Functional end-to end esophago-jejunal anastomosis using linear staplers following laparoscopic total gastrectomy

Introduction

Technical difficulty of laparoscopic Roux-en-Y reconstruction is a major reason of less prevalence of laparoscopic total gastrectomy (LTG). Reconstruction-related complications, such as anastomotic leakage or stenosis were reported in higher rate than in distal gastrectomy (1). To overcome the technical obstacle and establish a standardized reconstruction method, we introduced intracorporeal functional end-to end (FETE) esophago-jejunal anastomosis using endoscopic linear staplers in September 2006 (2,3). This video article demonstrates our standard laparoscopic procedure of Roux-en-Y reconstruction using endoscopic linear staplers following total gastrectomy (Video 1).

Surgical technique

After completion of total gastrectomy, a jejunal loop about 20 cm distal to the ligament of Treitz is marked with dye, and the jejunal mesentery is divided to create a 50-cm Roux-en-Y limb. Marginal vessels are always divided so that Roux-en-Y limb could reach the esophagus without tension. Jejunal branches are also divided, if necessary. Side-to-side jejunojejunostomy is performed using a 45 mm linear stapler. After the entry hole is closed by continuous suture with 3-0 Vicryl^®, the jejunal mesenteric defect is also closed with 3-0 continuous suture with non-absorbable thread.

Then, the Roux-en-Y limb was brought up via the antecolic route to create an esophagojejunostomy. Small holes are made at the end of the Roux-en-Y limb on the antimesenteric side, and on the left dorsal side of the esophageal stump. To make the lumen of the esophagus easier to detect, a nasogastric tube was advanced through the hole. Through the left lower trocar, a 45 mm endoscopic linear stapler is inserted. The anvil fork is inserted into the Roux-en-Y limb, and then the cartridge side is inserted into the esophageal lumen using the nasogastric tube as a guide. After the entry hole is roughly closed with staplers that is used for fixation of mesh in hernia repair, closure is completed with a linear stapler through the right lower trocar. An air leakage test is performed to confirm the tightness of the anastomosis. Hand-sewn closure of the Petersen’s defect is done using non-absorbable thread.

Results

From September 2006 to December 2012, LTG with FETE esophagojejunostomy were planned in 119 patients. LTG was accomplished in 117 patients (98.3%). Reasons of two conversion were, bleeding from the splenic hilum and involvement of a naso-gastric tube during esophagojejunal anastomosis. Postoperative complications occurred in 27 patients (22.6%). Among them, reconstruction-related complications were opserved in five patients (4.3%): two anastomotic leakage of esophagojejunostomy (1.7%), two Roux stasis (1.7%), and one duodenal stump leakage (0.9%). Median postoperative hospital stay was 14 days. During median observation period of 30 months, adhesive ileus occurred in 5 patients (4.3%), and internal hernia through the jejunal mesenteric defect occurred in three patients (2.6%). No anastomotic stenosis was observed. While all patients with adhesive ileus were successfully treated with fasting and/or decompression, all three patients with internal hernia required emergent operation. Mesenteric defects had not been closed during initial LTG in all three patients.

Conclusions

Intracorporeal FETE esophago-jejunal anastomosis was safely performed with less postoperative reconstruction-related complications. The advantages of FETE esophagojejunostomy include safe anastomosis under better visualization, and less anastomotic leakage or stenosis. Mesenteric defects should be closed to prevent internal hernia.

Acknowledgements

Disclosure : The authors declare no conflict of interest.

References

1. Jeong O, Ryu SY, Zhao XF, et al. Short-term surgical outcomes and operative risks of laparoscopic total gastrectomy (LTG) for gastric carcinoma: Experience at a large-volume center. Surg Endosc 2012;26:3418-25.
2. Okabe H, Obama K, Tanaka E, et al. Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer. Surg Endosc 2009;23:2167-71.
3. Okabe H, Obama K, Tsunoda S, et al. The advantage of completely laparoscopic gastrectomy with linear stapled reconstruction: A long-term follow-up study. Ann Surg 2013. [Epub ahead of print].