title: Stenosis after use of the double-stapling technique for reconstruction after laparoscopy-assisted total gastrectomy.
abstract: BACKGROUND
  The double-stapling technique (DST) for esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien Japan, Tokyo, Japan) is one of the reconstruction methods used after laparoscopy-assisted total gastrectomy (LATG). This technique has potential advantages in terms of less invasive surgery without the need to create a complicated intraabdominal anastomosis.
  
  
  METHODS
  From 2008 to 2011, 262 patients with gastric cancer underwent total gastrectomy and reconstruction with a Roux-en-Y anastomosis, and 52 patients underwent LATG with DST. A retrospective analysis then was performed comparing the patients who experienced postoperative stenosis after LATG-DST (positive group) and the patients who did not (negative group). A comparative analysis was performed among patients comparing conventional open total gastrectomy and LATG, and multivariate analysis was performed to evaluate risk factors for the development of anastomotic stenosis.
  
  
  RESULTS
  A minor leak was found in 1 patient (1.9 %), and 11 patients experienced anastomotic stenosis (21 %) after LATG with DST. Among the patients with anastomotic stenosis, three (3/4, 75 %) anastomoses were performed with the 21-mm end-to-end anastomosis (EEA) stapler, and eight anastomoses were performed (8/47, 17 %) with the 25-mm EEA stapler. The median interval to the diagnosis of anastomotic stenosis was 43 days after surgery. The patients with stenosis needed endoscopic balloon dilation an average of four times, and the rate of perforation after dilation was 13 %. The clinical and operative characteristics did not differ between the two groups. Anastomotic stenosis after open total gastrectomy occurred in two cases (0.98 %). Multivariate analysis showed that the size of the EEA stapler and the use of DST were risk factors for anastomotic stenosis.
  
  
  CONCLUSIONS
  Esophagojejunostomy using DST with OrVil is useful in performing a minimally invasive procedure but carries a high risk of anastomotic stenosis.
authors.affiliation: Department of Surgery, Jichi Medical University, Yakushiji, Shimotsuke, Tochigi, 3311-1, Japan, th-zuiki@jichi.ac.jp.
authors.forename: Toru
authors.initials: T
authors.lastname: Zuiki
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Hosoya
authors.forename: Yuji
authors.initials: Y
authors.lastname: Kaneda
authors.forename: Kentaro
authors.initials: K
authors.lastname: Kurashina
authors.forename: Shin
authors.initials: S
authors.lastname: Saito
authors.forename: Takashi
authors.initials: T
authors.lastname: Ui
authors.forename: Hidenori
authors.initials: H
authors.lastname: Haruta
authors.forename: Masanobu
authors.initials: M
authors.lastname: Hyodo
authors.forename: Naohiro
authors.initials: N
authors.lastname: Sata
authors.forename: Alan T
authors.initials: AT
authors.lastname: Lefor
authors.forename: Yoshikazu
authors.initials: Y
authors.lastname: Yasuda
mesh_terms: D000368:Aged; D000713:Anastomosis, Roux-en-Y; D004106:Dilatation / Q000009:adverse effects / Q000379:methods; D004867:Equipment Design; D004940:Esophageal Stenosis / Q000209:etiology*; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005743:Gastrectomy / Q000379:methods*; D006801:Humans; D007582:Jejunostomy / Q000379:methods*; D010535:Laparoscopy / Q000379:methods*; D007813:Laparotomy / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology*; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000601:surgery; D013528:Surgical Staplers; D017792:Surgical Stapling / Q000379:methods*