Esophagojejunostomy after laparoscopic total gastrectomy by OrVil™ or hemi-double stapling technique.
OBJECTIVE
To investigate the feasibility, advantages and disadvantages of two types of anvil insertion techniques for esophagojejunostomy after laparoscopic total gastrectomy.


METHODS
This was an open-label prospective cohort study. Laparoscopy-assisted radical total gastrectomy with D2 lymph node dissection was performed in 84 patients with primary non-metastatic gastric cancer confirmed by pre-operative histological examination. Overweight patients were excluded, as well as patients with peritoneal dissemination and invasion of adjacent organs. After total gastrectomy, all patients were randomized into two groups. Patients in Group I underwent esophagojejunostomy using a transorally-inserted anvil (OrVil(TM)), while patients in Group II underwent esophagojejunostomy using the hemi-double stapling technique (HDST). Both types of esophagojejunostomy were performed under laparoscopy. Patients' baseline characteristics, preoperative characteristics, perioperative characteristics, short-term postoperative outcomes and operation cost were compared between the two groups. The primary endpoint was evaluation of the surgical outcome (operating time, time of digestive tract reconstruction and time of anvil insertion) and the medical cost of each operation (operation cost and total cost of hospitalization). The secondary endpoints were time to solid diet, post-surgical hospitalization time, time to defecation, time to ambulation and intra-operative blood loss. In addition, complications were assessed and compared.


RESULTS
Laparoscopic total gastrectomy and esophagojejunostomy were successfully performed in all 84 patients, without conversion to laparotomy. There were no significant differences in the operative time and time for total gastrectomy between the two groups (287.8 ± 38.4 min vs 271.8 ± 46.1 min, P = 0.09, and 147.7 ± 31.6 min vs 159.8 ± 33.8 min, P = 0.09, respectively). The time for digestive tract reconstruction and for anvil insertion were significantly decreased in Group II compared with Group I (47.8 ± 12.1 min vs 55.4 ± 15.7 min, P = 0.01, and 12.6 ± 4.7 min vs 18.7 ± 7.5 min, P = 0.001, respectively). Intra-operative blood loss (96.4 ± 32.7 mL vs 88.2 ± 36.9 mL, P = 0.28), time to defecation (3.5 ± 0.9 d vs 3.2 ± 1.1 d, P = 0.12), time to ambulation (3.9 ± 0.7 d vs 3.6 ± 1.1 d, P = 0.12), time to solid diet (7.6 ± 1.4 d vs 8.0 ± 2.7 d, P = 0.31) and total hospitalization (10.6 ± 2.6 d vs 10.8 ± 3.5 d, P = 0.80) were similar between the two groups. In addition, the total costs of hospitalization were similar between the two groups (73848.7 ± 11781.0 RMB vs 70870.3 ± 14003.5 RMB, P = 0.296), but operation cost was significantly higher in Group I compared with Group II (32401.9 ± 1981.6 RMB vs 26961.9 ± 2293.8 RMB, P < 0.001).


CONCLUSIONS
Anvil insertion was faster and easier using the HDST technique compared with OrVil(TM), and was more cost-effective. There was no significant difference in safety.
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Hao
H
Wang
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Qun
Q
Hao
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Meng
M
Wang
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Min
M
Feng
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Feng
F
Wang
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Xin
X
Kang
Hao Wang, Meng Wang, Min Feng, Feng Wang, Xin Kang, Wen-Xian Guan, Department of General Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nanjing 210008, Jiangsu Province, China.
Wen-Xian
WX
Guan
D000368:Aged; D016063:Blood Loss, Surgical; D002681:China; D004867:Equipment Design; D004946:Esophagostomy / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation / Q000379:methods; D005240:Feasibility Studies; D005260:Female; D005743:Gastrectomy / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D017721:Hospital Costs; D006801:Humans; D007582:Jejunostomy / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation / Q000379:methods; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics; D008297:Male; D008875:Middle Aged; D061646:Operative Time; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D020127:Recovery of Function; D013274:Stomach Neoplasms / Q000191:economics / Q000473:pathology / Q000601:surgery*; D013528:Surgical Staplers / Q000191:economics; D013536:Suture Techniques / Q000009:adverse effects / Q000191:economics / Q000295:instrumentation; D013997:Time Factors; D016896:Treatment Outcome
Cohort analysis; Esophagojejunostomy; Gastrectomy; Gastric cancer; Laparoscopy