Background
Gastric cancer in remnant stomach is categorized as carcinoma arising from the remnant stomach after partial gastrectomy, regardless of the histology of the primary lesion (benign or malignant) or its risk of recurrence[
1]. It has a poor prognosis and surgical resection remains the only effective modality of treatment. Most patients cannot withstand the huge blow caused by conventional open surgery because of their poor general condition. Therefore, laparoscopic surgery, well known for its minimally invasive advantages, is likely a preferable choice for these patients. However, the technical difficulty required for the procedure remains the major concern, especially for the safety of laparoscopic adhesiolysis and intracorporeal esophagojejunostomy. Our surgical term introduced the laparoscopic technique on the gastric cancer in remnant stomach successfully in our department based on our experience in the laparoscopic approach for diseases of digestive tract[
2‐
5]. Herein, we report three cases of laparoscopic total gastrectomy with intracorporeal esophagojejunostomy (LTGIE) for gastric cancer in remnant stomach, with detailed operative procedures to evaluate its safety and feasibility, as well as to summarize surgical experience. This study protocol was prospectively approved by the ethics committee of Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University and informed consent was signed by each patient prior to surgery.
Discussion
The incidence of gastric cancer in remnant stomach is about 3 to 5%[
7,
8]. Previous reports show gastric cancer in remnant stomach may be associated with the lower acidic environment in the gastric stump, duodenogastric reflux, Helicobacter pylori infection and Billroth II reconstruction[
9,
10]. Gastric cancer in remnant stomach has often been described as having a poor clinical outcome, with five-year survival rates of between 7 and 33% in previous studies[
11,
12], and surgery is still the mainstay way to cure. Many patients with gastric cancer in remnant stomach are aged, with denutrition from prior gastrectomy. Thus, it is a great challenge for them to undergo conventional open surgery uneventfully and some patient-friendly procedures, such as laparoscopic procedures, are needed. Laparoscopic procedures for gastric cancer have gradually gained acceptance worldwide, and especially in some East Asian countries it has become the preferably choice due to advantages resulting from its minimally invasive approach[
13,
14].
However, the technical complexity of the procedure caused by adhesion and the anatomical deterioration has compelled many surgeons to discontinue their trials. Severe intraperitoneal adhesion was previously considered as contraindicative for laparoscopic procedures. With the development of the laparoscopic devices and surgical skill, laparoscopic procedures nowadays are performed in the treatment of postoperative adhesive ileus and incisional hernia[
15,
16]. Thus, it is possible to perform laparoscopic adhesiolysis safely on patients with gastric cancer in remnant stomach. Moreover, the laparoscopic magnified view allows adhesiolysis to be more meticulous than open surgery. We also believe that insertion of the first trocar in the open method can reduce risk of intestinal injury, and great care is needed to avoid injuring the colonic arteries and the colon when separating severe adhesion between mesocolon and jejunum.
To date, a few laparoscopic procedures for gastric cancer in remnant stomach have been reported and most were laparoscopic-assisted gastrectomy (LAG)[
17‐
19]. Kwon
et al. reported LAG are technically feasible approaches for the management of remnant gastric cancer for experienced surgeons[
20]. However, LAG requires mini-laparotomy, which appears to spoil it’s minimally invasiveness advantages. Some surgeons have reported that laparoscopic gastrectomy with intracorporeal anastomosis has advantages over LAG, such as better cosmesis, less pain and less intraoperative blood loss[
21,
22]. Additionally, LAG is not suitable for obese patients or those with a short esophageal stump[
23]. Forceful tension and limited vision will cause tearing of the structure near the anastomosis, leading to a higher risk of fistula. Therefore, we chose to perform LTGIE for our patients. In our studies, the patients’ postoperative outcomes are consistent with previous studies[
24], with a fast recovery and short hospital stay.
The technical difficulty of intracorporeal esophagojejunostomy is another critical obstacle for surgical safety. To overcome this problem, some modified techniques have been reported[
25,
26]. These methods help to simplify the procedure of reconstruction and shorten the operation time. The most representative method is the side-to-side approach using an endoscopic linear staple. With this method, the anastomosis is not dependent on the size of the esophagus or the jejunum, but the endoscopic linear staple. A large anastomosis can be easily achieved, imposing less risk of anastomotic stricture. In our study two cases were successfully performed with this method with no anastomosis-related postoperative complications. Also, one patient had a Roux-en-Y gastrojejunostomy during a prior operation in our study. To preserve the Roux limb as long as possible, considering proper length of the Roux limb to protect the esophagus from entero-esophageal reflux, an end-to-side anastomosis seemed to be the most suitable approach. As a representative technique for intracorporeal end-to-side esophagojejunostomy, the OrVil™ (anvil) technique facilitates the conventional intracorporeal anastomosis and is time-saving. However, this technique may bring the risks of oral bacterium infection and injure the esophagus during insertion and it was unavailable in our institution. Thus, we performed the intracorporeal anastomosis with a conventional circular stapler rather than the OrVil™ technique.
Conclusions
LTGIE can be a safe, feasible and promising option for patients suffering from gastric cancer in remnant stomach, with advantages of being a less invasive procedure and having a faster recovery time.
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Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
YPM, XWX and KC performed the operation. JQC, DW and YCZ collected case data. Pan Y wrote the manuscript. YPM proofread and revised the manuscript. All authors approved the version to be published.