Comparison of totally laparoscopic total gastrectomy using an endoscopic linear stapler with laparoscopic-assisted total gastrectomy using a circular stapler in patients with gastric cancer: A single-center experience

Abstract

Aim: To evaluate the safety and efficacy of totally laparoscopic total gastrectomy (TLTG) with esophagojejunostomy using a linear stapler compared with laparoscopic-assisted total gastrectomy (LATG) using a circular stapler in gastric cancer patients.

Methods: We retrospectively reviewed 687 patients who underwent laparoscopic total gastrectomy for gastric cancer at a single institution from August 2008 to August 2014. The patients were divided into two groups according to the type of operation: 421 patients underwent TLTG and 266 underwent LATG. Clinicopathologic characteristics and surgical outcomes in the two groups were compared and analyzed.

Results: The TLTG group had higher mean ages at the time of operation (57.78 ± 11.20 years and 55.69 ± 11.96 years, P = 0.020) and more histories of abdominal surgery (20.2% and 12.4%, P = 0.008) compared with the LATG group. Surgical outcomes such as intraoperative and postoperative transfusions, combined operations, pain scores and administration of analgesics, and complications were similar between the two groups. However, compared with the LATG group, the TLTG group required a shorter operation time (149 min vs 170 min, P < 0.001), had lower postoperative hematocrit change (3.49% vs 4.04%, P = 0.002), less intraoperative events (3.1% vs 10.2%, P < 0.001), less intraoperative anastomosis events (2.4% vs 7.1%, P = 0.003), faster postoperative recovery such as median time to first flatus (3.30 d vs 3.60 d, P < 0.001), faster median commencement of soft diet (4.30 d vs 4.60 d, P < 0.001) and shorter length of postoperative hospital stay (6.75 d vs 7.02 d, P = 0.005).

Conclusion: The intracorporeal method for reconstruction of esophagojejunostomy using a linear stapler may be considered a feasible procedure comparing with extracorporeal anastomosis using circular stapler because TLTG is simpler and more straightforward than LATG. Therefore, TLTG can be recommended as an appropriate procedure for gastric cancer.

Keywords: Gastric cancer; Laparoscopic-assisted total gastrectomy; Totally laparoscopic total gastrectomy.

Figure 1

Forming an esophagojejunostomy. A: Nearly two-thirds of the esophagus diameter is transected 2 cm above the gastroesophageal junction using an endoscopic linear stapler; B: The first intracorporeal suture is made at the end of the staple line of the esophageal stump; C: The unstapled esophagus is transected with laparoscopic scissors after the remnant stomach has been clipped with manual titanium clips to avoid spillage of cancer cells; D: The second and third intracorporeal sutures are made at the esophagostomy site of the esophageal stump; E: To create an esophagojejunostomy, an endoscopic linear stapler is inserted by the operator between the esophagostomy and enterostomy of the jejunum. At this time the first assistant retracts the first thread towards the operator’s direction inside the abdominal cavity, and the second assistant retracts the second thread through the right lower trocar from the outside of the abdomen; F: After an esophagojejunostomy has been constructed, the entry hole is held with tress suturing to approximate the tissue; G: The remnant entry hole is closed by the operator with an endoscopic linear stapler; H: An esophagojejunal anastomosis after completion of the reconstruction.