Different Methods of Minimally Invasive Esophagojejunostomy After Total Gastrectomy for Gastric Cancer: Outcomes from Two Experienced Centers

Abstract

Background: Esophagojejunostomy after minimally invasive total gastrectomy (MITG) for gastric cancer (GC) is technically challenging. Failure of the esophagojejunal anastomosis can lead to significant morbidity, leading to short- and long-term quality of life (QoL) impairment or mortality. The optimal reconstruction method following MITG remains controversial. We evaluated outcomes of minimally invasive esophagojejunostomy after laparoscopic or robotic total gastrectomies.

Methods: We retrospectively reviewed MITG patients between 2015 and 2020 at two high-volume centers in China and the United States. Eligible patients were divided into groups by different reconstruction methods. We compared clinicopathologic characteristics, postoperative outcomes, including complication rates, overall survival rate (OS), disease-free survival rate (DFS), and patient-reported QoL.

Results: GC patients (n = 105) were divided into intracorporeal esophagojejunostomy (IEJ, n = 60) and extracorporeal esophagojejunostomy (EEJ, n = 45) groups. EEJ had higher incidence of wound infection (8.3% vs 13.3%, P = 0.044) and pneumonia (21.7% vs 40.0%, P = 0.042) than IEJ. The linear stapler (LS) group was inferior to the circular stapler (CS) group in reflux [50.0 (11.1-77.8) vs 44.4 (0.0-66.7), P = 0.041] and diarrhea [33.3 (0.0-66.7) vs 0.0 (0.0-66.7), P = 0.045] while LS was better than CS for dysphagia [22.2 (0.0-33.3) vs 11.1 (0.0-33.3), P = 0.049] and eating restrictions [33.3 (16.7-58.3) vs 41.7 (16.7-66.7), P = 0.029] at 1 year. OS and DFS did not differ significantly between LS and CS.

Conclusions: IEJ anastomosis generated better results than EEJ. LS was associated with a better patient eating experience, but more diarrhea and reflux compared with CS. Clinical and patient-reported outcomes show the superiority of IEJ with the LS reconstruction method in MITG for GC.

Keywords: Esophagojejunal reconstruction; Esophagojejunostomy; Gastric cancer; Intracorporeal esophagojejunostomy; Minimally invasive total gastrectomy; Quality-of-life.

Fig. 1

Flow chart demonstrating patient selection and grouping

Fig. 2

Quality of life changes and survival analysis for different EJ reconstruction methods. The change of EORTC QLQ-C30 and QLQ-STO22 score in LS and CS: a Preoperative QoL scores and b postoperative QoL scores at 1 year follow-up. c, d Survival curves by LS and CS: c overall survival and d disease-free survival. The dashed lines indicate the 95% confidence intervals

Fig. 3

Esophagojejunal anastomosis. During overlap reconstruction, if the tension is high, the stapler will cause intestinal perforation (a). And before firing the stapler, the nasogastric tube for guidance should be unplugged, or it might get stitched (b). In the π-shaped anastomosis, if the common opening has not been closed, one arm of the stapler may slip into it and cause anastomosis failure (c). The white arrows are pointing at the intestinal perforation caused by the stapler (a), the stitched nasogastric tube (b), and the failure anastomosis due to the stapler entering the common opening (c), respectively. Right side shows magnified images from dashed-line boxes on left side