Intracorporeal End-to-Side Esophagojejunostomy Using a Laparoscopic Purse-String Clamp during Laparoscopic Total Gastrectomy

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to establish the feasibility of using a newly developed purse-string suture instrument (“Lap-Jack”), which can be used in performance of intracorporeal anastomosis.

Methods: From April, 2010 to February, 2011, 50 patients with upper gastric cancer underwent LTG with intracorporeal Roux-en-Y esophagojejunostomy using the Lap-Jack. Retro- spective data for gender, age at the time of surgery, past medical history, operative time, estimated blood loss, TNM staging, and postoperative complications were reviewed.

Results: Among the 50 patients, 33 were male and 17 were female. Median age was 59.9 years. The average operative time was 217.4±41.7 minutes. Based on the AJCC 7

edition of Gastric Cancer Staging, 19 patients were stage IA, three

without any mortality. Complications included wound problems (2.0%, n=1), pleural effusion (2.0%, n=1), urinary retention (4.0%, n=2), efferent loop obstruction due to adhesion (4.0%, n=2), postoperative ileus (2.0%, n=1), postoperative bleeding (2.0%, n=1), and intra-abdominal abscess (2.0%, n=1). No leakage or stenosis of esophagojejunostomy was reported.

Conclusion: The Lap-Jack is feasible and suitable for use in performance of esophagojejunostomy during LTG.

󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Key words: Laparoscopic total gastrectomy (LTG), Intracor- poreal esophagojejunostomy, Purse-string clamp, Gastric cancer

Received April 13, 2012, Revised 1st May 19, 2012; Revised 2nd May 27, 2012, Accepted May 27, 2012

※ Corresponding author：Hyung-Ho Kim

Department of Surgery, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam 463-707, Korea Tel：+82-31-787-7095, Fax：+82-31-787-4055

E-mail：hhkim@snubh.org

INTRODUCTION

After the first laparoscopic gastric surgery in 1992 by Goh et al.

in Singapore, laparoscopic surgery has been widely used for gastric cancer because of its minimally invasive nature.

However, laparoscopic total gastrectomy (LTG) in gastric cancer patients, first performed by Huscher

in 1992, is not widely accepted due to the absence of established, optimal methods for anastomosis.

Esophagojejunostomy during LTG is recognized as the most critical and technically challenging part of operation. Till now, various methods for laparoscopic anastomosis are reported.

Methods for reconstructing bowel continuity during LTG are classified into extracorporeal and intracorporeal anastomosis.

Intracorporeal anastomosis is further classified into side-to-side anastomosis using linear staplers and end-to-side anastomosis using circular staplers. OrVil, Endo-PSI and Endo-PSI (II) are stapling devices used currently in intracorporeal anastomosis.

Recent studies suggest that intracorporeal anastomosis is superior to extracorporeal anastomosis,

and we previously reported that the end-to-side intracorporeal anastomosis is better than side-to-side intracorporeal anastomosis.

Based on these conclusions, we developed a new device, “Lap-Jack”, which can be used for intracorporeal esophagojejunostomy during LTG. When inserting this device extension of trocar site is not needed. Reduced time for inserting the device compared with previous ones is expected. In this study, we sought to establish the feasibility of intracorporeal esophagojejunostomy during LTG using Lap-Jack.

MATERIALS AND METHODS 1) Patients

From April, 2010 to February, 2011, 50 patients with upper

gastric cancer underwent LTG with intracorporeal Roux-en-Y

Fig. 1. Shape of Lap-Jack. (A) Closed. (B) Open. (C) Lap-Jack approaching the esophagus. (D) Lap-Jack opened intracorporeally: Once the button on the gripping part is pressed, the distal clamp pops out. After pushing forward the gripping part, the distal clamp is also released.

Fig. 2. Trocar placement.

esophagojejunostomy using Lap-Jack at Seoul National University Bundang Hospital. Patients with preoperatively diagnosed with resectable upper third gastric adenocarcinoma, the age of between 20 and 80 were included.

Patients with the indication of endoscopic submucosal dissection were not included. All patients gave informed consent. The study was conducted by reviewing the patient retrospective data including gender, age at operation, past medical history, operative time, estimated blood loss, number of harvested lymph nodes, duration of hospital stay, TNM staging and postoperative complications.

2) New laparoscopic purse-string clamp: “Lap-Jack”

The Lap-Jack device was developed by a Korean company,

“Eterne” (Kyeonggi-do, South Korea), in cooperation with a team at the Division of Gastrointestinal Surgery, Seoul National University Bundang Hospital, and gained approval from the Korea Food and Drug Administration (KFDA) on 1st April, 2010. Lap-Jack can be attached to a 12-mm trocar and opened in the peritoneal cavity during laparoscopic operation without extension of the trocar site during insertion (Fig. 1).

Consequently opportunity for making repeated pneumoperi- toneum would be decreased and reduced operative time is expected.

3) Surgical technique of esophagojejunostomy

Under general anesthesia, the patient was laid in the supine position. A pneumoperitoneum was made by CO

insufflation

through the subumbilical port. Four additional ports were made by skin incisions (two 5-mm and two 12-mm ports) (Fig. 2).

After radical lymphadenectomy and exposure of the abdomi-

nal esophagus, Lap-Jack was applied to the esophagus through

a 12-mm port located in the left lower quadrant (Fig. 3A). Once

the button on the gripping part is pressed, the distal clamp pops

out. After pushing forward the gripping part, the distal clamp

is also released. Placing the distal esophagus between the two

clamps and pushing forward the gripping part further until it

clicks, the two clamps come together. A straight needle with

a 2-0 polypropylene suture (Surgipro; U.S. Surgical) was

purse-string suture is made.

(D) Intracorporeal esophago- jejunostomy is performed un- der direct laparoscopic view.

Table 1. Patient characteristics and perioperative outcomes

Characteristics n (%)

Age (yr±SD) Gender (M:F) BMI (kg/m

±SD) Comorbidity Yes No

Combined splenectomy or pancreaticosplenectomy Yes

No

Harvested lymph nodes Lymph node dissection D1＋α

D1＋β D2 Stage IA IB II IIIA IIIB IIIC IV

Operation time (min±SD) Estimated blood loss (ml) Hospital stay (days±SD)

59.9±14.4 33 : 17 22.6±14.4

22 (44) 28 (56)

8 (30.8) 18 (69.2) 57.8±22.8 1 (2.0) 14 (28.0) 35 (70.0) 19 (38.0) 3 (6.0) 12 (24.0)

1 (2.0) 3 (6.0) 8 (16.0)

2 (4.0) 217.4±41.7 160.8±155.2

8.6±5.0 SD = standard deviation.

passed through the Lap-Jack (Fig. 3B). An endoscopic bulldog clamp was placed distally and the esophagus was transected perpendicularly between the two instruments. The left lower port was extended horizontally to a length of 3 cm and was then retracted and protected by a wound protector. The stomach was extracted, and the anvil head of a circular stapler was introduced into the abdominal cavity by mini-laparotomy incision. After pneumoperitoneum was reestablished using a surgical glove, the anvil head was inserted into the esophagus using an anvil holder (Fig. 3C) and an intracorporeal purse-st- ring suture was made. Reinforcement of the purse-string suture was done laparoscopically using Endoloop (Ethicon Endo-Sur- gery Inc., Cincinnati, OH, USA). A loop of jejunum 20-cm distal to the Ligament of Treitz was identified laparoscopically and transected extracorporeally. Esophagojejunostomy was performed using a circular stapler intracorporeally (Fig. 3D).

After the circular stapler was withdrawn, the open end of the jejunum was closed with an endoscopic linear stapler (Ethelon 60 white reloaded; Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). The Roux-en-Y anastomosis was completed by perfor- ming the jejuno-jejunal anastomosis extracorporeally.

RESULTS

Surgical outcomes are described in Table 1. The 50 patients

treated in this series consisted of 33 men and 17 women with

a mean age of 59.9 years and a mean body mass index of 22.6

kg/m

(±14.4). The average operative time was 217.4±41.7

Table 2. Complications

Complications n (%)

Wound problem Pleural effusion Urinary retention Efferent loop obstruction Postoperative ileus Postoperative bleeding Intra-abdominal abscess

1 (2.0) 1 (2.0) 2 (4.0) 2 (4.0) 1 (2.0) 1 (2.0) 1 (2.0)

minutes. Twenty-two patients (44.0%) had underlying diseases.

The mean number of harvested lymph nodes was 57.82±

22.76. Eight patients (30.8%) had combined organ resection during the operation. D1＋β lymphadenectomy (D1＋LN#7, 8, 9) was done for 14 patients (28.0%) whose preoperative clinical stage was less than T1b (submucosa). Thirty-five patients (70.0%) who were preoperatively suspected of advanced gastric cancer underwent D2 lymphadenectomy. One patient (2.0%) had D1＋α dissection due to underlying liver cirrhosis.

Based on AJCC 7

edition of Gastric Cancer Staging, 19 patients (38.0%) were stage IA, three (6.0%) were IB, 12 (24.0%) were II, one (2.0%) was IIIA, three (6.0%) were IIIB, eight (16.0%) were IIIC, and two (4.0%) were IV.

Overall morbidity rate was 18.0% without any mortality.

Complications included wound problems (2.0%, n=1), pleural effusion (2.0%, n=1), urinary retention (4.0%, n=2), efferent loop obstruction due to adhesion (4.0%, n=2), postoperative ileus (2.0%, n=1), postoperative bleeding (2.0%, n=1), and intra-abdominal abscess (2.0%, n=1) (Table 2). There were no cases of anastomosis leakage or stenosis. Two patients underwent a second operation, involving a revision of the Roux-en-Y jejunojejunostomy, for efferent loop obstruction due to adhesion. One patient manifested with intra-abdominal abscess, which was managed with percutaneous drainage and antibiotic therapy.

DISCUSSION

Laparoscopic surgery is recognized as superior to open surgery due to the small incision, which results in less pain, faster recovery, reduced risk of wound infection and shorter hospital stays. The field of laparoscopic surgery continues to expand, with coverage extending from simple benign diseases to complex malignant ones. With this expansion of traditional laparoscopic and robotic surgery, there is an ongoing need to

develop new and improved laparoscopic devices.

Laparoscopic surgery is widely used for gastric cancer due to its minimal invasiveness. The increased detection of early gastric cancer due to widespread medical checkups plays a significant role in the extensive use of laparoscopic surgery for gastric cancer, especially in eastern Asian countries, which have a high prevalence of gastric cancer. LTG, however, is not widely accepted because of its technical difficulty in comparison with laparoscopic distal gastrectomy (LDG). In particular, the esophagojejunostomy in LTG is thought to be particularly difficult.

Currently, various methods of anastomosis are widely used and are classified as intracorporeal and extracorporeal depen- ding on where the anastomosis is done. There have been many attempts to perform a laparoscopic esophagojejunostomy, with the most common being an extracorporeal approach through a mini laparotomy, constructing a classic end-to-side anastomosis with an EEA stapler (EEA; Ethicon Endo-Surgery Inc., Cincinnati, OH, USA).

Although this technique is widely used for LTG, it can be difficult because it is performed in a very deep and narrow working space, especially in obese patients.

Esophagojejunostomy using the bare eye rather than the laparoscopic view is not feasible because the operation is deeper than that in LDG even with full retraction of the mini-laparotomy wound. In addition, obtaining an adequate proximal margin would be compromised.

For intracorporeal anastomosis, several methods of side-to-side EJ (esophagojejunal) anastomosis using a linear stapler are reported.

Use of the linear stapler, however, requires a greater extent of dissection and longer exposure of the abdominal esophagus than with the typical circular stapler method.

Fewer cases involving circular stapling in EJ anastomosis , such as that used during conventional open total gastrectomy are reported. The most critical step in laparoscopic esophagojejunostomy using a circular stapler is thought to be making the purse-string suture of the abdominal esophagus. In 2009, Jeong et al. reported intracorporeal circular stapling esophagojejunostomy using a transorally-inserted device (OrVil

; Covidien, Mansfield, MA, USA). With this device, the purse-string suture and extension of the incision was not required. The instrument did, however, have to pass though the esophageal cavity, which is not sterile, thereby increasing the risk of contamination. In addition, passing the anvil head through the relatively narrow larynx, especially when compressed by the cuff of the endotracheal tube, may be quite difficult.

In 2007 and 2008, Usui et al.

reported new instruments

needing to make a repeat pneumoperitoneum, with a conse- quent reduction in the operative time (mean overall operative time: 305.9±57.6 minutes with Endo-PSI (II) versus 217.42±

41.74 minutes with Lap-Jack).

In this study, the primary endpoint was complications of esophagojejunostomy. It was notable that there were no cases of esophagojejunostomy leakage or stenosis. Furthermore, with the “Lap-Jack”, proximal resection can be done prior to No.

11p, 11d and 10 lymphadenectomy, which facilitates adequate lymph node dissection using downstream methods, especially in advanced gastric cancer patients.

This study was limited by its small patient population and lack of comparison with other instruments or with conventional open total gastrectomy. Further studies are needed to address these issues. We conclude that Lap-Jack is feasible and suitable for use in esophagojejunostomy during LTG, although further randomized controlled trials comparing Lap-Jack with other instruments are needed.

ACKNOWLEDGEMENTS

The entire team of authors, Seung yeon Noh, Ju-Hee Lee, Sang Hoon Ahn, Sang-Yong Son, Chang Min Lee, Do Joong Park, Hyung Ho Kim, Hyuk-Joon Lee and Han-Kwang Yang declare that they have no conflict of interest or disclosures to make.

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