A modified intracorporeal functional end-to-end esophagojejunostomy during total laparoscopic total gastrectomy for advanced gastric cancer

Xiaoqiao Zhang, MD, PhD. Jinan General Hospital

Background: Intracorporeal esophagojejunostomy is technically challenging and act as the key step of totally laparoscopic gastrectomy. In past decade, some practical methods have been introduced, but it is still quite technically challenging. Here we would like to share our modification to the functional end-to-end esophagojejuostomy with linear stapler during total laparoscopic total gastrectomy for gastric cancer.

Methods: From December, 2011 to June, 2014, patients with gastric cancer and indicated to laparoscopic total gastrectomy were enrolled for the application of totally laparoscopic intracorporeal functional end-to-end esophageojejunostomy. The intracorporeal functional end-to-end esophageojejunostomy was performed with linear stapler with 4-hole technique. When the lymph node dissection and mobilization of the stomach were completed, the whole length of abdominal esophagus was dissected and retracted by a string. The mesentery of 10-cm jejunum 25cm from the Trietz ligment was cut near the mesenteric border so to make the proximal jejunum to reach the infradiaphragmatic space with tension. Then a functional end-to-end esophageojejunostomy was accomplished by a linear stapler with 60-mm cartridge. The common entry was closed and the esophagus was transected by another fire with liner stapler. The integrity of the anastomosis was checked by insufflation through nasogastric tube. The time of esophageojejunostomy, proximal margin status, distance between the proximal margin and the lesion(PM) were collected. The patients were followed routinely and anastomosis related complication including leakage, bleeding and stricture were recorded.

Results. Thirty-two cases laparoscopic total gastrectomy were performed during the period without conversion to open surgery. 27 (84.4%)of them were totally laparoscopic surgery without an auxilary incision for digestive reconstruction. For the 27 cases, the time cost of the intracorporeal esophageojejunostomy was about 40 min averagely. No positive proximal margin confirmed by pathological examination and the distance between the proximal margin and the lesion was 3.3±2.8cm. All the patients recovered uneventfully, no leakage or bleeding occurred. On follow up with a median time for 18 months, for one patient, stricture of the esophageojejunostomy occurred 3 months after operation and was resolved by endoscopic dilatation.

Conclusions:Laparoscopic intracorporeal functional end-to-end esophageojejunostomy by linear stapler with 4-hole technique is safe and feasible for the digestive reconstruction for total laparoscopic gastrectomy. It is a somewhat simplest method for gastric cancer patients without esophageal or cardia infiltration.

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