Spade-Shaped Anastomosis after Laparoscopic Proximal Gastrectomy Using Double Suture Anchoring between the Posterior Wall of the Esophagus and the Anterior Wall of the Stomach (SPADE Operation): A Case Series

Abstract

We introduced SPADE operation, a novel anastomotic method after laparoscopic proximal gastrectomy (PG). Technical modifications were performed and settled. This report aimed to demonstrate the short-term clinical outcomes after settlement. Data from 34 consecutive patients who underwent laparoscopic PG with SPADE between June 2017 and March 2020 were retrospectively reviewed. Reflux was evaluated based on the patients' symptoms and follow-up endoscopy using Los Angeles (LA) classification and RGB Classification (Residue, Gastritis, Bile). Other complications were classified using the Clavien-Dindo method. The incidence of reflux esophagitis was 2.9% (1/34). Bile reflux was observed in six patients (17.6%), and residual food was observed in 16 patients (47.1%) in the endoscopy. Twenty-eight patients had no reflux symptoms (82.4%), while five patients (14.7%) and one patient (2.9%) had mild and moderate reflux symptoms, respectively. The rates of anastomotic stricture and ileus were 14.7% (5/34) and 11.8% (4/34), respectively. No anastomotic leakage was observed. The incidence of major complications (Clavien-Dindo grade III or higher) was 14.7%. The SPADE operation following laparoscopic PG is effective in reducing gastroesophageal reflux. Its clinical usefulness should be validated using prospective clinical trials.

Keywords: early gastric cancer; gastroesophageal reflux; laparoscopic surgery; proximal gastrectomy.

Figure 1

Illustration of SPADE operation. (A) Laparoscopic D1+ proximal gastrectomy was performed. (B,C) Both distal part of posterior wall of esophagus and proximal part of anterior wall of stomach were fixed with two interrupted sutures. (D) After an opening was made, one barbed continuous suture (V-Loc™) initiated at the left corner of esophagus posterior wall and stomach anterior wall, ended on the opposite right side. (E) After suturing of posterior wall anastomosis, anterior wall anastomosis was performed in the same maneuver. (F) After anastomosis was completed, a spade shape is made.

Figure 2

Postoperative endoscopic finding and upper gastrointestinal series after SPADE operation. (A) Endoscopic finding showing artificial His angle and pseudo-fornix. (B) Upper gastrointestinal series after SPADE method.