• Gastric cancer
• Minimally invasive surgery
• Overlap method
• Reconstruction

• Humans
• Gastrectomy/methods
• Gastrectomy/instrumentation
• Gastrectomy/adverse effects
• Male
• Female
• Retrospective Studies
• Middle Aged
• Aged
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Operative Time
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Stomach Neoplasms/surgery
• Surgical Staplers
• Anastomosis, Surgical/methods
• Anastomosis, Surgical/instrumentation
• Robotic Surgical Procedures/methods
• Suture Techniques/instrumentation
• Treatment Outcome
• Jejunum/surgery
• Surgical Stapling/instrumentation
• Surgical Stapling/methods
• Anastomosis, Roux-en-Y/methods

• Gastroesophageal junction cancer
• Overlap anastomosis
• Totally laparoscopic total gastrectomy
• π-shaped anastomosis

• Humans
• Gastrectomy/methods
• Laparoscopy/methods
• Stomach Neoplasms/surgery
• Male
• Female
• Retrospective Studies
• Anastomosis, Surgical/methods
• Anastomosis, Surgical/adverse effects
• Middle Aged
• Aged
• Esophagus/surgery
• Jejunum/surgery
• Adult
• Postoperative Complications/epidemiology
• Treatment Outcome

• No. QNJJ2022019 Clinical Research Fund For Distinguished Young Scholars of Beijing Cancer Hospital
• No. 82171720 National Natural Science Foundation of China
• ZYLX202116 Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support

• gastric cancer
• laparoscopic-assisted total gastrectomy
• overlap reconstruction
• postoperative complications
• randomized controlled trial
• siewert iii esophagogastric junction cancer
• totally laparoscopic total gastrectomy

• Humans
• Stomach Neoplasms/surgery
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Gastrectomy/methods
• Gastrectomy/adverse effects
• Female
• Male
• Esophagogastric Junction/surgery
• Esophagogastric Junction/pathology
• Middle Aged
• Laparoscopy/methods
• Laparoscopy/adverse effects
• Aged
• Treatment Outcome
• Postoperative Complications/epidemiology
• Adult

• Gastric cancer
• High-resolution impedance manometry
• Intraesophageal pressure
• Lower esophageal sphincter
• Postgastrectomy syndrome assessment scale-37
• Total gastrectomy

• Humans
• Gastrectomy/methods
• Quality of Life
• Male
• Female
• Retrospective Studies
• Middle Aged
• Stomach Neoplasms/surgery
• Manometry
• Aged
• Pressure
• Anastomosis, Roux-en-Y
• Esophagus/surgery
• Esophagus/physiopathology
• Postgastrectomy Syndromes/etiology
• Postgastrectomy Syndromes/physiopathology
• Adult

• Esophagojejunal reconstruction
• Esophagojejunostomy
• Gastric cancer
• Intracorporeal esophagojejunostomy
• Minimally invasive total gastrectomy
• Quality-of-life

• Humans
• Quality of Life
• Retrospective Studies
• Stomach Neoplasms/surgery
• Stomach Neoplasms/pathology
• Anastomosis, Surgical/adverse effects
• Anastomosis, Surgical/methods
• Laparoscopy/methods
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Diarrhea
• Treatment Outcome
• Postoperative Complications/epidemiology

• SU2CAACR-30-20 - 237459 SU2C Gastric Cancer Interception Award
• 2020KJ165 Natural Science Foundation of Tianjin Municipal Education Commission
• City of Hope

• Humans
• Retrospective Studies
• Constriction, Pathologic
• Laparoscopy/methods
• Anastomosis, Surgical/adverse effects
• Gastrectomy/methods
• Stomach Neoplasms/pathology
• Postoperative Complications/etiology
• Esophagogastric Junction/surgery
• Esophagogastric Junction/pathology
• Treatment Outcome

• 2021CR001 Clinical Research Program of Nanfang Hospital, Southern Medical University

• Laparoscopy
• Latter transection
• Oesophagojejunostomy
• Overlap
• Self-pulling

• Anvil
• Circular stapler
• Esophagojejunostomy
• Gastric cancer
• Laparoscopic total gastrectomy

• Gastric cancer
• Laparoscopic total gastrectomy
• Overall survival
• Postoperative complications
• Prognosis

• digestive tract reconstruction
• gastric cancer
• laparoscope
• total gastrectomy
• uncut Roux-en-Y

Overlapped esophagojejunostomy (OEJ) is a secure purely laparoscopic reconstruction after laparoscopic total gastrectomy (LTG). However, long-term surgical results have not been documented well.

In this paper, we report unusual patients who manifested jejunal limb stricture near the esophageal hiatus without anastomotic stenosis during long-term observation after surgery.

From April 2009 until May 2020, we retrospectively reviewed 211 patients underwent LTG following by OEJ for gastric carcinoma and took a standard surveillance program. We aimed to characterize a novel complicated disorder observed in these patients to assist treatment and prevention.

Five patients (2.4%) had unusual jejunal limb stricture after LTG and OEJ, occurring at a mean of 10 mo after initial radical LTG. All five patients had disturbed oral intake and marked weight loss, and two had aspiration pneumonia. Various diagnostic modalities and intraoperative findings in each patient revealed an intact anastomosis, bent or tortuous jejunal limb resulting from loose fibrous adhesions on the left crus at the esophageal hiatus and no cancer recurrence. All five patients were successfully treated by reoperation for adhesiolysis, division of the left crus and rearrangement of the jejunal limb.

Disturbed passage through the jejunal limb near the hiatus can occur after some types of OEJ following LTG. We speculate that it may result from a short remnant esophagus, excessive mobilization of the jejunal limb that permits bending or tortuosity and adhesions on the left crus at the hiatus. Prevention for this complication is possible during the original LTG procedure.

• Laparoscopic total gastrectomy
• Overlapped esophagojejunostomy
• Anastomotic stenosis
• Adhesiolysis
• Gastric carcinoma

Following a total gastrectomy, patients suffer the most severe form of postgastrectomy syndrome. This is a significant clinical problem as it reduces quality of life (QOL). Roux-en-Y reconstruction, which is regarded as the gold standard for post-total gastrectomy reconstruction, can be performed using various techniques. Although the technique used could affect postoperative QOL, there are no previous reports regarding the same.

To investigate the effect of different techniques on postoperative QOL. The data was collected from the registry of the postgastrectomy syndrome assessment study (PGSAS).

In the present study, we analyzed 393 total gastrectomy patients from those enrolled in PGSAS. Patients were divided into groups depending on whether antecolic or retrocolic jejunal elevation was performed, whether the Roux limb was “40 cm”, “shorter” (≤ 39 cm), or “longer” (≥ 41 cm), and whether the device used for esophageal and jejunal anastomosis was a circular or linear stapler. Subsequently, we comparatively investigated postoperative QOL of the patients.

Reconstruction route: Esophageal reflux subscale (SS) occurred significantly less frequently in patients who underwent antecolic reconstruction. Roux limb length: “Shorter” Roux limb did not facilitate esophageal reflux SS and somewhat attenuated indigestion SS and abdominal pain SS. Anastomosis technique: In terms of esophagojejunostomy techniques, no differences were observed.

The techniques used for total gastrectomy with Roux-en-Y reconstruction significantly affected postoperative symptoms. Our results suggest that elevating the Roux limb, which is not overly long, through an antecolic route may improve patients’ QOL.

• Total gastrectomy
• Roux-en-Y
• Postgastrectomy syndrome
• Quality of life
• Postgastrectomy Syndrome Assessment Scale-45

• Anastomosis technique
• gastric cancer
• laparoscopic total gastrectomy
• oesophagojejunostomy

• Gastric/gastroesophageal junction (G/GEJ) tumors
• Laparoscopy total gastrectomy
• OGT
• Overlap esophagojejunostomy

This study aimed to compare the surgical outcomes of total laparoscopic total gastrectomy without mesentery division (LTG without MD) and conventional total laparoscopic total gastrectomy (CLTG), as well as evaluate the appropriate method for esophagojejunostomy (EJ) reconstruction after total laparoscopic total gastrectomy (TLTG).

We retrospectively analyzed data from 301 consecutive patients who underwent TLTG for upper or middle third gastric cancer between January 2016 and May 2019. After propensity score matching, 95 patients who underwent LTG without MD and 95 who underwent CLTG were assessed. Data on clinical characteristics and surgical outcomes, including operation time, length of postoperative hospital stay, pathological findings, and postoperative complications were analyzed.

The LTG without MD group showed a shorter time to first flatus (3.26±0.80 vs. 3.62±0.81 days, P=0.003) and a shorter time to soft diet (2.80±2.09 vs. 3.52±2.20 days, P=0.002). The total EJ-related complications in the LTG without MD group were comparable to those in the CLTG group (9.47% vs. 3.16%, P=0.083). EJ-related leakage (6.32% vs. 3.16%, P=0.317) and EJ-related stricture (3.16% vs. 1.05%, P=0.317) rates were not significantly different between the LTG without MD and CLTG groups. No significant differences were found between the two groups in terms of other early surgical outcomes such as early complications, late complications, hospital stay, and readmission rate.

LTG without MD is a safe surgical treatment for upper or middle third gastric cancer. LTG without MD may be an alternative procedure for EJ anastomosis during TLTG.

• Anastomosis
• Gastrectomy
• Laparoscopic surgery
• Stomach neoplasms

Totally laparoscopic total gastrectomy (TLTG) using the overlap reconstruction method is associated with fewer postoperative complications and fast recovery than laparoscopic-assisted radical total gastrectomy (LATG). However, evidence on the safety and feasibility of TLTG (overlap reconstruction) in patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach is scarce.

This study is a prospective, single-center, single-blind, two-arm randomized controlled trial designed to include 292 patients with advanced Siewert III esophagogastric junction cancer and gastric cancer of the upper and middle third of the stomach who will be randomly assigned to two groups: a TLTG overlap group (n=146) and an LATG group (n=146). The patients’ demographics, pathological characteristics, intraoperative variables, postoperative complications, postoperative recovery variables, 3-year disease-free survival and 3-year overall survival will be collected and analyzed. The primary outcome is the postoperative complications within 30 days after surgery including intra-abdominal hemorrhage, anastomotic leakage, duodenal stump fistula, pancreatic fistula, chyle leakage, abdominal infection, intestinal obstruction, wound complications, pulmonary infection, pleural effusion, pulmonary embolism, cardiovascular and cerebrovascular complications, and deep vein thrombosis. The secondary outcomes are the 3-year disease-free survival and 3-year overall survival.

This trial will provide high-level evidence for the safety and feasibility of TLTG (overlap reconstruction) compared with LATG in advanced Siewert III esophagogastric junction cancer and the upper and middle third of gastric cancer.

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

• Siewert III esophagogastric junction cancer
• gastric cancer
• laparoscopic-assisted total gastrectomy
• overlap reconstruction
• randomized controlled trial
• totally laparoscopic total gastrectomy

• Esophagojejunostomy
• Gastric cancer
• Laparoscopy
• Overlap

• circular stapler
• esophagojejunostomy
• laparoscopic total gastrectomy

In addition to the popularity of laparoscopic gastrectomy (LG), many reconstructive procedures after LG have been reported. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer (GC). Presently, no consensus exists regarding the optimal reconstructive procedure. In this review, the current state of digestive tract reconstruction after LG is reviewed. According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction, we divide these reconstruction procedures into three categories consistent with the resection procedures. We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes (length of surgery and blood loss) and postoperative complications (anastomotic leakage and stricture) to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

• Digestive tract reconstruction
• Laparoscopic gastrectomy
• Gastric cancer
• Quality of life

• Complication
• Esophagojejunostomy
• Gastric cancer
• Laparoscopic surgery
• Total gastrectomy

• hand-sewn
• intracorporeal anastomosis
• laparoscopic gastrectomy
• stomach neoplasms

• Anastomosis, Surgical/methods
• Female
• Gastrectomy/methods
• Gastric Bypass/methods
• Humans
• Laparoscopy/methods
• Lymph Node Excision
• Male
• Middle Aged
• Neoplasm Staging
• Operative Time
• Postoperative Complications
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery

The overlap method is one of the most popular procedures for construction of an esophagojejunostomy and its common entry is usually closed with sutures. This study aimed to report long-term complications and surgical outcomes of the overlap method with stapled closure (OMSC), to compare them with those of laparoscopy-assisted total gastrectomy (LATG), and to analyze a learning curve.

Between January 2015 and August 2017, 100 consecutive patients underwent laparoscopic total gastrectomy with OMSC for gastric cancer and the patients’ medical records were reviewed. Their clinicopathologic characteristics, surgical outcomes, and long-term complications were investigated and compared with those of the LATG group. A learning curve of OMSC was analyzed using the Exponentially Weighted Moving Average chart.

The overall duration of surgery was shorter in the LATG group; however, there was no difference in patients with early gastric cancer. Hospital admission was shorter and the pain scale was lower in the OMSC group. There was no difference in the number of harvested lymph nodes, date of flatus, or incidence of postoperative morbidity. Both groups showed no duodenal stump leakage, anastomosis-related complications, recurrence, or mortality during the follow-up period. Petersen hernia was a notable long-term event following OMSC compared with LATG. At least 27 cases of surgery were required to reach a plateau in terms of surgery duration for OMSC.

OMSC is a safe option for the treatment of gastric cancer and has favorable long-term results and surgical outcomes. Closure of mesenteric defects and Petersen space should be considered.

• Anastomotic stenosis
• Circular stapler
• Esophagojejunostomy
• Linear stapler
• Totally laparoscopic total gastrectomy

• Adult
• Aged
• Aged, 80 and over
• Anastomosis, Surgical/methods
• Esophagoplasty/methods
• Female
• Gastrectomy/methods
• Humans
• Laparoscopy/methods
• Male
• Middle Aged
• Propensity Score
• Retrospective Studies

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.

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.

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).

The overlap method was superior to the HDST with respect to anastomotic complications, especially anastomosis stricture.

• Anastomosis, Roux-en-Y
• Gastrectomy
• Gastric cancer
• Laparoscopy
• Postoperative complication

Laparoscopy-assisted radical total gastrectomy is technically demanding.

To introduce the “enjoyable space” approach to achieve D2 plus complete mesogastrium excision (CME) and to investigate its safety and feasibility.

Between January 2015 and December 2017, 165 patients with primary advanced upper gastric cancer underwent laparoscopy-assisted radical total gastrectomy. Among these patients, 81 underwent conventional D2 total gastrectomy (D2 group) and 84 underwent D2 plus CME total gastrectomy (D2 + CME group). Clinicopathological characteristics, surgical outcomes and postoperative complications were compared between the two groups.

There were no significant differences between the two groups (p > 0.05) in clinicopathological characteristics. However, the D2 + CME group had a longer mean operative time, lower mean blood loss and slightly higher mean number of retrieved lymph nodes (LNs) than the D2 group (p < 0.05 each). The mean time to first flatus, liquid diet, and soft diet and the duration of hospital stay were similar between the two groups (p > 0.05 each). No significant difference in postoperative complication rates was found between the groups (16.0% vs. 9.5%, p > 0.05).

The “enjoyable space” approach is an option to achieve D2 + CME, and its safety and feasibility over conventional method are confirmed with lower intraoperative blood loss and more harvested LNs.

• D2 lymphadenectomy
• complete mesogastrium excision
• gastric cancer
• laparoscopic surgery
• “enjoyable space” approach

Complete mesogastrium excision (CME) of the perigastric mesogastrium and dissection of lymph nodes (LNs) no. 10 and no. 11 remain technically challenging aspects of laparoscopic radical total gastrectomy (LRTG) plus CME. To address some of these difficulties, we introduced the laparoscopic perigastric mesogastrium excision technique (LPMET) and the concept of the “enjoyable space” to partly modify the procedures of conventional radical surgery and characterize the perigastric space and the surgical plane as well as its boundaries.

To introduce the laparoscopic perigastric mesogastrium excision technique (LPMET) and the “enjoyable space” when undergoing laparoscopic radical total gastrectomy.

From July 2016 to June 2017, 79 cases of upper gastric cancer that were treated by laparoscopic D2 gastrectomy plus CME were investigated. The retrospective database included the patient characteristics, intraoperative and postoperative outcomes, and morbidity and mortality rates depending on the completeness of their medical records.

Laparoscopic D2 gastrectomy plus CME was successfully performed in all 79 cases. The mean surgical time was 232.5 ±46.0 min, and the intraoperative blood loss was 67.6 ±52.3 ml. A total of 2245 LNs were retrieved (mean 28.1 ±10.8 retrieved from each specimen). The mean postoperative hospital stay was 10.3 ±1.6 days. The postoperative morbidity rate was 17.7%. After a median follow-up period of 12 months, one patient experienced liver metastasis; of the other 78 patients, none died or experienced tumor recurrence or metastasis.

Laparoscopic perigastric mesogastrium excision technique and the “enjoyable space” could be a novel, minimally invasive approach and space to achieve CME and provide benefit for the dissection of LNs no. 10 and no. 11.

• D2 lymphadenectomy
• enjoyable space
• gastric cancer
• laparoscopic surgery

Aortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy.

A 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site.

To our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

• Aortoenteric fistula
• Esophagogastric junction
• Linear stapler
• Overlap anastomosis

• esophagojejunostomy
• gastric cancer
• laparoscopic total gastrectomy
• lymphadenectomy
• postoperative complication

• Gastric cancer
• Intractable stenosis
• Laparoscopic total gastrectomy
• OrVil™
• Roux-en-Y reconstruction
• Twisting of the esophagojejunostomy

• Esophagojejunostomy
• Hand sewn
• Laparoscopy

• Esophagojejunostomy
• Gastric cancer
• Laparoscopic surgery

• Aged
• Anastomosis, Surgical/methods
• Esophagoplasty/methods
• Esophagus/surgery
• Female
• Gastrectomy/methods
• Humans
• Intestines/surgery
• Jejunostomy/methods
• Jejunum/surgery
• Laparoscopy/methods
• Length of Stay
• Male
• Middle Aged
• Retrospective Studies
• Robotic Surgical Procedures/methods
• Stomach Neoplasms/surgery
• Surgical Stapling/methods
• Suture Techniques
• Sutures

• Keywords Esophagojejunostomy
• gastric cancer
• laparoscopic total gastrectomy

• Anastomotic complication
• Esophagojejunostomy
• Gastric cancer
• Laparoscopic gastrectomy
• Total gastrectomy

• Esophagojejunostomy
• Gastric cancer
• Linear stapler
• Overlap method
• Totally laparoscopic total gastrectomy