A novel method of anvil placement of circular stapler for esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: results of consecutive 200 cases.

Background: Laparoscopic total gastrectomy for gastric cancer is still a demanding operation because of technical difficulties, especially of intracorporeal esophago-jejunal anastomosis.

Methods: We introduced a newly designed method of anvil placement of circular stapling devices (CS) for laparoscopic esophagojejunostomy (EJS). A small incision was made on the anterior wall of the stomach, from which the anvil was inserted into the stomach and proceeded to the thoracic esophagus. Then, the abdominal esophagus was transected by a linear stapler, and the anvil into the esophagus was drawn back to the esophageal stump by pulling out the cotton tape pre-attached to the anvil. Intracorporeal EJS by Roux-en-Y reconstruction was performed by CS inserted into the abdominal cavity from the umbilical wound.

Results: A total of consecutive 200 gastric cancer patients underwent laparoscopic total gastrectomy using this method. There was no operative mortality. Anastomotic complications occurred in 12 cases (6.0%): 9 cases of stenosis (4.5%) and 3 cases of bleedings (1.5%). Anastomotic leakage was not observed. As for non-anastomotic complications, there occurred 2 pulmonary complications (1.0%), 3 pancreatic leakages (1.5%), and 8 bowel obstructions due to internal hernia (4.0%). With a median follow-up period of 47.1 months, 5-year overall survival for assessable patients (n = 193) was 60.3% (95% CI 52.6-67.2). The total rate of peritoneal recurrence was 9.8%.

Conclusion: Our new method of anvil placement for laparoscopic EJS with CS is safe and feasible with favorable survival outcomes. It eliminates the need for suturing, and will promote the clinical application of laparoscopic total gastrectomy for gastric cancer.

Clinical Trials: UMIN000046119.