Hemi-double Stapling Technique Research Articles

Double stapling technique versus hemi-double stapling technique for esophagojejunostomy with OrVil™ after laparoscopic total gastrectomy: a single-blind, randomized clinical trial.

The transorally inserted anvil (OrVil™) is frequently selected for esophagojejunostomy after laparoscopic total gastrectomy (LTG) because of its versatility. During anastomosis with OrVil™, the double stapling technique (DST) or hemi-double stapling technique (HDST) can be selected by overlapping the linear stapler and the circular stapler. However, no studies have reported the differences between the methods and their clinical significance. A randomized controlled clinical trial with a parallel assignment and single-blind outcomes assessment analysis was conducted. Patients with gastric cancer eligible for LTG who met the selection criteria were randomized. Preoperative characteristics and perioperative and postoperative outcomes were compared between the DST and HDST. The primary endpoint was an anastomosis-related complication, and the secondary endpoints were perioperative outcomes and postoperative complications, excluding anastomosis-related complications. Thirty patients with gastric cancer were eligible and randomized. LTG and esophagojejunostomy were successfully performed in all patients, without conversion to laparotomy. Preoperative characteristics, excluding preoperative chemotherapy, were not significantly different between the two groups. One anastomotic leakage of Clavien-Dindo classification grade ≥ IIIa was observed in the DST, although no significant difference was found between the two groups (6.6% vs. 0%, P = 0.30). In the HDST, one case of anastomotic stricture required endoscopic balloon dilation. No significant differences were found in operative time, whereas the anastomosis time was significantly shorter in the HDST than in the DST (47.5 ± 15.8 vs. 38.2 ± 8.8min, P = 0.028). Except for anastomosis-related complications, postoperative complications (P = 0.282) and postoperative hospital stay for the DST and HDST were not significantly different. No superiority was found between the DST and HDST with OrVil™ in esophagojejunostomy of LTG for gastric cancer with respect to postoperative complications, whereas the HDST may be preferable in terms of the simplicity of the surgical technique.

Feasibility of augmented rectangle technique in laparoscopic distal gastrectomy: comparison with hemi-double stapling technique in a single-center retrospective cohort study.

Augmented rectangle technique (ART) anastomosis is a totally intracorporeal anastomosis of laparoscopic distal gastrectomy (LDG), Billroth I (B1) reconstruction for gastric cancer, which secures a wide anastomotic stoma. Since the conventional extracorporeal hemi-double stapling technique (HD) may have a narrow anastomotic stoma, our aim of this study was to evaluate the feasibility and usefulness of ART anastomosis by comparing the surgical outcomes with HD anastomosis. Clinical data of 89 patients undergoing LDG with B1 reconstruction were retrospectively collected. Patients were divided into ART group (n = 40) and HD group (n = 49). Surgical outcomes including short-term outcomes, postoperative endoscopic findings, and nutritional factors 1year after surgery were compared between the groups. Baseline characteristics were similar between the groups. In terms of short-term outcomes, blood loss was less (11.5mL vs 40mL, P = 0.011) and postoperative hospital stay was shorter (10days vs 12days, P = 0.022) in the ART group. In terms of endoscopic findings, residual food was less (P = 0.032) in the ART group. In terms of nutritional factors, percent decrease of visceral fat area (- 27.6% vs - 40.5%, P = 0.049) and subcutaneous fat area (- 25.7% vs - 39.3%, P = 0.050) 1year after surgery attenuated in the ART group. ART anastomosis is superior in perioperative course such as postoperative hospital stay. Moreover, a better nutritional recovery is expected by securing a wide anastomotic stoma leading to a favorable food passage.

Hemi-double stapling technique performed with a transorally inserted anvil for esophagojejunostomy in the surgical treatment of gastric cancer.

A transorally inserted anvil has been developed to facilitate the creation of a stapled anastomosis without the need for a purse string to secure the anvil into place during laparoscopic total gastrectomy (LTG). We describe a hemi-double stapling technique and application of a transorally inserted anvil for esophagojejunostomy during LTG, and we report the results of a retrospective study in which we examined the feasibility and safety of this method. We also describe the key technical details of the method. Our anastomotic method has four chief features: (a) the esophagus is cut at a slant, and its left cut end is cut and punched for the hemi-double stapling technique; (b) the anvil and circular stapler are connected, placing the distal jejunum in cranial traction; (c) a single layer of sutures is used to correct dog-earing and overlapping, and these points are completely closed with Lembert sutures; and (d) the jejunal limb is fixed to the duodenal stump to prevent kinking of the jejunal limb and to decrease tension on the anastomosis. This method has been used in 53 patients thus far. LTG with Roux-en-Y reconstruction was successful in all patients, and there was no need for conversion to open surgery. The mean operative time was 313 minutes, and the mean blood loss was 106 mL. The mean postoperative hospital stay was 18 days. There was no anastomotic leakage or stenosis. Hemi-double stapling technique with a transorally inserted anvil for LTG can be performed safely and easily and safely. It can also product good outcomes.

Early outcomes of laparoscopic total gastrectomy with hemi-double stapling technique in gastric cancer

Early outcomes of laparoscopic total gastrectomy with hemi-double stapling technique in gastric cancer

A modified efficient purse-string stapling technique (mEST) that uses a new metal rod for intracorporeal esophagojejunostomy in laparoscopic total gastrectomy.

Intracorporeal esophagojejunostomy after laparoscopic total gastrectomy is technically difficult because this procedure should be performed in a narrow surgical field in the upper abdomen even when completely laparoscopic approaches are used. The placement of the anvil of a circular stapling device into the esophagus and connection the instrument to the anvil are extremely difficult steps in this surgery. Therefore, we developed a simple technique for intracorporeal esophagojejunostomy using hemi-double stapling technique; we named this technique the efficient purse-string stapling technique (EST). More recently, we have developed a modified EST (mEST) that utilizes a new stainless steel anvil rod instead of a plastic rod. Relative to the plastic rod, the steel rod is reusable and shorter; thus, it was easier to perform anvil placement into the esophagus with the steel rod. Anvil preparation for mEST: a stainless steel rod is attached to the shaft of the anvil, and the needle and thread are sutured to the tip of the rod. After complete insertion of the anvil into the esophageal cavity, the needle and thread are used to penetrate the anterior esophageal wall, and the esophagus is then clamped using a linear stapler just distal to the site penetrated by the thread. The linear stapler is fired, and anvil placement in the esophagus is simultaneously accomplished. After the rod is removed from the anvil, the instrument is intracorporeally connected to the anvil and then fired to complete the gastrojejunostomy. This technique is simple and facilitates intracorporeal reconstruction procedures in laparoscopic total gastrectomy.

Does the Single-Stapling Technique for Circular-Stapled Esophagojejunostomy Reduce Anastomotic Complications After Laparoscopic Total Gastrectomy?

Laparoscopic total gastrectomy (LTG) is used for early gastric cancer (EGC) in the upper stomach. However, the incidences of postoperative anastomotic complications such as leakage and stricture remain high. This study investigated whether using a single-stapling technique (SST) instead of a hemi-double-stapling technique (HDST) for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG. This retrospective study included 136 patients with EGC treated by LTG with intracorporeal circular-stapled esophagojejunostomy. Originally, HDST was used for esophagojejunostomy in 71 patients (original group). Thereafter, the esophagojejunostomy procedure was modified, and SST was used in a further 65 patients (modified group). The impact of the anastomotic procedure (SST or HDST) on anastomotic complications after LTG was determined by uni- and multivariate analyses. The incidence of anastomotic complications was significantly lower in the modified group (7.7 %) than in the original group (22.5 %; P = 0.017). The frequency of anastomotic leakage was lower in the modified group (3.1 %) than in the original group (9.9 %), although the difference was not statistically significant. Meanwhile, the frequency of anastomotic stricture was significantly less common in the modified group (6.2 %) than in the original group (18.3 %; P = 0.032). Multivariate analysis showed that anastomotic procedure with SST was significantly associated with a lower rate of postoperative anastomotic complications (odds ratio [OR], 0.217; 95 % confidence interval [CI], 0.063-0.631; P = 0.004), as was the operation time (OR, 0.237; 95 % CI 0.082-0.667; P = 0.007). The use of SST for intracorporeal circular-stapled esophagojejunostomy could reduce anastomotic complications after LTG.

Comparison of two types of esophagojejunostomy following laparoscopic total gastrectomy: a prospective study

Objective To investigate the clinical efficacy of 2 types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.Methods The clinical data of 18 patients with esophagogastric cancer and 14 patients with gastric cancer who were admitted to the Drum Tower Hospital from May 2011 to October 2012 were prospectively analyzed.After laparoscopic gastrectomy and D2 lymph node dissection,all the patients were randomly divided into 2 groups according to the random number table.All the patients underwent esophagojejunostomy using the transorally inserted anvil (OrVil group,7 patients with esophagogastric cancer and 9 patients with gastric cancer) or the hemi-double stapling technique (HDST,HDST group,11 patients with esophagogastric cancer and 5 patients with gastric cancer).Patients were followed up by phone call or out-patient examination to learn the prognosis and dietary intake.The follow-up was ended in December 2012.The measurement data and the count data were analyzed using the Student's t test or Fisher exact probability.Results Laparoscopic total gastrectomy was successfully performed on all the 32 patients with no conversion to open surgery.The mean operation time,time for total gastrectomy and lymph node dissection and time for esophagojujunostomy were (303 ±51)minutes,(153 ±35)minutes,(57 ± 15)minutes in the OrVil group,and (283 ±49)minutes,(160 ± 31) minutes,(48 ± 12) minutes in the HDST group,with no significant difference between the 2 groups (t =1.19,0.59,1.78,P ＞ 0.05).The time for stapler anvil insertion was (18 ± 6)minutes in the OrVil group,which was significantly longer than (13 ± 5) minutes in the HDST group (t =2.56,P ＜ 0.05).The intraoperative blood loss,number of lymph node dissected,length of incision,time for anal exhuast,time for out-of-bed activity,time for food intake and postoperative duration of hospital stay were (96 ± 30) mL,24 ± 5,(3.7 ± 0.4) cm,(3.4 ±0.9) days,(3.9 ± 0.7) days,(7.6 ± 1.4) days,(10.4 ± 1.6) days in the OrVil group,and (92 ± 40) mL,27 ±5,(3.6±0.6)cm,(3.3±1.0)days,(3.5±0.7)days,(8.3±3.0)days,(11.1 ± 3.8) days in the HDST group,with no significant difference between the 2 groups (t =0.35,0.01,2.50,0.37,1.51,0.82,0.67,P ＞ 0.05).The distance between the incisal margin on proximal esophagus and the tumor was (3.1 ± 0.5)cm in the OrVil group and (2.9 ± 0.6) cm in the HDST group.No residual tumor,anastomotic stricture or bile reflux was observed in the 2 groups.Two patients were complicated with atelectasis,1 with fat liquefaction of abdominal operative incision and 2 with postoperative anginosis in the OrVil group; 1 patient was complicated with pleural effusion,1 with esophagojejunal anastomotic fistula,and they were cured by drainage or enteral nutrition in the HDST group.No feeding difficulty or reflux was observed.All the patients were followed up for 1-18 months,and the median time for follow up was 8 months.All the patients were survived with no regional recurrence or distal metastasis.Conclusions The 2 types of esophagojejunostomy can be performed under laparoscope,with no significant differences in safety and efficacy.HDST technique is faster and easier for the insertion of anvil when compared with OrVil. Key words: Adenocarcinoma of the esophagogastric junction ; Gastric neoplasms ; Laparoscopy ; Esophagojejunostomy

Laparoscopy-assisted Total Gastrectomy: A Simplified Approach

Laparoscopy-assisted total gastrectomy (LATG), esophagojejunostomy is an effective but difficult procedure to perform. We describe a simple modification that substantially facilitates insertion of the anvil into the esophagus and avoids oral injuries and complications. After mobilization of the stomach and esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An OrVil anvil (Orvil, Covidien, Norwalk, CT, USA) is delivered laparoscopically and secured with a POLYSORB (Covidien) suture to the esophagus. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is transected with the stapler at this point. A circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed for 40 patients with gastric cancers (T1N0M0). All procedures were completed laparoscopically without any complications. The time required to place the anvil averaged 5 min compared with 9 min reported by others. There were no major complications or mortality in this series. The major advantage of this technique is that circular stapling is much easier than linear stapling, allowing surgeons without advanced surgical skills in LATG to perform the procedure effectively and safely.

Various types of intracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer

Even for expert surgeons, esophagojejunostomy after laparoscopic total gastrectomy (LTG) is not always easy to perform. Herein, we compare various types of esophagojejunostomy in terms of the technical aspects and postoperative outcomes. A total of 48 patients underwent LTG for gastric cancer by the same surgeon. Four types of intracorporeal esophagojejunostomies have been applied after LTG: type A, a conventional anvil head method; type B, an OrVil™ system method; type C, a hemi-double stapling technique with anvil head; and type D, side-to-side esophagojejunostomy with linear stapler. We describe and review these types of esophagojejunostomy using a step-by-step approach. The mean reconstruction times were longer for types A and B than for types C and D (p < 0.05). In terms of complications, there were five cases (10.4%) of anastomosis leakage, which was more common in types A and B: two cases in each of type A and B and one case in type C. Moreover, anastomosis stricture requiring intervention was more common in types A and B (p < 0.05). To date, there are no reliable reconstruction methods after LTG. Therefore, special care is needed to prevent postoperative complication regardless of methods; also, technical innovations to support development of the safest methods of esophagojejunostomy are warranted.

Reconstruction of the Gastrointestinal Tract byHemi-DoubleStapling Method for the Esophagus andJejunum Using EEA OrVil in Laparoscopic Total Gastrectomy and Proximal Gastrectomy

We report the method of anastomosis based on a hemi-double stapling technique (hereinafter, HDST) using a trans-oral anvil delivery system (EEA OrVil) for reconstructing the esophagus and lifted jejunum following laparoscopic total gastrectomy or proximal gastric resection. As a basic technique, end-to-side anastomosis was used for the cut-off stump of the esophagus and lifted jejunum. After the gastric lymph node dissection, the esophagus was cut off obliquely to the long axis using an automated stapler. EEA OrVil was orally, and a small hole was created at the tip of the obliquely cut-off stump with scissors to let the valve tip pass through. When it was confirmed that the automated stapler and center rod were made completely linear, the anvil and the main unit were connected with each other and firing was carried out. Then, HDST-based anastomosis was completed. The method may safe laparoscopic anastomosis between the esophagus and reconstructed intestine.

A Simple and Safe Method for Gastrojejunostomy in Laparoscopic Distal Gastrectomy Using the Hemidouble-Stapling Technique: Efficient Purse-String Stapling Technique

Aim: To describe a simple technique for intracorporeal circular-stapled gastrojejunostomy in laparoscopic distal gastrectomy with Roux-en-Y reconstruction. Methods: After the stomach and duodenum were mobilized, gastrotomy was established in the anterior gastric wall. An anvil, which was secured with a suture needle, was inserted completely through the gastrotomy. The needle was advanced to the greater curvature of the gastric wall to enable penetration of the central rod into the gastric wall. Subsequently, the stomach was cut using a linear stapler to secure the anvil on the stomach and was sequentially transected using another linear stapler to achieve distal gastrectomy. Circular-stapled gastrojejunostomy was then performed intracorporeally using the hemidouble-stapling technique, while handling the shaft of the instrument via the umbilical incision. The jejunal stump was closed using a linear stapler. Results: Gastrojejunostomies were successfully performed in 20 gastric cancer patients using this technique. None of the patients showed anastomotic leakage and/or stenosis. There were no mortalities in this series. Conclusions: Gastrojejunostomy performed using the above-mentioned technique was safe and simple. The most important feature of the technique was the elimination of the need for purse-string suture placement, as well as the achievement of better cosmesis using the transumbilical approach.

Roux-en-Y Gastrojejunostomy Using Modified Hemi-Double Stapling

For reconstruction after distal gastrectomy, the Roux-en-Y gastrojejunostomy is superior to the Billroth II gastrojejunostomy in terms of bile reflux. Roux-en-Y gastrojejunostomy prevents reflux gastritis, esophagitis, and carcinogenesis of the gastric remnant. However, the Roux-en-Y gastrojejunostomy is relatively complicated and lengthy. The authors perform a simple, safe Roux-en-Y gastrojejunostomy using modified hemi-double stapling. We applied this technique to 42 patients with gastric cancer. The average operating and reconstruction times were 172.6 ± 42.0 and 26.2 ± 4.8 min, respectively. The postoperative courses were uneventful and the patients were discharged 11.2 ± 2.4 days postoperatively. Neither leakage nor bleeding from the gastrojejunostomy has occurred postoperatively. The postoperative follow-up was 7–24 months and no local recurrence or stricture at the gastrojejunostomy site occurred. Roux-en-Y gastrojejunostomy using the modified hemi-double stapling technique can achieve reconstruction more simply, safely and quickly, and may provide an alternative reconstruction method for distal gastrectomy.

Totally laparoscopic sigmoid colectomy: a simple and safe technique for intracorporeal anastomosis

Current techniques of laparoscopic colectomy require an abdominal incision for extraction of the specimen. Although this incision is smaller than that for open laparotomy incision, it may reduce the advantages of laparoscopic surgery. In totally laparoscopic sigmoid colectomy, intracorporeal anastomosis is technically difficult. A safe and simple technique for circularly stapled intracorporeal anastomosis is described. After mobilization of the colon and division of the mesentery, a semicircumferential colotomy is made at the anterior colonic wall just proximal to the transection site. The anvil of a circular stapling device, secured with a Prolene suture, is introduced via the colotomy. The suture is advanced anteriorly so that the center rod of the circular stapling device penetrates the colonic wall. The colon is staple-transected at this point to secure the anvil on the proximal colon. A grasping forceps is brought through the rectum, and the specimen is extracted through the colotomy made at the distal staple line. After the colotomy is reclosed with a linear stapler, anastomosis is established using a hemidouble stapling technique. Totally laparoscopic sigmoid colectomies were performed for 16 patients with colon cancers. All the patients were treated laparoscopically without any complications. The average operation time was 180 min. Although one patient experienced wound infection, no major complications occurred. There was no mortality in this series. The procedure of totally intracorporeal anastomosis combined with transanal extraction of the specimen can be performed easily, enabling surgeons to achieve minimal invasiveness comparable with that of hybrid natural orifice translumenal endoscopic surgery (NOTES).

A simple and safe technique for esophagojejunostomy using the hemidouble stapling technique in laparoscopy-assisted total gastrectomy

In laparoscopy-assisted total gastrectomy, esophagojejunostomy is technically difficult. We describe a safe and simple technique for circular-stapled esophagojejunostomy. After mobilization of the stomach and the esophagus, a semicircumferential esophagotomy is made at the anterior esophageal wall. An anvil of a circular stapling device, secured with a Prolene suture (Ethicon, Inc, Somerville, NJ), is introduced via the esophagotomy. The suture is advanced anteriorly so that the center rod penetrates the esophageal wall. The esophagus is staple transected at this point. The circular-stapled esophagojejunostomy is then performed using the hemidouble stapling technique. Laparoscopy-assisted total gastrectomies were performed in 10 patients with gastric cancers. All patients were completed laparoscopically without any complications. The time of anvil placement was 9 minutes in median. Although a wound infection occurred in 1 patient, there were no major complications. There was no mortality in this series. Esophagojejunostomy using this technique is safe and simple. Its practical value is the elimination of the need for pursestring suture placement.

Hemidouble Stapling for Esophagogastrostomy During Laparoscopically Assisted Proximal Gastrectomy

In esophagogastrostomy during laparoscopically assisted proximal gastrectomy, some problems have occurred; the main ones being reflux esophagitis and the technical difficulty in anastomosis. We have had good results with a hemidouble stapling technique; the center rod of circular stapler is pierced through the left end of the staple line of the stomach. The longest distance from the pylorus to the esophagogastrostomy can be fired in this position. The distance is longer, so alkaline esophagitis is rarer. When the center rod is pierced through the anterior or posterior gastric wall, the operator may be worried about ischemia of the area surrounded by the linear stapler and circular stapler. In hemidouble stapling, an ischemic area is not created at all structurally. Any surgeon can perform a reproducible anastomosis because the place pierced with the center rod is fixed. This technique is easy and safety to operate via minilaparotomy.