Outcome of functional end-to-end esophagojejunostomy in totally laparoscopic total gastrectomy

Since the first laparoscopy-assisted distal gastrectomy for early gastric cancer was performed in 1991 [1], the development of dedicated instruments and surgical techniques has led to laparoscopic distal gastrectomy (LDG) to treat gastric cancer. However, laparoscopic total gastrectomy (LTG) for gastric cancer has not become as popular as LDG, because reconstruction is more complex after LTG than after LDG, especially for esophagojejunostomy. Construction of an esophagojejunostomy is technically difficult, and serious complications can arise. Use of a circular stapler can be technically challenging during laparoscopic procedures for obese patients and for those with a relatively narrow esophagus. Some surgeons have used an extracorporeal approach through a mini-laparotomy, constructing an end-to-side anastomosis with an end-to-end anastomosis stapler [2]. One recent report has described LTG using a transorally inserted anvil for esophagojejunostomy [3]. However, an optimal procedure for esophagojejunostomy has yet to be established.

The entire anastomotic procedure can be clearly viewed during totally LTG (TLTG), and thus, tension and damage can be prevented. We have performed 65 TLTG procedures using functional end-to-end anastomosis for esophagojejunostomy since January 2006. This article describes the intraoperative manipulations and postoperative outcomes of TLTG with functional end-to-end esophagojejunostomy.

Table 1 shows the clinical features of the patients. The mean age was 65.9 ± 10.2 years, and 45 (69.2 %) male and 20 (30.8 %) female patients underwent TLTG with functional end-to-end esophagojejunostomy. Their mean BMI was 23.5 ± 4.0 kg/m². The upper and middle regions of the stomach were affected by malignancies in 53 (81.5 %) and 12 (18.5 %) patients, respectively. The clinical stages were stages IA and IB in 41 (63.1 %) and 24 (36.9 %) patients, respectively. Table 2 shows details of the surgical and pathological data. The mean surgical duration was 271.5 ± 64.7 min, and the mean blood loss was 85.2 ± 143.2 g. One (1.5 %) patient was converted to open surgery due to low blood pressure of uncertain cause during the procedure. The type of lymph node dissection was D1+ in 62 (95.4 %) patients and D2+ splenectomy in 3 (4.6 %) patients, and 30.2 ± 12.4 lymph nodes were dissected. The cancer had invaded the mucosa, submucosa, muscle, subserosa, and serosa in 18 (27.7 %), 28 (43.1 %), 9 (13.8 %), 5 (7.7 %), and 5 (7.7 %) patients, respectively. The histological type was well, moderately, and poorly differentiated in 19 (29.2 %), 16 (24.6 %), and 30 (46.2 %) patients, respectively. Twelve (18.5 %) patients had lymph node metastasis. Table 3 shows the postoperative outcomes. Ten (15.4 %) patients developed postoperative complications comprising jejunojejunostomy leakage in one (1.5 %), duodenal stump leakage in one (1.5 %), esophagojejunostomy stenosis in three (4.6 %), pancreatic juice fistula in two (3.1 %), paralytic ileus in one (1.5 %), and wound infection in two (3.1 %). No esophagojejunostomy leaked after TLDG, and related complications that developed in three (4.6 %) patients were resolved by endoscopic dilation. One patient who underwent reoperation for afferent loop syndrome died of septic shock on postoperative day 90. The means of elapsed time until first flatus, resuming a soft diet, and discharge were 1.9 ± 0.7, 4.6 ± 1.8, and 21.4 ± 13.5 days, respectively. Cancer did not recur in any of the patients during a median follow-up of 37 (11–68) months.

Laparoscopic surgery confers upon patients the advantages of faster recovery, fewer complications, reduced hemorrhaging that reduces the likelihood of needing a blood transfusion, a smaller incision that reduces pain, the probability of intestinal obstruction, and the risk of wounding. Since its introduction in 1994, LDG for gastric cancer has become a commonplace due to the development of dedicated instruments and surgical techniques [1]. Many surgeons have described their experiences with totally laparoscopic gastrectomy and have found it safe and feasible [5‐8]. Kim et al. concluded that TLDG helps to improve early surgical outcomes [9]. A policy of totally laparoscopic gastrectomy was adopted at our hospital from its inception because we considered that it would confer several advantages. Extracorporeal anastomosis via mini-laparotomy incisions during laparoscopy-assisted gastrectomy could cause forceful tension and damage structures around an anastomosis because of limited vision, especially in obese patients [6, 10]. The entire anastomotic procedure can be clearly viewed during totally laparoscopic gastrectomy, which prevents such tension and damage. However, circular staplers are usually used for esophagojejunostomy in most LTG with mini-laparotomy incisions [11, 12]. The intra-abdominal application of a circular stapler might be challenging, and intracorporeal purse-string sutures and anvil placement are required for obese patients as well as for those with a relatively narrow esophagus [11, 13]. Okabe et al. noted that a circular stapler has not been specifically designed for endoscopic surgery and such staplers have usually been extracorporeally applied because of difficulties with applying them under a limited laparoscopic view [14]. If force is applied to a relatively large anvil, the mucosa can slip off and rupture the esophageal wall, which would result in serious complications [15]. In contrast, a linear stapler can be easily manipulated intra-abdominally. Steichen introduced a functional end-to-end anastomosis that has been adopted worldwide [16]. Matsui et al. and Lee et al. concluded that functional end-to-end esophagojejunostomy after a total gastrectomy is convenient, safe, reliable, and independent of the esophagus and depth of the esophageal hiatus [17, 18]. Functional end-to-end esophagojejunostomy after total gastrectomy in open surgery has become accepted, whereas laparoscopic esophagojejunostomy seems quite rare. We adopted this technique from the introduction of TLTG at our hospital. We have not experienced esophagojejunostomy leakage, and esophagojejunostomy stenosis that developed in three (4.6 %) patients was resolved by endoscopic dilation, the frequency of which varies from 3 to 10 % when a circular stapler is applied [19, 20]. One of our patients died in the hospital due to afferent loop syndrome caused by an internal hernia, which is a potentially serious complication after TLTG. Because of this experience, we close mesenteric defects using an intracorporeal suture. We do not apply this method to patients with tumors that have invaded the esophagus, and we perform intracorporeal circular stapling for esophagojejunostomy using a transorally inserted OrVil^TM anvil (Covidien, Mansfield, MA, USA). If a tumor is close to the esophago-cardiac junction, we transect the abdominal esophagus before starting an esophagojejunostomy. We have not experienced anastomotic stenosis since using the 45-mm linear stapler, which has more grasping power. As a result, the suture line between the esophageal and the intestinal wall does not shift. The long-term outcomes of functional end-to-end esophagojejunostomy in TLTG remain unknown, and thus, further clinical trials and prospective controlled studies are required for comparisons with other types of anastomosis. We achieved functional end-to-end esophagojejunostomy in TLTG without anastomotic leakage and consider this technique safe and feasible.