Commentary on “Modified Techniques and Early Outcomes of Totally Laparoscopic Total Gastrectomy with Side-to-Side Esophagojejunostomy”

Throughout the last decade, laparoscopic surgery for cancer has been gaining acceptance among surgeons around the world. Early gastric cancer is not the exception. Total laparoscopic gastrectomy (TLG) has been proven to be an excellent alternative for early gastric cancer, with many advantages over the open technique, such as shorter hospital stay, less pain, faster recovery of gastrointestinal function, and better cosmetic results. In addition, the oncologic principles are preserved, and the amount of nodes recovered is comparable to that with open surgery. In the particular case of early gastric cancer, the feared dissemination of the cancer by the pneumoperitoneum does not seem to be a major issue of concern.

To complete a total gastrectomy laparoscopically requires an enormous amount of surgical skills. The surgeon needs to be familiarized with laparoscopic stapling and suturing techniques, two of the most challenging steps in laparoscopic surgery. In TLG, the limiting step seems to be the safely creation of the esophagojejunostomy. Even when done properly, complications following TLG may arise from this step, including strictures, leaks, anastomotic ulcers, and bleeding. I believe that, for TLG's widespread acceptance, a simple, effective, and safe esophagojejunostomy technique is necessary.

Several techniques for this particular step have been described in the literature, including various modifications of hand-sewn, circular-stapled, and linear-stapled anastomoses. To facilitate this step, even the aid of robots has been described. Like for many operations, when there are several surgical techniques to do the same procedure it is probably because none of them is superior to the others. Therefore, the surgeon should perform the one he or she has learned and can do best.

I believe the esophagojejunostomy technique described in this article ¹ to be straightforward and therefore easily reproduced. This is an excellent example that not all of what we do through open surgery has to be translated identically to laparoscopic surgery. For this step in open surgery, the most common technique is the circular end-to-side esophagojejunostomy. Nonetheless, the purse-string suture and anvil insertion in the distal end of the esophagus can be quite challenging and time-consuming. Besides, the linear stapled anastomosis provides a more ample anastomosis in order to avoid postoperative strictures.

Additionally, one very important aspect is that it could be easily taught to residents and fellows as well. It requires fewer instruments and less suturing skills to master. And, according to the authors, the technique has excellent results with few short-term complications. However, these results come from an experienced group of laparoscopic surgeons and cannot be extrapolated to all surgeons.

The teaching aspect of any surgical technique is very important. Very few fellowship training programs around the world offer a comprehensive training in both oncologic and laparoscopic surgery. Consequently, most surgeons performing oncologic operations do not have advanced laparoscopic surgery training, and vice versa. A team with a combination of physicians with experience in both surgical specialties might be required at the beginning to surpass the steep learning curve of this operation.

The description of a new technique or a modification of a previously described technique procedure is of particular interest to this journal. I always find it exciting about learning something that could improve my surgical technique and therefore my outcomes. This is an example of a technique that can help TLG to gain the acceptance in the surgical community so that it can be performed more regularly and more patients can benefit from its advantages over the open technique.