J Gastric Cancer.  2019 Sep;19(3):290-300. 10.5230/jgc.2019.19.e26.

A Novel Technique of Hand-Sewn Purse-String Suturing by Double Ligation Method (DLM) for Intracorporeal Circular Esophagojejunostomy

• Takayama Y
• Kaneoka Y
• Maeda A
• Fukami Y
• Takahashi
• Uji M

• KMID: 2458829
• DOI: http://doi.org/10.5230/jgc.2019.19.e26

Abstract

PURPOSE
The optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus.
MATERIALS AND METHODS
This retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods.
RESULTS
The average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien-Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed.
CONCLUSIONS
Our procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.

Keyword

Laparoscopy; Gastrectomy; Anastomosis; Postoperative complications

MeSH Terms

Anastomotic Leak
Classification
Constriction, Pathologic
Dilatation
Esophagus
Gastrectomy
Head
Humans
Incidence
Laparoscopy
Ligation*
Methods*
Mortality
Postoperative Complications
Retrospective Studies
Sutures

Figure

• 

  Fig. 1 Trocar placement. Infra-umbilical incision sites (12 mm) for the scope; right upper port (5 mm) for the instruments in the left hand of the operator; left upper port (5 mm) for the instruments in the right hand of the assistant; right lower port (12 mm) for the instruments in the right hand of the operator; and left lower port (5 mm) for the instruments in the left hand of the assistant. An aspiration tube was introduced through the 5 mm port on the right side of the umbilical port (5 mm) (arrow) for the aspirating tube in the right hand of the scopist.

• 

  Fig. 2 Anvil fixation technique. (A) After incising 3/4 of the esophageal wall, a laparoscopic hand-sewn purse-string suturing was performed. (B) An anvil rim was introduced into the esophageal lumen by sliding on the posterior wall of the esophagus. (C) The purse-string suturing was ligated. (D) Kelly forceps were passed through the posterior wall of the esophagus to grasp the ligated thread. (E) The ligated thread was turned through the posterior wall of the esophagus. (F) The turned thread was ligated again. (G) The remnant esophageal wall was incised. (H) The anvil fixation was completed.

• 

  Fig. 3 The schema of purse-string suturing for anvil fixation into the esophagus. (A) After incising 3/4 of the esophageal wall, a hand-sewn purse-string suturing was performed. (B) After ligation, the ligated thread was turned through the remnant posterior wall of the esophagus.

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