Abstract
Abstract
Background:
Construction of an esophagojejunostomy is a major concern in totally laparoscopic total gastrectomy (TLTG). Use of a circular stapler can be technically challenging in laparoscopic procedures. We aimed to introduce our modified techniques and to assess the early outcomes following TLTG with side-to-side esophagojejunostomy using a linear stapler in patients with gastric cancer.
Subjects and Methods:
From December 2010 to June 2011, 27 patients who underwent TLTG for gastric cancer were retrospectively reviewed. Their clinicopathologic characteristics, surgical time, hospital stay, morbidity, and mortality were analyzed.
Results:
The mean age of patients was 59.1 years, and the average body mass index was 24.6 kg/m2. The mean operating time was 126.2 minutes, and the hospital stay averaged 8.1 days. No conversion to open laparotomy was required. There were 2 luminal bleeding cases and 1 intra-abdominal bleeding case, but all were successfully managed with conservative treatment only. No patient experienced reoperation, anastomosis leakage, stricture, duodenal stump leakage, or wound problems.
Conclusions:
Our TLTG with side-to-side esophagojejunostomy method can be a feasible and safe option for patients with gastric cancer.
Introduction
Subjects and Methods
From December 2010 to June 2011, in total, 91 laparoscopic total gastrectomies for gastric cancer were performed at the Asan Medical Center (Seoul, Korea). Of those cases, 27 underwent TLTG performed by the same surgeon and are the subject of this study. After institutional review board approval we reviewed their medical records in terms of gender, age at operation, body mass index (BMI), surgical time, type of lymphadenectomy, tumor location, staging, hospital stay, morbidity, and mortality.
Surgical technique
Patients were placed in a supine position with the right arm abducted. Pneumatic compressive devices were applied to both legs to prevent deep vein thrombosis. The surgeon stood on the right side of the patient, and the laparoscopist sat next to him, with the first assistant and a scrub nurse positioned on the opposite side.
We usually used six ports. Using an open technique, a 2.5-cm main port was placed across the umbilicus for laparoscope entry, carbon dioxide insufflation, specimen delivery, and, if necessary, application of additional surgical instruments. Each 12-mm and 5-mm trocar was inserted on both sides of the upper abdomen for manipulation. To retract the liver, an additional 5-mm port was placed in the epigastrium, and a surgical thread was hung around the falciform ligament (Fig. 1).
Placement of surgical ports. A 25-mm port was used for position A. For positions C and E, 12-mm ports were used. For positions B, D, and F, 5-mm ports were used.
With the patient in the reverse Trendelenburg position, surgery commenced with division of the gastrohepatic ligament and clearance of structures around the esophagus, including the vagus nerves. We then performed an omentum-preserving total gastrectomy and extended lymph node dissection, similar to an open procedure.
After identification that the stomach was fully mobilized except for the connection with the esophagus, jejunal preparation commenced. Using a linear stapler, the jejunum was divided at a point 20 cm distal to the ligament of Treitz, and a small enterotomy was made using an endo-scissors on the anti-mesenteric side of the efferent jejunal end. An incision was also made on the right wall of the esophagus just over the gastroesophageal junction using electrocautery. The jejunum was drawn up to the right side of the esophagus, and each limb of a 60-mm linear stapler was introduced into the jejunum and esophagus to construct an antecolic Roux-en-Y side-to-side esophagojejunal anastomosis (Fig. 2). The common opening was approximated with three sutures and finally closed with an additional linear stapler, resulting in complete separation of the stomach (Fig. 3). The specimen was delivered through the main port, and the margin state was evaluated. After reinsufflation of carbon dioxide, a jejunojejunal side-to-side stapled anastomosis was made at about 40 cm below the esophagojejunostomy in the same way. Finally, we added one anchoring suture between the esophagus, the Roux limb of the jejunum, and the diaphragm (Fig. 4). One drain was placed in the abdominal cavity through a right 5-mm port, and other port sites were closed. The main wound was closed using interrupted layer-by-layer sutures.
An anchoring suture was placed between the esophagus, the jejunum, and the diaphragmatic crus.
Results
The study involved 16 men and 11 women, with a mean age of 59.1 years (range, 36–78 years). The average BMI was 24.6 kg/m2 (range, 20.6–30.1 kg/m2). All patients were diagnosed with early gastric cancer based on preoperative gastroscopy and abdominal computed tomography. Patients with gastroesophageal junction cancer were excluded. Of the 27 patients, 5 were referred after endoscopic mucosal resection or endoscopic submucosal dissection due to margin status. We routinely performed a D1+β lymphadenectomy. The average operating time was 126.2 minutes (range, 80–166 minutes). One patient had chronic calculous cholecystitis and therefore also underwent cholecystectomy.
There were 19 upper third (70.4%), 3 middle third (11.1%), 1 lower third (3.7%), 3 entire (11.1%), and 1 multiple (3.7%) lesions according to the Japanese Gastric Cancer Association classification. In the case of 1 patient with a lower third malignancy, she had a CDH1 mutation on genetic analysis and decided to undergo a total gastrectomy after counseling. Cancer invaded the mucosal layer in 10 (37.0%), submucosa in 13 (48.2%), proper muscle in 1 (3.7%), subserosa in 1 (3.7%), and serosa in 2 (7.4%) patients. Lymph node metastasis was present in only 1 patient. The mean tumor size was 3.3 cm (range, 0.5–7.5 cm), and the mean number of harvested lymph nodes was 33.7 (range, 14–82) (Table 1).
Staging was based on the American Joint Committee on Cancer staging manual, 7th edition.
BMI, body mass index.
All patients were admitted electively and fasted until the morning of postoperative Day 3. In the afternoon of the same day, they commenced drinking water, and they were permitted to eat after passing flatus. Eighteen patients (66.7%) were discharged within 7 days after surgery, 5 patients (18.5%) between postoperative Days 8 and 10, and 3 (11.1%) between Days 11 and 14. One patient with postoperative intra-abdominal bleeding was conservatively managed and was discharged after 22 days. The mean hospital stay was 8.1 days (range, 6–22 days).
No case required conversion to open laparotomy. Complications occurred in 3 patients, consisting of 2 cases of luminal bleeding cases and 1 case of intra-abdominal bleeding. Those complications were successfully managed using conservative treatment only. No patient experienced reoperation, anastomosis leakage, stricture, duodenal stump leakage, or wound problems (Table 2).
Discussion
The linear stapled anastomosis technique was devised by Walther et al. 8 and has since been used in open and laparoscopic total gastrectomy. One study used two 45-mm linear staplers for wide anastomosis between the jejunum and esophagus (ranging from 3.5 to 4.0 cm) and reported that there were no anastomotic leaks or stenoses at 7–12 months after surgery. 5
The present method had some particular advantages. First, it involved the use of a linear rather than an EEA stapler, and therefore the risk of mucosal injury in the esophagus was reduced, and time-consuming purse-string sutures were avoided. Although several methods involving a transorally inserted anvil have been developed to address EEA stapler issues, some reports describe difficulties in introducing the anvil into the lower esophagus at the level of the tracheal bifurcation and in correcting the tilted anvil in a narrowed lumen. 9 Second, we placed an anchoring suture between the esophagus, jejunum, and diaphragm, which reduced the tension on the anastomosis and consequently the possibility of anastomosis leakage. The anchoring suture may also be useful in that a side-to-side TLTG requires a longer length of dissected esophagus than the circular stapler technique, and that can result in the widening of the hiatus and possibly increase the risk of a hiatal hernia. The anchoring suture can reduce that risk. Finally, the initial incision was maintained throughout the operation; there was no need to lengthen that incision or create further incisions. This helps to minimize postoperative pain and the risk of wound-related complications.
The overlap method reported by Inaba et al. 6 also used side-to-side esophagojejunostomy with linear staplers. Compared with our procedure, however, the overlap method has an increased risk of hiatal hernia because it divides the left diaphragmatic crus to create a surgical field sufficient to perform the anastomosis. In addition, the direct manipulation of the esophageal stump to introduce a fork of the stapler into the esophagus can induce the esophageal wall injury. To avoid this, we usually handle the upper stomach during the esophageal entry of the stapler. On the other hand, in our method, as the proximal margin is revealed after constructing the esophagojejunostomy, it is difficult to apply our method to patients with gastroesophageal junction cancer without sufficient hiatal dissection.
As a supplement to our procedure, a surgeon may consider using an endo-intestinal clamp before making an incision at the esophageal wall and identifying the gastroesophageal junction. This approach may address issues relating to tumor cell seeding and remnant gastric tissue. Currently, we use the clamp during the anastomosis in a routine manner.
The present technique resulted in a shorter operating time and lower complication rate than other laparoscopic total gastrectomy methods.10–17 There were 2 cases in which luminal bleeding occurred, and although we did not attempt to identify the bleeding focus, a jejunojejunostomy has a higher possibility of hemorrhage than an esophagojejunostomy because of the richer blood supply. There were no serious complications related to the anastomosis between the esophagus and jejunum. The present study indicates that TLTG with side-to-side esophagojejunostomy using a linear stapler can be a feasible and safe option for patients with early gastric cancer. However, it should be used cautiously for patients with gastric cancer involving the gastroesophageal junction.
Footnotes
Disclosure Statement
No competing financial interests exist.