Performing esophagojejunostomy is considered a main obstacle in LTG [10]. During laparoscopy-assisted total gastrectomy, most surgeons previously performed extracorporeal esophagojejunostomy using additional minilaparotomy. However, it is not always feasible through the deep, narrow abdominal space. This procedure can be adversely affected if the patient is obese and entails a risk of unnecessary tension at the anastomosis. Therefore, we have performed LTG with intracorporeal esophagojejunostomy and have investigated four types of anastomosis since 2009. We summarize here the surgical outcomes of previous studies for the various types of esophagojejunostomies in LTG (Table 2).
Table 2 Literature review of reconstruction methods after laparoscopic total gastrectomy
A commercially available device, the OrVil, consisting of a 25-mm anvil with the head pretilted and the tip attached to an 18-Fr. orogastric tube, permits esophagojejunal stapled anastomosis, with the anvil introduced through the mouth. This system appears to lessen the burden of retrograde insertion of the anvil head, which can tear the esophagus, but as previously noted, it entails the risks of oral bacterium contamination and injury to the esophagus during insertion [14].
Jeong and Park [14] summarized their surgical outcomes of LTG with type B esophagojejunostomy. They reported a mean operation time of 194 min (range, 160–270 min), and one patient had an intraabdominal abscess that required surgical drainage. In our study, the mean operation time was 226 min (range, 145–260 min), and no patient had surgical intervention.
As a result of these drawbacks of the OrVil system, we also investigated the use of a the conventional EEA stapling device to facilitate esophagojejunostomy. To facilitate the “purse-string” procedure, several modifications have been proposed. However, in total laparoscopic procedures, none of these seemed easy. The insertion of the anvil head to the distal esophagus is the most technically challenging and stressful step.
Takiguchi et al. [15] and Usui et al. [16] reported their outcomes of LTG with type A reconstruction. Takiguchi et al. [15] developed a simple laparoscopic purse-string suture technique using a semiautomatic suturing device (Endo Stitch, Covidien). Usui et al. [16] developed an endoscopic purse-string instrument, the so-called Endo-PSI (Hope Electronics, Chiba, Japan). Their mean operation time was longer than ours: 301 versus 229 min. One minor leakage of esophagojejunostomy happened with no open conversion. Although it seemed applicable, the jaw of the “Endo-PSI” was 50 mm in size and sometimes it was not always easy to use in a narrow-angled abdominal space.
Takiguchi et al. used Endostitch®, an semiautomatic suturing device, which was designed to make purse-string sutures effectively. They used five trocars instead of four, and the additional 33-mm trocar was for the Endostitch®. Although the Endostitch was a ready-to-make suture device, it required additional troca and could not be a solution for secure anvil head insertion to the esophagus.
Hiki et al. [17] developed a modified laparoscopic esophagogastric circular stapled anastomosis. By this method, they eliminated the necessity of making purse-string sutures and reduced the difficult of large, stiff anvil insertion. Before making the esophageal stump, only the anterior wall of the stomach was opened for entry of the anvil, and after the introduction of the anvil, the esophagus was transected. In their report, they prepared an anvil head with detachable sutures connected to a retrievable Levin tube, which they used while performing laparoscopic proximal gastrectomy. We modified this method slightly and used it to perform esophagojejunostomy. Before making the esophageal stump, gastrotomy was performed on the anterior wall to insert the anvil head. It was an easy-to-perform technique; however, it was required to perform it on selective cases in which the tumor located 2–3 cm below from the esophagojejunal (EJ) junction.
Inaba et al. introduced “overlapped” esophagojejunostomy, performed in a relatively large series of LTG, which comprised 53 cases. This technique was designed to reduce the complexity of anastomosis with a circular stapler [18]. A longer operation time was required compared to ours: a mean operation time of 373 min versus 205 min each. Also, they reported higher complication rates of 24.5 % including anastomotic leakage and stenosis. It seemed “easy-to-do” under the limited laparoscopic vision and therefore lessens the burden of injury to the esophageal wall as compared with the circular stapler. Moreover, minilaparotomy for esophagojejunostomy is not necessary. However, it is necessary to ensure a sufficient length of the abdominal esophagus for the anastomosis, especially in cases where the tumor is located near the esophagogastric junction.
Although each study described the merits and feasibility of its own method, direct comparison between the types of anastomosis had not done previously. To the best of our knowledge, this is the first report that compares the four types of anastomosis after LTG.
We recommend that the reconstruction type must be selected on the basis of the location of the tumor. For example, for tumors located near the esophagogastric (EG) junction, type A or B would be appropriate, and for the tumors located at least 3 cm below from the EG junction, type C or D would be safe. Also, if the surgeon was not well experienced with the laparoscopic purse-string technique, type C or D would be a relatively good choice.
This study has several limitations. First, because it is retrospective, it is presumed to have a critical selection bias and we cannot conclude which type would be superior. Second, four types of reconstruction have been used with various timelines. Therefore, the matter of the learning curve for the technique can be an issue. Although all four types of reconstruction have been performed by a single, laparoscopic expert, there could be a matter of an intrapersonnel learning curve. Third, we also tried to use our own selection criteria for reconstruction types, but there is also the matter of the surgeon’s discretion to select the type.