Endoscopy-assisted anastomosis: a modified technique for laparoscopic side-to-side esophagojejunostomy following a total gastrectomy

Introduction: Esophagojejunostomy with a circular stapling device is sometimes difficult to perform in a laparoscopic setting. On the other hand, a side-to-side anastomosis with a linear stapling device is technically challenging. Methods: Between June 2002 and March 2008, 10 consecutive patients underwent a laparoscopy-assisted total gastrectomy using a side-to-side anastomosis technique. Of these patients, four underwent a laparoscopy-assisted total gastrectomy with a modified anastomosis technique. A small wound was created on the antimesenteric side of the jejunum 5 cm distal to the resected portion and then in the lower esophagus. A peroral endoscope was advanced to the hole, and the cartridge fork was introduced into the lower esophagus under endoscopic guidance. The device (45mm, blue) was fired to create an antiperistaltic side-to-side anastomosis. The common entry hole was closed by transecting the jejunum and the esophagus with another linear stapler and by using an endoscope as a stent. Results: Four patients underwent the modified procedure and did not require an open procedure. One patient developed a pancreatic fistula, which was treated conservatively. The average operative time, reconstruction time and blood loss were 483 +/- 133 minutes, 139 +/- 31 minutes, and 199 +/- 121 mL, respectively. An introduction of the stapler into the lower esophagus and a closure of the common entry hole were performed safely without any stress. Conclusion: Although several techniques must be compared to determine the ideal procedure for laparoscopic esophagojejunostomy, the modified side-toside anastomosis technique may be useful in clinical settings.