Intracorporeal esophagojejunostomy using a linear stapler in laparoscopic total gastrectomy: comparison with circular stapling technique

Abstract

Background: Laparoscopic total gastrectomy for gastric cancer is feasible but less commonly performed compared to laparoscopic distal gastrectomy due to technical difficulties such as reconstruction. There is no standard esophagojejunal anastomosis technique in laparoscopic total gastrectomy due to a lack of evidence.

Methods: We retrospectively analyzed data from 213 patients with gastric cancer who underwent laparoscopic total gastrectomy from October 2012 to December 2016. Of these, 109 and 104 patients underwent esophagojejunostomy with linear and circular stapling, respectively. We compared short-term postoperative outcomes, including surgical complications and anastomosis costs between both groups.

Results: The mean operation time in the linear stapler group was longer than the circular stapler group (Linear stapler, 235.3 ± 57.9 vs. Circular stapler, 217.1 ± 55.8 min; P = 0.021); however, D2 lymph node dissection was performed more in the linear stapler group (Linear stapler, 36.7% vs. Circular stapler, 23.1%; P = 0.030). There were two anastomosis leakages in each group (Linear stapler, 1.8% vs. Circular stapler, 1.9%; P > 0.999). Anastomosis stenosis only occurred in the circular stapler group (Linear stapler, 0% vs. Circular stapler, 7.7%; P = 0.003). Although the linear stapling technique used more stapler cartridges (Linear stapler, 7.6 ± 1.1 vs. Circular stapler, 4.8 ± 0.9; P < 0.001), costs related to anastomosis were lower in the linear stapler group (Linear stapler, 1,904,679 ± 342,116 vs. Circular stapler, 2,246,150 ± 427,136KRW; P < 0.001).

Conclusions: Esophagojejunostomy with the linear stapling technique reduces anastomosis stenosis in laparoscopic total gastrectomy. It can be recommended as a safe and more cost-effective method for esophagojejunal anastomosis.

Keywords: Circular stapler; Esophagojejunostomy; Laparoscopic total gastrectomy; Linear stapler; Stenosis.

Fig. 1

Esophagojejunostomy using the linear stapling technique. a Partial transection of the esophagus using a linear stapler. b Complete transection of the esophagus using an ultrasonic device. c Intracoporeal anastomosis using the overlap method. d Closure of the entry hole. e Jejunum transection without mesenteric division using a linear stapler. f Jejunojejunostomy 50 cm distal to the esophagojejunostomy

Fig. 2

Esophagojejunostomy using the circular stapling technique. a Application of two laparoscopic bulldog clamps. b Transection of the esophagus using an ultrasonic device. c Purse-string suture. d Introduction of an anvil into the esophagus. e Approximation of the circular stapler. f Jejunal stump closure