Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy

Evaluating the Role of Robotic Surgery Gastric Cancer Treatment: A Comprehensive Review by the Robotic Global Surgical Society (TROGSS) and European Federation International Society for Digestive Surgery (EFISDS) Joint Working Group

INTRODUCTION

Robot-assisted minimally invasive gastrectomy (RAMIG) represents a significant advancement in the surgical management of gastric cancer, offering superior dexterity, enhanced visualization, and improved ergonomics compared to laparoscopic gastrectomy (LG). This review systematically evaluates the current evidence on perioperative outcomes, oncological efficacy, learning curves, and economic considerations, providing insights into RAMIG's potential role in modern gastric cancer surgery.

METHODS

A thorough analysis of retrospective, prospective, and meta-analytic studies was conducted to compare RAMIG with LG. Key outcomes, including operative time, intraoperative blood loss, lymph node retrieval, postoperative complications, learning curve duration, and cost-effectiveness, were assessed. Emphasis was placed on both short-term and long-term oncological outcomes to determine the clinical value of RAMIG.

RESULTS

Evidence indicates that RAMIG is associated with reduced intraoperative blood loss, lower morbidity rates, and a shorter learning curve, with proficiency achieved after 11-25 cases compared to 40-60 cases for LG. The robotic platform's articulated instruments and enhanced three-dimensional visualization enable more precise lymphadenectomy, particularly in complex anatomical regions. Despite these advantages, operative time remains longer, and costs remain higher due to system acquisition, maintenance, and consumable expenses. However, emerging data suggest a gradual narrowing of cost disparities. While short-term outcomes are favorable, further high-quality, multicenter studies are needed to validate long-term oncological efficacy and survival outcomes.

CONCLUSION

RAMIG offers significant technical and clinical advantages over conventional LG, particularly in terms of precision and learning efficiency. However, the long-term oncological benefits and economic feasibility require further validation. Future research should focus on cost optimization, advanced technological integration such as near-infrared fluorescence and artificial intelligence, and multicenter trials to solidify RAMIG's role as a standard approach for gastric cancer surgery.

Final results of a randomized controlled trial: comparison of the efficacy and safety between totally laparoscopic and laparoscopic-assisted total gastrectomy for advanced Siewert III esophagogastric junction cancer and upper and middle third gastric cancer

BACKGROUND

This study aimed to compare the efficacy and safety of TLTG with the overlap technique to LATG in patients with advanced Siewert III Esophagogastric Junction Cancer and upper and middle third gastric cancer.

METHODS

This single-center RCT enrolled 292 patients with the mentioned cancers, randomly assigned to TLTG overlap ( n =146) or LATG ( n =146) groups. Data on demographics, pathology, intraoperative variables, postoperative complications, recovery parameters, and 3-year survival were collected. Main outcome: postoperative complications within 30 days. Secondary outcomes: 3-year disease-free and overall survival.

RESULTS

TLTG versus LATG: TLTG had shorter incision, faster flatus/defecation, reduced analgesia, less opioid use, and shorter hospital stay. Similar operation time, anastomosis time, blood loss, and lymph node harvest. TLTG had a lower overall post-op complication rate (P=0.047) and no significant difference in serious complications ( P =0.310). Variances in anastomotic stenosis occurrence at 3 months. No rehospitalization or mortality at 30 days. No significant differences in 3-month disease-free survival ( P =0.058) or overall survival ( P =0.236).

CONCLUSION

The overlap method for anastomosis in TLTG is safe and feasible for advanced middle-upper-third gastric cancer, with positive short-term outcomes. This technique has the potential to be the preferred esophagojejunostomy approach in TLTG.

TRIAL REGISTRATION

This trial has been registered at Chinese Clinical Trial Registry: ChiCTR1900025667 (registration date: 4 September 2019).

Safety and feasibility of "Pant-Shaped" anastomosis in laparoscopic-assisted total gastrectomy: Study of 210 cases at a single center

BACKGROUND

Advancements in laparoscopic technology have popularized laparoscopic total gastrectomy over traditional open surgery, yet postoperative complications like anastomotic leakage and stenosis persist, particularly in esophagojejunostomy. To address this, since 2017, the authors have introduced the "Pant-Shaped" esophagojejunostomy as an improvement over the classic Roux-en-Y method, especially beneficial for patients with small intestinal diameters or those with gastric body cancer or Siewert III.

OBJECTIVE

To assess the viability and safety of employing 'Pant-Shaped' anastomosis following laparoscopic-assisted total gastrectomy.

METHODS

A method of descriptive case study was used. In our department of the First Affiliated Hospital of Wannan Medical College, records of 210 patients who underwent laparoscopic-assisted total gastrectomy for gastric body cancer or adenocarcinoma at the junction of esophagus and jejunum with "Pant-Shaped" anastomosis between January 2017 and December 2022 were examined. Clinicopathological features and postoperative conditions were also examined and assessed.

RESULTS

The mean age of the 164 male and 46 female research participants was 69.2 ± 8.3 years. There was a mean estimated blood loss of 63.4 ± 29.7 ml, an anastomosis time of 25.9 ± 3.0 minutes, an operation time of 208.2 ± 40.4 minutes, and a postoperative hospital stay of 12.2 ± 8.0 days. Nine patients (4.3%) experienced postoperative problems (Clavien-Dindo > grade II), including two episodes of anastomotic leakage that were resolved with irrigation and drainage, anti-infection therapy, and nutritional assistance. After an unforeseen reoperation, two cases of duodenal stump leaking were resolved. Anastamotic hemorrhage was treated with hemostasis and blood transfusion, and the patient made a full recovery. Due to a Peterson's hernia, one patient required emergent open surgery. three months subsequent to LATG.

CONCLUSIONS

The "Pant-Shaped" anastomosis method after laparoscopic-assisted total gastrectomy is simple, easy to promote, and has fewer complications. It is a safe and feasible modified method for esophagojejunostomy, especially suitable for patients with poor intestinal dilation and contraction ability and small jejunal diameter.

Configuration of anastomotic doughnuts of stapled anastomoses in upper gastrointestinal surgery is associated with anastomotic leakage

OBJECTIVE

The aim of this study was to evaluate whether the configuration of anastomotic doughnuts from upper gastrointestinal surgeries was associated with anastomotic leakage (AL).

BACKGROUND

AL is a severe postoperative complication after upper gastrointestinal cancer surgeries. AL is associated with an increase in overall and cancer-related morbidity and mortality in patients with esophageal and gastric cancer. New intraoperative biomarkers are needed to predict the risk of AL to implement early preventive measures.

MATERIALS AND METHODS

Anastomotic doughnuts from 102 patients undergoing surgery for esophageal or gastric cancer using circular staplers were examined. The minimal and maximal height and width of the anastomotic doughnuts were measured and correlated with the postoperative AL rate.

RESULTS

The AL rate in our study collective was 15,7 %. The minimal width (Wmin) of the oral and aboral anastomotic doughnuts was significantly lower in patients with AL compared to patients without AL (p = 0.002 and p = 0.041 respectively). The Wmin of the esophageal anastomotic doughnut was an independent risk factor for AL in the multivariable analysis (p = 0.034). Negative predictive values for the measurements of anastomotic doughnuts (Wmin) with regard to the risk of AL were higher than for the commonly used postoperative biomarker C-reactive protein.

CONCLUSION

Minimal anastomotic doughnut width was statistically significantly associated with AL. Thus, not only the evaluation of the completeness of the anastomotic doughnuts but also intraoperative measurements could be used to predict the risk of AL to initiate early preventive measures to prevent the development of AL and/or reduce AL-associated morbidity.

A retrospective study of provisional outcomes of intracorporeal esophagojejunostomy versus extracorporeal anastomosis during laparoscopic total gastrectomy for gastric cancer. a single -center

Gastric cancer (GC) treatment is increasingly undergoing laparoscopic total gastrectomy (LTG) procedures. However, we conducted this research to evaluate postoperative outcomes, particularly surgical complications associated with intracorporeal and extracorporeal esophagojejunostomies using linear or circular stapling techniques following LTG for GC treatment. We aimed to compare short-term postoperative outcomes, such as surgical complications and anastomotic outcomes, between the two groups. Method From January 2020 to August 2022, we conducted a retrospective analysis of data from 160 consecutive patients diagnosed with GC who received either IEJ (n = 35) or EEJ (n = 125) during LTG. We utilized the Mann-Whitney U test to ascertain the statistical significance between the two groups. For comparing categorical variables, including numbers and percentages, we employed either the Pearson chi-square test, continuity correction, or Fisher's exact test as appropriate.ResultsThe operative time was similar (IEJ: 184.57 ± 36.489 vs. EEJ: 189.22 ± 43.584; P = 0.565), however, the number of positive lymph nodes was performed more in the IEJ group (IEJ: 4.71 ± 6.114 vs. EEJ: 6.39 ± 9.067 (P = 0.305). The blood loss in the IEJ group was lower than that of the EEJ (IEJ: 73.1429.182 vs. EEJ: 100.6461.693 mL, P = 0.012). There were three anastomosis leakages in the EEJ and one in the IEJ group (EEJ, 3.2% vs. IEJ, 2.8%; P > 0.999). Anastomosis bleeding only occurred in the EEJ (EEJ 1%; P = 0.003). Although the EEJ linear stapling technique had two deaths (EEJ, 1.6%).ConclusionAlthough EEJ is frequently utilized in the linear stapling technique, research indicates that the use of IEJ minimizes the incidence of complications in LTG.

Short-term outcomes depending on type of oesophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: retrospective study based on a Korean Nationwide Survey for Gastric Cancer in 2019

BACKGROUND

The study aimed to assess postoperative complication rates of different oesophagojejunostomy (EJ) techniques used in laparoscopic total gastrectomy for gastric cancer.

METHODS

A total of 1155 patients who underwent laparoscopic total gastrectomy were retrospectively selected from the data obtained from the Korean Nationwide Survey for gastric cancer in 2019. Morbidity rate was compared between patients who received intracorporeal or extracorporeal EJ using linear or circular staplers during laparoscopic total gastrectomy. The variables of the groups were balanced using the inverse probability of treatment weighting.

RESULTS

Seven hundred and seventy-three patients received intracorporeal EJ using a linear stapler (IL), 137 received intracorporeal EJ using a circular stapler (IC), 134 received extracorporeal EJ using a linear stapler (EL) and 111 received extracorporeal EJ using a circular stapler (EC). The overall complication rates were lower in the extracorporeal group (EL: 13.4% versus EC: 12.6%) compared to the intracorporeal group (IL: 22.6% versus IC: 17.5%) (P = 0.006). Fewer major complications were observed in the extracorporeal group (EL: 1.4% versus EC: 1.8%) compared to the intracorporeal group (IL: 9.4% versus IC: 7.3%) (P = 0.004). There was no significant difference in EJ-related complications between the groups (P = 0.418 in EJ leakage and P = 0.474 in EJ stricture). Multivariable analysis showed that the IL method correlated with more overall and major complications than the extracorporeal method.

CONCLUSION

The results of this study suggest that despite its widespread use, the IL method is a challenging procedure with higher complication rates than the extracorporeal method. Further high-quality studies are required to confirm the results.

Current status and future trends of real-time imaging in gastric cancer surgery: A literature review

Technological advances are crucial for the optimization of gastric cancer surgery, and the success of any gastric cancer surgery is based on the correct and precise anatomical determination of the primary tumour and tissue structures. Real-time imaging-guided surgery is showing increasing potential and utility, mainly because it helps to aid intraoperative decision-making. However, intraoperative imaging faces many challenges in the field of gastric cancer. This article summarizes and discusses the following clinical applications of real-time optical imaging and fluorescence-guided surgery for gastric cancer: (1) the potential of quantitative fluorescence imaging in assessing tissue perfusion, (2) vascular navigation and determination of tumour margins, (3) the advantages and limitations of lymph node drainage assessment, and (4) identification of peritoneal metastases. In addition, preclinical study of tumour-targeted fluorescence imaging are discussed.

The safety and feasibility assessment of overlap esophagojejunostomy with self-pulling and latter transection technique in totally laparoscopic total gastrectomy

BACKGROUND

This study presented an innovative technique in totally laparoscopic total gastrectomy (TLTG) for overlap esophagojejunostomy (E-J), termed self-pulling and latter transection (SPLT) (overlap SPLT). It evaluated the effectiveness and short-term outcomes of this novel method through a comparative analysis with the established functional end-to-end (FETE) E-J incorporating SPLT.

METHODS

From September 2018 to September 2023, this study enrolled 68 patients with gastric cancer who underwent TLTG with overlap SPLT anastomosis and 120 patients who underwent TLTG with FETE SPLT anastomosis. Clinicopathologic characteristics and surgical and postoperative outcomes data for overlap SPLT cases were gathered and retrospectively compared with those from FETE SPLT TLTG to evaluate the effectiveness and clinical safety.

RESULTS

The duration of anastomosis for overlap SPLT was 25.3 ± 7.4 minutes, significantly longer than that for the FETE SPLT (18.1 ± 4.0 minutes, P = .031). Perioperatively, 1 anastomosis-related complication occurred in each group, but this did not constitute a statistically significant difference (P = .682). No statistically significant differences were found between the 2 groups in terms of operative time, postoperative hospital stay, operative cost, surgical margins, or number of lymph nodes removed. Postoperative morbidity rates were similar between the groups (4.4% vs 5.8%, P = .676).

CONCLUSION

The overlap SPLT technique is regarded as a safe and feasible method for anastomosis. There were no apparent differences in complications between overlap SPLT and FETE SPLT, but overlap SPLT costed 1 additional stapler cartridge and required a longer duration.

[Technique and Study Results of Laparoscopic Gastrectomy for Gastric Cancer]

The aim of this paper was to describe the technique of laparoscopic gastrectomy for gastric carcinoma and to present a review of current international studies on this topic.The first part describes and documents a standard laparoscopic gastrectomy for carcinoma. In the second part, after an EMBASE and PubMed search, a total of 123 quality-relevant randomised (RCT) and non-randomised (non-RCT) studies on laparoscopic gastrectomy are identified from a primary total of 3,042 hits by systematic narrowing. The study results are then summarised conclusively for the target criteria of feasibility, outcome, oncological quality, morbidity and mortality.Both, laparoscopic subtotal resection for distal gastric carcinomas and laparoscopic gastrectomy can now be performed safely and with few complications. In a recent literature review of a total of 15 RCTs with 5,576 patients (laparoscopic 2,793 vs. open 2,756), there were no significant differences in terms of feasibility, intraoperative outcome and oncological quality (R0 and lymph node harvest). Surgical morbidity and mortality were comparable. Patients after laparoscopic surgery showed a significantly faster early postoperative recovery with a lower overall morbidity. In contrast, the operating time was significantly longer - by a mean of 45 min - compared to the open technique. The advantages of the laparoscopic technique were equally evident in studies on early gastric carcinoma and advanced carcinomas (>T2).Laparoscopic gastrectomy for gastric carcinoma is safe to perform and shows better early postoperative recovery. Complication rates, morbidity and mortality as well as long-term oncological results are comparable with open surgery.

Application of hand-sewn esophagojejunostomy in laparoscopic total gastrectomy

OBJECTIVE

To investigate the clinical efficacy and prognostic implication of hand-sewn anastomosis in laparoscopic total gastrectomy (LTG).

METHODS

Retrospective analysis is adopted to the clinicopathologic data of 112 patients with gastric cancer (GC) who went through LTG in the Department of General Surgery, the Second Affiliated Hospital of Anhui Medical University between October 2020 and October 2022. Among them, 60 individuals receiving medical care were split into the hand-sewn anastomosis group (Group H, N = 60); while, 52 individuals were split into the circular stapler anastomosis group (Group C, N = 52) The clinical efficacy and prognostic conditions of hand-sewn anastomosis are compared with those of circular stapler anastomosis in the application of LTG.

RESULTS

The analysis results indicated that no notable difference was observed in intraoperative bleeding volume, time to first flatus (TFF), postoperative hospitalization duration and postoperative complications among the two groups (P > 0.05). Group H had shorter esophagojejunal anastomosis duration (20.0 min vs. 35.0 min) and surgery duration (252.6 ± 19.4 min vs. 265.9 ± 19.8 min), smaller incisions (5.0 cm vs. 10.5 cm), and lower hospitalization costs (58415.0 CNY vs. 63382.5 CNY) compared to Group C (P < 0.05).

CONCLUSION

The clinical efficacy and the postoperative complications of hand-sewn esophagojejunostomy are basically equivalent in comparison to the circular stapler anastomosis in the application of LTG. Its advantage lies in shorter esophagojejunal anastomosis duration, shorter surgery duration, smaller incisions, lower hospitalization costs and wider adaptability of the location of the tumor.

Successful treatment of an anastomotic leakage after total gastrectomy using a fully covered self-expandable metal stent with an anchoring thread: A case report

INTORODUCTION AND IMPORTANCE

The incidence of anastomotic leakage in the esophagojejunostomy after total gastrectomy is a serious complication of this procedure. Here, we report a case in which a fully covered stent was endoscopically placed into a fistula caused by anastomotic leakage after total gastrectomy.

CASE PRESENTATION

An 88-year-old man diagnosed with advanced gastric cancer had tumor invasion close to the esophagogastric junction. We performed a laparoscopic total gastrectomy and Roux-en-Y reconstruction. On postoperative day (POD) 3, the patient experienced septic shock due to anastomotic leakage and subsequent mediastinitis. Mediastinal irrigation and drainage under laparotomy were performed. Sepsis improved with drainage, but the fistula persisted due to anastomotic leakage.

CLINICAL DISCUSSION

Based on a diagnosis of refractory fistula, a fully covered self-expandable metal stent (HANAROSTENT® Esophagus) was inserted POD 21 using esophagoscopy. To prevent stent migration, a 3-0 silk thread was attached to the ostial side of the stent and fixed at the nose. The stent was endoscopically removed 36 days. Esophagoscopy after stent removal revealed that the fistula had resolved and that the anastomotic leakage had healed. The patient started oral intake and was discharged home.

CONCLUSION

This case demonstrates the potential for use of a fully covered self-expandable metal stent with an anchoring thread for anastomotic leakage after total gastrectomy for gastric cancer.

Efficacy of Biomarkers in Predicting Anastomotic Leakage After Gastrointestinal Resection: A Systematic Review and Meta-Analysis

Our systematic review and meta-analysis were designed to evaluate the published literature from 2016 to 2019 on which the role of biomarkers in predicting the anastomotic leakage (AL) in gastroesophageal cancer surgery was investigated. This extensive literature search was conducted on the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) were used to gather the relevant information. No restrictions were made on the type of biomarkers. Wald or likelihood ratio (LRT) fixed effect tests were used to estimate the pooled prevalence to generate the proportions with 95% confidence intervals (CI) and model-fitted weights. For analyzing heterogeneity, the Cochran Q test and I square test were used. The Egger regression asymmetry test and funnel plot were used for publication. In this meta-analysis, a total of 15 studies were recruited with 1892 patients undergoing the resection. The pooled elevated C-reactive protein (CRP) was observed as 13.9% ranging from 11.6% to 16.1%. The pooled prevalence of other biomarkers with AL was observed as 4.4%. Significant heterogeneity was observed between studies that reported CRP and other biomarkers (92% each with chi-squared values of 78.80 and 122.78, respectively). However, no significant publication was observed between studies (p=0.61 and p=0.11, respectively). We concluded our study on this note that different biomarkers are involved in the diagnosis of AL. However, all these biomarkers are poor predictors with insufficient predictive value and sensitivity.

Gastrointestinal Fistula in Radical Distal Gastrectomy: Case-Control Study from a High-Volume Hospital

Background: Postoperative gastrointestinal fistula (PGF) is one of the main causes of abdominal infection and perioperative death. This study was designed to investigate the risk factors of PGF, anastomotic fistula (AF), and duodenal stump fistula (DSF) for patients who underwent radical distal gastrectomy. Materials and Methods: In this retrospective observational study, 2652 gastric cancer cases who received radical distal gastrectomy from 2010 to 2020 were selected as research subjects. Subsequently, we adopted the univariate and multivariate logistic regression analysis as statistical method to screen the risk factors for PGF, AF, and DSF, respectively. Results: In univariate analysis, gender (P = .022), operative time (P = .013), intraoperative blood loss (P < .001), tumor diameter (P = .002), and tumor stage (P < .001) were related to PGF. Multivariate logistic regression analysis identified the male (odds ratio [OR] = 2.691, P = .042), massive intraoperative hemorrhage (OR = 1.002, P = .008), and advanced tumor (OR = 2.522, P = .019) as independent predictors for PGF. Moreover, diabetes (OR = 4.497, P = .008) and massive intraoperative hemorrhage (OR = 1.003, P = .010) were proved to be associated with AF, while massive intraoperative hemorrhage (OR = 1.001, P = .050) and advanced tumor (OR = 6.485, P = .005) were independent risk factors of DSF. Conclusions: The gender, intraoperative hemorrhage, tumor stage, and diabetes were expected to be used as predictors of PGF for radical distal 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.

Comparison of short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis in laparoscopic total gastrectomy

BACKGROUND

To compare short-term and long-term clinical effects of modified overlap anastomosis and conventional incision-assisted anastomosis for laparoscopic total gastrectomy.

METHODS

This retrospective cohort study included patients with gastric cancer admitted to the Second Affiliated Hospital of Fujian Medical University from January 2016 to March 2020. Quality of life, intraoperative and postoperative conditions were analyzed.

RESULTS

Compared with the conventional assisted group, the modified overlap group showed a shorter auxiliary incision, milder postoperative pain, shorter time to the first postoperative anal exhaust, shorter time to the first postoperative liquid food intake, and shorter postoperative stay. There were no differences between the two groups regarding operation time, esophagus-jejunum anastomosis time, intraoperative blood loss, number of lymph nodes dissected, and length of the upper incision margin. There were no differences between the two groups regarding postoperative early and late complications. There were no differences between the two groups regarding the QLQ-C30 scale three years after the operation. The scores of the QLQ-STO22 scale 3 years after the operation showed significantly lower scores for dysphagia and feeding limit in the modified overlap group than those in the conventional assisted anastomosis group. There was no recurrence in the modified overlap group but one patient in the conventional assisted group.

CONCLUSIONS

Patients undergoing totally laparoscopic total gastrectomy with modified overlap anastomosis have better minimal invasiveness and faster post-operative recovery than conventional incision-assisted anastomosis.

Dysphagia After Esophageal Replacement and Its Treatment

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Short-term outcomes of different esophagojejunal anastomotic techniques during laparoscopic total gastrectomy: a network meta-analysis

BACKGROUND

Different techniques have been described for esophagojejunostomy (EJ) during laparoscopic total gastrectomy (LTG) for gastric cancer. Linear stapled techniques include overlap (OL) and functional end-to-end anastomosis (FEEA) while single staple technique (SST), hemi-double staple technique (HDST), and OrVil® are circular stapled approaches. Nowadays, the choice among techniques for EJ depends on operating surgeon personal preference.

PURPOSE

To compare short-term outcomes of different EJ techniques during LTG.

METHODS

Systematic review and network meta-analysis. OL, FEEA, SST, HDST, and OrVil® were compared. Primary outcomes were anastomotic leak (AL) and stenosis (AS). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrI) were used to measure relative inference.

RESULTS

Overall, 3177 patients (20 studies) were included. The technique for EJ was SST (n = 1026; 32.9%), OL (n = 826; 26.5%), FEEA (n = 752; 24.1%), OrVil® (n = 317; 10.1%), and HDST (n = 196; 6.4%). AL was comparable for OL vs. FEEA (RR = 0.82; 95% CrI 0.47-1.49), OL vs. SST (RR = 0.55; 95% CrI 0.27-1.21), OL vs. OrVil® (RR = 0.54; 95% CrI 0.32-1.22), and OL vs. HDST (RR = 0.65; 95% CrI 0.28-1.63). Similarly, AS was similar for OL vs. FEEA (RR = 0.46; 95% CrI 0.18-1.28), OL vs. SST (RR = 0.89; 95% CrI 0.39-2.15), OL vs. OrVil® (RR = 0.36; 95% CrI 0.14-1.02), and OL vs. HDST (RR = 0.61; 95% CrI 0.31-1.21). Anastomotic bleeding, time to soft diet resumption, pulmonary complications, hospital length of stay, and mortality were comparable while operative time was reduced for FEEA.

CONCLUSIONS

This network meta-analysis shows similar postoperative AL and AS risk when comparing OL, FEEA, SST, HDST, and OrVil® techniques. Similarly, no differences were found for anastomotic bleeding, operative time, soft diet resumption, pulmonary complications, hospital length of stay and 30-day mortality.

Feasibility and Potential of Reduced Port Surgery for Total Gastrectomy With Overlap Esophagojejunal Anastomosis Method

PURPOSE

Reduced port surgery (RPS) for gastric cancer has been frequently reported in distal gastrectomies but rarely in total gastrectomies. This study aimed to determine the feasibility of 3-port totally laparoscopic total gastrectomy (TLTG) with overlapping esophagojejunal (EJ) anastomosis.

MATERIALS AND METHODS

A total of 81 patients who underwent curative TLTG for gastric cancer (36 and 45 patients with 3-port and 5-port TLTG, respectively) were evaluated. All 3-port TLTG procedures were performed with the same method as 5-port TLTG, including EJ anastomosis with the intracorporeal overlap method using a linear stapler, except for the number of ports and assistants. Short-term outcomes, including the number of lymph nodes (LNs) harvested by station and postoperative complications, were analyzed retrospectively.

RESULTS

Clinical characteristics were not significantly different among the groups, except that the 3-port TLTG group was younger and had a lower rate of pulmonary comorbidity. There were no cases of open conversion or additional port placement. All operative details and the number of harvested LNs did not differ between the groups, but the rate of suprapancreatic LN harvest was higher in the 3-port TLTG group. No significant differences were observed in the overall complication rates between the 2 groups.

CONCLUSIONS

Three-port TLTG with overlapping EJ anastomoses using a linear stapler is a feasible RPS procedure for total gastrectomy to treat gastric cancer.

Treatment and Prevention of Postoperative Leakage after Gastrectomy for Gastric Cancer

Anastomotic leakage is one of the common causes of serious morbidity and death after gastrectomy. The use of surgical treatment for leakage decreased due to the development of nonsurgical management. However, if nonsurgical management fails to control the spread of intra-abdominal infection, emergency surgical treatment is required. The authors wished to determine in which cases surgical treatment is needed for postoperative leakage and to identify treatment and prevention strategies. If a patient's vital signs are stable, local abscesses can be cured by conservative treatment after percutaneous drain insertion; if there is no improvement in anastomotic leakage, endoscopic treatment such as clipping, vacuum, and stent placement can be performed. If a patient's vital signs are unstable or patient shows diffuse peritonitis, surgical treatment should be performed. A surgical plan can be established according to leakage location. The duodenal stump may first require conservative treatment. It is recommended that surgical treatment be attempted first for anastomotic leakage of gastrojejunostomy site and gastric stump in remnant stomach. In conclusion, the need for surgical treatment is determined depending on vital signs and presence of diffuse peritonitis. During surgical treatment, a strategic approach is required according to the patient's condition and the anatomical location of leakage.

Linear- Versus Circular-Stapled Esophagojejunostomy During Total Gastrectomy: Systematic Review and Meta-Analysis

Background: While numerous techniques have been defined for esophagojejunostomy (EJ) during total gastrectomy including hand-sewn and stapled anastomoses, mechanical linear-stapled (LS) and circular-stapled (CS) anastomoses are widely adopted. However, there are scarce data on the optimal stapled technique for EJ during total gastrectomy. Materials and Methods: Scopus, Web of Science, MEDLINE, and PubMed were investigated up to October 30, 2022. We considered articles that appraised short-term outcomes after LS versus CS anastomosis in patients undergoing total gastrectomy for gastric cancer. Anastomotic leak (AL), anastomotic stricture (AS), and anastomotic bleeding (AB) were primary outcomes. Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures, whereas 95% confidence intervals (95% CIs) were used to calculate related inference. Results: Sixteen studies (3156 patients) were incorporated. Overall, 1540 (48.8%) underwent CS, whereas 1616 (51.2%) underwent LS. Compared with CS, LS was related to a condensed RR for AS (RR: 0.27; 95% CI 0.15-0.49; P < .01), whereas no differences were found for AL (RR: 0.75; 95% CI 0.51-1.10; P = .14) and AB (RR: 0.59; 95% CI 0.24-1.44; P = .25). Postoperative pneumonia (RR: 0.98; P = .94), operative time (SMD: 0.51; P = .31), days to soft diet (SMD: -0.08; P = .36), hospital stay (SMD: 0.19; P = .46), and 30-day mortality (RR: 1.76; P = .31) were comparable between LS and CS. Conclusions: For EJ during total gastrectomy, our results suggest that LS seems related to a reduced risk of AS compared with CS, although no significant differences were found for the risk of AL and AB between the two techniques. Clinical Trial Registration number: CRD42022381221.

Hand-sewn esophagojejunostomy in transthoracic single-port assisted laparoscopic esophagogastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction with esophageal invasion > 3 cm

BACKGROUND

An optimal method for digestive tract reconstruction (DTR) in laparoscopic radical resection of Siewert type II adenocarcinoma of esophagogastric junction (AEG) has not yet been standardized. The aim of this study was to evaluate the safety and feasibility of a hand-sewn esophagojejunostomy (EJ) technique during transthoracic single-port assisted laparoscopic esophagogastrectomy (TSLE) for Siewert type II AEG with esophageal invasion > 3 cm.

METHODS

The perioperative clinical data and short-term outcomes for patients who underwent TSLE using hand-sewn EJ for Siewert type II AEG with esophageal invasion > 3 cm between March 2019 and April 2022 have been retrospectively reviewed.

RESULTS

A total of 25 patients were eligible. All 25 patients were successfully operated. None was converted to open surgery or mortality. 84.00% of patients were male and 16.00% were female. The mean age, body mass index (BMI), and the American Society of Anesthesiologists (ASA) score were 67.88 ± 8.10 years, 21.30 ± 2.80 kg/m², and 2.08, respectively. The average incorporated operative and hand-sewn EJ procedural times were 274.92 ± 57.46 and 23.36 ± 3.00 min, respectively. The length of extracorporeal esophageal involvement and proximal margin was 3.31 ± 0.26 cm and 3.12 ± 0.12 cm, respectively. The average time for the first oral feeding and hospital stay were 6 (3-14) and 7 (3-18) days, respectively. Two patients (8.00%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pleural effusion and 1 case of anastomotic leakage, both of whom were cured by puncture drainage.

CONCLUSION

Hand-sewn EJ in TSLE is safe and feasible for Siewert type II AEG. This method can ensure safe proximal margins and could be a good option with an advanced endoscopic suture technique for type II tumor with esophageal invasion > 3 cm.

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy in patients with gastric cancer

Purpose

Esophagojejunostomy leakage after total gastrectomy for gastric cancer is one of the most serious and sometimes life-threatening adverse events. The purpose of this study was to evaluate complications after total gastrectomy in patients with gastric cancer during the period when Histoacryl (B. Braun) injection was performed. Therapeutic outcome of endoscopic Histoacryl injection for esophagojejunostomy leakage was also determined.

Methods

This was a single-center retrospective study. Between January 2016 and December 2021, clinicopathologic characteristics and surgical outcomes of 205 patients who underwent total gastrectomy were investigated. Baseline characteristics and clinical outcomes of 10 patients with esophagojejunostomy leakage were also investigated.

Results

Postoperative complication and mortality rates of total gastrectomy in 205 patients were 25.4% and 0.9%, respectively. Serious complications more than Clavien-Dindo IIIb accounted for 6.3%. Ten (4.9%) esophagojejunostomy leakages occurred in 205 patients. Among 10 esophagojejunostomy leakage patients, endoscopic Histoacryl injection was performed on eight patients and leakage was successfully managed with endoscopic Histoacryl injection in seven patients (87.5%). Mean postinjection hospital stay of seven successfully managed patients was 13.8 days. They were able to drink water at 1-6 days after injection. Among eight patients with endoscopic Histoacryl injection, six patients were injected once and two patients were injected three times.

Conclusion

Endoscopic Histoacryl injection for esophagojejunostomy leakage after total gastrectomy can be considered as a useful treatment for some selected cases.

A novel method of anvil placement of circular stapler for esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: results of consecutive 200 cases

BACKGROUND

Laparoscopic total gastrectomy for gastric cancer is still a demanding operation because of technical difficulties, especially of intracorporeal esophago-jejunal anastomosis.

METHODS

We introduced a newly designed method of anvil placement of circular stapling devices (CS) for laparoscopic esophagojejunostomy (EJS). A small incision was made on the anterior wall of the stomach, from which the anvil was inserted into the stomach and proceeded to the thoracic esophagus. Then, the abdominal esophagus was transected by a linear stapler, and the anvil into the esophagus was drawn back to the esophageal stump by pulling out the cotton tape pre-attached to the anvil. Intracorporeal EJS by Roux-en-Y reconstruction was performed by CS inserted into the abdominal cavity from the umbilical wound.

RESULTS

A total of consecutive 200 gastric cancer patients underwent laparoscopic total gastrectomy using this method. There was no operative mortality. Anastomotic complications occurred in 12 cases (6.0%): 9 cases of stenosis (4.5%) and 3 cases of bleedings (1.5%). Anastomotic leakage was not observed. As for non-anastomotic complications, there occurred 2 pulmonary complications (1.0%), 3 pancreatic leakages (1.5%), and 8 bowel obstructions due to internal hernia (4.0%). With a median follow-up period of 47.1 months, 5-year overall survival for assessable patients (n = 193) was 60.3% (95% CI 52.6-67.2). The total rate of peritoneal recurrence was 9.8%.

CONCLUSION

Our new method of anvil placement for laparoscopic EJS with CS is safe and feasible with favorable survival outcomes. It eliminates the need for suturing, and will promote the clinical application of laparoscopic total gastrectomy for gastric cancer.

CLINICAL TRIALS

UMIN000046119.

Short and long-term outcomes of prophylactic total gastrectomy in 54 consecutive individuals with germline pathogenic mutations in the CDH1 gene

BACKGROUND

Germline mutation of CDH1 is rare and leads to hereditary diffuse gastric cancer (DGC).

METHODS

Patients (pts) with CDH1 mutation who underwent multidisciplinary counseling followed by open prophylactic total gastrectomy (PTG) by a single surgeon were reviewed.

RESULTS

Fifty-four pts with a median age of 41 years (16-70 years) underwent PTG between 2006 and 2021. Median operative time was 161 min, and median hospital stay was 7 days (range 6-12). There were 5 complications (9.2%) within 30 days, and two complications (pulmonary embolism and pancreatitis) required readmission. There were no anastomotic leaks. The pathologic analysis of the first 10 pts included the entire gastric mucosa, revealing a median of 15 foci of DGC (range 5-136). The subsequent 44 pts with more limited analysis had a median of 2 foci (range 0-5), and two pts (3.7%) had no foci identified. Median maximum weight loss was 19%. In long-term follow-up (median 4.6 years) of 20 pts, median global QOL was 2.0 (very good), the majority had persistent difficulty with certain foods or liquids, and all stated they would again elect PTG over surveillance endoscopy.

CONCLUSIONS

PTG can be performed safely at high-volume referral centers with very good QOL but nutritional sequelae persist.

Predictive Factors for Anastomotic Leakage after Laparoscopic and Open Total Gastrectomy: A Systematic Review

The aim of this systematic review is to identify patient-related, perioperative and technical risk factors for esophago-jejunal anastomotic leakage (EJAL) in patients undergoing total gastrectomy for gastric cancer (GC). A comprehensive literature search of PubMed/MEDLINE, Embase and Scopus databases was performed. Studies providing factors predictive of EJAL by uni- and multivariate analysis or an estimate of association between EJAL and related risk factors were included. All studies were assessed for methodological quality, and a narrative synthesis of the results was performed. A total of 16 studies were included in the systematic review, with a total of 42,489 patients who underwent gastrectomy with esophago-jejunal anastomosis. Age, BMI, impaired respiratory function, prognostic nutritional index (PNI), alcohol consumption, chronic renal failure, diabetes and mixed-type histology were identified as patient-related risk factors for EJAL at multivariate analysis. Likewise, among operative factors, laparoscopic approach, anastomosis type, additional organ resection, blood loss, intraoperative time and surgeon experience were found to be predictive factors for the development of EJAL. In clinical setting, we are able to identify several risk factors for EJAL. This can improve the recognition of higher-risk patients and their outcomes.

Postoperative short-term use of the nonsteroidal anti-inflammatory drug flurbiprofen did not increase the anastomotic leakage rate in patients undergoing elective gastrointestinal surgery-a retrospective cohort study

Background

Flurbiprofen has been one of the most commonly used nonsteroidal anti-inflammatory drugs (NSAIDs) in China and other Asian countries for perioperative multimodal analgesia in recent years, yet its association with anastomotic leakage in gastrointestinal anastomoses is unknown. The current study was designed to investigate whether short-term administration of flurbiprofen would increase the risk of anastomotic leakage in patients undergoing gastrointestinal surgery for cancer resection.

Methods

A total of 3653 patients (2487 (66.1%) men) undergoing elective operation for gastrointestinal cancer between 18 July 2017 and 30 Oct 2020 were included. The median age was 61 years (interquartile range 53–67 years). The exposure was the short-term postoperative use of flurbiprofen (defined as flurbiprofen treatment within the first week after surgery). The primary outcome was the frequency of clinical anastomotic leakage.

Results

Of 3653 patients with available data who were included in the final analysis, 2282 received flurbiprofen administration, and 1371 did not. Anastomotic leakage was not significantly increased among the patients receiving flurbiprofen compared with those who did not (1.62% v 1.46%; P=0.70). In-hospital mortality was comparable between the two groups (0.04% v 0.07%; P=0.72). After adjusted analysis, male sex (OR 3.51, 95% CI 1.80–6.85), ASA score of 3–4 (OR 2.69, 95% CI 1.62–4.48), and intraoperative infusion (OR 2.24, 95% CI 1.19–4.21) were identified as risk factors for anastomotic leakage.

Conclusions

Postoperative short-term use of flurbiprofen did not increase the risk of anastomotic leakage in gastrointestinal anastomoses.

Modified -shaped esophagojejunostomy in totally laparoscopic total gastrectomy: a report of 40 consecutive cases from a single center

Objective

Intracorporeal esophagojejunostomy remains a challenging technique in totally laparoscopic total gastrectomy (TLTG) because of the lack of an established standard anastomosis method. However, π-shaped esophagojejunostomy in TLTG is reportedly safe and feasible. Therefore, we evaluated the short-term surgical outcomes of our modified π-shaped esophagojejunostomy in TLTG.

Methods

This study involved patients without neoadjuvant therapy diagnosed with gastric cancer who underwent TLTG by the same surgeon with modified π-shaped esophagojejunostomy from April 2018 to October 2019. Clinicopathologic data were collected and retrospectively analyzed.

Results

Forty patients diagnosed with gastric cancer were included. The mean operative time and estimated blood loss were 264.6 ± 56.9 minutes and 68.5 ± 53.3 mL, respectively. Postoperative flatus occurred at 4.6 ± 1.7 days. The mean time to resumption of diet was 7.4 ± 1.7 days postoperatively. One patient was diagnosed with anastomotic leakage and managed with conservative therapy. Pleural effusion was the most common complication, occurring in four (10%) patients. One patient developed intra-abdominal bleeding that required reoperation. Other complications were atrial fibrillation and wound infection. No mortality occurred during the 6-month follow-up.

Conclusions

Modified π-shaped esophagojejunostomy is safe and feasible for intracorporeal anastomosis in TLTG and showed favorable surgical outcomes in this study.

Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments: A case report

BACKGROUND

Gastrografin swallow, methylthioninium chloride test, and computed tomography (CT) are the main methods for postoperative anastomotic fistula detection. Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy, which are conducive to postoperative recovery.

CASE SUMMARY

A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer. The patient developed a fever after surgery. The methylthioninium chloride test and early CT suggested no anastomotic fistula, but gastrografin swallow and late CT showed the opposite result. The fistula was successfully closed using an endoscopic clip. The methylthioninium chloride test, gastrografin, and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different. The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.

CONCLUSION

The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy. The size of the leakage of the anastomosis is an important basis for selecting the repair method.

Antibiotic Bowel Decontamination in Gastrointestinal Surgery—A Single-Center 20 Years’ Experience

Objective

Anastomotic leakage, surgical site infections, and other infectious complications are still common complications in gastrointestinal surgery. The concept of perioperative antibiotic bowel decontamination demonstrates beneficial effects in single randomized controlled trials (RCTs), but data from routine clinical use are still sparse. Our aim was to analyze the data from the routine clinical use of perioperative antibiotic bowel decontamination in gastrointestinal surgery.

Methods

Based on 20 years’ experience, we performed a retrospective analysis of all cases in oncologic gastrointestinal surgery with the use of antibiotic bowel decontamination in gastric, sigmoid, and rectal cancer. Clinical data and perioperative outcomes were analyzed, especially regarding anastomotic leakage, surgical site infections, and other infectious complications.

Results

A total of n = 477 cases of gastrointestinal surgery in gastric cancer (n = 80), sigmoid cancer (n = 168), and rectal cancer (n = 229) using a perioperative regimen of antibiotic bowel decontamination could be included in this analysis. Overall, anastomotic leakage occurred in 4.4% (2.5% gastric cancer, 3.0% sigmoid cancer, 6.1% rectal cancer) and surgical site infections in 9.6% (6.3% gastric cancer, 9.5% sigmoid cancer, 10.9% rectal cancer). The incidence of all infectious complications was 13.6% (12.5% gastric cancer, 11.3% sigmoid cancer, 15.7% rectal cancer). Mortality was low, with an overall rate of 1.1% (1.3% gastric cancer, 1.8% sigmoid cancer, 0.4% rectal cancer). Antibiotic decontamination was completed in 98.5%. No adverse effects of antibiotic bowel decontamination could be observed.

Conclusion

Overall, in this large cohort, we can report low rates of surgery-related serious morbidity and mortality when perioperative antibiotic bowel decontamination is performed. The rates are lower than other clinical reports. In our clinical experience, the use of perioperative antibiotic bowel decontamination appears to improve patient safety and surgical outcomes during gastrointestinal oncologic procedures in a routine clinical setting.

Association between Vascular Calcification and Esophagojejunal Anastomotic Complications after Total Gastrectomy for Gastric Cancer: A Propensity-Matched Study

Esophagojejunal anastomosis (EJA) complications after total gastrectomy are related to significant morbidity and mortality. The aim of this study was to evaluate the association between arterial calcifications and EJA complications such as leak and stricture for gastric cancer. Between January 2014 and October 2019, 30 patients with EJA complications after total gastrectomy were enrolled and matched to 30 patients without complications through retrospective data review. Arterial calcification grade on preoperative computed tomography (CT) was reported in the abdominal aorta and superior mesenteric artery (SMA) as “absent”, “minor”, or “major”, and in the jejunal vascular arcade (JVA) and left inferior phrenic artery (LIPA) as “absent” or “present”. A Chi-square test was used to compare the variables between the two groups. p-Value < 0.050 was considered statistically significant. Among 30 patients, the numbers of patients with leak and stricture were 23 and seven, respectively. Aortic calcifications were not associated with EJA complications regardless of their grade (p = 0.440). Only major SMA calcifications were associated with EJA complications, as they were present in five patients (16.7%) in the complication group and absent in the non-complication group (p = 0.020). Major SMA calcifications were more related to anastomotic stricture than leak. Three (13.0%) out of 23 patients with leak and two (28.6%) out of seven with stricture had major SMA calcifications (p = 0.028). No calcifications were detected in the JVA or LIPA in any of the 60 patients. Major SMA calcifications were found to be associated with EJA complications, especially in stricture.

Comparison of reverse puncture device and overlap in laparoscopic total gastrectomy for gastric cancer

BACKGROUND

Intracorporeal oesophagojejunostomy is one of the key steps in laparoscopic total gastrectomy (LTG). At present, there is no widely accepted anastomosis technique in oesophagojejunostomy.

MATERIALS AND METHODS

We retrospectively studied 63 patients with gastric cancer who underwent LTG. Two types of anastomosis techniques have been applied during LTG: the reverse puncture device (RPD) (28 patients) and overlap (35 patients).

RESULTS

A total of 63 patients (51 males and 12 females: mean age = 58 years and mean body mass index [BMI] = 26.3 kg/m2) were enrolled in this study. There were no significant difference in age, BMI, duration of surgery, duration of anastomosis, blood loss, post-operative hospital stay, tumour location, tumour size, degree of tumour differentiation, Borrmann type, total number of lymph nodes, number of positive lymph nodes, hospital stay, hospitalisation costs, intra-operative complications, post-operative complications and prognosis between the RPD group and the overlap group. RPD group showed a significant advantage in terms of the distance between the top border of tumours and the top resection margin (P < 0.001). We further found that the oesophageal lateral negative surgical margin distance of the upper gastric cancer in the RPD group was significantly longer than that in the overlap group (P < 0.001).

CONCLUSIONS

Both the RPD and overlap techniques are safe and applicable in LTG. However, RPD has the advantage of obtaining an adequate safe margin compared with that of overlap technique, especially in patients with gastro-oesophageal junction carcinoma.

Fluorescence-based bowel anastomosis perfusion evaluation: results from the IHU-IRCAD-EAES EURO-FIGS registry

BACKGROUND

Anastomotic leakage (AL) is one of the dreaded complications following surgery in the digestive tract. Near-infrared fluorescence (NIRF) imaging is a means to intraoperatively visualize anastomotic perfusion, facilitating fluorescence image-guided surgery (FIGS) with the purpose to reduce the incidence of AL. The aim of this study was to analyze the current practices and results of NIRF imaging of the anastomosis in digestive tract surgery through the EURO-FIGS registry.

METHODS

Analysis of data prospectively collected by the registry members provided patient and procedural data along with the ICG dose, timing, and consequences of NIRF imaging. Among the included upper-GI, colorectal, and bariatric surgeries, subgroup analysis was performed to identify risk factors associated with complications.

RESULTS

A total of 1240 patients were included in the study. The included patients, 74.8% of whom were operated on for cancer, originated from 8 European countries and 30 hospitals. A total of 54 surgeons performed the procedures. In 83.8% of cases, a pre-anastomotic ICG dose was administered, and in 60.1% of cases, a post-anastomotic ICG dose was administered. A significant difference (p < 0.001) was found in the ICG dose given in the four pathology groups registered (range: 0.013-0.89 mg/kg) and a significant (p < 0.001) negative correlation was found between the ICG dose and BMI. In 27.3% of the procedures, the choice of the anastomotic level was guided by means of NIRF imaging which means that in these cases NIRF imaging changed the level of anastomosis which was first decided based on visual findings in conventional white light imaging. In 98.7% of the procedures, the use of ICG partly or strongly provided a sense of confidence about the anastomosis. A total of 133 complications occurred, without any statistical significance in the incidence of complications in the anastomoses, whether they were ICG-guided or not.

CONCLUSION

The EURO-FIGS registry provides an insight into the current clinical practice across Europe with respect to NIRF imaging of anastomotic perfusion during digestive tract surgery.

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

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Large anastomotic leak: endoscopic treatment using combined fibrin glue and polyglycolic acid (PGA) sheets

Anastomotic leak after gastrectomy is a major complication and various endoscopic methods have been suggested. However, the treatment of large-sized leaks remains a challenge. Here, we present a case of a large anastomotic leak successfully treated endoscopically using a combination of fibrin glue and polyglycolic acid (PGA) sheets. A 68-year-old man who underwent laparoscopic total gastrectomy and oesophagojejunal anastomosis presented with abdominal pain and fever. In the endoscopic examination, two fistulas were observed at the anastomosis site. One was small (0.6 cm) while the other measured 2.5 cm. For the large leak, endoscopic treatment using endoclip and detachable snare was attempted, but failed. Subsequently, fibrin glue was injected into the large fistula through an endoscope. After 28 days, the size of the fistula was reduced and PGA sheets were inserted into the remaining fistula. After about 4 weeks, leaks were observed to be completely healed.

Application of Machine Learning for Predicting Anastomotic Leakage in Patients with Gastric Adenocarcinoma Who Received Total or Proximal Gastrectomy

Anastomotic leakage is a life-threatening complication in patients with gastric adenocarcinoma who received total or proximal gastrectomy, and there is still no model accurately predicting anastomotic leakage. In this study, we aim to develop a high-performance machine learning tool to predict anastomotic leakage in patients with gastric adenocarcinoma received total or proximal gastrectomy. A total of 1660 cases of gastric adenocarcinoma patients who received total or proximal gastrectomy in a large academic hospital from 1 January 2010 to 31 December 2019 were investigated, and these patients were randomly divided into training and testing sets at a ratio of 8:2. Four machine learning models, such as logistic regression, random forest, support vector machine, and XGBoost, were employed, and 24 clinical preoperative and intraoperative variables were included to develop the predictive model. Regarding the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy, random forest had a favorable performance with an AUC of 0.89, a sensitivity of 81.8% and specificity of 82.2% in the testing set. Moreover, we built a web app based on random forest model to achieve real-time predictions for guiding surgeons’ intraoperative decision making.

Effectiveness of a Novel Covered Stent without External Thread Fixation for Anastomotic Leakage after Total or Proximal Gastrectomy for Gastric Cancer

A thread-fix stent entails long hospitalization and patient discomfort. We aimed to evaluate the efficacy of a novel stent with silicone-covered outer double layers without external fixation (Beta stent) for anastomotic leakage after total or proximal gastrectomy. The outcomes were compared between gastric cancer patients who underwent stent placement using a thread-fix stent between 2014 and 2015 (Thread-Fix Group) and those who received a Beta stent in the succeeding period until October 2018 (Beta Stent Group). The Beta Stent Group (n = 14) had a significantly higher leakage healing rate by the first stent placement (92.9% vs. 53.8%; p = 0.021) and had a shorter hospitalization period (median: 16 days vs. 28 days; p = 0.037) than the Thread-Fix Group (n = 13). Further, 50% of the Beta stent patients received outpatient management until stent removal. Stent maintenance duration was significantly longer in the Beta Stent Group (median, 28 days vs. 18 days; p = 0.006). There was no significant between-group difference in stent-related complications except for stent migration (7.1% (Beta Stent Group) vs. 0% (Thread-Fix Group), p = 0.326). In conclusion, the Niti-S Beta stent is an effective treatment for anastomotic leakage from total or proximal gastrectomy for gastric cancer. Stent maintenance is possible without hospitalization.

Can intraoperative endoscopy prevent esophagojejunal anastomotic leakage after total gastrectomy?

BACKGROUND

Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

METHODS

We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

RESULTS

Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

DISCUSSION

After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

CONCLUSION

Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Short-Term and Quality of Life Outcomes of Patients Using Linear or Circular Stapling in Esophagojejunostomy after Laparoscopic Total Gastrectomy

BACKGROUND

Studies comparing the incidence of reflux esophagitis (RE) and patients' quality of life (QoL) when using circular stapler (CS) and linear stapler (LS) in esophagojejunostomy (EJS) after laparoscopic total gastrectomy (LTG) are rare, and certainly there are not enough to make a definitive decision on best practice. Presented herein is a study on the comparison of the short-term outcomes, QoL of the patients with the focus on the incidence of RE after both linear and circular stapling in LTG.

METHODS

From January 2014 to October 2018, 120 patients were analyzed; of these, 42 patients underwent laparoscopy-assisted total gastrectomy (LATG) with CS (CS group) and 78 patients who underwent totally laparoscopic total gastrectomy (TLTG) with LS (LS group). We examined the results obtained in terms of perioperative outcomes, reflux-related assessments (GerdQ questionnaire and endoscopy findings with all cases; 24-h pH monitoring with limited cases), and EORTC QLQ-C30 and QLQ-STO22. In addition, questionnaires were also supplied to patients and the results were recorded.

RESULTS

The incidence of anastomotic stenosis (7.1% vs. 0; P < 0.05) and the median intraoperative blood loss (180.0 vs. 100.0 mL; P < 0.05) of the CS group were higher than the LS group. The factor aside, no significant differences were observed between the two groups with regard to the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases) (P > 0.05). In the EORTC QLQ-C30 and QLQ-STO22, it was noted that the score of constipation [0 (0, 0) vs. 0 (0, 33.3); P = 0.028] and postoperative dysphagia [0 (0, 0) vs. 0 (0, 22.2); P = 0.046] of the LS group in a 1-year follow-up were lower than the CS group.

CONCLUSIONS

TLTG with LS generated better results than LATG with CS in terms of the incidence of anastomotic stenosis, intraoperative blood loss, and postoperative constipation and dysphagia. Furthermore, when compared with circular stapling, linear stapling in EJS did not increase the incidence of RE assessed by the QLQ-STO22 reflux scale, the GerdQ scores, endoscopy (in all cases), or the percent time of pH > 7 (in limited cases).

Laparoscopic mechanical latero-lateral oesophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results

BACKGROUND

The realization of a oesophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We here report our laparoscopic experience in intracorporeal oesophagojejunostomy.

METHODS

Adults who underwent laparoscopic total gastrectomy for cancer with laterolateral (functional termino-terminal) Roux en Y intracorporeal oesophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra and postoperative outcomes including 30-day readmissions and mortality were considered.

RESULTS

32 patients were included. Nodal dissection D1's were 16. Median operative time was 280'. median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent Non Operative Management. Median postoperative stay was 8.5 days.

CONCLUSIONS

This technique may improve the ergonomics of oesophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy: A comparative study

BACKGROUND

Although several methods of totally laparoscopic total gastrectomy (TLTG) have been reported. The best anastomosis technique for LTG has not been established.

AIM

To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy (OTG) using the circular stapled method.

METHODS

We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018. Surgical and oncological outcomes were compared between groups using propensity score matching. In addition, we analyzed the risk factors associated with postoperative complications.

RESULTS

Patients who underwent TLTG were discharged earlier than those who underwent OTG [TLTG (9.62 ± 5.32) vs OTG (13.51 ± 10.67), P < 0.05]. Time to first flatus and soft diet were significantly shorter in TLTG group. The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group. No significant difference in early, late and esophagojejunostomy (EJ)-related complications or 5-year recurrence free and overall survival between groups. Multivariate analysis demonstrated that body mass index [odds ratio (OR), 1.824; 95% confidence interval (CI): 1.029-3.234, P = 0.040] and American Society of Anaesthesiologists (ASA) score (OR, 3.154; 95%CI: 1.084-9.174, P = 0.035) were independent risk factors of early complications. Additionally, age was associated with ≥ 3 Clavien-Dindo classification and EJ-related complications.

CONCLUSION

Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG, it yields lower pain score, earlier bowel recovery, and discharge. Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity, high ASA scores, and older ages.

Aorta Calcification Increases the Risk of Anastomotic Leakage After Gastrectomy in Gastric Cancer Patients

Purpose

The purpose of the present study was to evaluate whether vascular calcification is a risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

Methods

Patients with confirmed gastric cancer were collected from the database of a single clinical center from January 2013 to January 2019. The calcification score and anastomotic leakage were recorded, and predictors of anastomotic leakage were analyzed.

Results

A total of 856 patients were included in this study; 818 patients had no anastomotic leakage, and 38 patients had anastomotic leakage. The ratio of hypertension status (p=0.011), open gastrectomy (p=0.012), postoperative length of stay (p=0.000), aorta calcification score (p=0.000) and celiac axis calcification (p=0.000) were higher in the anastomotic leakage group than in the nonanastomotic leakage group. In multivariate analysis, aorta calcification (p=0.029, odds ratio =2.425, 95% CI=1.095–5.491) was an independent predictor of the anastomotic leakage.

Conclusion

Aorta calcification is an independent risk factor for anastomotic leakage after gastrectomy in gastric cancer patients.

[Evidence in minimally invasive oncological gastric surgery]

BACKGROUND

The aim of this study was to systematically review the current evidence on laparoscopic and robotic distal and total gastrectomy in comparison to open surgery.

MATERIAL AND METHODS

A systematic search of EMBASE and PubMed was conducted and 197 randomized (RCT) and non-randomized (non-RCT) studies were identified. An evaluation of early gastric cancer (EGC) and advanced (AGC) gastric cancer was carried out.

RESULTS

For EGC and laparoscopic distal resection (LDG) and total gastrectomy (LTG) a total of 10 RCT and 6 non-RCT, including 4329 patients (laparoscopic 2010 vs. open 2319) were identified. At a high evidence level (1+, 1++) there was no significant difference in terms of feasibility, intraoperative outcome and oncological quality, mortality and long-term oncological outcome compared to open gastrectomy (OG). After LDG and LTG patients showed a significantly faster early postoperative recovery and lower total morbidity. In contrast, the operation times were significant longer compared to ODG and OTG. For distal AGC and LDG in 6 RCT, including 2806 patients (LDG 1410 vs. ODG 1369) comparable results could be found also with a high evidence level (1++). The evidence for LTG in cases of AGC was lower (2-, 2+). Currently ,only 6 non-RCT with a total of 1090 patients (LTG 539 vs. OTG 551) are available, which showed comparable results to LDG but further high-quality RCTs are necessary. Robotic gastrectomy (RG) is currently being evaluated. According to the first studies RG for EGC seems to be equivalent to LDG; however, the evidence is currently low (3 to 2-).

Advantageous Short-Term Outcomes of Esophagojejunostomy Using a Linear Stapler Following Open Total Gastrectomy Compared with a Circular Stapler

BACKGROUND

Esophagojejunostomy is one of the most important surgical procedures in total gastrectomy. In the past, esophagojejunostomy was exclusively performed using a circular stapler in open total gastrectomy (OTG). With the increasing frequency of its use in laparoscopic gastrectomy, esophagojejunostomy using a linear stapler has been performed in OTG. However, it is still unclear whether the use of a linear stapler in esophagojejunostomy following OTG has any advantages compared with the conventional use of a circular stapler.

METHODS

A total of 298 patients who underwent OTG for gastric cancer between 2014 and 2019 were enrolled in this study. Patients were categorized into circular and linear groups (group C and group L) according to the stapler type used for the esophagojejunostomy. After propensity score matching, 136 patients (68 each in groups C and L) were selected to compare the surgical outcomes including incidence of esophagojejunostomy-related complications and postoperative nutritional status.

RESULTS

The median operation time was significantly longer in group L than in group C (261.5 min versus 325.5 min; P < 0.001). The incidence of esophagojejunostomy-related complications did not differ between the two groups (5.9% versus 2.9%; P = 0.68); however, no anastomotic stricture and bleeding occurred in group L. Bodyweight loss was significantly lower in group L than in group C at 6 months (15.9% versus 12.6%; P = 0.007) after surgery.

CONCLUSIONS

Esophagojejunostomy using a linear stapler following OTG is equally safe and possibly advantageous in anastomotic stricture, bleeding and nutritional status compared with the use of a circular stapler.

Laparoscopic versus open transhiatal approach for adenocarcinoma of the esophagogastric junction: A systematic review and meta-analysis

BACKGROUND

The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing worldwide. Laparoscopic transhiatal approach (LTH) has gained growing popularity in the treatment of AEG. However, its safety and efficacy need to be evaluated.

METHODS

Original studies comparing LTH with open transhiatal approach (OTH) were searched. Meta-analysis was performed using RevMan 5.3.

RESULTS

Nine studies involving 2149 patients were eligible. Compared with OTH, LTH was associated with longer operation time (mean difference [MD] = 31min, 95%CI [20,41], P < 0.001) while less blood loss (MD = -103ml [-135, -72], P < 0.001), and harvested similar number of lymph nodes (MD = 0.1 [-1.2, 1.4], P = 0.89). There were no differences in time to ambulation (MD = -0.79 days [-1.77, 0.20], P = 0.12) or time to first flatus (MD = -0.82 days [-1.76, 0.11], P = 0.08); however, LTH was associated with shorter postoperative hospital stay (MD = -1.70 days [-2.34, -1.05], P < 0.001). The mortality after surgery was comparable for LTH and OTH (risk difference [RD] = -0.00 [-0.01, 0.01], P = 0.55). The incidence of total major complications was similar in LTH (6.1%) and OTH (8.4%) (RD = -0.02 [-0.05, 0.01], P = 0.12); there were no significant differences in the incidence of each complication. Furthermore, LTH achieved similar 2-year overall survival (OS) rate (risk ratio [RR] = 1.17 [0.86, 1.60], P = 0.31) while higher 5-year OS rate (RR = 1.43 [1.18, 1.73], P = 0.0003) and significant improvement of OS (univariable hazard ratio = 0.65 [0.50, 0.84], P = 0.0009; multivariable hazard ratio = 0.59 [0.44, 0.80], P = 0.0006).

CONCLUSIONS

LTH is feasible and safe for AEG, and may provide more favorable short-term outcomes and potential long-term survival benefit, which needs to be confirmed by randomized trials.

Incidence and Prognostic Factors for the Development of Symptomatic and Asymptomatic Marginal Ulcers After Roux-en-Y Gastric Bypass Procedures

INTRODUCTION

Marginal ulcer (MU) is a serious complication after Roux-en-Y gastric bypass (RYGB) procedures. This study reports the incidence, risk factors, and treatment outcomes of symptomatic and incidentally, at routine endoscopy diagnosed, MU.

METHODS

All patients undergoing RYGB procedures between 2013 and 2018 at a single center were included. Upper endoscopy was performed in case of symptoms and/or routinely 2 and 5 years postoperatively.

RESULTS

In total, 568 patients (83.3% female) underwent RYGB procedure with a median age of 40 years and median initial body mass index of 41 kg/m². The median time to follow-up was 2.99 years. Routine 2- and 5-year upper endoscopy was performed in 256 (55.3%) and 65 (38.0%) eligible patients, respectively. In 86 (15.1%) patients, MU was diagnosed at a median time of 14.2 months (4.58-26.2) postoperatively and 24.4% of patients with MU were asymptomatic. In total, 76.7% of MUs were located on the side of the Roux limb. 88.4% of MUs were treated conservatively; re-operation was necessary in 10 (11.6%) patients. Smoking and type 2 diabetes mellitus were the only independent risk factors for MU development in multivariate analysis with a hazard ratio of 2.65 and 1.18 (HbA1c per unit >6.0), respectively.

CONCLUSION

MU is a common complication after gastric bypass surgery with 25% of patients being asymptomatic. Follow-up routine endoscopy is recommended for early MU detection and subsequent accurate therapy, especially in patients with the independent risk factors smoking and type 2 diabetes mellitus.

Risk factors for esophagojejunal anastomotic leakage after curative total gastrectomy combined with D2 lymph node dissection for gastric cancer

OBJECTIVE

To explore the risk factors associated with esophagojejunal anastomotic leakage (EJAL) after curative total gastrectomy combined with D2 lymph node dissection for gastric cancer.

METHODS

We reviewed the data for 390 consecutive patients undergoing Roux-en-Y esophagojejunostomy reconstruction after total gastrectomy. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for EJAL.

RESULTS

Of the 390 patients enrolled in this study, EJAL occurred in 10 patients (2.6%), and one patient (1/10) with EJAL died. Univariate analysis identified age, alcohol consumption, pulmonary insufficiency, and intraoperative blood loss as risk factors for EJAL. Of these four risk factors, age and alcohol consumption were retained as independent risk factors by multivariate analysis.

CONCLUSION

Surgeons should be very careful regarding anastomotic leakage after esophagojejunal anastomosis, perioperatively, especially in patients with advanced age and a history of alcohol consumption. Pulmonary insufficiency and intraoperative blood loss, although not identified as independent risk factors, should also be considered.