An Isoperistaltic Jejunum-Later-Cut Overlap Method for Esophagojejunostomy Anastomosis After Totally Laparoscopic Total Gastrectomy: A Safe and Feasible Technique

Background. Intracorporeal anastomosis after totally laparoscopic total gastrectomy (TLTG) has been increasingly applied. (1-7) We assessed the intracorporeal isoperistaltic jejunum-later-cut overlap method (IJOM) for esophagojejunostomy anastomosis (EA). Methods. From January to June 2014, a total of 19 patients with resectable gastric cancer (cT1-T4aNOM0) underwent TLTG. IJOM was performed by creating side-to-side stapled anastomosis through enterotomies proximal to the left esophageal resection margin and on the antimesenteric jejunal border, 30 cm distal to the Trietz ligament. Conjoined enterotomies were sutured closed. The IJOM reduces jejunal motion and controls the EA direction. The biliary jejunal limb was transected <= 5 cm proximal to anastomosis, and a gastrografin esophagram was performed 5-7 days after the operation to diagnose anastomotic leakage. Follow-ups were performed every 3 months from the date of surgery to last follow-up by esophagram or computed tomography. Results. For the 19 patients, the esophagojejunostomy time was 26 min, and blood loss was 50 ml (interquartile ranges [IQRs] 22-31 and 50-60, respectively). There were no conversions to open surgery. Liquid intake and soft diet were initiated on days 4 and 7, respectively, for 37 and 53% of patients (n = 7 and 10; IQRs 4-5 and 7-8, respectively). One patient with abdominal infection had delayed oral intake (day 11). Hospitalization duration was 12 days (IQR 11-16), and no patients experienced anastomosis-related complications (i.e. anastomotic leakage, stricture, hemorrhage, dysphagia, or dilation) or recurrence at anastomosis during follow-up (19 months; IQR 18-20). Conclusions. IJOM for EA after TLTG is feasible. These early results do not reveal a high complication rate but additional outcome monitoring is needed.