Laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis using a knifeless endoscopic linear stapler

Abstract

Proximal gastrectomy has been applied for selected patients with early upper gastric cancer, because of its potential advantages over total gastrectomy, such as preserving gastric capacity and entailing fewer hormonal and nutritional deficiencies. Esophago-gastric anastomosis is a simple reconstruction method with an excellent postoperative outcome provided that gastroesophageal reflux is properly prevented. Following open surgery, the esophagus is anastomosed to the anterior stomach wall with partial fundoplication to prevent esophageal reflux. We developed a novel laparoscopic hand-sewn method to reproduce the anti-reflux procedure that is used in open surgery. The esophagus is first fixed to the anterior stomach wall with a knifeless endoscopic linear stapler. This fixation contributes to maintaining a stable field for easier hand-sewn anastomosis, and allows us to complete the left side of the fundoplication at the same time. This novel technique was used to successfully perform complete laparoscopic proximal gastrectomy with a hand-sewn esophago-gastric anastomosis in ten patients, without any postoperative complications. No patient had symptoms of gastroesophageal reflux during a median follow-up period of 19.9 months. One patient developed anastomotic stenosis, and this was resolved with endoscopic dilatation. The mean percent body weight loss at 12 months after surgery, in comparison to the preoperative weight, was 10.4 %. Laparoscopic proximal gastrectomy with an esophago-gastric anastomosis using our novel technique would be a feasible choice would be a feasible choice and would show benefit for selected patients with early upper gastric cancer.

Potential benefits of laparoscopy-assisted proximal gastrectomy with esophagogastrostomy for cT1 upper-third gastric cancer

“…Therefore, anastomotic strictures may not have been caused by acid exposure of the anastomotic site. Indeed, proximal gastric resection is mostly reported not to result in significant reflux [34,35]. However, if our higher rate of anastomotic stricture is due to acid reflux, acid reflux in proximal gastric resection is really serious.…”

Proximal gastrectomy with exclusion of no. 3b lesser curvature lymph node dissection could be indicated for patients with advanced upper-third gastric cancer

“…The reasons why on -third of patients with a T1 U tumor received total gastrectomy in our institute may be related to this problem. Recently, we and others developed novel methods for modified esophagogastrostomy by creating a reliable angle of His using a stapler [26,27]. These techniques may become a feasible choice for simple reconstruction after proximal gastrectomy.…”

Side overlap esophagogastrostomy to prevent reflux after proximal gastrectomy

“…Although this method is very simple, it breaks the antireflux, high-pressure zone in the lower end of the esophagus. Okabe et al [10] first fixated the esophagus onto the anterior wall of the stomach with a knifeless linear stapler and then performed end-to-side anastomosis by hand suture. Intracorporal anastomosis is difficult to perform by hand suture and is likely the cause of anastomotic stenosis.…”

“…Attempts to add a valve-like mechanism to prevent reflux after esophagogastrostomy have been reported since 1964 [2,3]. However, despite the many reports that have been published on this topic [4][5][6][7][8][9][10], no optimal method of anastomosis has come into wide use because of problems associated with the reliability of reflux prevention, the occurrence of anastomotic stenosis, and technical difficulties.…”