J Gastric Cancer.  2019 Sep;19(3):344-354. 10.5230/jgc.2019.19.e34.

Esophagojejunal Anastomosis after Laparoscopic Total Gastrectomy for Gastric Cancer: Circular versus Linear Stapling

• Park KB
• Kim EY
• Song KY

• KMID: 2458833
• DOI: http://doi.org/10.5230/jgc.2019.19.e34

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.

Keyword

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

MeSH Terms

Anastomosis, Roux-en-Y
Constriction, Pathologic
Gastrectomy*
Humans
Incidence
Laparoscopy
Logistic Models
Methods
Multivariate Analysis
Postoperative Complications
Risk Factors
Stomach Neoplasms*

Figure

• 

  Fig. 1 Flow diagram of the study. LTG = laparoscopic total gastrectomy; TG = total gastrectomy; HDST = hemi-double-stapling technique.

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  Fig. 2 Hemi-double-stapling technique. (A) A 3-cm vertical incision was made in the direction of the esophagus approximately 1–2 cm below the esophagogastric junction. (B) The anvil in the abdominal cavity was pushed into the opening using the anvil holder. (C) The thread tied to the central rod was held upward, and esophageal transection was performed using an Endo GIA™ linear stapler. (D) As the thread was subsequently pulled out, the central rod was pulled out of the esophageal stump. (E) The central rod was removed, and the anvil head and EEA™ stapler were connected. (F) Anastomosis between the jejunum and esophageal stump was performed.

• 

  Fig. 3 Overlap method. (A) Esophageal transection was performed using an Endo GIA™ linear stapler, leaving about 1 cm of the left side of the esophagus attached. (B) The remaining 1-cm portion was resected using a harmonic scalpel to create an opening. (C) The true lumen of the esophageal stump was confirmed. (D) The jejunum was approximated to confirm the tension of the Roux limb. (E) Esophagojejunostomy was performed using an Endo GIA™ linear stapler. (F) The entry hole was closed in 2 layers using barbed sutures.

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