• Journal of Gastric Cancer
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• v.12 no.3
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• pp.133-139
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• 2012

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.

• Journal of Gastric Cancer
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• v.11 no.4
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• pp.212-218
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• 2011

Purpose: Intracorporeal anastomosis during laparoscopic gastrectomy is becoming increasingly prevalent. However, selection of the anastomosis method after laparoscopic distal gastrectomy is equivocal because of a lack of technical feasibility and safety. We compared intracorporeal gastroduodenostomy with gastrojejunostomy using linear staplers to evaluate the technical feasibility and safety of intracorporeal anastomoses as well as its' minimally invasiveness. Materials and Methods: Retrospective analyses of a prospectively collected database for gastric cancer revealed 47 gastric cancer patients who underwent laparoscopic distal gastrectomy with either intracorporeal gastroduodenostomy or gastrojejunostomy from March 2011 to June 2011. Perioperative outcomes such as operation time, postoperative complication, and hospital stay were compared according to the type of anastomosis. Postoperative inflammatory response was also compared between the two groups using white blood cell count and high sensitivity C-reactive protein. Results: Among the 47 patients, 26 patients received gastroduodenostomy, whereas 21 patients received gastrojejunostomy without open conversion or additional mini-laparotomy incision. There was no difference in mean operation time, blood loss, and length of postoperative hospital stays. There was no statistically significant difference in postoperative complication or mortality between two groups. However, significantly more staplers were used for gastroduodenostomy than for gastrojejunostomy (n=6) than for gastroduodenostomy and (n=5). Conclusions: Intracorporeal anastomosis during laparoscopic gastrectomy using linear stapler, either gastroduodenostomy or gastrojejunostomy, shows comparable and acceptable early postoperative outcomes and are safe and feasible. Therefore, surgeons may choose either anastomosis method as long as oncological safety is guaranteed.

• Asian Pacific Journal of Cancer Prevention
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• v.15 no.16
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• pp.6733-6736
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• 2014

Background: Despite the growing acceptance of laparoscopic colon surgery, an abdominal incision is needed to remove the specimen and perform an anastomosis. Recently, natural orifice specimen extraction (NOSE) and intracorporeal anastomosis have been proposed to minimize abdominal wall trauma and improve the quality of laparoscopic colon resections Objective: To evaluate the feasibility and safety of a new approach combining intracorporeal delta-shaped anastomosis and transvaginal specimen extraction for totally laparoscopic sigmoid colectomy. Materials and Methods: Mobilization of bowel and dissection of lymph nodes were performed laparoscopically. After both proximal and distal incisal edges about 10.0 cm distance from sigmoid neoplasm were transected with an Endoscopic Linear Cutter-Straight, a small incision about 1.0 cm was created on the each colon wall of the contralateral side of the mesentery. Then anvils of an Endoscopic Linear Cutter-Straight were inserted into each colon through the small incisions, and incision and anastomosis between the walls of each colon were performed with a linear stapler. A V-shaped anastomosis was made on the wall and the remnant openings was reclosed with the Endoscopic Linear Cutter-Straight. The culdotomy was enlarged with laparoscopic ultrasound dissector. Transvaginal extraction of specimens was accomplished through a wound protector. Results: Surgery was performed for 11 patients with sigmoid cancer. No intraoperative complications or conversions occurred. The mean operating time was 132 min. All the patients were treated laparoscopically without any postoperative complications. Conclusions: The procedures of intracorporeal delta-shaped anastomosis and transvaginal specimen extraction are safe and oncologically acceptable for selected colon cancer cases.

• Journal of Gastric Cancer
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• v.19 no.3
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• pp.355-364
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• 2019

Totally laparoscopic distal gastrectomy (TLDG) frequently involves the use of delta shaped gastroduodenostomy (DSG) for intracorporeal anastomosis. However, DSG has some drawbacks, and the book binding technique (BBT) was developed as a new technique to overcome these drawbacks. Subsequently, this technique was further improved with the development of modified book binding technique (MBBT). This study evaluated the safety and feasibility of MBBT in patients undergoing TLDG. Thirty-three patients who underwent TLDG with MBBT were retrospectively evaluated. The mean operation time was $277.6{\pm}37.1minutes$, including $51.9{\pm}15.7minutes$ for reconstruction. Two patients had anastomosis-related complications, one patient with stricture after leakage and 1 patient with stenosis. The former patient was treated with endoscopic balloon dilatation, and the latter was managed conservatively; neither required re-operation. MBBT is a safe and feasible technique, with acceptable surgical outcomes. It may be a good alternative option for the treatment of intracorporeal anastomosis in patients undergoing TLDG.

• Journal of Gastric Cancer
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• v.22 no.2
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• pp.135-144
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• 2022

Purpose: This study aimed to compare the surgical and oncological outcomes between totally laparoscopic pylorus-preserving gastrectomy (TLPPG) with intracorporeal anastomosis and laparoscopy-assisted pylorus-preserving gastrectomy (LAPPG) with extracorporeal anastomosis. Materials and Methods: A retrospective analysis was performed in 258 patients with cT1N0 gastric cancer who underwent laparoscopic pylorus-preserving gastrectomy using two different anastomosis methods: TLPPG with intracorporeal anastomosis (n=88) and LAPPG with extracorporeal anastomosis (n=170). The following variables were compared between the two groups to assess the postoperative surgical and oncological outcomes: proximal and distal margins, number of resected lymph nodes (LNs) in total and in LN station 6, operation time, postoperative hospital stay, and postoperative morbidity including delayed gastric emptying (DGE). Results: The average length of the proximal margin was similar between the TLPPG and LAPPG groups (2.35 vs. 2.73 cm, P=0.070). Although the distal margin was significantly shorter in the TLPPG group than in the LAPPG group (3.15 vs. 4.08 cm, P=0.001), no proximal or distal resection margin-positive cases were reported in either group. The average number of resected LN was similar in both groups (36.0 vs. 33.98, P=0.229; LN station 6, 5.72 vs. 5.33, P=0.399). The operation time was shorter in the TLPPG group than in the LAPPG (200.17 vs. 220.80 minutes, P=0.001). No significant differences were observed between the two groups in terms of postoperative hospital stay (9.38 vs. 10.10 days, P=0.426) and surgical complication rate (19.3% vs. 22.9%), including DGE (8.0% vs. 11.8%, P=0.343). Conclusions: The oncological safety and postoperative complications of TLPPG with intracorporeal anastomosis are similar to those of LAPPG with extracorporeal anastomosis.

• Journal of Gastric Cancer
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• v.19 no.2
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• pp.193-201
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• 2019

Purpose: There is no consensus on the optimal method for intracorporeal esophagojejunostomy (EJ) in laparoscopic total gastrectomy (LTG). This study aims to compare 2 established methods of EJ anastomosis in LTG. Materials and Methods: A total of 314 patients diagnosed with gastric cancer that underwent LTG in the period from January 2013 to October 2016 were enrolled in the study. In 254 patients, the circular stapler with purse-string "Lap-Jack" method was used, and in the other 60 patients the linear stapling method was used for EJ anastomosis. After propensity score matching, 58 were matched 1:1, and retrospective data for patient characteristics, surgical outcome, and post-operative complications was reviewed. Results: The 2 groups showed no significant difference in age, body mass index, or other clinicopathological characteristics. After propensity score matching analysis, the linear group had shorter operating time than the circular group ($200.3{\pm}62.0$ vs. $244.0{\pm}65.5$, $P{\leq}0.001$). Early postoperative complications in the circular and linear groups occurred in 12 (20.7%) and 15 (25.9%, P=0.660) patients, respectively. EJ leakage occurred in 3 (5.2%) patients from each group, with 1 patient from each group needing intervention of Clavien-Dindo grade III or more. Late complications were observed in 3 (5.1%) patients from the linear group only, including 1 EJ anastomosis stricture, but there was no statistical significance. Conclusions: Both circular and linear stapling techniques are feasible and safe in performing intracorporeal EJ anastomosis during LTG. The linear group had shorter operative time, but there was no difference in anastomosis complications.

• Journal of Gastric Cancer
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• v.21 no.2
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• pp.132-141
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• 2021

Purpose: Intracorporeal esophagojejunostomy during reduced-port gastrectomy for proximal gastric cancer is a technically challenging technique. No study has yet reported a robotic technique for anastomosis. Therefore, to address this gap, we describe our reduced-port technique and the short-term outcomes of intracorporeal esophagojejunostomy. Materials and Methods: We conducted a retrospective review of patients who underwent a totally robotic reduced-port total or proximal gastrectomy between August 2016 and March 2020. We used an infra-umbilical Single-Site^® port with two additional ports on both sides of the abdomen. To transect the esophagus, a 45-mm endolinear stapler was inserted via the right abdominal port. The common channel of the esophagojejunostomy was created between the apertures in the esophagus and proximal jejunum using a 45-mm linear stapler. The entry hole was closed with a 45-mm linear stapler or robot-sewn continuous suture. All anastomoses were performed without the aid of an assistant or placement of stay sutures. Results: Among the 40 patients, there were no conversions to open, laparoscopic, or conventional 5-port robotic surgery. The median operation time and blood loss were 254 min and 50 mL, respectively. The median number of retrieved lymph nodes was 40.5. The median time to first flatus, soft diet intake, and length of hospital stay were 3, 5, and 7 days, respectively. Three (7.5%) major complications, including two anastomosis-related complications and a case of small bowel obstruction, were treated with an endoscopic procedure and re-operation, respectively. No mortality occurred during the study period. Conclusions: Intracorporeal esophagojejunostomy during reduced-port gastrectomy can be safely performed and is feasible with acceptable surgical outcomes.

• Journal of Gastric Cancer
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• v.20 no.3
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• pp.277-289
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• 2020

Purpose: To evaluate the feasibility and safety of intracorporeal overlapping gastrogastrostomy between the proximal anterior wall and antrum posterior wall (PAAP; PAAP anastomosis) of the stomach in minimally invasive pylorus-preserving gastrectomy (PPG) for early gastric cancer (EGC). Materials and Methods: From December 2016 to December 2019, 17 patients underwent minimally invasive PPG with PAAP anastomosis for EGC in the high body and posterior wall of the stomach. Intraoperative gastroscopy was performed with the rotation maneuver during proximal transection. A longer antral cuff (>4-5 cm) was created for PAAP than for conventional PPG (≤3 cm) at the point where a safe distal margin and good vascular perfusion were secured. Because the posterior wall of the proximal remnant stomach was insufficient for intracorporeal anastomosis, the anterior wall was used to create an overlapping anastomosis with the posterior wall of the remnant antrum. The surgical and oncological outcomes were analyzed, and the stomach volume was measured in patients who completed the 6-month follow-up. The results were compared to those after conventional PPG (n=11 each). Results: PAAP anastomosis was successfully performed in 17 patients. The proximal and distal resection margins were 2.4±1.9 cm and 4.0±2.6 cm, respectively. No postoperative complications were observed during the 1-year follow-up esophagogastroduodenoscopy (n=10). The postoperative remnant stomach (n=11) was significantly larger with PAAP than with conventional PPG (225.6±118.3 vs. 99.1±63.2 mL; P=0.001). The stomach length from the anastomosis to the pylorus was 4.9±2.4 cm after PAAP. Conclusions: PAAP anastomosis is a feasible alternative for intracorporeal anastomosis in minimally invasive PPG for highly posteriorly located EGC.

• Journal of Gastric Cancer
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• v.19 no.1
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• pp.111-120
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• 2019

Background: Billroth I anastomosis is one of the most common reconstruction methods after distal gastrectomy for gastric cancer. Intracorporeal Billroth I (ICBI) anastomosis and extracorporeal Billroth I (ECBI) anastomosis are widely used in laparoscopic surgery. Here we compared ICBI and ECBI outcomes at a major gastric cancer center. Methods: We retrospectively analyzed data from 2,284 gastric cancer patients who underwent laparoscopic distal gastrectomy between 2009 and 2017. We divided the subjects into ECBI (n=1,681) and ICBI (n=603) groups, compared the patients' clinical characteristics and surgical and short-term outcomes, and performed risk factor analyses of postoperative complication development. Results: The ICBI group experienced shorter operation times, less blood loss, and shorter hospital stays than the ECBI group. There were no clinically significant intergroup differences in diet initiation. Changes in white blood cell counts and C-reactive protein levels were similar between groups. Grade II-IV surgical complication rates were 2.7% and 4.0% in the ECBI and ICBI groups, respectively, with no significant intergroup differences. Male sex and a body mass index (BMI) ${\geq}30$ were independent risk factors for surgical complication development. In the ECBI group, patients with a BMI ${\geq}30$ experienced a significantly higher surgical complication rate than those with a lower BMI, while no such difference was observed in the ICBI group. Conclusion: The surgical safety of ICBI was similar to that of ECBI. Although the chosen anastomotic technique was not a risk factor for surgical complications, ECBI was more vulnerable to surgical complications than ICBI in patients with a high BMI (${\geq}30$).

• Journal of Gastric Cancer
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• v.7 no.3
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• pp.146-151
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• 2007

Purpose: Pledget is a PTFE felt that is usually used for suture reinforcement in cardiovascular surgery. In order to minimize the difficulty in intracorporeal continuous gastrointestinal suturing by reducing the number of tied knots, we have used pledget as substitute for a knot (pledget suturing). Materials and Methods: Thirty-two consecutive patients who underwent totally laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy in our institution were enrolled in this study, and the patients were divided into three groups according to the method of intracorporeal anastomosis. Basically, intracorporeal anastomosis was performed by several firings of linear staplers; however, the entry holes for the stapler at the jejunojejunostomy and the gastrojejunostomy were closed by pledget suturing in group A (8 patients), the entry hole for the stapler at jejunojejunostomy was closed by conventional suturing in group B (8 patients), and all of the entry holes for the stapler were closed by stapling in group C (16 patients). The surgical outcomes of each group were compared to each other. Results: The anastomotic time in group A was not longer than in group B, although there were more sutures used in group A, but it was longer than in group C. The number of stapler cartridges used in group A was the smallest among the three groups. In group B, there were two cases of a break of suture material during anastomosis, there were no such cases in group A. There was no complication related to anastomosis in all of the groups. Conclusion: Pledget was found to be useful for minimizing the difficulty in intracoproreal continuous gastrointestinal suturing and reducing the number of stapler cartilages used in intracorporeal anastomosis.