Prospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 7, 2015; 21(29): 8943-8951
Published online Aug 7, 2015. doi: 10.3748/wjg.v21.i29.8943
Esophagojejunostomy after laparoscopic total gastrectomy by OrVilTM or hemi-double stapling technique
Hao Wang, Qun Hao, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China
Qun Hao, Department of Obstetrics and Gynecology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
Author contributions: Wang H and Hao Q contributed equally to this study as first co-authors; Wang H and Hao Q participated in data collection and analysis and wrote the manuscript; Wang M, Feng M, Wang F and Kang X participated in data collection and performed the statistical analysis; Guan WX conceived of the study, participated in its design and provided the critical revision; all authors read and approved the final manuscript.
Supported by Grants from the Special Foundation for Young Scientists of Nanjing City, China.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of Drum Tower Hospital, Medical School of Nanjing University.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All authors declare that they have no conflict of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at guanwenxiansci@126.com. No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Wen-Xian Guan, MD, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, No. 321 Zhongshan Road, Nanjing 210008, Jiangsu Province, China. guanwenxiansci@126.com
Telephone: +86-25-83106666-60996 Fax: +86-21-64085875
Received: December 22, 2014
Peer-review started: December 23, 2014
First decision: February 2, 2015
Revised: March 25, 2015
Accepted: May 7, 2015
Article in press: May 7, 2015
Published online: August 7, 2015
Processing time: 229 Days and 2.8 Hours
Abstract

AIM: To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.

METHODS: This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group I underwent esophagojejunostomy using a transorally-inserted anvil (OrVilTM), while patients in Group II underwent esophagojejunostomy using the hemi-double stapling technique (HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients’ baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were compared between the two groups. The primary endpoint was evaluation of the surgical outcome (operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation (operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared.

RESULTS: Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups (287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group II compared with Group I (47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intra-operative blood loss (96.4 ± 32.7 mL vs 88.2 ± 36.9 mL, P = 0.28), time to defecation (3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation (3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet (7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization (10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups (73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group II (32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P < 0.001).

CONCLUSION: Anvil insertion was faster and easier using the HDST technique compared with OrVilTM, and was more cost-effective. There was no significant difference in safety.

Keywords: Laparoscopy; Gastrectomy; Gastric cancer; Esophagojejunostomy; Cohort analysis

Core tip: Reconstruction of the digestive tract after total gastrectomy is technically difficult using laparoscopy. This study investigated two different methods to simplify this technique: a transorally inserted anvil (OrVilTM) and the hemi-double stapling technique (HDST). The patients were randomized for comparison of these methods after laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection. Both methods had similar safety and operation success. However, anvil insertion was faster and easier with HDST than with OrVilTM, and was more cost-effective.