Assessment Of Optimization For Overlap Esophagojejunostomy During Laparoscopic Total Gastrectomy For Gastric Cancer

Background:Reconstruction of the digestive tract in laparoscopic total gastrectomy(LTG)still is challenging,especially esophagojejunostomy(EJS).EJS is the major limitation of LTG.However,there is no standard EJS technique for LTG,because each method has its own advantages and disadvantages.Thus,how to perform the EJS safely and conveniently deserves attention and exploration.Therefore,this study analyzed and summarized the safety and efficiency of different digestive tract reconstruction during LTG in our center,and conducted a questionnaire survey among gastrointestinal surgeons across the country to define the main technical difficulties of EJS for LTG.It is expected to optimize and innovate EJS technologies based on the results of these analyses and investigations.Chapter Ⅰ:Safety and effectiveness of Roux-en-Y esophagojejunostomy after laparoscopic total gastrectomyMethods:Retrospective cohort study of 261 cases of LTG for gastric cancer(GC)in the General Surgery Department of Nanfang Hospital from December 2018 to June 2021.Among these 261 patients,139 underwent EJS with a circular stapler via mini-laparotomy(extracorporeal group),while 122 underwent intracorporeal EJS(intracorporeal group),including 43 with OrVilTM anastomosis(OrVilTM subgroup)and 79 with Overlap anastomosis(Overlap subgroup).The safety and effectiveness of the extracorporeal group and intracorporeal group,and OrVilTM subgroup and Overlap subgroup were compared and analyzed,respectively.Results:Most baseline variables were balanced between the extracorporeal group and intracorporeal group.The incidence of positive proximal margins,conversion to laparotomy/thoracotomy and conversion to other esophagojejunostomy methods were basically the same between two groups.In terms of postoperative recovery,the extracorporeal group recovered faster and was discharged from hospital faster after surgery.Intraoperative complications occurred in 4 cases(2.9%)in the extracorporeal group and 5 cases(4.1%)in intracorporeal group.The incidence of early postoperative complications in two groups was not statistically significant different(extracorporeal group vs.intracorporeal group:25.9%vs.31.1%,P=0.348).There was also no significant difference in the incidence of postoperative EJS complications(extracorporeal group vs.intracorporeal group:5.0%vs.82.%,P=0.302).Among them,there were 3 cases of anastomotic leakage,1 case of anastomotic stenosis,and 3 cases of anastomotic bleeding in extracorporeal group;8 cases of anastomotic leakage,3 cases of anastomotic stenosis,and no case of anastomotic bleeding.The most common postoperative complication in two groups was pulmonary infection,which was 11.5%in extracorporeal group and 9.8%in the intracorporeal group,with no significant difference(P=0.663).There was no significant difference in the severity of postoperative complications between two groups(P=0.289).The OrvilTM anastomosis of intracorporeal group met one case of unplanned secondary operation,while extracorporeal group had not one.There were no perioperative deaths in both groups.In the comparisons of the OrvilTM subgroup and Overlap subgroup,both subgroups confronted one case of conversion to other esophagojejunostomy methods,and both groups encountered one case of positive proximal margin.The Overlap subgroup was superior to the OrvilTM subgroup in terms of intraoperative complications rate,postoperative complications rate and severity,but did not reach a statistical difference.Conclusion:The intracorporeal EJS after LTG has similar safety to extracorporeal EJS.As for intracorporeal EJS,the Overlap method is safer and has more potential advantages than OrvilTM method,and is worthy of further exploration and optimization,and provides ideas for improving the efficacy of esophagojejunostomy.Chapter Ⅱ:Exploration on the optimization of Overlap esophagojejunostomy technique for laparoscopic total gastrectomyMethods:A questionnaire survey was conducted among gastrointestinal surgeons across the country to define the main technical difficulties of Overlap method in LTG.According to the survey results,the improvement plan for Overlap method was determined.Results:A total of 307 gastrointestinal surgeons across the country filled out the questionnaire.70.3%of surgeons chose esophagojejunostomy as the most difficult part of LTG.In the selection of linear stapler esophagojejunostomy for LTG,65.15%of surgeons preferred Overlap anastomosis.For the most difficult and time-consuming step of Overlap esophagojejunostomy,54.72%of surgeons chose the operation of inserting the anvil fork into the esophageal cavity and 41.04%chose the closure of the common opening.For the most worrying intraoperative esophagojejunostomy-related complications of Overlap method,intraoperative leakage caused by poor anastomotic nailing(71.66%),esophagus or jejunum Perforation(43.97%)and formation of false esophagus(42.02%)were the main choices.For postoperative esophagojejunostomy-related complications,95.11%of surgeons chose anastomotic leakage.The above findings are consistent with the clinical practice findings of our center,which can be attributed to the low controllability of putting anvil fork into the esophageal cavity.Therefore,to solve at this problem,we design the Overlap guide tube(OGT)(ZL 202120839956.6)to assist esophagojejunostomy,and design the technical concept of OGT-assisted Overlap esophagojejunostomy.Conclusion:The difficulties of Overlap esophagojejunostomy in LTG could be attributed to the low controllability of putting anvil fork into the esophageal cavity.Therefore,we designed an Overlap guiding tube(OGT)to assist the Overlap esophagojejunostomy to increase the controllability of putting anvil fork into the esophageal cavity,thus avoiding the formation of esophageal "false canals",minimizing the common opening,shortening anastomosis time,then reducing the risk of anastomosis.Chapter Ⅲ:Assessment of the application value of Overlap guide tube in Overlap esophagojejunostomy during laparoscopic total gastrectomyMethods:The clinicopathological data of 38 gastric cancer patients performed with OGT-assisted Overlap esophagojejunostomy during LTG in Nanfang Hospital of Southern Medical University from June to September 2021 were retrospectively collected and analyzed.Then,148 gastric cancer patients performed with Overlap method during LTG[including 83 cases of traditional Overlap esophagojejunostomy and 65 cases of OGT-assisted Overlap esophagojejunostomy)in Nanfang Hospital of Southern Medical University from June 2018 to January 2022.The surgical safety of Overlap group and OGT group were compared.Results:Retrospective single arm study:all 38 patients successfully completed OGT Overlap esophagojejunostomy during LTG.Negative proximal margins were obtained in all 38 cases.The anvil fork that connected with OGT was successfully placed in the expected position of esophageal lumen with an insertion operation once in 37 cases(97.4%).The operation time,time of esophagojejunal anastomosis,volume of intraoperative blood loss,and length of surgical incision were 317.6±51.5 min,20.8±3.8 min,61.1±38.6 ml,and 5.2±0.8 cm,respectively.All patients achieved R0 proximal resection margin.No procedures were converted to other laparoscopic anastomosis techniques or open approaches.Among them,1 of 38 developed esophagojejunal anastomotic leakage,and was treated with self-expanding metal stent endoscopically.But the 3-month follow-up did not reveal any anastomotic stenosis.No esophagojejunal anastomotic bleeding occurred.None of the patients developed anastomotic stenosis or confronted unplanned secondary surgery and perioperative death after 3 months of follow-up.In the comparative analysis,3 cases(3.6%)in Overlap group confronted intraoperative complications,and 2 cases(3.1%)in OGT group.The incidence of early postoperative complications was 28.9%(24/83)in Overlap group and 20.0%(13/65)in OGT group.There was no significant difference in the incidence of esophagojej unostomy anastomotic complications between two groups[Overlap group vs.OGT group:6.0%(5/83)vs.3.1%(2/65),P=0.654].Among them,4 cases(4.8%)of anastomotic leakage in OGT group were treated with self-expanding metal stent endoscopically;1 case(1.2%)developed anastomotic stenosis was treated with endoscopy dilation therapy;no cases confronted anastomotic bleeding.In the OGT group,2 cases(3.1%)of anastomotic leakage were treated with self-expanding metal stent endoscopically;there were no case of anastomotic stenosis or bleeding.No significant difference was observed in the severity of postoperative complications in two groups(P=0.450).There was not cases of unplanned secondary operations after surgery in either group.There were no perioperative deaths in either group.Conclusion:OGT-assisted Overlap esophagojejunostomy in laparoscopic total gastrectomy is safe and feasible,with good short-term effects.It suggested that OGT has the potential value in reducing the difficulty and risk of esophagojejunostomy.Prospective randomized controlled clinical studies can be further designed to provide high-level evidence-based medical evidence for the safety and efficacy of OGT-assisted Overlap esophagojejunostomy.Chapter Ⅳ:Randomized controlled trial on the safety and efficacy of OGT-assisted Overlap esophagojejunostomy versus traditional Overlap method after laparoscopic total gastrectomyParticipants:Patients were diagnosed with primary gastric cancer confirmed pathologically by endoscopic biopsy in Nanfang Hospital can be recruited when meeting the inclusion criteria:age from over 18 to under 75 years;located in the middle and upper stomach;laparoscopic total gastrectomy was expected;the preoperative ECOG performance status score was 0-2,and the preoperative ASA score was Ⅰ-Ⅱ.Study Design:Prospective,randomized,controlled,non-inferiority trial Arms and Interventions Experimental Arm A):OGT-assisted Overlap esophagojejunostomy group Active Comparator(Arm B):Traditional Overlap esophagojejunostomy group Sample size:312(Arm A:156;Arm B:156) Primary endpoint:Early complication rate[Time Frame:30 days] Secondary endpoints:Anastomotic-related complications Time of digestive tract reconstruction Time of Esophagojejunostomy Intraoperative complications Positive rate proximal margin Rate of anvil fork successfully placed in the expected position of esophageal lumen with an insertion operation once The number of insertion operations required to insert an anvil fork into the esophagus Early postoperative recovery process...