Intracorporeal anastomosis in laparoscopic gastric cancer surgery.

Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.

Introduction

Since the first laparoscopic gastrectomy was described by Goh et al.(1) in 1992, the safety and feasibility of laparoscopic gastrectomy in the treatment of early gastric cancer have been demonstrated.(2,3) Reported advantages of laparoscopic gastrectomy compared to open gastrectomy include improved cosmesis, less pain, earlier recovery, and better quality of life. According to the Korean Gastric Cancer Association, 1,089 cases of laparoscopic gastric surgery were performed in 2004.(4) In Japan, more than 1,500 gastrectomies were performed laparoscopically in 2003.(3)

Many of those resections were performed by a laparoscopic-assisted technique that requires a mini-laparotomy, mainly for anastomosing the bowel. More recently, several methods of intracorporeal anastomosis have been used not only for laparoscopic distal gastrectomy (LDG), but also for laparoscopic total gastrectomy (LTG) and laparoscopic proximal gastrectomy (LPG). These advances allow a gastrectomy to be performed by a totally laparoscopic approach. In this review, we describe the recent technical innovations and the early surgical outcomes of intracorporeal anastomosis in gastric cancer surgery.

LDG (Table 1)

1. Billroth-I anastomosis

In both Korea and Japan, many surgeons tend to choose Billroth-I anastomosis following distal gastrectomy. Because of the technical difficulty of intracorporeal gastroduodenostomy, most surgeons have preferred laparoscopy-assisted distal gastrectomy (LADG) rather than totally laparoscopic distal gastrectomy (TLDG).(5) In 1992, we developed a simple and secure method of intracorporeal gastroduodenostomy, using only endoscopic linear staplers, which we have named the delta-shaped anastomosis.(6) This technique creates a functional end-to-end anastomosis between the posterior wall of the stomach and the duodenal bulb. Because of its advantages, this procedure is gaining widespread acceptance among surgeons in Japan and Korea, where it is becoming a standard reconstruction procedure in LDG.(5-10) Recently we reported the short and long-term outcomes of the initial 100 consecutive cases with a mean follow-up period of 54.9 months.(7) The learning curve for the surgeons was steep; mean time to perform the anastomosis was 13 minutes. One patient developed a minor anastomotic leak, and another suffered from postoperative dumping syndrome. Two-thirds of the patients tolerated a 1,500 kcal/day soft diet at the time of discharge. According to these results, we concluded that the delta-shaped anastomosis is safe, simple, and provides satisfactory postoperative outcomes.

With the acceptance of our delta-shaped anastomosis, several retrospective analyses comparing early surgical outcomes of TLDG using delta-shaped anastomosis with those of LADG have been reported.(8-11) In all of these studies, the reconstruction in LADG was performed with extracorporeal Billroth-I anastomosis, with a circular stapler. In TLDG groups the umbilical wound was extended up to 3 cm for specimen extraction, while in LADG groups, a 4~6 cm mid-line incision in the epigastrium was added. Early postoperative outcomes, such as blood loss, return of gastrointestinal function, pain scores, and hospital stay were significantly improved in TLDG compared with LADG.(9,10) Furthermore, in obese patients overall complication rates were significantly lower in TLDG than in LADG.(9) In performing LADG, the extracorporeal anastomosis that is done through a small incision can cause excessive traction on the organs and increase operative manipulation, especially in obese patients. To the contrary, in an intracorporeal anastomosis, direct visualization by laparoscopy provides a better operative field and minimizes surgical trauma; these advantages are also independent of body habitus.

Other techniques for intracorporeal Billroth-I anastomosis have been reported. Tanimura et al.(12) described a triangulating stapling technique with linear staplers. The posterior walls of the stomach and duodenal bulb are stapled in an inverted fashion, and the anterior walls are stapled with 2 staplers in an everted manner, making the shape of the anastomosis triangular. They reported on the feasibility of this procedure with their 111 cases experience. Omori et al.(13) described an intracorporeal circular-stapled Billroth-I anastomosis in a single-incision laparoscopic operation. They obviated the need for a purse-string suture for anvil head insertion into the duodenal bulb, and safely employed the technique in 20 patients.

The long-term surgical outcomes for these procedures are expected.

2. Roux-en-Y anastomosis

Roux-en-Y reconstruction is another option for distal gastrectomy, with the advantage of less bile reflux into the gastric remnant or reflux esophagitis. Similarly in LADG, Roux-en-Y reconstruction provided better surgical outcomes than Billroth-I reconstruction, preventing postoperative complications (i.e. anastomotic leak or stricture) and bile reflux into the gastric remnant.(14) However, long-term follow-up is still necessary, because Roux-en-Y gastrojejunostomies are considered relatively ulcerogenic.(15) There are other disadvantages as well: any subsequent need for endoscopic access to the ampulla of Vater is more difficult, and Roux-stasis syndrome, a unique complication of this procedure, may occur. Regarding the anastomotic techniques, both linear staplers(16-18) and circular staplers(19,20) have been reported with successful results. The uncut Roux-en-Y method using a linear stapler provided better results in preventing Roux-stasis syndrome.(16) Noshiro et al.(17) reported a novel stapling technique with linear staplers that is possible when the residual stomach is small. Circular stapling techniques have been used by transoral anvil placement.(20) Elimination of the purse-string suture has also been described.(21) Long-term follow-up results with larger number of patients are expected.

3. Billroth-II anastomosis

Billroth-II anastomosis is another standard method of reconstruction, although there are some concerns of gastric remnant carcinogenesis due to alkaline reflux gastritis.(22,23) There are reports using both linear(16,24) and circular staplers.(25) When using linear staplers, care must be taken to avoid stricturing of the efferent loop of the jejunum, especially when the entry hole is closed with a stapler.(16) Uyama et al.(16) make the enterotomy on the afferent loop and perform an antiperistaltic Billroth-II anastomosis, placing some stitches between the afferent loop and the lesser curvature of the gastric remnant to prevent food from flowing into the afferent loop. We think these concepts are reasonable, and may provide better surgical outcomes for patients.

LTG (Table 2)

LTG with intracorporeal anastomosis has been utilized less than LDG because of the technical difficulty of esophagojejunostomy. Since 1999, however, some novel techniques to achieve a safe esophagojejunostomy have been reported with good outcomes, both with linear and circular staplers.(5,26-33)

1. Esophagojejunostomy with linear staplers

Functional end-to-end anastomoses for esophagojejunostomy have been reported.(5,26-27) One technique is fashioning an antiperistaltic side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was also closed with staplers.(26,27) A nasogastric tube, as an insertion guide to the esophageal lumen, was quite helpful for identification of the lumen.(27) An isoperistaltic esophagojejunostomy, the so-called 'Overlap method' has also been reported,(28-30) in which the entry hole was closed with intracorporeal hand-sewn sutures. Because the anastomosis is made in an isoperistaltic manner, the jejunal limb straightens, which may be advantageous when the anastomosis is located in the confined mediastinal space.(28)

2. Esophagojejunostomy with a circular stapler

The esophagojejunostomy with a circular stapler is a common method in conventional open total gastrectomy, and surgeons are familiar with this procedure. However, it is often difficult to complete circular-stapled esophagojejunostomy through a mini-laparotomy, because inserting and/or fixing the anvil in a narrow and deep operative field can be difficult, especially in obese patients. With improvements of surgeons' skills and dedicated devices, an intracorporeal circular-stapled anastomosis has become more practical. Novel procedures include an endoscopic purse-string suture instrument 'Endo-PSI(II)',(31) transorally inserted anvil (Orvil™, Covidien, Mansfield, MA, USA),(32,33) hand-sewn purse-string suturing techniques,(34) and hand-sewn esophagojejunostomy(35) have been developed. The insertion and fixation of the anvil becomes easier with these devices and techniques. Early surgical outcomes using the Orvil™ have been reported. Operative time and blood loss were reduced compared to anastomosis with mini-laparotomy.(32) Adequate extension of the neck, appropriate selection of the anvil head,(32) and caution in the insertion of the anvil, to prevent larynx or esophageal injury, are crucial. Preventing abdominal infection is also important when using Orvil™.(33)

Techniques with both linear and circular staplers in LTG seem feasible, but most of the data are technical reports with a limited number of patients. Further study including larger number of patients, and comparison studies with other techniques measuring short-term and long-term surgical outcomes are warranted to evaluate these anastomotic procedures.

LPG (Table 3)

Several techniques of performing intracorporeal anastomosis in LPG have been reported.(36) Intracorporeal anastomosis with jejunal interposition was first reported in 2000,(36) but seemed complicated and time-consuming. Esophagogastrostomy with linear staplers(37,38) and circular staplers(39,40) have been reported but no standardized techniques have been established. To achieve a secure anastomosis with satisfactory postoperative quality of life, the addition of an antireflux procedure is necessary to prevent postoperative regurgitive esophagitis. Wrapping the anastomosis, or creating a new notch corresponding to the normal cardiac notch to form a flap valve, is necessary as an antireflux procedure. In previous reports,(37,38) anastomosis was made between the posterior wall of the esophagus and the anterior wall of the remnant stomach, which created a new cardiac notch at the dorsal side of the anastomosis. Sakuramoto et al.(38) added a Toupet-like partial fundoplication.

We recently developed a novel method of esophagogastric-tube reconstruction with stapled fundoplication for LPG (unpublished data). In this method, the left dorsal side of the esophagus and the anterior wall of the gastric-tube were connected with a 45 mm no-knife stapler in the isoperistaltic manner similar to the 'Overlap method'.(28,30) The common lumen was created by cutting the center of the staple rows for a length of 15 mm, followed by the closure of the entry hole with interrupted sutures. The remaining connected stomach along the uncut 30 mm staple line functions as a pseudo-fornix, forming an acute angle that attempts to re-create an angle of His. By using a long gastric-tube, a tension-free anastomosis is possible even with bulky tumors invading the distal esophagus. Eight patients with Siewert type II adenocarcinoma of the esophagogastric junction underwent this procedure with good results. We have proposed this procedure as an alternative in LPG, especially for Siewert type II adenocarcinoma of the esophagogastric junction.

Reports on intracorporeal esophagogastrostomy for LPG are still limited, and further clinical studies evaluating surgical outcomes and postoperative quality of life are necessary.

Conclusions

In this review, recent reports regarding intracorporeal anastomosis in laparoscopic gastric cancer operations were reviewed. These innovations are causing a shift from 'laparoscopy-assisted' to 'totally laparoscopic', and the surgeons' skills and instruments are still developing. Further clinical studies evaluating the procedures in large number of patients are necessary to provide solid evidence to determine the place of intracorporeal anastomosis in laparoscopic gastric cancer surgery.

Table 1

Previous reports of intracorporeal anastomosis in laparoscopic distal gastrectomy

B-I = Billroth-I; LADG = laparoscopy assisted distal gastrectomy; B-II = Billroth-II.

Table 2

Previous reports of intracorporeal anastomosis in laparoscopic total gastrectomy

*All the reconstructions were performed with Roux-en-Y method.

Table 3

Previous reports of intracorporeal anastomosis in laparoscopic proximal gastrectomy