Intracorporeal esophagojejunostomy with Roux-en-Y reconstruction after laparoscopic total gastrectomy
Editorial

Intracorporeal esophagojejunostomy with Roux-en-Y reconstruction after laparoscopic total gastrectomy

Mikito Inokuchi1, Toshiro Tanioka1, Masatoshi Nakagawa1, Kazuyuki Kojima2

1Department of Gastrointestinal Surgery, 2Center for Minimally Invasive Surgery, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan

Correspondence to: Mikito Inokuchi, MD, PhD. Department of Gastrointestinal Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. Email: m-inokuchi.srg2@tmd.ac.jp.

Provenance: This is an invited article commissioned by Editor-in-Chief Minhua Zheng (Department of General Surgery, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai Minimal Invasive Surgery, Shanghai, China).

Comment on: Hong J, Wang YP, Wang J, et al. A novel method of self-pulling and latter transected reconstruction in totally laparoscopic total gastrectomy: feasibility and short-term safety. Surg Endosc 2017;31:2968-76.


Received: 26 September 2017; Accepted: 10 October 2017; Published: 20 October 2017.

doi: 10.21037/ales.2017.10.01


Laparoscopic gastrectomy has been established as a minimally invasive treatment. Laparoscopic total gastrectomy or laparoscopy-assisted total gastrectomy (LTG) is being more frequently performed, but requires a more complex surgical procedure (1). Anastomotic leakage of the esophagojejunostomy after LTG can negatively affect the quality of life of patients by prolonging the postoperative hospital stay and increasing the risk of reoperation and even mortality. In our previous meta-analysis, LTG had slightly higher incidences of anastomotic complications such as leakage and stenosis than did open total gastrectomy (3.0% vs 2.1%) (2). According to the Japanese National Clinical Database, the incidence of anastomotic leakage was 4.4% among more than 20,000 patients who underwent total gastrectomy, including both open and laparoscopic approaches in 2011 (3). Various procedures for intracorporeal esophagojejunostomy have frequently been reported, because an intracorporeal approach provides a better view of the anastomosis than an extracorporeal approach (4-10). A new device (OrVilTM, Covidien, Mansfield, MA, USA) using a transorally inserted anvil and a circular stapler was developed to perform intracorporeal esophagojejunostomy (11). However, the incidences of anastomotic leakage were similar for intracorporeal procedures (1.1–3.2%) and extracorporeal procedures (2.1%) in our previous review (2). The best procedure should reduce the risk of postoperative complications in patients and be easily performed by all surgeons, although which procedure is best remains unclear.

Hong et al. recently described a modified procedure for totally intracorporeal Roux-en-Y reconstruction after LTG, referred to as the self-pulling and latter transection (SPLT) technique (12). Their procedure is based on construction of a functional end-to-end anastomosis (FEEA) with the use of linear staplers. One distinctive feature of the SLPT procedure is ligation of the cardia using a hemp rope before making the entry hall. This step can prevent the implantation of tumor cells and pollution of the peritoneal cavity by gastric contents. Another feature is synchronized closure of the entry hall with removal of stomach. The SPLT procedure is reasonable and was not associated with anastomotic leakage or stenosis in 40 patients. However, the SPLT procedure seems to have several critical problems similar to esophagojejunostomy constructed by FEEA. First, the lower esophagus must be adequately mobilized to the mediastinum. Second, the procedure is difficult to perform after resection of esophagogastric junction cancer, in which anastomosis should be performed in the mediastinum, because closure of the entry hall by a stapler is technically difficult in the narrow space of mediastinum. In addition, preceding transection of esophagus sometimes makes it easy to dissect lymph nodes along the left inferior phrenic artery, short gastric artery, or splenic artery. In the study by Hong et al., the SPLT procedure was applied even for tumors with serosal invasion (12). However, the tumor specimen was moved without protection during reconstruction, which may have increased the risk of scattering tumor cells from tumors with serosal invasion. Therefore, the procedure might not be feasible in patients with far advanced tumors.

The procedure for intracorporeal esophagojejunostomy can be performed by using either linear staplers or circular staplers. In a review of esophagojejunostomy after LTG by Umemura et al., the use of circular staplers was significantly associated with higher incidences of both anastomotic leakage (4.7%) and stenosis (8.3%) as compared with the use of linear staplers (1.1% and 1.8%, respectively) (13). Moreover, the procedures for intracorporeal esophagojejunostomy were classified into five types in detail, although the incidence of anastomotic leakage was similar among those types (2). On the other hand, the incidence of anastomotic stenosis was higher in the procedures that used an OrVilTM transoral anvil delivery system (8.8%) than in the other procedures (1.0–3.6%) (2). Use of a smaller OrVilTM anvil increased the incidence of anastomotic stenosis (14). In a retrospective comparative study, the risk of anastomotic stenosis of the intracorporeal esophagojejunostomy was significantly lower with the overlap procedure performed using a linear stapler than with the use of an OrVilTM anvil (15). Another Japanese multicenter study also showed that FEEA significantly reduced anastomotic leakage of esophagojejunostomy than the use of a circular stapler (16). The use of a linear stapler can secure a large delta-shaped anastomosis as compared with the use of a circular stapler, thus reducing the risk of anastomotic stenosis. The use of a circular stapler has some difficulties associated with insertion of the anvil head into the esophagus, while ischemia, which is cause of anastomotic leakage, is an important concern at the double or hemi-double stapled margin after the use of an OrVilTM anvil. Indeed, the use of an OrVilTM anvil tended to increase anastomotic leakage in the study as compared with the use of linear staplers (15). The anastomotic procedures performed using linear staplers are classified into two types: overlap procedure and FEEA. The overlap procedure is isoperistaltic anastomosis, and the entry hall for inserting a stapler is closed by hand-sewing or a linear stapler. An inverse T-shaped anastomosis is classified as an overlap procedure (17). The FEEA is an antiperistaltic anastomosis, and the entry hall is usually closed with the use of a linear stapler. Anastomotic leakage and stenosis did not differ between the overlap procedure and FEEA in our previous review (overlap, 2.9% and 1.0%; FEEA, 1.1% and 2.2%; respectively) (2). The use of a linear stapler is also associated with several problems; for example, longer dissection of the esophagus is sometimes required for insertion of a linear stapler. The FEEA is more difficult to complete in patients in whom the anastomosis has to be performed in the mediastinum because of poor operability (16). In addition, ischemia of the double-stapled margin is a concern with FEEA. Overlap procedure also requires skilled technique to close of the entry hall in the mediastinum.

Less experience of surgeons was significantly associated with the incidence of postoperative local complications in a study of laparoscopic distal gastrectomy (18). The incidence of anastomotic leakage was higher during the early introduction phase of LTG in a retrospective study. However, an independent risk factor for anastomotic leakage was the prognostic nutritional index in that study (19). In a single-institutional retrospective study of LTG, postoperative complications did not differ among three periods classified according to the esophagojejunostomy procedures performed. Various procedures decided by the surgeon were used during the first period. An OrVilTM delivery system was used during the second period, and FEEA was used during the third period (20). Experience performing LTG in approximately 45 or 100 patients was required to master the procedure according to studies of the learning curve associated with LTG (21,22). A prospective phase II study of LTG and laparoscopic proximal gastrectomy is ongoing in Japan, with anastomotic leakage as the primary endpoint, and that study is expected to provide conclusive evidence on anastomotic problems of esophagojejunostomy after laparoscopic gastrectomy (23).

The best procedure for esophagojejunostomy probably differs according to the surgeon, and a standardized procedure for esophagojejunostomy may be the key to successful esophagojejunostomy. Much experience and improved procedures can reduce the risk of anastomotic problems after LTG.


Acknowledgements

None.


Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.


References

  1. Kunisaki C, Makino H, Takagawa R, et al. A systematic review of laparoscopic total gastrectomy for gastric cancer. Gastric Cancer 2015;18:218-26. [Crossref] [PubMed]
  2. Inokuchi M, Otsuki S, Fujimori Y, et al. Systematic review of anastomotic complications of esophagojejunostomy after laparoscopic total gastrectomy. World J Gastroenterol 2015;21:9656-65. [Crossref] [PubMed]
  3. Watanabe M, Miyata H, Gotoh M, et al. Total gastrectomy risk model: data from 20,011 Japanese patients in a nationwide internet-based database. Ann Surg 2014;260:1034-9. [Crossref] [PubMed]
  4. Usui S, Nagai K, Hiranuma S, et al. Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument "Endo-PSI (II)" and circular stapler. Gastric Cancer 2008;11:233-7. [Crossref] [PubMed]
  5. Kinoshita T, Oshiro T, Ito K, et al. Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy. Surg Endosc 2010;24:2908-12. [Crossref] [PubMed]
  6. Omori T, Oyama T, Mizutani S, et al. A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy. Am J Surg 2009;197:e13-7. [Crossref] [PubMed]
  7. Nunobe S, Hiki N, Tanimura S, et al. Three-step esophagojejunal anastomosis with atraumatic anvil insertion technique after laparoscopic total gastrectomy. J Gastrointest Surg 2011;15:1520-5. [Crossref] [PubMed]
  8. Huscher CG, Mingoli A, Sgarzini G, et al. Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer: early and long-term results of a 100-patient series. Am J Surg 2007;194:839-44; discussion 844. [Crossref] [PubMed]
  9. Inaba K, Satoh S, Ishida Y, et al. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg 2010;211:e25-9. [Crossref] [PubMed]
  10. Ziqiang W. A modified method of laparoscopic side-to-side esophagojejunal anastomosis: report of 14 cases. Surg Endosc 2008;22:2091-4. [Crossref] [PubMed]
  11. Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil) after laparoscopic total gastrectomy. Surg Endosc 2009;23:2624-30. [Crossref] [PubMed]
  12. Hong J, Wang YP, Wang J, et al. A novel method of self-pulling and latter transected reconstruction in totally laparoscopic total gastrectomy: feasibility and short-term safety. Surg Endosc 2017;31:2968-76. [Crossref] [PubMed]
  13. Umemura A, Koeda K, Sasaki A, et al. Totally laparoscopic total gastrectomy for gastric cancer: literature review and comparison of the procedure of esophagojejunostomy. Asian J Surg 2015;38:102-12. [Crossref] [PubMed]
  14. Zuiki T, Hosoya Y, Kaneda Y, et al. Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy. Surg Endosc 2013;27:3683-9. [Crossref] [PubMed]
  15. Kawamura H, Ohno Y, Ichikawa N, et al. Anastomotic complications after laparoscopic total gastrectomy with esophagojejunostomy constructed by circular stapler (OrVil™) versus linear stapler (overlap method). Surg Endosc 2017. [Epub ahead of print]. [Crossref] [PubMed]
  16. Sugiyama M, Oki E, Ogaki K, et al. Clinical Outcomes of Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy: A Multicenter Study. Surg Laparosc Endosc Percutan Tech 2017;27:e87-91. [Crossref] [PubMed]
  17. Nagai E, Ohuchida K, Nakata K, et al. Feasibility and safety of intracorporeal esophagojejunostomy after laparoscopic total gastrectomy: inverted T-shaped anastomosis using linear staplers. Surgery 2013;153:732-8. [Crossref] [PubMed]
  18. Kim W, Song KY, Lee HJ, et al. The impact of comorbidity on surgical outcomes in laparoscopy-assisted distal gastrectomy: a retrospective analysis of multicenter results. Ann Surg 2008;248:793-9. [Crossref] [PubMed]
  19. Oshi M, Kunisaki C, Miyamoto H, et al. Risk Factors for Anastomotic Leakage of Esophagojejunostomy after Laparoscopy-Assisted Total Gastrectomy for Gastric Cancer. Dig Surg 2017. [Epub ahead of print]. [Crossref] [PubMed]
  20. Yasukawa D, Hori T, Kadokawa Y, et al. Impact of stepwise introduction of esophagojejunostomy during laparoscopic total gastrectomy: a single-center experience in Japan. Ann Gastroenterol 2017;30:564-70. [PubMed]
  21. Jeong O, Ryu SY, Choi WY, et al. Risk factors and learning curve associated with postoperative morbidity of laparoscopic total gastrectomy for gastric carcinoma. Ann Surg Oncol 2014;21:2994-3001. [Crossref] [PubMed]
  22. Jung DH, Son SY, Park YS, et al. The learning curve associated with laparoscopic total gastrectomy. Gastric Cancer 2016;19:264-72. [Crossref] [PubMed]
  23. Kataoka K, Katai H, Mizusawa J, et al. Non-Randomized Confirmatory Trial of Laparoscopy-Assisted Total Gastrectomy and Proximal Gastrectomy with Nodal Dissection for Clinical Stage I Gastric Cancer: Japan Clinical Oncology Group Study JCOG1401. J Gastric Cancer 2016;16:93-7. [Crossref] [PubMed]
doi: 10.21037/ales.2017.10.01
Cite this article as: Inokuchi M, Tanioka T, Nakagawa M, Kojima K. Intracorporeal esophagojejunostomy with Roux-en-Y reconstruction after laparoscopic total gastrectomy. Ann Laparosc Endosc Surg 2017;2:153.

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