Application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy

Abstract

Objective To investigate the application value of the modified Overlap esophagojejunostomy in totally laparoscopic total gastrectomy (TLTG). Methods The retrospective cross-sectional study was conducted. The clinicopathological data of 32 patients who underwent TLTG with modified Overlap esophagojejunostomy in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine between January 2015 and December 2017 were collected. The main points of the modified Overlap method: surgeons stood on the right of patients when digestive tract reconstruction, suspension of left half liver and clockwise rotation before esophageal transection were performed, regulating esophageal opening position and building jejunal loop, and then closing openings using 45.0 mm Endo-GIA and barbed wire. Patients who were diagnosed as ⅠA stage by postoperative pathological examination were followed up; patients with lymph node metastases underwent chemotherapy of XELOX regimen and patients in ⅠB and Ⅱ stages without lymph node metastases underwent oral S-1 single agent. Observation indicators: (1) surgical and postoperative recovery situations; (2) follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative adjuvant therapy, long-term complications and survival up to March 2018. Measurement data with normal distribution were represented as ±s, and measurement data with skewed distribution were described as M (range). Results (1) Surgical and postoperative recovery situations: all the 32 patients underwent successful TLTG and modified Overlap esophagojejunostomy. The operation time, esophagojejunostomy time, volume of intraoperative blood loss, time to initial anal exsufflation, time for initial fluid diet intake, time for initial semi-fluid diet intake and time of postoperative drainage-tube removal were respectively (227±19)minutes, (22±7)minutes, (69±11)mL, (2.1±0.5)days, (3.4±0.4)days, (4.9±0.6)days and (7.5±1.7)days. There was no anastomotic stoma-related complication in 32 patients. One patient was complicated with duodenal stump leakage at 5 days postoperatively and was cured by continuous three-cavity irrigation and conservative treatment. Results of postoperative pathological examination: number of lymph node dissected in 32 patients was 32±4. TNM staging: 1, 5, 7, 11, 6, 1 and 1 patients were detected respectively in ⅠA, ⅠB, ⅡA, ⅡB, ⅢA, ⅢB and ⅢC. Duration of postoperative hospital stay of 32 patients was (8.1±2.1)days. (2) Follow-up and survival situations: 32 patients were followed up for 3-38 months, with a median time of 18 months. During the follow-up, in addition to 1 patient in IA stage, 31 patients underwent postoperative adjuvant therapy; patients can take the common soft food, without symptoms of choking and burning feelings, and gastroscopy reexamination was performed at 6 months postoperatively and showed anastomosis patency. One patient died of malignant tumor of maxillary sinus at 9 months postoperatively, 1 was detected liver metastasis at 20 months postopeartively and survived with tumor, the other patients had no tumor recurrence or metastasis. Conclusion The modified Overlap esophagojejunostomy is safe and feasible in TLTG, with good short-term outcomes. Key words: Gastric neoplasms; Gastric carcinoma, upper; Carcinoma of esophagogastric junction; Radical resection; Total gastrectomy; Digestive tract reconstruction; Esophagojejunostomy; Laparoscopy