental total gastrectomy. A comparative study using manually sutured or stapled anastomoses

Comparative evaluation of two reconstructive methods following laparoscopic assisted subtotal gastrectomy in dogs

BACKGROUND

Laparoscopic gastrectomy is a new and technically challenging surgical procedure with potential benefit. The objective of this study was to investigate clinical and para-clinical consequences following Roux-en-Y and Jejunal Loop interposition reconstructive techniques for subtotal gastrectomy using laparoscopic assisted surgery.

RESULTS

Following resection of the stomach attachments through a laparoscopic approach, stomach was removed and reconstruction was performed with either standard Roux-en-Y (n = 5) or Jejunal Loop interposition (n = 5) methods. Weight changes were monitored on a daily basis and blood samples were collected on Days 0, 7 and 21 post surgery. A fecal sample was collected on Day 28 after surgery to evaluate fat content. One month post surgery, positive contrast radiography was conducted at 5, 10, 20, 40, 60 and 90 minutes after oral administration of barium sulfate, to evaluate the postoperative complications. There was a gradual decline in body weight in both experimental groups after surgery (P < 0.05). There was no difference in blood parameters at any time after surgery between the two methods (P > 0.05). Fecal fat content increased in the Roux-en-Y compared to the Jejunal loop interposition technique (P < 0.05). No major complications were found in radiographs and gastric emptying time was similar between the two groups (P > 0.05).

CONCLUSION

Roux-en-Y and Jejunal loop interposition techniques might be considered as suitable approaches for reconstructing gastro-intestinal tract following gastrectomy in dogs. The results of this study warrant further investigation with a larger number of animals.

Intersecting staple lines and blood flow in oesophagojejunal anastomoses

Total gastrectomy and oesophagojejunostomy with linear stapling devices were performed on 22 pigs to evaluate whether intersecting staple lines reduce the blood flow with an increased risk of anastomotic leakage. The blood flow at intersecting staple lines and single row staple lines of the anastomosis was studied with the reference organ method 24 h after the first operation. The mean blood flow in intersecting staple lines was 0.305 ml min-1 g-1 tissue and 0.307 ml min-1 g-1 tissue for single row staple lines. The confidence interval for the reduction in blood flow for intersecting staple lines compared with non-crossing staple lines was from -16 to +17 per cent. In one animal the reduction in blood flow was 37 per cent; in all other animals there was no reduction in blood flow or a reduction less than 25 per cent. An equivalence test shows that if a reduction in blood flow exists it is most likely to be less than 30 per cent (P less than 0.001). Our data confirm that intersecting staple lines in oesophagojejunal anastomoses do not reduce mean anastomotic blood flow to a dangerous level.

Total gastrectomy and oesophagojejunostomy--a prospective randomized trial of hand-sutured versus mechanically stapled anastomoses

Eighty patients undergoing total gastrectomy for malignant disease were entered into a prospective randomized study, comparing anastomoses constructed mechanically (staples) with hand-sewn (single layer Maxon) anastomoses. The groups were matched with respect to clinical features, medical risk factors and were staged for tumour. Only one anastomotic leak was observed after operation and this was in the group of stapled anastomoses. One patient died in each group (owing to cardiac infarction and multiorgan failure). Operating time, morbidity and hospital stay showed no significant differences between groups. These results indicate that hand-sewn and mechanically stapled oesophagojejunostomy anastomoses allow the same high standard of performance.

Total gastrectomy and oesophagojejunostomy with linear stapling devices

When performing total gastrectomy and oesophagojejunostomy with a circular stapling device two disadvantages are obvious; firstly, a purse-string suture is needed, and secondly the instrument can be extremely difficult to introduce if the oesophagus is narrow, so that the risk of rupture is substantial. We therefore developed the following technique. When the specimen is attached only to the oesophagus, and the Roux-en-Y loop has already been divided with a linear stapling device, a small incision is made on the back wall of the oesophagus and antimesenterically 6 cm distal to the cut end of the Roux-en-Y loop. The two forks of the GIA or the PLC 50 instrument are introduced into the oesophagus and jejunum, and the two organs are brought together at the hiatus. The instrument is closed and fired. The residual opening is closed with a linear stapler which also includes the front wall of the oesophagus. With a knife, the oesophagus and excessive amounts of tissue are trimmed away, and the oesophagojejunostomy is completed. Fifteen patients (median age 67 years) had a postoperative hospital stay of 10 days (range 8-45 days) after this operation. Leakage occurred in one patient and one patient died. The anastomosis took 12 min to perform (range 8-20 min). Three reoperations were needed: intestinal obstruction, leakage and a negative exploration. The median width of the oesophagojejunal anastomosis 6 months after operation was 32 mm (range 27-40 mm). Oesophagojejunostomy performed with two linear staplers allows a quick and reliable anastomosis independent of oesophageal lumen size and a time-consuming purse-string suture.

[Controlled study comparing mechanical and manual esophago-jejunostomy following gastrectomy]

40 patients with gastric malignancies were entered into a prospective randomised study of mechanical stapling (EEA) vs. manual single layer suturing of the esophago-jejunostomy following total gastrectomy. The groups were well matched with respect to clinical features, medical risk factors and tumor stage. Following manual technique, no anastomotic leak was observed. In the group with automatic mechanical suturing one technical failure and one insufficiency was seen. This difference, however, is not statistically significant. One patient died (cardiac infarction). The analysis of operating time, morbidity and hospital stay showed no significant differences. These results indicate that by use of a precise standardized conventional suture technique the same security performing an esophago-jejunostomy can be achieved as with mechanical staplers.

[The devil's advocate--commentary on sutures]

The decision between hand suture or stapler was tested for the large bowel in randomized trials whereas retrospectively only in the upper gastrointestinal and respiratory tract. No clear difference was seen concerning patient's security and cost-time consumption. The stapler is more comfortable but the handsuture technique is still recommended. By the stapler anatomically very difficult anastomoses can be performed. Whether this is an advantage for the patient has to be tested because the technical progress may decrease physical function (incontinence!) and quality of life. In summary, the stapler, if applied critically, seems to be useful.