A modified technique for esophagojejunostomy or esophagogastrostomy after laparoscopic gastrectomy

Reconstruction of the digestive tract involving esophageal anastomosis after laparoscopic gastrectomy is a surgically difficult procedure. In this study, a newly developed transoral pretilted circular anvil, a "the oral to the abdomen" method, was proven to be effective.

A total of 34 consecutive patients underwent esophageal anastomosis using the OrVil in our hospital from July 2009 to February 2011. The esophagus was transected and a small hole was then made in the esophageal stump through which the nasogastric tube of the OrVil was passed to insert the anvil into the abdominal cavity. After fixation with a stapler and a glove at the jejunal loop or the remnant stomach, the abdominal cavity was entered through the minilaparotomy. Pneumoperitoneum and airtightness were reestablished after the glove edge was turned over to seal off the protector. Eventually, intracorporeal esophagojejunostomy or esophagogastrostomy was accomplished under the guidance of laparoscopy.

There were 34 patients in the study: 1 with Zollinger-Ellison syndrome, 7 with stromal tumors in cardia, 23 with adenocarcinoma in the stomach, and 3 with cardia adenocarcinoma involving the lower esophagus. The surgical margins for all tumor patients were negative for tumor cells. The mean operative time was 175.0 minutes (90 to 240 min) and the mean intraoperative blood loss was 195.6 mL (50 to 800 mL). The 34 patients underwent successful laparoscopic surgeries with no open conversions. For 32 patients, there were no technological complications in the transoral insertion of the anvil to the esophageal stump. There were no anastomotic leaks after the surgery.

The use of the OrVil device, a "the oral to the abdomen" method, changes the direction of the anvil insertion and significantly decreases both difficulty and duration of the laparoscopic surgery. More importantly, if the mass is at a higher position, this approach can achieve a higher surgical margin compared with the hand-sewn purse-string suture technique, thus avoiding the need to undergo a thoracotomy (Supplemental Digital Content 1, http://links.lww.com/SLE/A83).