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

Abstract

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 $\pm$ 8.3 years. There was a mean estimated blood loss of 63.4 $\pm$ 29.7 ml, an anastomosis time of 25.9 $\pm$ 3.0 minutes, an operation time of 208.2 $\pm$ 40.4 minutes, and a postoperative hospital stay of 12.2 $\pm$ 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.

Keywords

Laparoscopy gastric cancer gastrectomy anastomosis Roux-en-Y

1. Introduction

With the progress of laparoscopic instruments and technology, the advantages of laparoscopic surgery are becoming more and more obvious. Compared with traditional open total gastrectomy, laparoscopic total gastrectomy is becoming more and more popular. On the other hand, anastomotic leakage and stenosis are examples of postoperative anastomosis problems that might occasionally arise. Complications from anastomosis have an impact on both the postoperative quality of life and the postoperative survival rate. The most challenging anastomosis in laparoscopic complete gastrectomy is esophagojejunostomy, which carries a risk of anastomotic stricture and leaking [1]. Therefore, the gastrointestinal surgeons focused on the appropriate esophagojejunostomy. The classic method of esophagojejunostomy is Roux-en-Y esophagojejunostomy, but for patients with small intestinal diameters, this anastomosis method has certain difficulties. It is difficult for the main operating rod of the circular stapler to insert the small intestine to complete Roux-en-Y anastomosis. The choice of esophagojejunostomy after total laparoscopic gastrectomy generally overlaps [2], but it has some limitations and cannot obtain a higher surgical margin, so it is generally suitable for patients with gastric body cancer or Siewert III [3]. For this reason, since 2017, the author team has improved the Roux-en-Y anastomosis and put forward the “Pant-Shaped” esophagojejunostomy [4, 5]. Now we analyze and summarize the cases of “Pant-Shaped” anastomosis in recent years, and explore its feasibility and safety, to promote the popularization and popularization of “Pant-Shaped” anastomosis.

2. Materials and methods

2.1 General information

The descriptive case study approach was employed by the individuals. From January 2017 to December 2022, 210 patients with gastric body cancer or esophageal junction adenocarcinoma underwent laparoscopic total gastrectomy and esophagojejunostomy in the Department of Gastrointestinal Surgery of the first affiliated Hospital of Southern Anhui Medical College. Every case was handled by the same team of operators. Prior to the procedure, a gastroscopy and a pathological diagnostic were performed on each patient. Before the procedure, the patients and their families signed an informed consent form after being made aware of the wind risk associated with the procedure. This study was reviewed and approved by the Wannan Medical College’s first associated hospital’s ethics committee. Table 1 displays all patients’ baseline data.

Table 1
Basic data of 210 patients with “Pant-Shaped” esophagojejunostomy after laparoscopically assisted total gastrectomy

Project	Data
Gender (Male: Female)	164:46
Age	69.2 $\pm$ 8.3 (32 $\sim$ 85)
BMI	23.3 $\pm$ 3.1 (16.7 $\sim$ 32.5)
Complications (%)	163 (77.6)
Diabetes	45
Hypertension	87
Cardiovascular disease	31
Previous abdominal surgery history	32
Tumor size (cm)	3.7 $\pm$ 0.8 (2.5 $\sim$ 10)
Lauren classification of tumor
Diffuse type (%)	78 (37.1)
Intestinal type (%)	114 (54.3)
Mixed type (%)	18 (8.6)
T stage
Mucous layer (T1a) (%)	14 (6.7)
Submucosa (T1b) (%)	18 (8.6)
Muscular layer (T2) (%)	25 (11.9)
Subserous layer(T3) (%)	64 (30.5)
Penetrating serosa (T4) (%)	89 (42.4)
N stage
N0 (%)	79 (37.6)
N1 (%)	38 (18.1)
N2 (%)	33 (15.7)
N3 (%)	60 (28.6)
Neoadjuvant chemotherapy (%)	21 (10.0)

Table 2

Perioperative condition of 210 patients with esophagojejunostomy after laparoscopic-assisted total gastrectomy

Project	Data
Operation time (Min)	208.2 $\pm$ 40.4
Anastomosis time (Min)	25.9 $\pm$ 3.0
Intraoperative blood loss (Ml)	63.4 $\pm$ 29.7
Lymph node dissection number	28.8 $\pm$ 8.3
Postoperative hospital stay (D)	12.2 $\pm$ 8.0
Postoperative complications (Clavien-Dindo Grade II)	9 (4.3)
Anastomotic leakage	2
Duodenal stump leakage	2
Anastomotic bleeding	1
Pneumonia	3
Intraperitoneal hernias	1

2.2 Criteria for inclusion and exclusion

(1) patients aged from 18 to 85 years old; (2) individuals who received laparoscopic-assisted total gastrectomy for cancer located in the gastric body or adenocarcinoma at the junction between the stomach and esophagus; (3) there was no distant organ metastasis before and during operation. Exclusion criteria: (1) patients with other organ malignant tumors; (2) patients with partial or total resection of other organs during operation.

2.3 The operation method

Anesthesia method chooses the trachea intubation general anesthesia. The supine split leg position was used during the operation. The observation hole was under the umbilical cord, the main operating hole was 2 cm below the costal edge of the left anterior axillary line, and the other operating holes were 2 cm below the costal edge of the right anterior axillary line and 2 cm where the midline of the left and right clavicle intersected with the navel horizontally. These locations corresponded to the traditional 5-hole method. 12–14 mmHg was the pneumoperitoneum pressure setting. After the establishment of pneumoperitoneum, routine procedures were carried out to separate the entire stomach and perform D2 lymph node dissection. The method of “Pant-Shaped” esophagojejunostomy: after lymph node dissection, the upper abdominal median incision (5 $\sim$ 8 cm) entered the abdomen, fully dissociated the esophagus, 2 cm at the upper edge of the tumor, severed the esophagus, removed the specimen, and the 25 mm stapler anvil (COVIDIEN, EEA25) was inserted into the esophagus. The section of the jejunum was removed, specifically at a distance of 20 cm from the Treitz ligament. Purse suture was performed on the mesenteric margin of the jejunum about 10 cm from the cutting edge of the distal jejunum, and the intestinal wall was cut open. From then on, the stapler was cut into the linear stapler (ETS, Ethicon Endo-Surgery, white nail). The input loop of the jejunum accommodated the nail chamber, while the output loop housed the anvil. The distal jejunal side-to-side anastomosis was accomplished by closing the linear stapler. Exit the linear stapler, cut the intestinal wall at the mesenteric margin of the distal jejunum, enlarge the diameter of the intestinal, insert the 25 mm circular stapler through the distal jejunum, pierce the stapler nail from the purse suture of the jejunal wall, tighten the charge line and ligate, connect the stapler with the center rod of the nailing anvil, clamp the stapler, wait 15 seconds before firing, complete the “Pant-Shaped” anastomosis, exit the stapler. To check the nailing effect of the anastomosis and bleeding, use a linear stapler (ETS, Ethicon Endo-Surgery, white nail) to close the jejunal stump. The jejunum was secured using a purse suture approximately 45 cm below the esophagojejunostomy. Subsequently, an incision was made in the intestinal wall and the 21 mm circular stapler anvil was inserted into the main body of the stapler starting from the proximal jejunal stump. This step facilitated the completion of end-to-side jejunojejunostomy, while ensuring closure of the stump with a linear stapler (Ethicon Endo-Surgery, white nail). The surgical procedures in the “Pant-Shaped” esophagojejunostomy are shown (Fig. 1).

Figure 1.

Specific surgical procedure image of “Pant-Shaped” anastomosis. (1A) Purse suture was performed on the mesenteric margin of the jejunum about 10 cm from the cutting edge of the distal jejunum; (1B) Complete side-to-side jejunostomy through purse suture; (1C) The distal jejunal incisal margin cut open the intestinal wall on the opposite side of the mesenteric margin to enlarge the intestinal diameter; (1D) The stapler nail was pierced from the purse suture of the jejunal wall; (1E) A stapler is connected with the center rod of the nail anvil to clamp the stapler to complete the “Pant-Shaped” anastomosis of the esophagus and jejunum; (1F) The picture of the finished “Pant-Shaped”.

2.4 Observation indexes and evaluation criteria

Mainly observe the peri-operative related indexes, mount of blood loss during the operation, count of lymph nodes retrieved, length of hospital stay after surgery, and occurrence of any postoperative complications. Among them, the operation time is from the incision of the skin to the end of the suture of the skin. The time of esophagojejunostomy starts from the severing of the esophagus to the end of closing the stump of the jejunum. The grading standard of postoperative complications was based on Clavien’s Dindo complication classification system [6].

2.5 Statistical analysis

Replaces the use of Statistic Package for Social Science (SPSS) 26.0 software (IBM SPSS INC. Chicago, IL, USA) with a statistical credit analysis tool to analyze the data. The counting data is expressed as an example (%), and the measurement data by normal distribution is expressed as “ $\bar{x}\pm s$ ”.

3. Results

3.1 Basic characteristics of patients

A total of 210 patients who underwent “Pant-Shaped” esophagojejunostomy following laparoscopically assisted total gastrectomy were included in this study. The cohort comprised 164 males and 46 females, with a mean age of 69.2 $\pm$ 8.3 years (range: 32–85 years). The average BMI was 23.3 $\pm$ 3.1 kg/m² (range: 16.7–32.5 kg/m²). Notably, 163 patients (77.6%) had pre-existing complications, including diabetes (45 patients), hypertension (87 patients), and cardiovascular disease (31 patients). Additionally, 32 patients had a history of previous abdominal surgery. The mean tumor size was 3.7 $\pm$ 0.8 cm (range: 2.5–10 cm). According to the Lauren classification, 78 patients (37.1%) had diffuse type tumors, 114 patients (54.3%) had intestinal type tumors, and 18 patients (8.6%) had mixed type tumors. Regarding the T stage, 14 patients (6.7%) were classified as T1a (mucous layer), 18 patients (8.6%) as T1b (submucosa), 25 patients (11.9%) as T2 (muscular layer), 64 patients (30.5%) as T3 (subserous layer), and 89 patients (42.4%) as T4 (penetrating serosa). For the N stage, 79 patients (37.6%) were N0, 38 patients (18.1%) were N1, 33 patients (15.7%) were N2, and 60 patients (28.6%) were N3. Additionally, 21 patients (10.0%) received neoadjuvant chemotherapy.

3.2 Perioperative outcomes

The mean operation time was 208.2 $\pm$ 40.4 minutes, with the anastomosis time averaging 25.9 $\pm$ 3.0 minutes. The average intraoperative blood loss was 63.4 $\pm$ 29.7 ml. The mean number of lymph nodes dissected was 28.8 $\pm$ 8.3. The average postoperative hospital stay was 12.2 $\pm$ 8.0 days. Postoperative complications were observed in 9 patients (4.3%), classified as Clavien-Dindo Grade II. Specific complications included anastomotic leakage in 2 patients, duodenal stump leakage in 2 patients, anastomotic bleeding in 1 patient, pneumonia in 3 patients, and intraperitoneal hernias in 1 patient. These results indicate that “Pant-Shaped” esophagojejunostomy following laparoscopically assisted total gastrectomy is associated with manageable perioperative outcomes and a relatively low rate of severe postoperative complications.

4. Discussion

At present, gastric cancer is the cause of the fourth highest number of deaths worldwide among all types of cancer and it stands as the fifth most commonly occurring form of cancer [7]. Primary treatment for gastric cancer typically involves radical gastrectomy [8]. The primary surgical procedure for stomach cancer is now laparoscopic radical gastrectomy, thanks to advancements in operation technology and laparoscopic equipment development [9]. Digestion tract rebuilding is a challenging and hot site following laparoscopic complete gastrectomy for a variety of reasons, including deep position, restricted space, and challenging surgery. There is currently no universal standard and a wide range of reconstruction techniques for digestion, each with pros and cons. Surgeons have long preferred Roux-en-Y esophagojejunostomy as a classical procedure, However, there are some challenges as well [10]. The jejunum typically has a diameter of 25–30 mm. A 25 mm circular stapler is typically used for esophagojejunostomy; however, because the jejunum’s diameter is frequently less than 25 mm, the primary operational rod of the circular stapler cannot be inserted into the small intestine, making esophagojejunostomy impossible to complete. Surgeons may select a 21 mm stapler with a smaller diameter for anastomosis in elderly patients, patients with poor intestinal dilatation, and patients with small intestinal esophageal diameters; however, a too-small stapler diameter will result in postoperative anastomotic stenosis and lower the patient’s quality of life following surgery. Following surgery, certain patients could also require endoscopic esophagojejunal anastomotic dilatation. In such cases, some surgeons would decide to manually suture the jejunum and esophagus during the procedure.

One benefit of sutures is that they do not require the use of anastomotic instruments, which lowers operating costs. However, sutures also come with disadvantages, such as difficult operations, high operator suture technique, and deeper anastomosis position. Robot suture anastomosis, which benefits from a three-dimensional image, a high-degree-of-freedom rotatable wrist device, and filter hand tremor, lessens the difficulty of suturing in robot surgery [11]. However, the operator must possess skilled operation skills, and at the moment, only a small number of third-class hospitals in China have da Vinci robot equipment; additionally, the cost of operation is high and few hospitals use this technology. Consequently, the side-to-side jejunojejunostomy was performed before the esophagojejunostomy. As a result, the side-to-side jejunojejunostomy is similar to enlarging the jejunum’s diameter before the esophagojejunostomy, facilitating the easy entry of the circular stapler’s primary working rod into the jejunum to finish the esophagojejunostomy. The development of a fresh anastomosis could bring up fresh surgical problems. Complications from anastomosis have a major impact on a patient’s ability to recuperate quickly, and their quality of life following the procedure, and can even result in an unanticipated reoperation or death. The complications of esophagojejunostomy include anastomotic leakage, anastomotic stricture, and anastomotic bleeding. Although there has been a significant decrease in esophagojejunostomy-related complications, there is still a 1.2% incidence of 14.6% [12]. The incidence of anastomotic leakage was 0.5% $\sim$ 14.6% [13], the incidence of anastomotic bleeding was 0.2%–2.0% [14], anastomotic stenosis 0.6%–0.8% [15], duodenal stump leakage 1%–4% [16]. In this study, there were 2 cases of anastomotic leakage (0.95%), 2 cases of duodenal stump leakage (1.0%), and 1 case of anastomotic bleeding (0.5%). The safety of esophagojejunostomy was confirmed.

The function of Food storage is the first consideration in digestive tract reconstruction after total gastrectomy, but Roux-en-Y has no food storage function. Therefore, to achieve a better quality of life or maintenance after operation, it is very necessary to establish a simplified and reasonable gastric substitute pouch with a storage function. Since the first successful implementation of Roux-en-Y anastomosis by Roux in 1907, a variety of Roux-en-Y anastomosis plus pouch anastomosis methods have been derived. Esophagojejunostomy is divided into esophagojejunostomy with food not passing through duodenum and esophagojejunostomy with food through duodenum, such as “J” jejunal loop Roux-en-Y anastomosis [17], “P” jejunal interposition [18] and functional jejunal interposition [19]. At present, no operation is considered to be the best method, and each operation has its advantages. Clinicians often choose the corresponding operation according to their own habits or traditional ideas. The “trouser” esophagojejunostomy in this study has the following advantages: (1) it is easy to operate, does not need to cut off the jejunal loop, maintains the continuity of the nerve-muscle function of the jejunum, avoids the intestinal dysfunction, and preserves the normal physiological motor function of the jejunum. (2) there is no need to separate the jejunal mesentery and cut off the jejunal loop, thus ensuring the blood supply of the side-to-side jejunal anastomosis and reducing the occurrence of anastomotic leakage; (3) it is equivalent to the construction of a storage bag, which can not only increase the food intake of patients but also delay emptying, reducing the discomfort of patients after eating.

This study also has some shortcomings. This study is a single-center retrospective study. All operations are performed by doctors in this treatment group. As a new method of esophagojejunostomy, multiple centers and doctors are needed. More cases confirm the safety and effectiveness of this method and further explore the surgical method and hand effect of this operation.

5. Conclusion

In conclusion, the “Pant-Shaped” esophagojejunostomy following laparoscopic total gastrectomy addresses the issue of the small diameter of the jejunum and establishes the function of a storage bag. This technique is safe and straightforward, offering an improved method for esophagojejunostomy. It can serve as a useful reference for similar procedures following laparoscopic total gastrectomy. Further research is needed to explore additional benefits, including potential improvements in postoperative comfort and quality of life for patients.

Ethical approval

This research was granted ethical approval by the ethics committee at The First Affiliated Hospital of Wannan Medical College. All patients and/or their legal guardians provided signed written consent after being fully informed

Funding

This study was supported by The key natural science research of Wannan Medical college (WK2023 ZZD30).

Author contributions

Wang Bing is responsible for statistical analysis and drafting articles; Wu Zehui, Liu Gang, Yang Wanchao, Yang Chao, and Liu Ben assists the first author in collecting data, analyzing data, implementing research, and guiding the content of the article. Shi Lianghui is the designer of this study, and critically reviews and guides the article’s intellectual content.

Footnotes

Conflict of interest

The authors declare no potential conflicts of interest that are pertinent to this article.

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

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Materials and methods

2.1 General information

Table 1 Basic data of 210 patients with “Pant-Shaped” esophagojejunostomy after laparoscopically assisted total gastrectomy

2.3 The operation method

2.5 Statistical analysis

3. Results

3.1 Basic characteristics of patients

3.2 Perioperative outcomes

4. Discussion

5. Conclusion

Ethical approval

Funding

Author contributions

Footnotes

Conflict of interest

References

Table 1
Basic data of 210 patients with “Pant-Shaped” esophagojejunostomy after laparoscopically assisted total gastrectomy