Jejunal Stump Research Articles

Overlapping Esophagojejunostomy Using a Linear Stapler in Laparoscopic Total or Proximal Gastrectomy.

Background: Performing an intracorporeal esophagojejunostomy during laparoscopic-assisted total or proximal gastrectomy is challenging. We developed an ingenious method of overlapping esophagojejunostomy using a linear stapler to avoid stapler-related intraoperative complications. Methods: Following lymph node dissection, the esophagus was transected anterior-posteriorly. A linear stapler was used to divide the jejunum ∼20 cm distal to the Treitz ligament. A small enterotomy was then created 5 cm distal to the elevated jejunal stump to insert the linear stapler cartridge. An electronic knife was used to make a full-thickness incision, with the tip of the nasogastric tube (NGT) pressed against the posterior wall of the esophageal stump as a guide. Full-thickness sutures were placed on both the anterior and posterior walls of the entry hole in the esophageal stump to prevent the anvil fork from being misinserted into the submucosal layer of the esophagus. The thread on the posterior wall was guided through the port to the outside of the abdominal cavity, where the linear stapler was inserted to perform the side-to-side anastomosis. A 45-mm cartridge fork and an anvil fork were inserted into the elevated jejunum and esophageal stump entry holes, respectively, following which the esophageal stump was gently grasped. The thread on the posterior wall side was pulled from outside the abdominal cavity through the port. This step is necessary to close the gap between the esophageal and jejunal walls. After confirming that the anvil fork was not misinserted into the submucosal layer of the esophagus and that there was no gap between the esophagus and the elevated jejunum, the linear stapler was fired to create the anastomosis. The insertion hole was closed with hand-sewn sutures or linear staples to complete the esophagojejunostomy. Results: Eleven patients underwent this procedure with no anastomotic complications. Conclusions: This method enables us to perform an easier and more stable esophagojejunostomy.

The "Tube Submarine Technique": a safe and easy technique to place an external drainage tube during hepaticojejunostomy in minimally invasive surgery.

Pancreaticoduodenectomy (PD) is a standard procedure for various pancreatic head lesions. Recently, minimally invasive surgery (MIS), including laparoscopic PD (LPD) or robotic PD (RPD), has been widely performed. The hepaticojejunostomy (HJ) technique in MIS is more difficult than that in open procedures, and the placement of an external drainage tube (EDT) is not common in MIS owing to its complicated procedure. Here, we demonstrate the "Tube Submarine Technique" (TST) to facilitate EDT placement without hampering the anastomotic maneuver in MIS. After resection of the MIS-PD, the jejunal stump was extracted from the umbilical incision, and a small jejunostomy was performed. A retrograde insertion of the EDT was carried out from this hole towards the jejunal stump. A 4-0 suture was applied through the tip and neighboring side hole, and ligated with a margin of approximately 1-2cm without needle release. The needle was passed through the anterior jejunal limb wall from the inside to the outside, and the tube was placed into the jejunal limb like a submarine and fixed to the anterior inside wall. After posterior wall suturing during HJ in MIS, the tube-fixing suture was cut immediately below the knot, the tube-like surface of the submarine was pulled up from the jejunal hole and inserted into the bile duct. The procedure of tube fixation inside the jejunal limb and tube surfacing was safe and easy with no complications. The TST can significantly help in the placement of an EDT in MIS.

Comparing intracorporeal mechanical anastomosis vs. hand-sewn esophagojejunostomy after total laparoscopic gastrectomy for esophagogastric junction cancer: a single-center study

ObjectiveThis study aimed to compare the effects of continuous hand-sewn esophagojejunostomy with barbed suture and mechanical anastomosis in total laparoscopic gastrectomy for esophagogastric junction cancer.Materials and methodsThe clinical data of 60 patients who underwent total laparoscopic total gastrectomy from January 2020 to October 2021 were collected retrospectively. Baseline data and short-term surgical results of patients in the hand-sewn anastomosis (n = 30) and mechanical anastomosis (n = 30) groups were analyzed.ResultsNo significant differences were detected in the baseline data between groups. Meanwhile, the hand-sewn group had a shorter anastomosis time (21.2 ± 4.9 min vs. 27.9 ± 6.9 min, p < 0.001) and a decreased operation cost (CNY 70608.3 ± 8106.7 vs. CNY 76485.6 ± 3149.9, p = 0.001). The tumor margin distance in the hand-sewn group was longer than in the mechanical group (2.7 ± 0.4 cm vs. 2.2 ± 0.75 cm, p = 0.002). In esophagojejunostomy anastomosis, the distance between the jejunal opening and jejunal stump in the hand-sewn group was significantly shorter than that in the mechanical group (2.2 ± 0.54 cm vs. 5.7 ± 0.6 cm, p < 0.001). No significant difference was detected in the incidence of postoperative anastomotic complications.ConclusionThe continuous hand-sewn anastomosis with barbed suture in total laparoscopic gastrectomy for esophagogastric junction cancer is practical, safe, and cost-effective. It is also an effective supplementary technique for mechanical anastomosis.

A Simple and Safe T-Shaped Esophagojejunostomy for Laparoscopic Total Gastrectomy

BackgroundIn laparoscopic total gastrectomy, esophago-jejunal anastomosis is still considered a complicated procedure, even though laparoscopic surgery has become widespread. Esophagojejunostomy leakage can be fatal and adversely affect postoperative cancer treatment. The leakage rate has been reported to be 2.4–5.5%, and a safer and more reliable technique needs to be established. In this multi-media article, we describe the technique of laparoscopic esophagojejunostomy using a simple and safe T-shaped esophagojejunostomy. MethodsWe performed laparoscopic total gastrectomy with ante-colic Roux-en-Y reconstruction using a T-shaped anastomosis. First, insertion holes are made on the right side of the esophageal stump and the opposite side of the mesentery of the lift-up jejunal stump. Second, a linear stapler is inserted into each insertion hole, and a 40–45-mm V-shaped esophageal jejunal anastomosis is performed. Third, three temporary sutures are added for closing the common edge. Finally, a second stapling is used to close the entry hole and resect the esophageal stump. ResultsWe performed this procedure in 35 patients between May 2016 and December 2018. The median duration of surgery was 338 min (range, 248–542 min) and median bleeding was 20 mL (range, 0–240 mL). There were no esophagojejunostomy-related complications higher than Clavien-Dindo grade II. Additionally, no postoperative stenosis occurred during the follow-up period (median: 48 months, range: 4–68 months). ConclusionConsidering the present results, T-shapedesophago-jejunal anastomosis is a simple and safe procedure and a promising laparoscopic total gastrectomy option.

Resolución laparoscópica de un caso de “Candy Cane” en un postoperatorio de By Pass Gástrico

El by pass gástrico (BPG) es una técnica de cirugía bariátrica de probada eficacia en el control de la obesidad y la resolución de enfermedades asociadas, como diabetes e hipertensión. El dolor abdominal en el postoperatorio alejado del BPG es un verdadero desafío, y exige para su diagnóstico etiológico comprender la técnica quirúrgica y las posibles causas que originan el dolor. Las principales causas de dolor son la úlcera de neoboca, las hernias internas (por el espacio de Petersen o la brecha mesentérica), la litiasis vesicular sintomática y el síndrome del “bastón de caramelo” (o “Candy Cane syndrome” por su nombre anglosajón). El mismo resulta de una excesiva longitud del cabo yeyunal ciego del asa alimentaria, luego de la anastomosis gastro yeyunal. Cuando mide más de 4 cm puede llenarse de alimentos, actuando como una bolsa o reservorio, generando dolor, náuseas o vómitos. El diagnóstico surge de la clínica y un estudio contrastado que demuestre la longitud excesiva del extremo del asa alimentaria. El tratamiento es quirúrgico y la desaparición de los síntomas confirma el diagnóstico. Ver el video en: https://www.youtube.com/watch?v=wxLU_Xh8o7Q

Endoscopic "stenting bridge" to treat combined gastric perforation, jejunal stump dehiscence, and biliodigestive anastomosis leak after duodenopancreatectomy followed by pancreatic totalization.

Endoscopic "stenting bridge" to treat combined gastric perforation, jejunal stump dehiscence, and biliodigestive anastomosis leak after duodenopancreatectomy followed by pancreatic totalization.

Efficacy of endoscopic management for anastomotic leakage after gastrectomy in patients with gastric cancer

BackgroundAnastomotic leakage (AL) after gastrectomy in gastric cancer patients is associated with high mortality rates. Various endoscopic procedures are available to manage this postoperative complication. The aim of study was to evaluate the outcome of two endoscopic modalities, clippings and stents, for the treatment of AL.Patients and methodsThere were 4916 gastric cancer patients who underwent gastrectomy between December 2007 and January 2016 at the National Cancer Center, Korea. A total of 115 patients (2.3%) developed AL. Of these, 85 patients (1.7%) received endoscopic therapy for AL and were included in this retrospective study. The endpoints were the complete leakage closure rates and risk factors associated with failure of endoscopic therapy.ResultsOf the 85 patients, 62 received endoscopic clippings (with or without detachable snares), and 23 received a stent insertion. Overall, the complete leakage closure rate was 80%, and no significant difference was found between the clipping and stent groups (79.0% vs. 82.6%, respectively; P = 0.89). The complete leakage closure rate was significantly lower in the duodenal and jejunal stump sites (60%) than esophageal sites (86.1%) and gastric sites (94.1%; P = 0.026). The multivariate analysis showed that stump leakage sites (adjusted odds ratio [aOR], 4.51; P = 0.031) and the presence of intra-abdominal abscess (aOR, 4.92; P = -0.025) were associated with unsuccessful leakage closures.ConclusionsEndoscopic therapy using clippings or stents is an effective method for the postoperative management of AL in gastric cancer patients. This therapy can be considered a primary treatment option due to its demonstrated efficacy, safety, and minimally invasive nature.

Expanding endoscopic treatment strategies for pancreatic leaks following pancreato-duodenectomy: a single centre experience.

Clinically relevant pancreatic leaks of jejunal-pancreatic anastomosis after pancreato-duodenectomy (PD) occur in 9-15% of cases. Endoscopic strategies for management of pancreatic fistula, may allow to avoid reoperation and shorten times for fistula closure, but are still understudied and not widely performed. Aim of the present paper is to describe different endoscopic techniques used to treat such conditions. It was a retrospective, single centre, study. All patients who underwent endoscopic treatment for pancreatic leaks following PD between 1st January 2013 and 31th May 2019 at our Centre were reviewed. Depending on the morphology and severity of the leak, four main endoscopic techniques were performed: (1) trans-anastomotic intraductal pancreatic stent insertion; (2) lumen-apposing metal stent between the jejunal loop and the retroperitoneum toward the pancreatic stump insertion ("yoyo-stent"); (3) large calibre nose-to-retroperitoneum drain insertion; (4) when a wide damage of the jejunal wall or a coexistent biliary-jejunal leak were observed, triple metal stent insertion was performed as follow in order to close the defect: enteral fully-covered SEMS in the jejunal stump, a pancreatic metal stent into the Wirsung duct and a fully-covered SEMS across the bilio-digestive anastomosis, through the meshes of the enteral stent. In all cases, surgical drain was simultaneously retracted. We identified 13 patients who underwent endoscopic treatment for POPF after PD. In total, 5 patients underwent "Yoyo stent insertion", 3 with nose-to-collection drain placement and four patients were treated with triple-stent insertion; in only one patient intrapancreatic SEMS insertion was performed. Technical success was 100% and clinical success was 83.3%. Mean time for leak closure was 4.8days (range 2-10). During the follow-up interval, no leak recurrences were observed. Our experience confirms efficacy and safety of endoscopic management of POPF following pancreatoduodenectomy management. Endoscopy should play a central role in this clinical scenario.

Hepaticojejunostomy vs. Hepaticoduodenostomy after Excision of Choledochal Cyst in Paediatric Population- A Retrospective Study

Introduction: Choledochal cyst is a rare congenital anomaly of the bile duct with female predominance. Surgical excision of the choledochal cyst with hepaticoduodenostomy or hepaticojejunostomy is the standard of care in the last few decades. Many surgeons favour hepaticojejunostomy. Aim: To evaluate the outcomes of open hepaticoduodenostomy vs. hepaticojejunostomy procedure in excision of choledochal cyst in paediatric population. Materials and Methods: This was a retrospective cohort study conducted from January 2015 to December 2019 on data of 16 paediatric patients who underwent choledochal cyst excision with biliary reconstruction in a tertiary health institute. The data of these patients were collected from Medical Records Department (MRD) on type of surgery performed, mean operating time, postoperative hospital stay, the onset of oral feeds and complications associated with the surgery and were analysed and evaluated in July 2021. All statistical analyses were performed with Statistical Package for Social Sciences (SPSS) version 23.0. A p-value of &lt;0.05 was considered as statistically significant. Results: A total of 16 patients (5 males and 11 females) were included, out of them 9 (56%) had undergone hepaticoduodenostomy and 7 (44%) had undergone hepaticojejunostomy. The most common typeofcholedochalcystwasType1(n=7,43.7%).Operativetimewas longer for the hepaticojejunostomy than the hepaticoduodenostomy (212.86±31.33 vs 88.89±15.16 min; p-value 0.001). Patients who underwent hepaticoduodenostomy early feeds were started as compared to the hepaticojejunostomy (2.22 vs 5.29 days; p-value 0.001). Hospital stay was longer with the hepaticojejunostomy than the hepaticoduodenostomy (14.71±7.76 days vs 8.11±4.48 days; p-value 0.05). There were three complications (biliary enteric fistula that opened into the anterior abdominal wall at the previous surgical site incision, jejunal stump formed the fistulous tract with high output bile leak and surgical site infection was noted) in total noted in both groups. Conclusion: The present study concluded that hepaticoduodenostomy had a better outcome in factors such as operating time, the onset of feeds and hospital stay than with the hepaticojejunostomy.

The key points of prevention for special surgical complications after radical operation of gastric cancer

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.

Application value of semi-end-to-end esophagojejunal anastomosis for the Roux-en-Y digestive tract reconstruction after laparoscopy-assisted total gastrectomy

Objective To investigate the application value of semi-end-to-end esophagojejunal anastomosis for the Roux-en-Y digestive tract reconstruction after laparoscopy-assisted total gastrectomy (LATG). Methods The retrospective cohort study was conducted. The clinical data of 205 gastric adenocarcinoma patients who underwent LATG at the Southwest Hospital of the Third Military Medical University from January 2012 to December 2015 were collected. Among 205 patients, 140 who underwent Roux-en-Y digestive tract reconstruction with end-to-side esophagojejunal anastomosis were allocated into the control group, and 65 who underwent Roux-en-Y digestive tract reconstruction with semi-end-to-end esophagojejunal anastomosis were allocated into the study group. All the patients underwent LATG according to Japanese gastric cancer treatment guidelines (ver.3). Observation indicators included: (1) surgical situations: operation completion, operation time, time of digestive tract reconstruction, volume of intraoperative blood loss and number of patients with intraoperative esophagojejunal anastomosis-site complications (anastomosis-site stenosis and bleeding). (2) Postoperative situations: time to initial anal exsufflation, time of postoperative drainage tube removal, number of patients with postoperative esophagojejunal anastomosis-site complications (anastomosis-site stenosis, bleeding and leakage), number of patients with postoperative non-esophagojejunal anastomosis-site complications (pulmonary infection, pleural effusion, wound infection, abdominal abscess, intra-abdominal bleeding, duodenal stump fistula, intestine obstruction and internal abdominal hernia) and duration of postoperative hospital stay. (3) Follow-up situations. Follow-up using outpatient examination or telephone interview was performed to detect the survival of patients and tumor recurrence or metastasis up to April 2016. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the t test. Measurement data with skewed distribution were represented as M (range) and comparison between groups was analyzed using the nonparametric test. Comparison of count data was analyzed using the chi-square test, and ranked data was analyzed using the nonparametric test. Results (1) Surgical situations: all the patients received successful LATG and Roux-en-Y digestive tract reconstruction. Operation time and time of digestive tract reconstruction were (254±57)minutes, (53±10)minutes in the control group and (233±55)minutes, (41±9)minutes in the study group, respectively, with statistically significant differences between the 2 groups (t=2.508, 8.191, P 0.05). Of 8 patients with anastomosis-site stenosis in the control group, 4 didn′t receive special treatment, 1 underwent end-to-side esophagojejunal anastomosis again after dismantling anastomosis-site and 3 underwent side-to-side anastomosis between jejunal stump and distal jejunum again due to higher anastomosis-site surface. One patient with intraoperative anastomosis-site bleeding in the study group underwent strengthening suture of anastomosis-site and then bleeding was stopped. (2) Postoperative situations: number of patients with anastomosis-site stenosis, bleeding and leakage (postoperative esophagojejunal anastomosis-site complications) was respectively 11, 0, 6 in the control group and 0, 0, 1 in the study group, with a statistically significant difference between the 2 groups (χ2=6.232, P 0.05). Of 11 patients with postoperative anastomosis-site stenosis in the control group, 5 didn′t received special treatment and 6 were improved through endoscopic balloon dilatation. Patients with postoperative anastomosis leakage were improved after adequate drainage, anti-infection and symptomatic treatments. Patients with pulmonary infection were improved after anti-infection treatment. Patients with pleural effusion, wound infection, abdominal abscess and duodenal stump fistula were improved after adequate drainage, anti-infection and symptomatic treatments. Bleeding of patients with intra-abdominal bleeding in the control group was controlled by reoperation, and hemostasis and symptomatic treatment were conducted for patients with intra-abdominal bleeding in the study group. Patients with intestine obstruction and internal abdominal hernia were improved after reoperation. (3) Follow-up situations: among 205 patients, 192 were followed up for 4-51 months with a median time of 28 months, including 130 in the control group and 62 in the study group. During the follow-up, death and tumor recurrence or metastasis were respectively detected in 19, 23 patients in the control group and 8, 10 patients in the study group. Conclusion Semi-end-to-end esophagojejunal anastomosis is safe and feasible for the Roux-en-Y digestive tract reconstruction after LATG, with advantages of shorter time of digestive tract construction and fewer postoperative esophagojejunal anastomosis-site complications. Key words: Gastric neoplasms; Gastrectomy; Semi-end-to-end anastomosis; Roux-en-Y reconstruction; Laparoscopy

Clinical application of reverse puncture device(RPD) in laparascopic esophagogastrectomy (esophagojejunostomy): a report of 18 cases

The authors report the newly developed reconstruction technique after laparoscopic total gastrectomy (LTG) or laparoscopic distal gastrectomy (LDG): intracorporeal circular stapling esophagojejunostomy(esophagojejunostomy) using the reverse puncture device(RPD). After LTG or LDG, The anvil is then transorally inserted into the esophagus by using the RPD system. Double-stapling esophagojejunostomy with a circular stapler is performed intracorporeally, and the jejunal stump is closed with an Echelon. There was no intraoperative complication or conversion to open surgery, the mean operation time was 155 min and blood loss was 75 ml. Postoperative fluorography revealed no anastomosis leakage or stenosis Patients resumed an oral liquid diet on postoperative day 2, and discharged at day 8. We have successfully performed LTG or LDG, reconstruction using our technique in 18 patients without any anastomosis complications. We believe that our procedure is a safe and reliable reconstruction method, which is especially useful in obese patients, in whom conventional extracorporeal anastomosis is often difficult.

Surgical treatment of severe pancreatic fistula after pancreaticoduodenectomy by wirsungostomy and repeat pancreatico-jejunal anastomosis

BackgroundAfter pancreaticoduodenectomy, severe pancreatic fistula may require salvage relaparotomy in patients with largely disrupted pancreaticojejunal anastomosis. Completion pancreatectomy remains the gold standard but yields high mortality and severe long-term repercussions. The authors report the results of a pancreas-preserving strategy used in this life-threatening condition. MethodsTwo hundred fifty-four pancreaticoduodenectomies with pancreaticojejunal anastomosis were performed between 2005 and 2011; 21 patients underwent salvage relaparotomy for grade C pancreatic fistula. Largely dehiscent pancreaticojejunal anastomoses were dismantled in 16 patients. Four patients underwent completion pancreatectomy, whereas in 12 patients detailed here, the remaining pancreas was preserved and drained by wirsungostomy with exteriorization or closure of the jejunal stump. Repeat pancreaticojejunal anastomosis was later planned to preserve pancreatic function. ResultsOne patient died of recurrent hemorrhage on day 1 after wirsungostomy (8.3%). All but 1 survivor developed postoperative complications, and 3 needed reoperation before hospital discharge. The median hospital stay was 62 days (range, 29 to 156 days). After a median delay of 130 days (range, 91 to 240 days) from salvage relaparotomy, repeat pancreaticojejunostomy was attempted in 10 patients and was successful in 9 (1 completion pancreatectomy was performed). One patient died postoperatively (10%). Long-term endocrine function was unaltered in 66% of patients who benefited from this conservative strategy. ConclusionsThis pancreas-preserving strategy yielded a whole mortality rate of 17% for largely disrupted pancreaticojejunal anastomosis requiring salvage relaparotomy. It compares favorably with systematic completion pancreatectomy and achieved preservation of remnant pancreatic function in 75% of patients.

Hemorrhage from the pancreatic cut end into the jejunum after binding pancreaticojejunostomy: report of a case

Recent studies have described that binding pancreaticojejunostomy (PJ) decreased the incidence of postoperative pancreatic fistulas and complications after pancreaticoduodenectomy. We herein describe the case of a 77-year-old male with papilla of Vater cancer who underwent subtotal stomach-preserving pancreaticoduodenectomy with end-to-side binding PJ. He developed postoperative gastrointestinal bleeding from the pancreatic cut end three separate times. Transcatheter arterial embolization was performed for the first bleeding event. Surgical hemostasis was performed and a temporary jejunostomy was constructed at the jejunal stump for the second event. For the third bleeding event, endoscopic coagulation through the jejunostomy was performed successfully, and no further bleeding was noted.

Successful Resection of Pancreatic Carcinoma Recurrence in the Remnant Pancreas after a Pancreaticoduodenectomy

We present a rare case in which a pancreatectomy was performed for a recurrent tumor in the remnant pancreas after a pancreaticoduodenectomy, and we review the associated literature. A 67-year old man underwent pancreaticoduodenectomy for pancreatic cancer on April 9, 2003. The tumor was composed of well differentiated adenocarcinoma and diagnosed as R0, pT2, pN1, pM0, pStage III according to UICC TNM classification. Five years and eight months later, his serum level of carcinoembryonic antigen was found to be elevated, and a computed tomography showed a low-density mass near the site of the pancreaticojejunostomy and dilatation of the jejunal stump. We conducted a total resection of the remnant pancreas including pancreaticojejunostomy, splenectomy and peripancreatic lymph node dissection without any residual macroscopic tumor. Histologically, it was diagnosed as a well differentiated adenocarcinoma, similar to the initial tumor. It is difficult to assess whether this tumor developing in the remnant pancreas was a local recurrence or a second primary cancer. However, we believe this tumor was a second primary tumor because of the long interval period and the absence of a neoplastic invasion in the resection margins of the initial specimens.

Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy

Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of technical difficulties, especially esophagojejunal anastomosis. Various modified procedures for reconstruction have been reported, but an optimal method has not been established. The authors report a circular-stapled anastomosis using hand-sewn purse-string sutures, which is a simple and classic method. However, no previous study has assessed its reliability. From September 2008 to May 2009, 10 consecutive patients (9 men and 1 woman) with gastric cancer underwent LTG at the authors' institution. These patients had a median age of 63.7 years (range, 45-80 years) and a body mass index of 22.4 kg/m(2) (range, 18-26 kg/m(2)). After transection of the abdominal esophagus, a hand-sewn purse-string suture along the cut end of the esophagus was performed using 3-0 monofilament thread. An anvil head then was inserted into the esophagus, and the thread was tied. A monofilament pretied loop suture was added to reinforce the ligation. After the creation of an Roux-en-Y jejunal limb, laparoscopic esophagojejunal anastomosis was performed using a circular stapler inserted via a surgical glove attached to a wound retractor at the incision point at the umbilicus. The jejunal stump was closed with an endoscopic linear stapler. Laparoscopic esophagojejunostomy was performed successfully for all the patients. No postoperative complications related to anastomosis occurred. In one patient, an intraabdominal abscess developed postoperatively and was treated conservatively. The mean operation time was 257 min, and the estimated blood loss was 69 ml. With the described method, esophagojejunostomy can be performed as in conventional open surgery. Hand-sewn purse-string suturing is demanding technically, but it can be performed safely by experienced laparoscopic surgeons. This technique is feasible and can lower the cost of the laparoscopic procedure. It may be considered in countries with limited access to other special devices.

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.

Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™) after laparoscopic total gastrectomy

Laparoscopic total gastrectomy (LTG) has not become as popular as laparoscopic distal gastrectomy (LDG) because of the more difficult reconstruction technique. Despite various modifications of reconstruction methods after LTG, an optimal procedure has yet to be established. The authors report the newly developed reconstruction technique after LTG: intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien, Mansfield, MA, USA). After full mobilization of the abdominal esophagus, the esophagus is transected with an endoscopic linear stapler. The anvil is then transorally inserted into the esophagus by using the OrVil system. After jejunojejunostomy is performed through a 4-cm midline minilaparotomy, preparing a 50-cm Roux-en-Y jejunal limb, a circular stapler is inserted into the jejunum and introduced into the abdominal cavity. Pneumoperitoneum is established by sealing off the laparotomy wound retractor with a surgical glove attached to the circular stapler. Double-stapling esophagojejunostomy with a circular stapler is performed intracorporeally, and the jejunal stump is closed with an endoscopic linear stapler. Of the 16 patients who underwent this operation, there was no intraoperative complication or conversion to open surgery, and no patient required an extension of the initial incision for anastomosis. Mean operation time and blood loss were 194 min and 272 ml, respectively. One patient developed an intra-abdominal abscess postoperatively. Postoperative fluorography revealed no anastomosis leakage or stenosis in any of the patients. Patients resumed an oral liquid diet on postoperative day 3-5, and the mean postoperative hospital stay was 11 days. We have successfully performed LTG with Roux-en-Y reconstruction using our technique in 16 patients without any anastomosis complications. We believe that our procedure is a secure and reliable reconstruction method after LTG, which is especially useful in obese patients, in whom conventional extracorporeal anastomosis often is difficult.

Laparoscopy-assisted esophagoenteral anastomosis using endoscopic purse-string suture instrument “Endo-PSI (II)” and circular stapler

It is said that laparoscopic esophagoenteral anastomosis is not easy. In particular, purse-string suture of the abdominal esophagus is difficult when using a circular stapler. We have developed an endoscopic purse-string suture instrument, the "Endo-PSI (II)", and the instrument was employed clinically during laparoscopy-assisted total gastrectomy. The device was inserted into the abdominal cavity through a 4-cm minilaparotomy of the epigastrium, and pneumoperitoneum was established by closing a Lap Disc. The Endo-PSI (II) was attached to the abdominal esophagus and a straight needle with a 2-0 polypropylene suture was passed through the device laparoscopically. After a purse-string suture of the abdominal esophagus was made, the abdominal esophagus was transected laparoscopically and the removed stomach was pulled out through the minilaparotomy. The anvil head of a circular stapler was inserted into the abdominal cavity through the minilaparotomy, and insertion of the anvil into the esophagus and ligation of the purse-string suture were performed laparoscopically, too. The combination of using a circular stapler for esophagojejunostomy and closure of the jejunal stump was also performed laparoscopically. Between May 2007 and May 2008, these products were used in 23 patients during laparoscopy-assisted total gastrectomy. There were no cases that required conversion to a conventional open procedure. The newly developed Endo-PSI (II) was useful for laparoscopic purse-string suture of the esophagus.

Use of cecal bypass via side-to-side ileocolic anastomosis without ileal transection for treatment of cecocolic intussusception in three horses

3 horses were evaluated for signs of colic; cecocolic intussusception was detected. Abnormalities detected included diminished intestinal sounds, inflammatory leukogram, dehydration, unremarkable fi ndings via rectal palpation, and ultrasonographic evidence of large intestine intussusception. Laparotomy revealed cecocolic intussusception. Cecal bypass via side-to-side ileocolic anastomosis without ileal transection was performed in each horse by use of an intraluminal anastomosis stapler device. Postoperative complications were minimal, and all horses recovered rapidly and were clinically normal at > 12 months after surgery. Cecal bypass via side-to-side ileocolic anastomosis without ileal transection seemed to offer 2 potential advantages over traditional surgical techniques for treating this condition. The risk of abdominal contamination was far less than with techniques in which the colotomy is needed to enable resection of the cecum or techniques in which the ileum is transected. Also, it was technically simpler to perform because there was no need to transect the ileum, oversew the ileal stump, perform cecal resection, or close the mesenteric space created by relocating the jejunal stump to the right ventral colon.