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Dieudonne M, Lv R, Xie W, Liu Q, Jiang J, Fu Y. Esophagojejunostomy using a circular stapler vs. a linear stapler for gastric cardia cancer patients: impact of upper margin length and tumor size on the survival rate. Front Surg 2024; 11:1385754. [PMID: 39444376 PMCID: PMC11496302 DOI: 10.3389/fsurg.2024.1385754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 08/26/2024] [Indexed: 10/25/2024] Open
Abstract
Background The incidence of gastric cancer is concomitantly rising with gastric cardia cancer worldwide. While the improvement of gastric cancer surgical techniques is glowing, this study assesses the impact of the upper margin length and tumor size on the survival rate for gastric cardia cancer patients who underwent total laparoscopic total gastrectomy(TLTG) or laparoscopic assisted total gastrectomy(LATG). Materials and methods A total of 63 patients with gastric cardia cancer who underwent laparoscopic total gastrectomy were retro-prospectively collected from January 2021 to May 2023. While assessing the impact of upper margin length and tumor size on the survival rate, esophagojejunostomy using a linear stapler has been compared to a circular stapler. Results The sixty-three patients met inclusion criteria; 32 (51%) underwent LATG and 31 (49%) underwent TLTG. Their mean age was 65 years (range, 45-77). The blood loss means in LATG and TLTG was 74.69 and 50.16 ml, respectively (p = 0.005), and surgery duration was higher in LATG than LATG with respective means of 247 min and 222.42 min. (p = 0.006). However, the tumor size means (p = 0.5), and upper margin length means (p = 0.052) were not significantly different in the LATG and TLTG groups, respectively. The number of resected and assessed lymph node was adequate in the LATG and TLTG groups. The current study still does not find an independent related risk from the upper margin length and tumor size to the survival rate according to the multiple regression analysis (p = 0.080). Conclusion The upper margin length and tumor size do not have a relationship with the survival rate of the compared esophagojejunostomy (EJS) methods. The EJS using a linear stapler requires a shorter surgery duration and less blood loss than EJS using a circular stapler.
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Affiliation(s)
- Maniragaba Dieudonne
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Renguang Lv
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wenjie Xie
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Qi Liu
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jianwu Jiang
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yang Fu
- First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
- Gastrointestinal Surgery Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Lehwald-Tywuschik N, Steinfurth F, Kröpil F, Krieg A, Sarikaya H, Knoefel WT, Krüger M, Benhidjeb T, Beshay M, Schulte Am Esch J. Dorsal Track Control (DTC): A Modified Surgical Technique for Atraumatic Handling of the Distal Esophagus in Esophagojejunostomy. J Gastric Cancer 2020; 19:473-483. [PMID: 31897349 PMCID: PMC6928082 DOI: 10.5230/jgc.2019.19.e35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022] Open
Abstract
Surgical therapy for adenocarcinoma of the esophagogastric junction II requires distal esophagectomy, in which a transhiatal management of the lower esophagus is critical. The ‘dorsal track control’ (DTC) maneuver presented here facilitates the atraumatic handling of the distal esophagus, in preparation for a circular-stapled esophagojejunostomy. It is based on a ventral semicircular incision in the distal esophagus, with an intact dorsal wall for traction control of the esophagus. The maneuver facilitates the proper placement of the purse-string suture, up to its tying (around the anvil), thus minimizing the manipulation of the remaining esophagus. Furthermore, the dorsally-exposed inner wall surface of the ventrally-opened esophagus serves as a guiding chute that eases anvil insertion into the esophageal lumen. We performed this novel technique in 21 cases, enabling a safe anastomosis up to 10 cm proximal to the Z-line. No anastomotic insufficiency was observed. The DTC technique improves high transhiatal esophagojejunostomy.
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Affiliation(s)
| | - Fabian Steinfurth
- Center of Visceral Medicine, Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Feride Kröpil
- Department of Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Andreas Krieg
- Department of Surgery, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Hülya Sarikaya
- Center of Visceral Medicine, Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | | | - Martin Krüger
- Center of Visceral Medicine, Department of Gastroenterology and Internal Medicine, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Tahar Benhidjeb
- Center of Visceral Medicine, Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Morris Beshay
- Department of Thoracic Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
| | - Jan Schulte Am Esch
- Center of Visceral Medicine, Department of General and Visceral Surgery, Protestant Hospital of Bethel Foundation, Bielefeld, Germany
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Park KB, Kim EY, Song KY. Esophagojejunal Anastomosis after Laparoscopic Total Gastrectomy for Gastric Cancer: Circular versus Linear Stapling. J Gastric Cancer 2019; 19:344-354. [PMID: 31598376 PMCID: PMC6769364 DOI: 10.5230/jgc.2019.19.e34] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/08/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose No standard technique has been established for esophagojejunal anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer owing to the technical difficulty and high complication rate of this procedure. This study was performed to compare the short-term outcomes of circular and linear stapling methods after LTG. Materials and Methods A total of 106 patients treated between July 2010 and July 2018 were divided into 2 groups according to the following anastomosis procedures: hemi-double-stapling technique (HDST; circular stapling method; group C, n=77) or overlap method (linear stapling method; group L, n= 29). The clinicopathological features and postoperative outcomes, including complications, were analyzed. Multivariate analysis was performed using a logistic regression model to identify the independent risk factors for anastomotic complications. Results The incidence of anastomotic complications was significantly higher in group C than in group L (28.0% vs. 6.9%, P=0.031). The incidence of anastomosis leakage did not differ between the groups (6.5% vs. 6.9%, P=1.000). However, anastomosis stricture occurred only in group C (13% vs. 0%, P=0.018). Multivariate analysis showed that the anastomosis type was significantly related to the risk of anastomotic complications (P=0.045). Conclusions The overlap method was superior to the HDST with respect to anastomotic complications, especially anastomosis stricture.
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Affiliation(s)
- Ki Bum Park
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Young Kim
- Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
| | - Kyo Young Song
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Korea
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Huang X, Xu L, Peng H, Hu H, Jin Y, Sun D, Hu K, Xia Y. Reverse puncture device technique: an innovation of esophagojejunostomy in radical laparoscopic total gastrectomy. Future Oncol 2019; 15:2807-2817. [PMID: 31340662 DOI: 10.2217/fon-2018-0837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aim: To evaluate the feasibility, safety, short- and long-term efficacy of a reverse puncture device (RPD) technique for esophagojejunostomy in laparoscopic-assisted total gastrectomy. Patients & methods: This retrospective study analyzed outcome data of 104 patients in propensity score matching whom were divided into the RPD and the purse-string suture technique group. Results: The RPD group had a shorter anvil placement time, shorter operative time, longer resected esophageal length, shorter incision length, shorter postoperative drainage time, shorter postoperative hospital stay and anastomotic complications than the purse-string suture technique group (p < 0.05). Multivariate analysis showed that BMI (odds ratio: 6.285, 1.446-27.322) and anvil placement time (odds ratio: 5.645, 1.089-29.321) were independent risk factors for anastomotic complications (p < 0.05). Conclusion: Laparoscopic-assisted total gastrectomy using an RPD technique is feasible, safe and effective.
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Affiliation(s)
- Xiaoxu Huang
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Li Xu
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Hui Peng
- Administration Office of Hospital Admission & Discharge, The First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Hao Hu
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Yan Jin
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Dayong Sun
- Department of General Surgery, People's Hospital of Linquan County, Fuyang, Anhui, PR China
| | - Kaifeng Hu
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
| | - Yabin Xia
- Department of Gastrointestinal Surgery, the First Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, PR China
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Takayama Y, Kaneoka Y, Maeda A, Fukami Y, Onoe S. Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study. Asian J Endosc Surg 2018; 11:329-336. [PMID: 29570950 DOI: 10.1111/ases.12469] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 07/25/2017] [Accepted: 01/14/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety. METHODS This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition. RESULTS The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group. CONCLUSION Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.
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Affiliation(s)
- Yuichi Takayama
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yuji Kaneoka
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Atsuyuki Maeda
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Yasuyuki Fukami
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
| | - Shunsuke Onoe
- Department of Surgery, Ogaki Municipal Hospital, Ogaki, Japan
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Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy. Surg Endosc 2018; 33:2128-2134. [PMID: 30341648 DOI: 10.1007/s00464-018-6484-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 10/11/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments. METHODS From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy. RESULTS In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series. CONCLUSIONS Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.
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Esophagojejunostomy With Linear Staplers in Laparoscopic Total Gastrectomy: Experience With 168 Cases in 5 Consecutive Years. Surg Laparosc Endosc Percutan Tech 2018; 27:e101-e107. [PMID: 28902037 DOI: 10.1097/sle.0000000000000464] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE We evaluate surgical outcomes of intracorporeal esophagojejunostomy in laparoscopic total gastrectomy using 2 linear stapler methods. MATERIALS AND METHODS The functional end-to-end anastomosis (FEEA) method was chosen as a first choice. The overlap method was chosen in cases with esophageal invasion. We retrospectively analyzed the early and late surgical outcomes of consecutive 168 laparoscopic total gastrectomy cases from April 2011 to December 2016. RESULTS AND CONCLUSIONS The FEEA method was selected in 120 cases, and the overlap method was selected in 48 cases. The mean time of esophagojejunostomy for the FEEA and overlap method was 13.2 and 36.5 minutes, respectively. Two cases with FEEA method and 3 cases with overlap method experienced complications due to esophagojejunostomy leakage. These cases were treated without performing a reoperation. One case with FEEA method was complicated due to esophagojejunostomy stenosis. This case was endoscopically treated. Our procedures are safe and feasible.
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Esophagojejunostomy Using the Purse-String Suturing Device After Laparoscopic Total or Proximal Gastrectomy for Gastric Cancer. World J Surg 2018; 41:2605-2610. [PMID: 28447165 DOI: 10.1007/s00268-017-4033-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Performing a safe esophagojejunostomy is important for the standardization of laparoscopic total gastrectomy. We have performed intracorporeal esophagojejunostomy by a circular stapler using the purse-string suturing device that we co-developed. The advantage of this device is that it makes use of the same surgical procedure as open surgery, but it does not depend on the surgeon's technical skills since this device does not require the laparoscopic hand-sewn technique. Furthermore, we have also adapted this device for double-tract reconstruction after laparoscopic proximal gastrectomy. In this study, we present the surgical procedures and postoperative short-term outcomes that were obtained using this novel technique. METHODS We enrolled 94 patients that underwent intracorporeal esophagojejunostomy by circular stapler using our device after laparoscopic total or proximal gastrectomy for gastric cancer between November 2009 and October 2016. RESULTS Postoperative complications related to esophagojejunostomy were due to anastomotic stenosis in two cases (2.1%) and leakage of the jejunum stump in one case (1.1%). CONCLUSIONS Intracorporeal esophagojejunostomy by circular stapler using the purse-string suturing device is safe and feasible. This method can be one of the standard procedures for performing intracorporeal esophagojejunostomy.
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Comparison of OrVil™ and RPD in laparoscopic total gastrectomy for gastric cancer. Surg Endosc 2017; 31:4773-4779. [PMID: 28409368 DOI: 10.1007/s00464-017-5554-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/28/2017] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic total gastrectomy (LTG) is frequently performed for treating patients with gastric cancer; however, the absence of anastomotic techniques with greater superiority has impaired its popularization. We have compared two types of anastomotic techniques with regard to technical perspectives and clinical outcomes. METHODS We reviewed 43 patients with gastric cancer who underwent LTG. Two types of anastomotic techniques have been applied after LTG-the trans-orally inserted anvil (OrVil™) and the reverse puncture device (RPD). Data on the type of anastomosis, blood loss, operation time, anastomosis time, location of tumors, distance between the top border of tumors and top resection margin, diameter of tumor, length of postoperative hospital stay, early and late postoperative complications, and total cost of surgical consumables were obtained by reviewing patient medical records and analyzed thereafter. RESULTS We included 32 men and 11 women (mean age 61 years). The loss to follow-up rate was 13.2%. The median survival time for the OrVil™ and RPD groups was 23 and 22 months, respectively. The total rate of complications was 9.3%. The difference in the anastomosis times between the groups was statistically significant. OrVil™ required more time than RPD and cost more than RPD. CONCLUSIONS Both the OrVil™ and RPD techniques showed good safety and applicability in LTG. RPD showed an advantage with regard to lesser operative complexity and lower cost.
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Ali B, Park CH, Song KY. Intracorporeal esophagojejunostomy using hemi-double-stapling technique after laparoscopic total gastrectomy in gastric cancer patients. Ann Surg Treat Res 2016; 92:30-34. [PMID: 28090503 PMCID: PMC5234430 DOI: 10.4174/astr.2017.92.1.30] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/20/2016] [Accepted: 08/31/2016] [Indexed: 12/15/2022] Open
Abstract
Purpose To present the feasibility and safety of Roux-en-Y esophagojejunostomy using hemi-double-stapling technique after laparoscopic total gastrectomy. Methods We reviewed the outcomes from 58 consecutive patients with gastric cancer who underwent laparoscopic total gastrectomy. The clinicopathological characteristics including postoperative complications were examined. Results The mean age and body mass index were 57.3 ± 9.7 years and 23.7 ± 2.6 kg/m2, respectively. The mean overall total operation was 199.8 ± 57.0 minutes. Intraoperative blood loss was 81.6 ± 56.3 mL and there was no open conversion. The patients' hospital stay was a mean 9.6 ± 2 days. The mean proximal margin of the specimens was 2.7 ± 1.8 cm. There were 3 cases (5.1%) of anastomosis leakage, but all were controlled successfully by endoscopic stent. Conclusion The circular HDST technique is simple and reliable without any significant demerits with respect to safety concerns or difficulty of operation.
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Affiliation(s)
- Bandar Ali
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Cho Hyun Park
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Technical Feasibility and Short-Term Outcome of Intracorporeal Hand-Sewn Esophagojejunostomy After Laparoscopic Total Gastrectomy: Our Experience. Indian J Surg 2016; 79:497-503. [PMID: 29217899 DOI: 10.1007/s12262-016-1509-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/16/2016] [Indexed: 02/06/2023] Open
Abstract
The purpose of this study was to demonstrate the safety and technical feasibility of intracorporeal hand-sewn esophagojejunostomy after laparoscopic total gastrectomy. Laparoscopic total gastrectomy (LTG) is a technically challenging procedure, especially for esophagojejunal anastomosis (EJA). Various techniques have been described to overcome these difficulties using staplers with variable results. We report successfully performed complete intracorporeal hand-sewn EJA after LTG. The perioperative clinical data and short-term outcomes for 30 patients who underwent LTG using hand-sewn EJA for gastric cancer between 2013 and 2015 have been retrospectively reviewed. The mean age was 49.9 years; 64 % of patients were male and 36 % were female. The mean body mass index (kg/m2) was 22.4, and the mean American Society of Anesthesiologists (ASA) score was 1.4. Eleven patients had co-morbidities, and six patients had previous abdominal operations. The mean operative time, time for EJA, and blood loss was 136.9 min, 13.25 min, and 166 ml, respectively. The conversion rate was nil. The mean time for the first oral feeding and mean hospital stay was 8.3 and 9.8 days respectively. The postoperative complications were found in 16 % of patients with one case of 30-day mortality because of lobar pneumonia. There were three cases of anastomotic stenosis; however, no leakage was identified both clinically and radiologically. Complete intracorporeal hand-sewn EJA is a safe and feasible technique in the hands of experienced surgeons that can be considered as an alternative cost-effective method when performing LTG.
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Chen K, Pan Y, Cai JQ, Wu D, Yan JF, Chen DW, Yu HM, Wang XF. Totally laparoscopic versus laparoscopic-assisted total gastrectomy for upper and middle gastric cancer: a single-unit experience of 253 cases with meta-analysis. World J Surg Oncol 2016; 14:96. [PMID: 27036540 PMCID: PMC4815120 DOI: 10.1186/s12957-016-0860-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/24/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Laparoscopic-assisted total gastrectomy (LATG) is the most commonly used methods of laparoscopic gastrectomy for upper and middle gastric cancer. However, totally laparoscopic total gastrectomy (TLTG) is unpopular because reconstruction is difficult, especially for the intracorporeal esophagojejunostomy. We adopted TLTG with various types of intracorporeal esophagojejunostomy. In this study, we compared LATG and TLTG to evaluate their outcomes. METHODS From March 2006 to September 2015, 253 patients with upper and middle gastric cancer underwent laparoscopic total gastrectomy (LTG), 145 patients underwent LATG, and 108 patients underwent TLTG. The clinicopathological characteristics and postoperative outcomes were retrospectively compared between the two groups. Furthermore, a systematic review and meta-analysis were conducted. RESULTS The operation time and estimated blood loss were similar between the groups. There were no significant differences in first flatus, diet initiation, and postoperative hospital stay. The surgical complication rates were 17.2% (25/145) and 13.9% (15/108) in the LATG and TLTG groups, respectively. The meta-analysis also revealed no significant differences in the operation time, estimated blood loss, time to first flatus, length of hospital stay, overall, and anastomosis-related complications among the groups. CONCLUSIONS TLTG is a feasible choice for gastric cancer patients, with comparable results to the LATG approach.
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Affiliation(s)
- Ke Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Yu Pan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Jia-Qin Cai
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Di Wu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Jia-Fei Yan
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Ding-Wei Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Hong-Mei Yu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
| | - Xian-Fa Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
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Wang H, Hao Q, Wang M, Feng M, Wang F, Kang X, Guan WX. Esophagojejunostomy after laparoscopic total gastrectomy by OrVil TM or hemi-double stapling technique. World J Gastroenterol 2015; 21:8943-8951. [PMID: 26269685 PMCID: PMC4528038 DOI: 10.3748/wjg.v21.i29.8943] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/25/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.
METHODS: This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group I underwent esophagojejunostomy using a transorally-inserted anvil (OrVilTM), while patients in Group II underwent esophagojejunostomy using the hemi-double stapling technique (HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients’ baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were compared between the two groups. The primary endpoint was evaluation of the surgical outcome (operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation (operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared.
RESULTS: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups (287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group II compared with Group I (47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intra-operative blood loss (96.4 ± 32.7 mL vs 88.2 ± 36.9 mL, P = 0.28), time to defecation (3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation (3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet (7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization (10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups (73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group II (32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P < 0.001).
CONCLUSION: Anvil insertion was faster and easier using the HDST technique compared with OrVilTM, and was more cost-effective. There was no significant difference in safety.
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Matsuda T, Iwasaki T, Mitsutsuji M, Hirata K, Tsugawa D, Sugita Y, Shimada E, Kakeji Y. A Simple and Reliable Method for Intracorporeal Circular-Stapled Esophagojejunostomy Using a Hand-Sewn Over-and-Over Suture Technique in Laparoscopic Total Gastrectomy. Ann Surg Oncol 2015; 22 Suppl 3:S355. [PMID: 25948158 DOI: 10.1245/s10434-015-4541-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND The controversy regarding laparoscopic total gastrectomy (LTG) is mainly due to the difficulty associated with esophagojejunostomy during this procedure. Although several techniques have so far been reported to overcome this issue,1 (-) 4 a reliable technique has not yet been established. We developed intracorporeal esophagojejunostomy using a circular stapler in LTG with a hand-sewn over-and-over suture technique, and have shown its favorable outcomes compared with those of conventional open surgery.5 This technique is presented in the video. METHODS After transection of the esophagus, an over-and-over suture with a 2-0 monofilament is placed counterclockwise from the right to the left side of the cut end in an outside-to-inside direction, and then from the left to the right side in an inside-to-outside direction. After insertion of the anvil head into the esophagus, it was fixed by ligation of the thread. Finally, intracorporeal esophagojejunal anastomosis was performed using a circular stapler. RESULTS In LTG, reconstruction using this method was performed for 23 consecutive patients with gastric cancer. There were no serious intraoperative complications or need for conversion to open surgery. Anastomotic leakage and stenosis occurred in one case each, respectively. The mean time for fixation of the anvil to the esophagus was 15 min for the last 12 consecutive patients. CONCLUSIONS This method is simple and feasible, and the advantage of this technique is the elimination of the backhand stroke throughout the suturing procedure.
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Affiliation(s)
- Takeru Matsuda
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan.
| | - Takeshi Iwasaki
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Masaaki Mitsutsuji
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Kenro Hirata
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Daisuke Tsugawa
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Yutaka Sugita
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Etsuji Shimada
- Department of Surgery, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Kim JH, Choi CI, Kim DI, Kim DH, Jeon TY, Kim DH, Park DY. Intracorporeal esophagojejunostomy using the double stapling technique after laparoscopic total gastrectomy: A retrospective case-series study. World J Gastroenterol 2015; 21:2973-2981. [PMID: 25780295 PMCID: PMC4356917 DOI: 10.3748/wjg.v21.i10.2973] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 12/08/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To introduce a simple and safe anvil insertion technique to esophagus during laparoscopic total gastrectomy (LTG).
METHODS: Between July 2010 and December 2012, 58 consecutive patients with early gastric cancer underwent LTG were enrolled. We performed a simple and safe Roux-en-Y esophagojejunostomy using the double stapling technique to all patients. Then patients’ characteristics, perioperative outcome and histopathologic data were analyzed retrospectively.
RESULTS: The mean age and body mass index were 59.3 ± 9.7 years and 22.7 ± 2.6 kg/m2. The mean operation, reconstruction and anvil insertion times (from gastric incision to linear stapling) were 251.8 ± 57.0, 43.1 ± 2.8 and 4.2 ± 1.9 min, respectively. Intraoperative blood loss was 204.6 ± 156.3 mL and there was no open conversion. The postoperative complications were in 8 cases (delayed gastric emptying in 4 cases, pulmonary complication in 2 cases, pancreatitis in 1 case, anastomotic stricture in 1 case). Anastomotic stricture occurred after discharge and was recovered by endoscopic intervention. The patients were discharged at a mean of 9.6 ± 2.0 d after surgery. Neither leakage nor bleeding from the esophagojejunostomy occurred postoperatively. The mean proximal margin of specimen was 2.7 ± 2.8 cm
CONCLUSION: Roux-en Y esophagojejunostomy using the double stapling technique is simple and rapid, and it may offer a solid, alternative reconstruction method for LTG or proximal gastrectomy.
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Matsuda T, Iwasaki T, Mitsutsuji M, Hirata K, Maekawa Y, Tsugawa D, Sugita Y, Shimada E, Kakeji Y. Surgical outcomes of intracorporeal circular-stapled esophagojejunostomy using modified over-and-over suture technique in laparoscopic total gastrectomy. Surg Endosc 2015; 29:3386-91. [PMID: 25631108 DOI: 10.1007/s00464-015-4073-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 01/12/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophagojejunostomy in laparoscopic total gastrectomy (LTG) is a technically demanding procedure. Although several methods have been reported to date, none is considered consistently reliable. We developed a simple method for intracorporeal circular-stapled esophagojejunostomy using a modified over-and-over suture technique. The surgical outcomes of our technique were evaluated in comparison with those of open total gastrectomy (OTG). METHODS From April 2012 to August 2014, reconstruction using this method in LTG was performed for 21 consecutive patients with gastric cancer (LTG group). Their surgical outcomes were compared with those of 27 patients with gastric cancer who underwent OTG without splenectomy (OTG group) between January 2011 and April 2014. RESULTS Estimated blood loss was significantly lower, and the postoperative hospital stay was significantly shorter in the LTG group than in the OTG group. The operating time and the number of harvested lymph nodes were similar between the two groups. The incidence of overall complications did not differ significantly between the two groups. Anastomotic leakage developed in one of the 21 patients in the LTG group and in two of the 27 patients in the OTG group. Anastomotic stenosis was observed in one patient in the LTG group. CONCLUSIONS We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.
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Affiliation(s)
- Takeru Matsuda
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan.
| | - Takeshi Iwasaki
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Masaaki Mitsutsuji
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Kenro Hirata
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Yoko Maekawa
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Daisuke Tsugawa
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Yutaka Sugita
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Etsuji Shimada
- Department of Surgery, National Hospital Organization Kobe Medical Center, 3-1-1 Nishi-Ochiai, Suma-ku, Kobe, 654-0155, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Morimoto M, Kitagami H, Hayakawa T, Tanaka M, Matsuo Y, Takeyama H. The overlap method is a safe and feasible for esophagojejunostomy after laparoscopic-assisted total gastrectomy. World J Surg Oncol 2014; 12:392. [PMID: 25527860 PMCID: PMC4364598 DOI: 10.1186/1477-7819-12-392] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 12/03/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic procedures are increasingly being applied to gastric cancer surgery, including total gastrectomy for tumors located in the upper gastric body. Even for expert surgeons, esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) can be technically challenging. We perform the overlap method of esophagojejunostomy after LATG for gastric cancer. However, technical questions remain. Is the overlap method safer and more useful than other anastomosis techniques, such as methods using a circular stapler? In addition, while we perform this overlap reconstruction after LATG in a deep and narrow operative field, can the overlap method be performed safely regardless of body habitus? This study aimed to evaluate these issues retrospectively and to review the literature. METHODS From October 2005 to August 2013, we performed LATG with lymph-node dissection and Roux-en-Y reconstruction using the overlap method in 77 patients with gastric cancer. This study examined pre-, intra- and postoperative data. RESULTS Mean operation time, time to perform anastomosis, and estimated blood loss were 391.4 min, 36.3 min, and 146.9 ml, respectively. There were no deaths, and morbidity rate was 13%, including one patient (1%) who developed anastomotic stenosis. Mean postoperative hospitalization was 13.4 days. Surgical outcomes did not differ significantly by body mass index. CONCLUSIONS First, the overlap method for esophagojejunostomy after LATG is safe and useful. Second, this method can be performed irrespective of the body type of the patient. In particular, in a deep and narrow operative field, the overlap method is more versatile than other anastomosis methods. We believe that the overlap method can become a standard reconstruction technique for esophagojejunostomy after LATG.
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Affiliation(s)
- Mamoru Morimoto
- />Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Hidehiko Kitagami
- />Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Tetsushi Hayakawa
- />Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Moritsugu Tanaka
- />Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
| | - Yoichi Matsuo
- />Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuhoku, Nagoya, 467-8601 Japan
| | - Hiromitsu Takeyama
- />Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Kawasumi 1, Mizuho-cho, Mizuhoku, Nagoya, 467-8601 Japan
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Cianchi F, Macrì G, Indennitate G, Mallardi B, Trallori G, Biagini MR, Badii B, Staderini F, Perigli G. Laparoscopic total gastrectomy using the transorally inserted anvil (OrVil™): a preliminary, single institution experience. SPRINGERPLUS 2014; 3:434. [PMID: 25152855 PMCID: PMC4141073 DOI: 10.1186/2193-1801-3-434] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 08/06/2014] [Indexed: 12/29/2022]
Abstract
Laparoscopic total gastrectomy (LTG) is not a commonly performed procedure due to the difficulty associated with surgical reconstruction. We present our preliminary results after intracorporeal circular stapling esophagojejunostomy using the newly developed transorally inserted anvil (OrVil™, Covidien, MA, USA). Between 2008 and June 2013, 51 patients underwent laparoscopic gastrectomy with D2 lymph node dissection for gastric cancer. A total of 12 patients underwent LTG: of these, 5 received an intracorporeal linear side-to-side esophagojejunal anastomosis and the remaining 7 underwent intracorporeal circular stapling esophagojejunostomy using the OrVil™ system. Short-term outcomes were compared between the two groups. There were no intraoperative complications or conversions to open surgery in any patients. The mean operative time was significantly shorter in the OrVil™ than in the side-to-side group (261.4 ± 12.0 vs 333.0 ± 15.0 minutes, respectively, p = 0.005). Postoperative fluorography revealed no anastomosis leakage or stenosis in either groups. All patients resumed an oral liquid diet on postoperative day 5 and the mean postoperative hospital stay was 9 days. Intracorporeal circular stapling esophagojejunostomy using the OrVil™ system is technically feasible and safe in LTG. This technique may be considered a simple and time-saving alternative to the side-to-side linear esophagojejunostomy.
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Affiliation(s)
- Fabio Cianchi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy ; Endocrine and Minimally Invasive Surgery, Azienda Ospedaliero-Universitaria Careggi, Center of Oncologic Minimally Invasive Surgery (COMIS), Department of Surgery and Translational Medicine, University of Florence, Largo Brambilla 3, 50134 Florence, Italy
| | - Giuseppe Macrì
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | | | | | - Giacomo Trallori
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Rosa Biagini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Benedetta Badii
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Fabio Staderini
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Giuliano Perigli
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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Knight BC, Rice SJ, Devitt PG, Lord A, Game PA, Thompson SK. Proximal anastomosis using the OrVil circular stapler in major upper gastrointestinal surgery. J Gastrointest Surg 2014; 18:1345-9. [PMID: 24553876 DOI: 10.1007/s11605-014-2478-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 01/28/2014] [Indexed: 01/31/2023]
Abstract
Anastomoses in major upper gastrointestinal surgery can be technically demanding, especially handsewn anastomoses traversing the diaphragmatic hiatus. The OrVil stapler is a unique circular stapler that allows rapid creation of various upper gastrointestinal anastomoses in technically challenging circumstances, particularly if additional proximal clearance is desirable. Little is reported in the literature regarding its outcomes and complication rates. In this 'How I do It' article, we describe our technique and experience with the OrVil in major upper gastrointestinal surgery.
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Affiliation(s)
- Benjamin C Knight
- Discipline of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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A modified technique for esophagojejunostomy or esophagogastrostomy after laparoscopic gastrectomy. Surg Laparosc Endosc Percutan Tech 2014; 23:e109-15. [PMID: 23752017 DOI: 10.1097/sle.0b013e31828e3939] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Reconstruction of the digestive tract involving esophageal anastomosis after laparoscopic gastrectomy is a surgically difficult procedure. In this study, a newly developed transoral pretilted circular anvil, a "the oral to the abdomen" method, was proven to be effective. METHOD A total of 34 consecutive patients underwent esophageal anastomosis using the OrVil in our hospital from July 2009 to February 2011. The esophagus was transected and a small hole was then made in the esophageal stump through which the nasogastric tube of the OrVil was passed to insert the anvil into the abdominal cavity. After fixation with a stapler and a glove at the jejunal loop or the remnant stomach, the abdominal cavity was entered through the minilaparotomy. Pneumoperitoneum and airtightness were reestablished after the glove edge was turned over to seal off the protector. Eventually, intracorporeal esophagojejunostomy or esophagogastrostomy was accomplished under the guidance of laparoscopy. RESULTS There were 34 patients in the study: 1 with Zollinger-Ellison syndrome, 7 with stromal tumors in cardia, 23 with adenocarcinoma in the stomach, and 3 with cardia adenocarcinoma involving the lower esophagus. The surgical margins for all tumor patients were negative for tumor cells. The mean operative time was 175.0 minutes (90 to 240 min) and the mean intraoperative blood loss was 195.6 mL (50 to 800 mL). The 34 patients underwent successful laparoscopic surgeries with no open conversions. For 32 patients, there were no technological complications in the transoral insertion of the anvil to the esophageal stump. There were no anastomotic leaks after the surgery. CONCLUSIONS The use of the OrVil device, a "the oral to the abdomen" method, changes the direction of the anvil insertion and significantly decreases both difficulty and duration of the laparoscopic surgery. More importantly, if the mass is at a higher position, this approach can achieve a higher surgical margin compared with the hand-sewn purse-string suture technique, thus avoiding the need to undergo a thoracotomy (Supplemental Digital Content 1, http://links.lww.com/SLE/A83).
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Wang W, Zhang X, Shen C, Zhi X, Wang B, Xu Z. Laparoscopic versus open total gastrectomy for gastric cancer: an updated meta-analysis. PLoS One 2014; 9:e88753. [PMID: 24558421 PMCID: PMC3928285 DOI: 10.1371/journal.pone.0088753] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 01/12/2014] [Indexed: 02/07/2023] Open
Abstract
Objective To expand the current knowledge on the feasibility and safety of laparoscopic total gastrectomy (LTG) for gastric cancer in comparison with open total gastrectomy (OTG). Background Additional studies comparing laparoscopic versus open total gastric resection have been published, and it is necessary to update the meta-analysis of this subject. Methods Original articles compared LTG and OTG for gastric cancer, which published in English from January 1990 to July 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, proximal resection margin, analgesic medication, first flatus day, first oral intake, postoperative hospital stay, postoperative complications, hospital mortality, 5-year overall survival (OS) and disease-free survival (DFS) were compared using STATA version 10.1. Results 17 studies were selected in this analysis, which included a total of 2313 patients (955 in LTG and 1358 in OTG). LTG showed longer operative time, less blood loss, fewer analgesic uses, earlier passage of flatus, quicker resumption of oral intake, earlier hospital discharge, and reduced postoperative morbidity. The number of harvested lymph nodes, proximal resection margin, hospital mortality, 5-year OS and DFS were similar. Conclusion LTG had the benefits of less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay and lower postoperative morbidity, at the price of longer operative time. There were no statistical differences in lymph node dissection, resection margin, hospital mortality, and long-term outcomes, which indicated the similar oncological safety with OTG. A positive trend was indicated towards LTG. So LTG can be performed as an alternative to OTG by the experienced surgeons in high-volume centers. Whereas, due to the relative small sample size of long-term outcomes and lack of randomized control trials, more studies are required.
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Affiliation(s)
- Weizhi Wang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoyu Zhang
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chen Shen
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaofei Zhi
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Baolin Wang
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
- * E-mail: (BW); (ZX)
| | - Zekuan Xu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- * E-mail: (BW); (ZX)
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Feasibility of laparoscopy-assisted total gastrectomy in patients with clinical stage I gastric cancer. Gastric Cancer 2014; 17:137-40. [PMID: 23430265 DOI: 10.1007/s10120-013-0235-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 01/15/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopy-assisted total gastrectomy (LATG) for gastric cancer is not yet widespread because of the technical difficulty of reconstruction. We have performed LATG on 100 patients with clinical stage I gastric cancer. This study investigated the short-term outcomes of LATG. METHODS Between September 2001 and September 2012, 100 patients with clinical stage I gastric cancer underwent LATG with D1 plus beta or D2 lymphadenectomy. Roux-en-Y esophagojejunostomy was performed intracorporeally using end-to-side anastomosis with a circular stapler (the purse-string suture method). The primary endpoint was the proportion of postoperative complications during hospitalization. RESULTS Mean operation time was 249 min; mean blood loss was 182 ml. There were no conversions to open surgery. According to the Clavien-Dindo classification, there were 8 grade II (8 %) and 10 grade IIIa/b (10 %) complications. There were no treatment-related deaths or grade IV complications. The most frequent complication was anastomotic or stump leakage (6 %), followed by pancreatic fistula (5 %). Reoperations were required in two patients with leakage. CONCLUSIONS The short-term outcomes of LATG in our study involving 100 patients were outlined. LATG for gastric cancer patients should be attempted preferably in a clinical trial setting by surgeons with sufficient experience in laparoscopic gastrectomy.
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Wang W, Li Z, Tang J, Wang M, Wang B, Xu Z. Laparoscopic versus open total gastrectomy with D2 dissection for gastric cancer: a meta-analysis. J Cancer Res Clin Oncol 2013; 139:1721-34. [PMID: 23990014 DOI: 10.1007/s00432-013-1462-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/14/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To elucidate the feasibility and safety of laparoscopic total gastrectomy with D2 dissection (LTGD2) for gastric cancer in comparison with open total gastrectomy with D2 dissection (OTGD2). BACKGROUND More surgeons have chosen laparoscopic total gastrectomy as an alternative to open total gastrectomy. But no meta-analysis has been performed to evaluate the value of LTGD2. METHODS Original articles compared LTGD2 and OTGD2 for gastric cancer, which published in English from January 1990 to March 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and hospital mortality were compared using STATA version 10.1. RESULTS 8 studies were selected in this analysis. A total of 1,498 patients were included (559 in LTG and 939 in OTG). LTGD2 showed longer operative time (WMD 39.29; 95 % CI 20.52, 58.06; P < 0.001), less blood loss (WMD -157.94; 95 % CI -245.25 -70.62; P < 0.001), fewer analgesic requirements (WMD -2.01; 95 % CI -3.10, -0.93; P < 0.001), earlier passage of flatus (WMD -0.73; 95 % CI -1.19, -0.27; P = 0.002), earlier hospital discharge (WMD -2.69; 95 % CI -3.42, -1.97; P < 0.001), and reduced postoperative morbidity (RR 0.70; 95 % CI 0.50, 0.98; P = 0.035). The number of harvested lymph nodes (WMD 0.27; 95 % CI -1.43, 1.98; P = 0.752) and hospital mortality rate (RR 0.57; 95 % CI 0.11, 3.09; P = 0.513) were similar. CONCLUSION LTGD2 was associated with less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay, and reduced postoperative morbidity, at the expense of longer operative time. No statistical differences were observed in lymph node dissection, and hospital mortality, which indicated the similar ability of lymph nodes clearance and short-term outcomes with OTGD2. A positive trend was indicated toward LTGD2. So we encourage the experienced surgeons to achieve LTGD2 instead of OTGD2. Whereas, due to non-randomized control trails and lack of long-term outcomes, more studies are required.
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Affiliation(s)
- Weizhi Wang
- Department of General Surgery, First Affiliated Hospital, Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, Jiangsu, China
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Chen K, Xu XW, Zhang RC, Pan Y, Wu D, Mou YP. Systematic review and meta-analysis of laparoscopy-assisted and open total gastrectomy for gastric cancer. World J Gastroenterol 2013; 19:5365-5376. [PMID: 23983442 PMCID: PMC3752573 DOI: 10.3748/wjg.v19.i32.5365] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 05/23/2013] [Accepted: 07/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the safety and efficacy of laparoscopy-assisted total gastrectomy (LATG) and open total gastrectomy (OTG) for gastric cancer.
METHODS: A comprehensive search of PubMed, Cochrane Library, Web of Science and BIOSIS Previews was performed to identify studies that compared LATG and OTG. The following factors were checked: operating time, blood loss, harvested lymph nodes, flatus time, hospital stay, mortality and morbidity. Data synthesis and statistical analysis were carried out using RevMan 5.1 software.
RESULTS: Nine studies with 1221 participants were included (436 LATG and 785 OTG). Compared to OTG, LATG involved a longer operating time [weighted mean difference (WMD) = 57.68 min, 95%CI: 30.48-84.88; P < 0.001]; less blood loss [standard mean difference (SMD) = -1.71; 95%CI: -2.48 - -0.49; P < 0.001]; earlier time to flatus (WMD= -0.76 d; 95%CI: -1.22 - -0.30; P < 0.001); shorter hospital stay (WMD = -2.67 d; 95%CI: -3.96 - -1.38, P < 0.001); and a decrease in medical complications (RR = 0.41, 95%CI: 0.19-0.90, P = 0.03). The number of harvested lymph nodes, mortality, surgical complications, cancer recurrence rate and long-term survival rate of patients undergoing LATG were similar to those in patients undergoing OTG.
CONCLUSION: Despite a longer operation, LATG can be performed safely in experienced surgical centers with a shorter hospital stay and fewer complications than open surgery.
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Safety of intracorporeal circular stapling esophagojejunostomy using trans-orally inserted anvil (OrVil) following laparoscopic total or proximal gastrectomy - comparison with extracorporeal anastomosis. World J Surg Oncol 2013; 11:209. [PMID: 23972079 PMCID: PMC3765957 DOI: 10.1186/1477-7819-11-209] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 08/01/2013] [Indexed: 12/13/2022] Open
Abstract
Background There have been several attempts to develop a unique and easier way to perform esophagojejunostomy during laparoscopy-assisted total gastrectomy or laparoscopy-assisted proximal gastrectomy. The OrVil™ system (Covidien, Mansfield, MA, USA) is one of those methods, but its technical and oncologic feasibility have not been proven and need to be observed. Methods Among 87 patients who underwent laparoscopy-assisted total gastrectomy (LATG; 79 cases) and laparoscopy-assisted proximal gastrectomy with double tract anastomosis (LAPG_DT; 8 cases) from April 2004, 47 patients underwent the conventional extracorporeal method (Group I; 2004–2008) were compared with 40 patients treated with the intracorporeal OrVil™ system (Group II; 2009–2012). Results There was no significant difference in clinicopathologic characteristics between the two groups except tumor location; more cardia lesions were involved in group II (p = 0.012). The mean time for esophagojejunostomy (E-J), defined as the time from anvil insertion to closure of the jejunal entry site has no significant difference (Group I vs II: 22.2 ± 3.2 min vs 18.6 ± 3.5 min, p = 0.623). In terms of anastomotic complication, there was no significant difference in E-J leakage and stricture. E-J leakage occurred in 2 out of 47 (4.3%) cases in group I and 2 out of 40 (5%) in group II (p = 0.628); half of them were treated conservatively in each group and the others underwent reoperation. E-J stricture occurred in 2 (4.3%) cases in group I and 1 (2.5%) in group II (p = 0.561), which required postoperative gastrofiberscopic balloon dilatation. Conclusions Esophagojejunostomy using the OrVil™ system was a feasible and safe technique compared with the conventional extracorporeal method through mini-laparotomy in terms of anastomotic complications. Moreover, it can help to reduce surgeon’s stress regarding esophagojejunostomy because it needs no purse-string procedure and serves a secure operation view laparoscopically.
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Various types of intracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer. Gastric Cancer 2013; 16:420-7. [PMID: 23097123 DOI: 10.1007/s10120-012-0207-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 10/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Even for expert surgeons, esophagojejunostomy after laparoscopic total gastrectomy (LTG) is not always easy to perform. Herein, we compare various types of esophagojejunostomy in terms of the technical aspects and postoperative outcomes. METHODS A total of 48 patients underwent LTG for gastric cancer by the same surgeon. Four types of intracorporeal esophagojejunostomies have been applied after LTG: type A, a conventional anvil head method; type B, an OrVil™ system method; type C, a hemi-double stapling technique with anvil head; and type D, side-to-side esophagojejunostomy with linear stapler. We describe and review these types of esophagojejunostomy using a step-by-step approach. RESULTS The mean reconstruction times were longer for types A and B than for types C and D (p < 0.05). In terms of complications, there were five cases (10.4%) of anastomosis leakage, which was more common in types A and B: two cases in each of type A and B and one case in type C. Moreover, anastomosis stricture requiring intervention was more common in types A and B (p < 0.05). CONCLUSIONS To date, there are no reliable reconstruction methods after LTG. Therefore, special care is needed to prevent postoperative complication regardless of methods; also, technical innovations to support development of the safest methods of esophagojejunostomy are warranted.
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Kong SH, Suh Y, Kwon S, Lee HJ, Kim HH, Yang HK. Stable purse-string suturing using an anterior esophagotomy for reconstruction with a circular stapler during laparoscopic total gastrectomy. Asian J Endosc Surg 2013; 6:82-9. [PMID: 23323665 DOI: 10.1111/ases.12014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 10/21/2012] [Accepted: 11/27/2012] [Indexed: 12/29/2022]
Abstract
INTRODUCTION During a laparoscopic total gastrectomy, the combined process of purse-string suture placement and anvil insertion of a circular stapler is one of the most difficult steps in the reconstruction. We have developed a stable and reliable technique in which purse-string suture placement and anvil insertion using anterior esophagotomy precede complete transection of the esophagus. METHODS The procedure involves tying the distal esophagus, insufflating the esophagus via a nasogastric tube, anterior wall purse-string suture, anterior esophagotomy, posterior wall purse-string suture, anvil insertion, fastening purse-string suture, and transecting the esophagus. The technique has been employed in nine patients since April 2011. RESULTS Eight of the nine gastrectomies were for patients with stage IA early gastric cancer and one was for a patient with medically intractable bleeding from multiple polyps. Three were men and six were women. Average BMI was 25.2 ± 5.3 (range, 16.3-33.9). Mean operation time was 276.2 ± 56.3 min (range, 215.0-395.0 min) and the mean duration for anvil insertion was 29.8 ± 7.0 min (range, 23.0-46.0 min). There were no intraoperative or postoperative anastomosis-related complications or mortality. CONCLUSION Our method of anvil insertion of a circular stapler can be a good option for safe and reliable esophagojejunostomy during a laparoscopic total gastrectomy.
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Affiliation(s)
- Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital, Seoul, Korea
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Zuiki T, Hosoya Y, Kaneda Y, Kurashina K, Saito S, Ui T, Haruta H, Hyodo M, Sata N, Lefor AT, Yasuda Y. Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy. Surg Endosc 2013; 27:3683-9. [PMID: 23572225 DOI: 10.1007/s00464-013-2945-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 03/17/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis. METHODS From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis. RESULTS A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis. CONCLUSION Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.
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Affiliation(s)
- Toru Zuiki
- Department of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, 3311-1, Japan,
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Kim HS, Kim MG, Kim BS, Lee IS, Lee S, Yook JH, Kim BS. Comparison of Totally Laparoscopic Total Gastrectomy and Laparoscopic-Assisted Total Gastrectomy Methods for the Surgical Treatment of Early Gastric Cancer Near the Gastroesophageal Junction. J Laparoendosc Adv Surg Tech A 2013; 23:204-10. [DOI: 10.1089/lap.2012.0393] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Hee Sung Kim
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Min Gyu Kim
- Department of Surgery, Guri Hospital, Hanyang University School of Medicine, Guri, Korea
| | - Beom Su Kim
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - In Seob Lee
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Sol Lee
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Jeoung Hwan Yook
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
| | - Byung Sik Kim
- Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul, Korea
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Intracorporeal esophagojejunostomy using a circular stapler with a new purse-string suture technique during laparoscopic total gastrectomy. J Am Coll Surg 2012. [PMID: 23200796 DOI: 10.1016/j.jamcollsurg.2012.10.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Eom BW, Kim YW, Lee SE, Ryu KW, Lee JH, Yoon HM, Cho SJ, Kook MC, Kim SJ. Survival and surgical outcomes after laparoscopy-assisted total gastrectomy for gastric cancer: case–control study. Surg Endosc 2012; 26:3273-81. [DOI: 10.1007/s00464-012-2338-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 04/24/2012] [Indexed: 12/13/2022]
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Jeong O, Ryu SY, Zhao XF, Jung MR, Kim KY, Park YK. Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: experience at a large-volume center. Surg Endosc 2012; 26:3418-25. [PMID: 22648120 DOI: 10.1007/s00464-012-2356-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/24/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Despite the popularity of laparoscopic distal gastrectomy (LDG), laparoscopic total gastrectomy (LTG) remains a challenging procedure because of its technical difficulties and possible complications. In this study, the authors evaluated the short-term surgical outcomes and operative risks of LTG. METHODS The records of 118 patients who underwent LTG for middle or upper gastric cancer were retrieved from a prospectively constructed database of 1,064 patients who underwent laparoscopic gastrectomy between 2007 and 2011. Surgical outcomes of LTG, such as operative results, postoperative courses, morbidities, and mortality, were investigated and compared with those of LDG patients. RESULTS Of the 118 LTG patients, one underwent open conversion and three experienced an intraoperative complication. Mean operating time was 292 ± 88 min, and the mean total number of harvested lymph nodes was 41 ± 16. As compared with the LDG group, the LTG group had a significantly longer operation time (292 vs. 220 min, p < 0.001), and significantly more intraoperative blood loss (256 vs. 191 ml, p = 0.002). The overall morbidity rate after LTG was 22.9%, which was significantly higher than after LDG (12.7%, p = 0.002). There were two postoperative mortalities in the LTG group. The most common complications after LTG were anastomosis leakage (n = 9) and luminal bleeding (n = 9), which were followed by anastomosis stricture (n = 4) and abdominal infection (n = 3). Univariate and multivariate analysis revealed that old age [≥60 years, odds ratio (OR) = 2.55, 95% confidence interval (CI) = 0.95-6.84], intraoperative blood loss >200 ml (OR = 3.33, 95% CI = 1.14-9.70), and D2 lymphadenectomy (OR = 3.87, 95% CI = 1.30-11.55) were independent risk factors for postoperative complications after LTG. CONCLUSIONS LTG is a feasible and acceptable procedure for treatment of middle or upper early gastric cancer. Further refinement of anastomosis techniques and considerable experience of laparoscopic gastrectomy are required for proper application of LTG in gastric carcinoma.
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Affiliation(s)
- Oh Jeong
- Department of Surgery, Chonnam National University Hwasun Hospital and Chonnam National University College of Medicine, 160, Ilsim-ri, Hwasun-eup, Hwasun-gun, Jeollanam-do, 519-809, South Korea.
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Abdel Khalek M, Joshi V, Kandil E. Robotic-assisted laparoscopic wedge resection of a gastric leiomyoma with intraoperative ultrasound localization. MINIM INVASIV THER 2011; 20:360-4. [PMID: 21919811 DOI: 10.3109/13645706.2010.549830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Gastric leiomyoma is a rare gastric neoplasm that traditionally has been resected for negative margins using an open approach. The laparoscopic approach may also treat various gastric tumors without opening the gastric cavity. Robotic surgery was developed in response to the limitations and drawbacks of laparoscopic surgery. Herein, we describe a case of robotic-assisted laparoscopic wedge resection of a gastric leiomyoma. A 63-year-old male complaining of abdominal pain was found to have an incidental 3 cm antral mass on an abdominal CT. Endoscopy with endoscopic ultrasound (EUS) confirmed a submucosal mass. Biopsy of the lesion was consistent with a leiomyoma. The DaVinci robotic system was used for partial gastrectomy and reconstruction, with the addition of intraoperative ultrasound to localize the lesion intraoperatively. Pathological examination of the resected mass confirmed a diagnosis of leiomyoma with negative margins. There were no intraoperative or postoperative complications. The patient was discharged home on the second postoperative day. Intraoperative endoscopic ultrasound is a safe technique that may improve the success rate of surgery by confirming the location of the lesion. Robotic assistance in gastric resection offers an easy minimally invasive approach to such tumors. This approach can achieve adequate surgical margins and lead to short hospital stays.
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Affiliation(s)
- Mohamed Abdel Khalek
- Department of Surgery, Department of Medicine, Tulane University School ofMedicine, New Orleans, LA, USA
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Nunobe S, Hiki N, Tanimura S, Kubota T, Kumagai K, Sano T, Yamaguchi T. Three-step esophagojejunal anastomosis with atraumatic anvil insertion technique after laparoscopic total gastrectomy. J Gastrointest Surg 2011; 15:1520-5. [PMID: 21557017 DOI: 10.1007/s11605-011-1489-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 03/10/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Esophagojejunostomy during laparoscopic total gastrectomy (LATG) using a circular stapler is a difficult procedure for which there remains no widely accepted standard technique. Based upon our experience with esophagogastrostomy during laparoscopic proximal gastrectomy, we have applied a modified lift-up method to LATG. MATERIAL AND METHODS Esophagojejunostomy using a modified lift-up method was performed during LATG in 41 patients with early gastric cancer, from July 2005 to June 2010. The lift-up technique comprises three steps, which together reduce the difficulty of anvil insertion by lifting up the nasogastric tube connected to the anvil head. RESULTS During the early stages of the present study, some patients who underwent LATG with the modified lift-up method developed anastomotic leakage, with stenosis occurring in two cases (4.9%) and three cases (7.3%), respectively. All patients who developed complications showed improvement following conservative treatment with no surgical procedure. The anastomotic leaks occurred during the later periods of the study. There was no mortality in the present study. CONCLUSIONS Our modified lift-up technique facilitates circular-stapled esophagojejunostomy in LATG and could provide a more feasible and safe option for an established procedure, especially for preventing anastomotic leak.
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Affiliation(s)
- Souya Nunobe
- Department of Gastrointestinal Surgery, Cancer Institute Ariake Hospital, Tokyo, Japan
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Göpel T, Härtl F, Schneider A, Buss M, Feussner H. Automation of a suturing device for minimally invasive surgery. Surg Endosc 2011; 25:2100-4. [PMID: 21298543 DOI: 10.1007/s00464-010-1532-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 10/26/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND In minimally invasive surgery, hand suturing is categorized as a challenge in technique as well as in its duration. This calls for an easily manageable tool, permitting an all-purpose, cost-efficient, and secure viscerosynthesis. Such a tool for this field already exists: the Autosuture EndoStitch(®). In a series of studies the potential for the EndoStitch to accelerate suturing has been proven. However, its ergonomics still limits its applicability. The goal of this study was twofold: propose an optimized and partially automated EndoStitch and compare the conventional EndoStitch to the optimized and partially automated EndoStitch with respect to the speed and precision of suturing. METHODS Based on the EndoStitch, a partially automated suturing tool has been developed. With the aid of a DC motor, triggered by a button, one can suture by one-fingered handling. Using the partially automated suturing manipulator, 20 surgeons with different levels of laparoscopic experience successfully completed a continuous suture with 10 stitches using the conventional and the partially automated suture manipulator. Before that, each participant was given 1 min of instruction and 1 min for training. Absolute suturing time and stitch accuracy were measured. The quality of the automated EndoStitch with respect to manipulation was tested with the aid of a standardized questionnaire. RESULTS To compare the two instruments, t tests were used for suturing accuracy and time. Of the 20 surgeons with laparoscopic experience (fewer than 5 laparoscopic interventions, n=9; fewer than 20 laparoscopic interventions, n=7; more than 20 laparoscopic interventions, n=4), there was no significant difference between the two tested systems with respect to stitching accuracy. However, the suturing time was significantly shorter with the Autostitch (P=0.01). The difference in accuracy and speed was not statistically significant considering the laparoscopic experience of the surgeons. The weight and size of the Autostitch have been criticized as well as its cable. However, the comfortable handhold, automatic needle change, and ergonomic manipulation have been rated positive. CONCLUSION Partially automated suturing in minimally invasive surgery offers advantages with respect to the speed of operation and ergonomics. Ongoing work in this field has to concentrate on minimization, implementation in robotic systems, and development of new operation methods (NOTES).
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Affiliation(s)
- Tobias Göpel
- Institute of Automatic Control Engineering, Fakultät für Elektro- und Informationstechnik, Technische Universität München, Theresienstraße 90, 80290, Munich, Germany.
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Hur H, Kim JY, Cho YK, Han SU. Technical feasibility of robot-sewn anastomosis in robotic surgery for gastric cancer. J Laparoendosc Adv Surg Tech A 2010; 20:693-697. [PMID: 20809816 DOI: 10.1089/lap.2010.0246] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although several studies have reported on the feasibility of robot-assisted gastric cancer surgery using the da Vinci surgical system, reconstruction techniques have depended on staplers or hand sewing through minilaparotomy. AIM The aim of this study is to report on the feasibility of reconstruction methods using a robot-sewing technique in robotic surgery for treatment of gastric cancer. PATIENT AND METHODS Between January and April 2010, 7 patients in whom gastric adenocarcinoma was diagnosed underwent robotic surgery including robot-sewn anastomosis. We demonstrated the surgical techniques with analysis of clinicopathologic characteristics and surgical outcomes. RESULTS All robotic surgeries were performed without other laparoscopic instruments. Two Roux-en-Y reconstructions for two total gastrectomy, two Roux-en-Y reconstructions, and three gastroduodenostomies, for five subtotal gastrectomies, were successfully accomplished. Total median operation time was 205 minutes, and median reconstruction time was 69 minutes. One patient was readmitted for stasis in the remnant stomach but conservatively recovered. CONCLUSIONS A robot-sewn anastomosis for reconstruction in robotic surgery for gastric cancer was feasible regardless of the reconstruction method.
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Affiliation(s)
- Hoon Hur
- Department of Surgery, School of Medicine, Ajou University, Suwon, Korea
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Kinoshita T, Oshiro T, Ito K, Shibasaki H, Okazumi S, Katoh R. Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy. Surg Endosc 2010; 24:2908-12. [PMID: 20383532 DOI: 10.1007/s00464-010-1041-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 03/13/2010] [Indexed: 12/27/2022]
Abstract
BACKGROUND Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of technical difficulties, especially esophagojejunal anastomosis. Various modified procedures for reconstruction have been reported, but an optimal method has not been established. The authors report a circular-stapled anastomosis using hand-sewn purse-string sutures, which is a simple and classic method. However, no previous study has assessed its reliability. METHODS From September 2008 to May 2009, 10 consecutive patients (9 men and 1 woman) with gastric cancer underwent LTG at the authors' institution. These patients had a median age of 63.7 years (range, 45-80 years) and a body mass index of 22.4 kg/m(2) (range, 18-26 kg/m(2)). After transection of the abdominal esophagus, a hand-sewn purse-string suture along the cut end of the esophagus was performed using 3-0 monofilament thread. An anvil head then was inserted into the esophagus, and the thread was tied. A monofilament pretied loop suture was added to reinforce the ligation. After the creation of an Roux-en-Y jejunal limb, laparoscopic esophagojejunal anastomosis was performed using a circular stapler inserted via a surgical glove attached to a wound retractor at the incision point at the umbilicus. The jejunal stump was closed with an endoscopic linear stapler. RESULTS Laparoscopic esophagojejunostomy was performed successfully for all the patients. No postoperative complications related to anastomosis occurred. In one patient, an intraabdominal abscess developed postoperatively and was treated conservatively. The mean operation time was 257 min, and the estimated blood loss was 69 ml. CONCLUSIONS With the described method, esophagojejunostomy can be performed as in conventional open surgery. Hand-sewn purse-string suturing is demanding technically, but it can be performed safely by experienced laparoscopic surgeons. This technique is feasible and can lower the cost of the laparoscopic procedure. It may be considered in countries with limited access to other special devices.
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Affiliation(s)
- Takahiro Kinoshita
- Department of Surgery, Toho University Sakura Medical Center, Shimoshizu 564-1, Sakura, 285-8741, Chiba, Japan.
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Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™) after laparoscopic total gastrectomy. Surg Endosc 2009; 23:2624-30. [DOI: 10.1007/s00464-009-0461-z] [Citation(s) in RCA: 135] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2009] [Accepted: 03/14/2009] [Indexed: 12/13/2022]
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Omori T, Oyama T, Mizutani S, Tori M, Nakajima K, Akamatsu H, Nakahara M, Nishida T. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg 2009; 197:e13-7. [DOI: 10.1016/j.amjsurg.2008.04.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 04/03/2008] [Accepted: 04/03/2008] [Indexed: 12/15/2022]
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Kim SG, Lee YJ, Ha WS, Jung EJ, Ju YT, Jeong CY, Hong SC, Choi SK, Park ST, Bae K. LATG with extracorporeal esophagojejunostomy: is this minimal invasive surgery for gastric cancer? J Laparoendosc Adv Surg Tech A 2008; 18:572-8. [PMID: 18721007 DOI: 10.1089/lap.2007.0106] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This retrospective study determined whether extracorporeal esophagojejunostomy after laparoscopy-assisted total gastrectomy (LATG) for gastric cancer can be considered minimally invasive surgery, compared to the conventional open total gastrectomy (OTG). PATIENTS AND METHODS This retrospective study involved 60 patients seen between January 2004 and July 2006. Twenty-seven patients underwent LATG, and 33 patients had OTG. The surgical procedure included the use of five ports with an upper vertical midline incision. In all patients, reconstruction was performed by using a Roux-en-Y esophagojejunostomy through the minilaparotomy site. In all cases, the jejunojejunostomy was performed extracorporeally as the conventional method. In OTG, a Roux-en-Y esophagojejunostomy was performed with an upper midline incision. RESULTS The mean number of retrieved lymph nodes was smaller and the mean operating time was longer in the LATG group. The postoperative hospital course was similar in both groups. In the LATG group, the mean length of the minilaparotomy incision was 8.0+/-1.2 cm (maximum length, 11 cm), and a direct relationship was observed between the distance from the xiphoid process to the esophageal hiatus (DisXE) and the minilaparotomy incision length (Spearman's correlation of rank coefficient: 0.386; P=0.046). CONCLUSIONS With the concept of minimal invasiveness, if the patient's DisXE exceeds 9 cm, the length of the minilaparotomy incision in laparoscopic surgery could be disadvantageous. Nevertheless, we consider LATG the treatment of choice for early gastric cancer. If the patient's DisXE exceeds 9 cm, we consider intracorporeal anastomosis with the laparoscopic total gastrectomy. The type of esophagojejunostomy may be determined preoperatively by using three-dimensional abdominal computed tomography.
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Affiliation(s)
- Sang-Gi Kim
- Department of Surgery, Postgraduate School of Medicine, Gyeongsang National University, Gyeongsang National University Hospital, Jinju, Gyeongsangnam-do, Korea
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Ziqiang W, ZhiMin C, Jun C, Xiao L, Huaxing L, PeiWu Y. A modified method of laparoscopic side-to-side esophagojejunal anastomosis: report of 14 cases. Surg Endosc 2008; 22:2091-4. [DOI: 10.1007/s00464-008-9744-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Revised: 10/15/2007] [Accepted: 11/28/2007] [Indexed: 12/28/2022]
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