Intracorporeal classic circular-stapled gastrojejunostomy and jejunojejunostomy during laparoscopic distal gastrectomy: A simple, safe "intraluminal poke technique" for anvil placement

Background Totally laparoscopic distal gastrectomy is being increasingly performed. However, an optimal procedure to achieve intracorporeal gastrojejunostomy and jejunojejunostomy for Roux-en-Y reconstruction after laparoscopic distal gastrectomy remains to be established. Compared with the simple and preferable circular-stapled Roux-en-Y reconstruction in open gastrectomy, application of intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy of Roux-en-Y reconstruction during laparoscopic distal gastrectomy have been limited (no report of intracorporeal circular-stapled jejunojejunostomy) because of the difficulties of intracorporeal purse-string suture and anvil placement. To address these problems, a simple and safe intraluminal poke technique of universal surgical concept and procedure was introduced and evaluated. Methods Between March 2018 and August 2018, 24 consecutive patients with gastric cancer underwent totally laparoscopic distal gastrectomy in our hospital. Roux-en-Y reconstruction of intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy with the intraluminal poke technique was performed in all patients. Demographic and clinicopathologic characteristics, perioperative details and postoperative outcomes were analyzed. Results The mean operative time was 203.6 +/- 26.2min, both proximal and distal tumor-free margins were achieved in all patients. The time for anvil placement at stomach and intestine was 5.9 +/- 1.3min and 3.9 +/- 0.7min, respectively. Intracorporeal gastrojejunostomy and jejunojejunostomy were successively completed following anvil placement with no any anastomosis-related sutures. There were 5 postoperative complications. Morbidities included pancreas fistula (n=1), stasis (n=2), atelectasis (n=1), pneumonia (n=1). These all patients recovered after conservative treatment. No postoperative anastomosis-related complications, such as anastomotic bleeding and leakage, or stenosis occurred during the median follow-up of 6.5 months. Conclusion The initial results suggest that the technique allowing easy and common anvil placement at stomach and intestine may be a simple, safe, preferable and time-saving procedure to accomplish intracorporeal circular-stapled gastrojejunostomy and jejunojejunostomy of Roux-en-Y reconstruction in totally laparoscopic distal gastrectomy as open surgery.