Step-by-step esophagojejunal anastomosis after intra-corporeal total gastrectomy for laparoscopic gastric cancer treatment: technique of "reverse anvil"

Abstract

BackgroundThe laparoscopic gastrectomy is a relatively new procedure due mainly to the difficulties related to lymphadenectomy and reconstruction. Until the moment, technique or device to perform the esophagojejunal anastomosis by laparoscopy is still a challenge. So, a safe, cheap and quickly performing technique is desirable to be developed.AimTo present technique proposed by the authors with its technical details on reconstruction with "reverse anvil".MethodAfter total gastrectomy completed intra-corporeally, the reconstruction starts with the preparation of the intra-abdominal esophagus cross-section next to the esophagogastric transition of 50%. A graduated device is prepared using Levine gastric tubes (nº. 14 and 10), 3 cm length, connected to the anvil of the circular stapler (nº. 25) with a wire thread (2-0 or 3-0) of 10 cm, which is connected to end of this device. The whole device is introduced in reverse esophagus. The esophagus is amputated and the wire is pulled after previous transfixation in the distal esophagus and the anvil positioned. The jejunal loop is sectioned 20-30 cm from duodenojejunal angle, and the anvil put in the jejunal loop and connect previously in the esophagus. Linear stapler (blue 60 mm) is used to close the opening of the jejunal loop.ConclusionThe "reverse anvil" technique used by the authors facilitated the transit reestablishment after total gastrectomy, contributing to obviate reconstruction problems after total gastrectomy.

Comparison of laparoscopic total gastrectomy and laparotomic total gastrectomy for gastric cancer

“…As to the resection of the organs associated to the removed stomach with neoplasia, which in this study occurred in 32.4% of the cases, there was no difference between groups (p=1.00), which meets the literature 26 , 16 .…”

“…Another limiting factor was the esophagojejunal anastomosis, requiring great skill of the surgeon 13 . The technique used for the intracavity esophagojejunal anastomosis performed here follows the standardization developed by the Barretos Cancer Hospital staff known as "reverse warhead" 16 . It is believed that the longer surgical time in the laparoscopic route of access observed in most published series is due mainly to the recent indication of the technique as a surgical treatment of gastric cancer.…”

Laparoscopic Gastric Resection for Gastric Cancer: Is Intracorporeal Anastomosis Necessary?

“…In order to perform esophagojejunal anastomosis laparoscopically, techniques such as using transorally inserted anvil (OrVil™), overlap technique and reverse anvil technique have been described. 20 - 22 In case series using transorally inserted anvil, a wide leak percentage range of 0.5-16.7% has been reported by Zuiki et al In the series of 52 cases reported, this rate was reported as 1.9% and the rate of anastomosis stricture was as high as 21%. 23 On the other hand, overlap anastomosis was performed predominantly.…”