Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Selection of two intrathoracic anastomosis methods for transabdominal radical surgery for Siewert type II adenocarcinoma of the esophagogastric junction

Introduction

The most common intrathoracic anastomosis techniques for Siewert type II adenocarcinoma of the esophagogastric junction (AEG) are the overlap and transorally inserted anvil (OrVil) methods. However, the criteria for choosing between these two methods require further study.

Aim

This retrospective study aimed to compare the efficacy and safety of overlap versus OrVil anastomosis in transabdominal radical surgery for Siewert type II adenocarcinoma of the esophagogastric junction.

Material and methods

A total of 34 patients with Siewert type II AEG who underwent transabdominal radical surgery and intrathoracic anastomosis with the overlap or OrVil methods at our center from January 2018 to June 2019 were retrospectively analyzed. The relevant surgical and postoperative complication data of the two groups were collected and analyzed.

Results

Clinical characteristics: the mean tumor size was 7.5 ±2.4 cm in the OrVil group and 4.3 ±1.9 cm in the overlap group (p < 0.05). Surgery: the distance from the upper resection margin of the esophagus to the tumor was 3.2 ±0.84 cm in the OrVil group and 2.4 ±0.6 cm in the overlap group (p < 0.05). Postoperative complications: there were two cases of pleural effusion in the OrVil group and 18 cases of pleural effusion in the overlap group (p < 0.05).

Conclusions

There is no significant difference between the OrVil and overlap anastomosis in terms of the feasibility and safety; however, OrVil anastomosis can provide a higher margin of resection of the esophagus and is suitable for tumors with extensive esophageal invasion.

Laparoscopic single-layer running "trapezoid-shaped" suture versus mechanical stapling for esophagojejunostomy after total gastrectomy for gastric cancer: cost-effect analysis of propensity score-matched study cohorts

OBJECTIVES

Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling.

METHODS

The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost.

RESULTS

The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations.

CONCLUSIONS

Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.