The Surgical Outcomes of Laparoscopic Assisted Total Gastrectomy With Upper Median Small Incision

Nobuhiro Takiguchi, MD PhD, Matsuo Nagata, MD, Yoshihiro Nabeya, MD, Atsushi Ikeda, MD, Osamu Kainuma, MD, Hiroaki Soda, MD, Akihiro Cho, MD, Takumi Ota, MD, Sjonjin Park, MD, Hiroshi Yamamoto, MD. Divsion of Gastroenterology, Chiba Cancer Center


The laparoscopic assisted total gastrectomy (LATG) is not accepted for standard operation because of the difficulty of the esophago-jejunostomy. Methods of esophago-jejunostomy have been proposed by using a circular stapler or by using linear staplers. Our procedure of esophago-jejunostomy by circular stapler is performed with upper median small incision. The purpose of this study is to evaluate the indication and short and long term surgical outcomes of LATG by our procedure.
[Methods] Our indication for LATG is gastric cancer under cT2 and cN1. The D1+β dissection is carried out laparoscopically. After the lymph nodes dissection and cutting off the duodenum by laparoscopic linear stapler, upper median mini-laparotomy is performed with an incision about 6cm. I. Making of working space; Two gauze mass are inserted in order to keep the good vision of the field of esophagus circumference and wide working space. II. The insertion of Anvil; Abdominal esophagus is transected using a purse string suture instrument (PSI) with 35mm width and 3-0 proline straight needle (EH7921). Esophagus is grasped by 3 Babcock forceps and anvil head of circular stapler (CDH 25mm) is inserted into the jejunal stump . III. Y limb anastomosis; Jejuno-jejunosotmy is performed by hand sewn and mesentery is sewn under direct vision. IV. Esophago-jejunum end to side anastomosis; The jejunum is lifted by antecolic route. Esophago-jejunum end to side anastomosis is performed by CDH25mm introduced through the jejunal stump. Jejunal stump was closed by laparoscopic linear cutter.
[Results] Forty one gastric cancer patients (32 males and 9 females) underwent LATG. Median follow up period was 22 months. Ten cases were advanced gastric cancer, and seven patients received adjuvant chemotherapy. The short term results of LATG was following; Operating time, blood loss, and post-operative hospital stay were 224.9±34 min, 141.4±124.9 ml, and 13.7 days, respectively. Perioperative complications were one esophago-jejunal leakage, one intra-peritoneal abscess, and two Y limb passage disorders. Five-year cumulative survival rate was 97%. One patient with pStageIIIA died due to the peritoneal recurrence. One emergency operation was performed because of the esophago-jejunal leakage.
[Conclusion] The point of LATG reconstruction is to make the complete esophago-jejunostomy by avoiding the excessive traction of esophagus in narrow working space. LATG using CDH with small upper median incision is a useful technique for gastric cancer in the confined indication from the point of short and long term results.

Session Number: Poster – Poster Presentations
Program Number: P245
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