Abstract
Introduction
Total gastrectomy (TG) is commonly performed for the treatment of patients with gastric cancer. However, reconstruction of the esophagojejunal (EJ) anastomosis can be technically demanding, with reported anastomotic leak rates in the Western world still approaching 10–15 %. We report our experience using the transoral anvil delivery system (OrVil™) for creation of the EJ anastomosis after TG.
Methods
From 2007 to 2011, 48 consecutive patients with gastric cancer underwent open (n = 31) or laparoscopic (n = 17) TG. EJ reconstruction was performed with the transoral anvil deliver system (OrVil™) in an end-to-side fashion. Demographic, clinic, and perioperative data were obtained from a prospectively maintained database.
Results
Of the 48 patients, 83 % were male. Median age at resection was 64 years. Median body mass index was 27.1 kg/m2. Seventy-nine percent (n = 38) of patients had at least one comorbidity. Fifteen patients (31 %) had at least one perioperative complication. There was one perioperative death (2 %) following a duodenal stump leak. There were four EJ leaks (8 %) and two EJ stenoses (independent of leak; 4 %). There was one EJ leak (6 %) and one EJ stenosis (6 %) following a case that was first attempted laparoscopically. There were no deaths as a consequence of an EJ leak.
Conclusions
The use of the transoral anvil delivery system during EJ reconstruction is a safe and effective option for reconstruction after open or laparoscopic TG with acceptable mortality and morbidity. The anastomotic leak rate appears to be comparable to that of other techniques.
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References
Barbour AP, Rizk NP, Gonen M, et al. Lymphadenectomy for adenocarcinoma of the gastroesophageal junction (GEJ): impact of adequate staging on outcome. Ann Surg Oncol. 2007;14:306–16.
Pacelli F, Papa V, Rosa F, et al. Four hundred consecutive total gastrectomies for gastric cancer: a single-institution experience. Arch Surg. 2008;143:769–75; discussion 775.
Siewert JR, Bottcher K, Stein HJ, Roder JD. Relevant prognostic factors in gastric cancer: ten-year results of the German Gastric Cancer Study. Ann Surg. 1998;228:449–61.
Oh SJ, Choi WB, Song J, et al. Complications requiring reoperation after gastrectomy for gastric cancer: 17 years experience in a single institute. J Gastrointest Surg. 2009;13:239–45.
Sierzega M, Kolodziejczyk P, Kulig J. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg. 2010;97:1035–42.
Huscher CG, Mingoli A, Sgarzini G, et al. Totally laparoscopic total and subtotal gastrectomy with extended lymph node dissection for early and advanced gastric cancer: early and long-term results of a 100-patient series. Am J Surg. 2007;194:839–44; discussion 844.
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.
Ziqiang W, ZhiMin C, Jun C, et al. A modified method of laparoscopic side-to-side esophagojejunal anastomosis: report of 14 cases. Surg Endosc. 2008;22:2091–4.
Shinohara T, Kanaya S, Taniguchi K, et al. Laparoscopic total gastrectomy with D2 lymph node dissection for gastric cancer. Arch Surg. 2009;144:1138–42.
Strong VE, Song KY, Park CH, et al. Comparison of gastric cancer survival following R0 resection in the United States and Korea using an internationally validated nomogram. Ann Surg. 2010;251:640–6.
O’Riordain DS, Buckley DJ, Waldron DJ, Kirwan WO. Purse-string suture for stapled oesophagogastric anastomosis: hand-sewn versus automatic. Br J Surg. 1993;80:734–6.
Kim HH, Hyung WJ, Cho GS, et al. Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report—a phase III multicenter, prospective, randomized Trial (KLASS Trial). Ann Surg. 2010;251:417–20.
Vinuela EF, Gonen M, Brennan MF, et al. Laparoscopic versus open distal gastrectomy for gastric cancer: a meta-analysis of randomized controlled trials and high-quality nonrandomized studies. Ann Surg. 2012;255:446–56.
Wainess RM, Dimick JB, Upchurch GR Jr, et al. Epidemiology of surgically treated gastric cancer in the United States, 1988–2000. J Gastrointest Surg. 2003;7:879–83.
Lee JH, Paik YH, Lee JS, et al. Abdominal shape of gastric cancer patients influences short-term surgical outcomes. Ann Surg Oncol. 2007;14:1288–94.
Ojima T, Iwahashi M, Nakamori M, et al. Influence of overweight on patients with gastric cancer after undergoing curative gastrectomy: an analysis of 689 consecutive cases managed by a single center. Arch Surg. 2009;144:351–8; discussion 358.
Tokunaga M, Hiki N, Fukunaga T, et al. Effect of individual fat areas on early surgical outcomes after open gastrectomy for gastric cancer. Br J Surg. 2009;96:496–500.
Kodera Y, Sasako M, Yamamoto S, et al. Identification of risk factors for the development of complications following extended and superextended lymphadenectomies for gastric cancer. Br J Surg. 2005;92:1103–9.
Ueda J, Ichimiya H, Okido M, Kato M. The impact of visceral fat accumulation on laparoscopy-assisted distal gastrectomy for early gastric cancer. J Laparoendosc Adv Surg Tech A. 2009;19:157–62.
Hiki N, Fukunaga T, Yamaguchi T, et al. Increased fat content and body shape have little effect on the accuracy of lymph node retrieval and blood loss in laparoscopic distal gastrectomy for gastric cancer. J Gastrointest Surg. 2009;13:626–33.
Makino H, Kunisaki C, Izumisawa Y, et al. Effect of obesity on laparoscopy-assisted distal gastrectomy compared with open distal gastrectomy for gastric cancer. J Surg Oncol. 2010;102:141–7.
Yasuda K, Sonoda K, Shiroshita H, et al. Laparoscopically assisted distal gastrectomy for early gastric cancer in the elderly. Br J Surg. 2004;91:1061–5.
Hwang SH, Park do J, Jee YS, et al. Risk factors for operative complications in elderly patients during laparoscopy-assisted gastrectomy. J Am Coll Surg. 2009;208:186–92.
Lee HJ, Kim HH, Kim MC, et al. The impact of a high body mass index on laparoscopy assisted gastrectomy for gastric cancer. Surg Endosc. 2009;23:2473–9.
Smith DL, Elting LS, Learn PA, et al. Factors influencing the volume-outcome relationship in gastrectomies: a population-based study. Ann Surg Oncol. 2007;14:1846–52.
Kunisaki C, Makino H, Takagawa R, et al. Efficacy of laparoscopy-assisted distal gastrectomy for gastric cancer in the elderly. Surg Endosc. 2009;23:377–83.
Isozaki H, Okajima K, Ichinona T, et al. Risk factors of esophagojejunal anastomotic leakage after total gastrectomy for gastric cancer. Hepatogastroenterology. 1997;44:1509–12.
Pol B, LeTreut YP, Hardwigsen J, et al. Mechanically stapled esophagojejunostomy. Results of a prospective series of 176 cases. Hepatogastroenterology. 1997;44:458–66.
Takeyoshi I, Ohwada S, Ogawa T, et al. Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique. Hepatogastroenterology. 2000;47:1026–9.
Doglietto GB, Papa V, Tortorelli AP, et al. Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg. 2004;139:1309–13; discussion 1313.
Lamb PJ, Griffin SM, Chandrashekar MV, et al. Prospective study of routine contrast radiology after total gastrectomy. Br J Surg. 2004;91:1015–9.
Pesko P, Bjelovic M, Stojakov D, Sabljak P. Modified stapling technique of esophagojejunal anastomosis. Dis Esophagus. 2002;15:303–4.
Sakuramoto S, Kikuchi S, Futawatari N, et al. Technique of esophagojejunostomy using transoral placement of the pretilted anvil head after laparoscopic gastrectomy for gastric cancer. Surgery. 2010;147:742–7.
Habu H, Kando F, Saito N, et al. Experience with EEA stapler for esophagojejunostomy. Int Surg. 1989;74:73–6.
Seufert RM, Schmidt-Matthiessen A, Beyer A. Total gastrectomy and oesophagojejunostomy: a prospective randomized trial of hand-sutured versus mechanical stapled anastomoses. Br J Surg. 1990;77:50–2.
Fujimoto S, Takahashi M, Endoh F, et al. Stapled or manual suturing in esophagojejunostomy after total gastrectomy: a comparison of outcome in 379 patients. Am J Surg. 1991;162:256–9.
Nomura S, Sasako M, Katai H, et al. Decreasing complication rates with stapled esophagojejunostomy following a learning curve. Gastric Cancer. 2000;3:97–101.
Hyodo M, Hosoya Y, Hirashima Y, et al. Minimum leakage rate (0.5 %) of stapled esophagojejunostomy with sacrifice of a small part of the jejunum after total gastrectomy in 390 consecutive patients. Dig Surg. 2007;24:169–72.
Bracale U, Marzano E, Nastro P, et al. Side-to-side esophagojejunostomy during totally laparoscopic total gastrectomy for malignant disease: a multicenter study. Surg Endosc. 2010;24:2475–9.
Inaba K, Satoh S, Ishida Y, et al. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg. 2010;211:e25–9.
Tsujimoto H, Uyama I, Yaguchi Y et al. Outcome of overlap anastomosis using a linear stapler after laparoscopic total and proximal gastrectomy. Langenbecks Arch Surg. 2012;397:833–40.
Carboni F, Lepiane P, Santoro R, et al. Laparoscopic surgery for gastric cancer: preliminary experience. Gastric Cancer. 2005;8:75–7.
Dulucq JL, Wintringer P, Perissat J, et al. Completely laparoscopic total and partial gastrectomy for benign and malignant diseases: a single institute’s prospective analysis. J Am Coll Surg. 2005;200:191–7.
Ibanez Aguirre FJ, Azagra JS, Erro Azcarate ML, et al. Laparoscopic gastrectomy for gastric adenocarcinoma. Long-term results. Rev Esp Enferm Dig. 2006;98:491–500.
Kim SG, Lee YJ, Ha WS, et al. LATG with extracorporeal esophagojejunostomy: is this minimal invasive surgery for gastric cancer? J Laparoendosc Adv Surg Tech A. 2008;18:572–8.
Mochiki E, Toyomasu Y, Ogata K, et al. Laparoscopically assisted total gastrectomy with lymph node dissection for upper and middle gastric cancer. Surg Endosc. 2008;22:1997–2002.
Topal B, Leys E, Ectors N, et al. Determinants of complications and adequacy of surgical resection in laparoscopic versus open total gastrectomy for adenocarcinoma. Surg Endosc. 2008;22:980–4.
Usui S, Nagai K, Hiranuma S, et al. Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument “Endo-PSI (II)” and circular stapler. Gastric Cancer. 2008;11:233–7.
Allieta R, Nardi M Jr, Brachet-Contul R, et al. Laparoscopic gastrectomy for treatment of advanced gastric cancer: preliminary experience on 38 cases. Minerva Chir. 2009;64:445–56.
Jeong GA, Cho GS, Kim HH, et al. Laparoscopy-assisted total gastrectomy for gastric cancer: a multicenter retrospective analysis. Surgery. 2009;146:469–74.
Lee SE, Ryu KW, Nam BH, et al. Technical feasibility and safety of laparoscopy-assisted total gastrectomy in gastric cancer: a comparative study with laparoscopy-assisted distal gastrectomy. J Surg Oncol. 2009;100:392–5.
Kinoshita T, Oshiro T, Ito K, et al. Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy. Surg Endosc. 2010;24:2908–12.
Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil) after laparoscopic total gastrectomy. Surg Endosc. 2009;23:2624–30.
Kachikwu EL, Trisal V, Kim J, et al. Minimally invasive total gastrectomy for gastric cancer: A pilot series. J Gastrointest Surg. 2011;15:81–6.
Kunisaki C, Makino H, Oshima T, et al. Application of the transorally inserted anvil (OrVil) after laparoscopy-assisted total gastrectomy. Surg Endosc. 2011;25:1300–5.
Marangogi G, Villa F, Shamil E. et al. OrVil™-assisted anastomosis in laparoscopic upper gastrointestinal surgery: friend of the laparoscopic surgeon. Surg Endosc. 2012;26:811–7.
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J. LaFemina and E. F. Viñuela are co-first authors.
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LaFemina, J., Viñuela, E.F., Schattner, M.A. et al. Esophagojejunal Reconstruction After Total Gastrectomy for Gastric Cancer Using a Transorally Inserted Anvil Delivery System. Ann Surg Oncol 20, 2975–2983 (2013). https://doi.org/10.1245/s10434-013-2978-6
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DOI: https://doi.org/10.1245/s10434-013-2978-6