title: Intracorporeal circular-stapled esophagojejunostomy using hand-sewn purse-string suture after laparoscopic total gastrectomy.
abstract: BACKGROUND
  Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of technical difficulties, especially esophagojejunal anastomosis. Various modified procedures for reconstruction have been reported, but an optimal method has not been established. The authors report a circular-stapled anastomosis using hand-sewn purse-string sutures, which is a simple and classic method. However, no previous study has assessed its reliability.
  
  
  METHODS
  From September 2008 to May 2009, 10 consecutive patients (9 men and 1 woman) with gastric cancer underwent LTG at the authors' institution. These patients had a median age of 63.7 years (range, 45-80 years) and a body mass index of 22.4 kg/m(2) (range, 18-26 kg/m(2)). After transection of the abdominal esophagus, a hand-sewn purse-string suture along the cut end of the esophagus was performed using 3-0 monofilament thread. An anvil head then was inserted into the esophagus, and the thread was tied. A monofilament pretied loop suture was added to reinforce the ligation. After the creation of an Roux-en-Y jejunal limb, laparoscopic esophagojejunal anastomosis was performed using a circular stapler inserted via a surgical glove attached to a wound retractor at the incision point at the umbilicus. The jejunal stump was closed with an endoscopic linear stapler.
  
  
  RESULTS
  Laparoscopic esophagojejunostomy was performed successfully for all the patients. No postoperative complications related to anastomosis occurred. In one patient, an intraabdominal abscess developed postoperatively and was treated conservatively. The mean operation time was 257 min, and the estimated blood loss was 69 ml.
  
  
  CONCLUSIONS
  With the described method, esophagojejunostomy can be performed as in conventional open surgery. Hand-sewn purse-string suturing is demanding technically, but it can be performed safely by experienced laparoscopic surgeons. This technique is feasible and can lower the cost of the laparoscopic procedure. It may be considered in countries with limited access to other special devices.
authors.affiliation: Department of Surgery, Toho University Sakura Medical Center, Shimoshizu 564-1, Sakura, 285-8741, Chiba, Japan. tkinoshita@sakura.med.toho-u.ac.jp
authors.forename: Takahiro
authors.initials: T
authors.lastname: Kinoshita
authors.forename: Takashi
authors.initials: T
authors.lastname: Oshiro
authors.forename: Katsuhiko
authors.initials: K
authors.lastname: Ito
authors.forename: Hidehito
authors.initials: H
authors.lastname: Shibasaki
authors.forename: Shinichi
authors.initials: S
authors.lastname: Okazumi
authors.forename: Ryoji
authors.initials: R
authors.lastname: Katoh
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D013274:Stomach Neoplasms / Q000601:surgery*; D017792:Surgical Stapling / Q000379:methods*; D013536:Suture Techniques
references.citation: Surg Endosc. 2009 Sep;23(9):2167-71
references.pmid: 18553203
references.citation: Gastric Cancer. 2007;10(3):176-80
references.pmid: 17922096
references.citation: Gastric Cancer. 2008;11(4):233-7
references.pmid: 19132486
references.citation: Surg Oncol. 2007 Aug;16(2):85-98
references.pmid: 17560103
references.citation: Obes Surg. 2008 Sep;18(9):1074-6
references.pmid: 18459016
references.citation: Surg Endosc. 2009 Nov;23(11):2624-30
references.pmid: 19343421
references.citation: Am J Surg. 2007 Dec;194(6):839-44; discussion 844
references.pmid: 18005781
references.citation: J Laparoendosc Adv Surg Tech A. 2008 Aug;18(4):572-8
references.pmid: 18721007
references.citation: Surg Endosc. 2008 Nov;22(11):2532-4
references.pmid: 18320277
references.citation: Gastric Cancer. 2007;10(3):181-6
references.pmid: 17922097
references.citation: Ann Surg. 2007 Jan;245(1):68-72
references.pmid: 17197967
references.citation: Surg Today. 2005;35(10):896-9
references.pmid: 16175476
references.citation: Br J Surg. 2007 Feb;94(2):204-7
references.pmid: 17058319
references.citation: Am J Surg. 2009 Jan;197(1):e13-7
references.pmid: 19101245