Laparoscopic single-layer running "trapezoid-shaped" suture versus mechanical stapling for esophagojejunostomy after total gastrectomy for gastric cancer: cost-effect analysis of propensity score-matched study cohorts.

OBJECTIVES: Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling. METHODS: The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost. RESULTS: The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations. CONCLUSIONS: Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.

Development and validation of the bile leakage grading criterion in patients following Roux-en-Y hepaticojejunostomy.

OBJECTIVE: The present research aimed to propose a severity grading criterion for bile leakage in pediatric patients after Roux-en-Y hepaticojejunostomy for choledochal cysts. SUMMARY BACKGROUND DATA: Despite a bile leakage classification system from the International Study Group of Liver Surgery (ISGLS) has been developed, a commonly used grading system for pediatric patients after Roux-en-Y hepaticojejunostomy has not yet been established. METHODS: A review of clinical, laboratory, and ultrasonographic parameters were used to develop a grading system for classifying the severity of bile leakage. A total of 267 patients with bile leakage were retrospectively assessed to review the system. RESULTS: We developed a grading system for bile leakage severity for use in pediatric patients following Roux-en-Y hepaticojejunostomy. By applying the criteria to 267 patients, grade I, II, or III bile leakage was determined in 103 patients (8.7%), 115 patients (9.8%), and 49 patients (4.2%) patients, respectively. The most severe bile leakage grade (grade III), was associated with significantly higher γ-glutamyl transpeptidase and amylase levels, greater drain fluid output, more intensive care unit (ICU) admissions, and longer postoperative hospital stay. Interestingly, patients with grade II leakage who underwent reoperation had significantly more ICU admissions, longer postoperative hospital stays (p < 0.05), and higher overall hospitalization cost (p < 0.05) compared with those who underwent conservation management. Of the patients with bile duct stricture and common bile duct (CBD) stones, there were no differences among the different grades of postoperative bile leakage. CONCLUSIONS: The proposed bile leakage criteria may optimize objective diagnosis and therapeutic modalities.

A comprehensive evaluation of the long-term economic impact of major bile duct injury.

BACKGROUND: Complications and litigation after bile duct injury (BDI) result in clinical and economic burden. The aim of this study was to comprehensively evaluate the long-term clinical and economic impact of major BDI. METHOD: Patients with long-term follow-up after Strasberg E BDI were identified. Costs of treatment and litigation were the primary outcome. Relationships between these outcomes and repair factors, like timing of repair and surgeon expertise, were secondary outcomes. RESULTS: Among 139 patients with a median follow up of 10.7 years, 40% of patients developed biliary complications. Repairs by non-specialist surgeons had significantly higher follow up and treatment costs than those by specialists (£25,814 vs. £14,269, p < 0.001). Estimated litigation costs were higher in delayed than immediate repairs (£23,295 vs. £12,864). As such, the lowest average costs per BDI are after immediate specialist repair and the highest after delayed non-specialist repair (£27,133 vs. £49,109, ×1.81 more costly, p < 0.001). Repair by a non-specialist surgeon (HR: 4.00, p < 0.001) and vascular injury (HR: 2.35, p = 0.013) were significant independent predictors of increased complication rates. CONCLUSION: Costs of major BDI are considerable. They can be reduced by immediate on-table repair by specialist surgeons. This must therefore be considered the standard of care wherever possible.

Assessment of the safety and efficacy of percutaneous laparoscopic endoscopic jejunostomy (PLEJ).

INTRODUCTION AND AIMS: Gastric feeding may not be possible in the neurologically impaired child with foregut dysmotility. Post-duodenal feeding can be crucial, thereby avoiding the need for parenteral nutrition. The aim of this study is to evaluate the technical success, complication and clinical outcome of our institution's technique in creating a jejunostomy using the percutaneous laparoscopic-endoscopic jejunostomy (PLEJ) technique. METHODS: Retrospective review of all paediatric patients (<18) with PLEJ between January 2008 and April 2015 was conducted. Patients were identified using the electronic procedure code and clinic letters. Data were collected in regard to the procedure technical success, short and long-term complications and clinical outcomes. RESULTS: Sixteen patients (age range, 2-17years) were identified. The procedure was successful in all cases. At a median follow up of 25months, eleven patients (68%) had significant improvement of their symptoms of feeding intolerance/aspirations and are permanently PLEJ fed and two (13%) were regraded to gastric feeds. Two patients moved from total parenteral nutrition to partial parenteral nutrition while on PLEJ feeds. All patients had experienced weight gain and either went up or maintained their weight centile. The only major complication was small bowel volvulus encountered in two patients with abnormal gastrointestinal anatomy requiring surgical intervention. CONCLUSIONS: In our small case series, PLEJ placement was safe as it provides valuable visualization of the bowel loops intraabdominally. It is a technically feasible and successful approach for children requiring long-term jejunal feeding especially those with foregut dysmotility.

Esophagojejunostomy after laparoscopic total gastrectomy by OrVil™ or hemi-double stapling technique.

AIM: 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). CONCLUSION: 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.

A cadaveric porcine model for assessment in laparoscopic bariatric surgery--a validation study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the most effective surgical therapy for morbid obesity. It is an advanced laparoscopic surgical procedure and has a protracted learning curve. Therefore, it is important to develop innovative ways of training and assessing surgeons. The aim of this study is to determine if a cadaveric porcine jejuno-jejunostomy model is an accurate way of assessing a surgeon's technical skills by determining if a correlation exists with how he performs in the operating room. METHODS: Eight surgeons of varying experience performed a side-to-side stapled jejuno-jejunostomy on a cadaveric bench model before proceeding to perform the procedure on a real patient scheduled for LRYGBP. Performance was assessed using a motion tracking device, the Imperial College Surgical Assessment Device. Each procedure was recorded in video and scored by two blinded expert surgeons using procedure-specific rating scales. RESULTS: The cadaveric bench model demonstrated concurrent validity with significant correlations between performance on the cadaveric model and patient for dexterity measures. Left-hand path length, r = 0.857 (median, 27, 41.3; P = 0.007), right-hand path length, r = 0.810 (median, 31.5, 60; P = 0.015) and total number of movements, r = 0.743 (median, 422, 637; P = 0.035). This correlation in performance was also demonstrated in the video rating scales, r = 0.727 (median, 13.2, 14.8; P = 0.041). No correlation was found in operative time (median, 541, 742; P = 0.071). CONCLUSIONS: This study demonstrates the concurrent validity of the cadaveric porcine model, showing similar performances in surgeons completing a jejuno-jejunostomy on the cadaveric model and the patient.

Laparoscopic gastrostomy and jejunostomy.

BACKGROUND: The percutaneous/endoscopic gastrostomy (PEG) has rapidly replaced the surgical gastrostomy as the preferred route for enteral access. In patients who are not candidates for a PEG, we prefer a laparoscopic gastrostomy to an open gastrostomy. Similarly, in patients who require a surgical jejunostomy, we prefer a laparoscopic approach. Minimally invasive techniques have several advantages over the standard open surgery. The purpose of this article is to review the indications, various techniques, and outcomes of laparoscopic gastrostomy and jejunostomy tubes. DATA SOURCES: Medline search from 1959-2002. CONCLUSIONS: The PEG remains the procedure of choice for placement of a gastrostomy. Laparoscopic gastrostomy is an excellent choice for patients who are not candidates for a PEG. Similarly, laparoscopic jejunostomy is an excellent choice for patients who require enteral access, but have contraindications to a gastrostomy tube. Placement of laparoscopic gastrostomy andjejunostomy tubes can be safely performed, and the success and complication rates of these procedures compare favorably with those of the corresponding open surgical procedure. Laparotomy is rarely needed to place enteral feeding tubes. Cost analysis has shown that laparoscopic procedures are similar to open procedures.

Modified technique for introducer-type percutaneous endoscopic gastrostomy and jejunostomy: assisted by a novel trocar and fasteners.

BACKGROUND AND PURPOSE: Commercially available kits for percutaneous endoscopic gastrostomy (PEG) and jejunostomy comprise a substantial proportion of the cost of patients for this procedure. A modified introducer-type technique and new instrumentation for PEG and jejunostomy that substantially reduces the cost of the kit were tested for efficacy and safety. METHODS: This technique was tested on 10 pigs as a pilot study, and then applied to seven consecutive patients undergoing gastrostomy and three patients undergoing gastrostomy with jejunostomy. The endoscopy and site selection for gastrostomy were the same as in standard PEG. Two novel fasteners for fixing the gastric wall to the abdominal wall and a guide-wire in the selected site were inserted separately into the stomach through 15-gauge needles. A stainless steel trocar with a detachable sheath was introduced into the stomach over the guide-wire. After the inner stylet was removed, a 24-French Foley catheter was inserted as a feeding tube. Gastrostomy was completed after balloon inflation and external fixation. If jejunostomy was indicated, a 12-French nasogastric tube was inserted through the gastrostomy. The procedure time, complications, and costs were compared with those for another 15 consecutive patients who underwent the conventional pull-through method of PEG and jejunostomy using commercially available kits. RESULTS: No significant difference was found in procedure time between patients who underwent the modified or conventional gastrostomy procedures (mean +/- standard deviation, 15.4 +/- 5.6 min). There was a similar incidence of short-term complications in the two treatment groups. The feeding catheters required replacement more quickly than did those in the commercial kits (80 +/- 58 vs 217 +/- 140 d). The cost to patients was much less with the new method than with conventional PEG. CONCLUSIONS: The new gastrostomy method achieves the same medical quality at far less cost for patients.

Percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) for decompression in the upper gastrointestinal tract. Initial experience with palliative treatment of gastrointestinal obstruction in terminally ill patients with advanced carcinomas.

BACKGROUND: Signs of gastrointestinal obstruction, with intractable vomiting and an inability to take oral food, are common symptoms in terminally ill cancer patients with advanced primary tumors or peritoneal carcinomatosis. The application of percutaneous endoscopic gastrostomy or jejunostomy (PEG/PEJ) instead of the usual nasoenteral tube is a simple method of achieving permanent decompression in the upper gastrointestinal tract. The goals of this study, in addition to establishing indications and outcome, were to identify specific aspects of tube placement and to determine the incidence of complications. METHOD: Over a period of 3 years, a total of 24 consecutive patients (mean age, 64 years; range, 37-83 years) underwent either a PEG (17/71%) or a PEJ (seven/29%). RESULTS: In all patients, PEG/PEJ obviated the need for the nasoenteral tube. A total of 22 patients (92%) were enabled to take liquids orally, and 20 (83%) were discharged to home care. With the exception of a single spontaneous dislodgement of the PEG tube, no major complications were observed. CONCLUSION: We believe that PEG/PEJ represents an effective, minimally invasive, and cost-effective method for gastrointestinal decompression in patients with advanced incurable cancer.

Radiologic gastrojejunostomy and percutaneous endoscopic gastrostomy: a prospective, randomized comparison.

PURPOSE: To compare the efficacy of radiologic guided placement of percutaneous gastrojejunostomy (PGJ) and percutaneous endoscopic gastrostomy (PEG). MATERIALS AND METHODS: Patients were randomized to PGJ (n = 66) or PEG (n = 69). Indications for gastrostomy were need for prolonged enteral nutrition (97%) or gastrointestinal decompression (3%), with etiologies of neurologic impairment (81%), head and neck neoplasm (12%), bowel obstruction (3%), or other (4%). Mean follow-up was 202 days and 30-day follow-up was obtained for 85% of patients. RESULTS: PEG was successful in 63 of 69 (91%) patients, while PGJ established access in all of 66 attempts (100%) (P = .014). Average procedural time was 53 minutes for PGJ and 24 minutes for PEG (P = .001). At 30-day follow-up, there were 33 and 45 complications in the PGJ and PEG groups, respectively. This difference was due to the greater incidence of pneumonia in the PEG group (P = .013). Long-term tube-related complications occurred with 17 PGJs and four PEGs (P = .007). The PGJ cost more than PEG, but this advantage was offset by the cost of complications. CONCLUSION: PGJ had higher success rate and fewer complications, due to a lower incidence of pneumonia. PEG took less time to perform, cost less, and required less tube maintenance.

Laparoscopic gastrostomy and jejunostomy: safety and cost with local vs general anesthesia.

BACKGROUND AND HYPOTHESIS: General anesthesia is used for laparoscopic enteral access because pneumoperitoneum requires relaxation of the abdominal muscles. We wanted to determine whether these procedures could be performed with similar results and cost under local anesthesia. DESIGN: Randomized controlled study with 30-day follow-up including a cost-benefit analysis. SETTING: University-affiliated hospitals. PATIENTS: Forty-eight patients (32 men, 16 women; mean age, 67 years) undergoing laparoscopic gastrostomies (n = 32) and jejunostomies (n = 16). INTERVENTION: Twenty-four patients underwent laparoscopic gastrostomy (n = 15) and jejunostomy (n = 9) under local anesthesia with intravenous conscious sedation and monitored anesthesia care. Twenty-four patients had general anesthesia. MAIN OUTCOME MEASURES: Conversion to general anesthesia, complications, and cost. RESULTS: Ten patients under local anesthesia had periods of deep sedation and 1 required conversion to general anesthesia. One patient under general anesthesia required conversion to open gastrostomy. No patients had intraoperative aspiration; however, 4 aspirated after the procedure. One patient died of myocardial infarction during the 30-day follow-up. We found no significant difference in the total mean cost and actual procedure time. The surgeon's fee accounted for 31% of the total cost. CONCLUSIONS: Some patients undergoing laparoscopic enteral access may require deep sedation and a rare patient may require general anesthesia. Clinical conditions and surgeon preference, therefore, should determine whether local anesthesia is suitable for laparoscopic gastrostomies and jejunostomies, and in what setting, since there is no difference in success rate or complications when compared with general anesthesia. Potential savings are possible from the operating room (26% of total cost) or anesthesiologist (12% of total cost) if these procedures are performed in an endoscopy suite without monitored anesthesia care.

Scintigraphic assessment of double tract reconstruction after total gastrectomy.

BACKGROUND/AIMS: This study was carried out to evaluate the clinical significance of double tract reconstruction after total gastrectomy. METHODS: 25 patients, 14 with jejunal pouch double tract reconstructions and 11 with rho-double tract reconstructions, were studied. Scintigraphy was used to evaluate duodenal and jejunal passage, and the jejunal/duodenal ratio was calculated. The patients were classified into 3 groups based on this ratio: group A (n = 14) ratio <1; group B (n = 6) ratio 1-2, and group C (n = 5) ratio >2. The reflux score, scintigraphic reflux index, emptying time of the jejunal pouch or rho-limb, and various nutritional parameters were compared between the 3 groups. RESULTS: The emptying time was shortest in group B, but there was no significant difference among the 3 groups in the Sigstad dumping scores. The reflux score, scintigraphic reflux index, and most nutritional parameters also showed no significant differences between the 3 groups. Leakage at the duodenojejunostomy did not occur in any patient. CONCLUSION: Our findings suggest that there was no preferential passage via the duodenum or jejunum after double tract reconstruction. This method is also useful for decompression of the duodenal stump and group B seemed to have the ideal reconstruction on the basis of emptying time.

Percutaneous endoscopic stomas for enteral feeding and drainage.

The use of safe and cost-effective endoscopic techniques for the placement of tubes in the gastrointestinal tract has led to increased utilization of long-term enteral feeding in patients with impaired GI function, including many cancer patients. Of an estimated 148,000 US patients who received long-term enteral feeding outside hospitals in 1992, 43% were cancer patients. The technique of percutaneous endoscopic gastrostomy is used primarily for enteral feeding, but can also be used to place wide tubes for drainage of an obstructed GI tract. Aspiration problems can be eliminated by endoscopic placement of a feeding tube directly into the jejunum (percutaneous endoscopic jejunostomy). Patients with advanced cancer who are not surgical candidates may benefit from an external GI bypass placed endoscopically, which allows drainage through a gastrostomy and feeding through a jejunostomy distal to the obstruction.

Laparoscopic-guided feeding jejunostomy.

Access for long-term enteral nutrition has long been the job of the surgeon. While percutaneous endoscopic gastrostomy has revolutionized the way we provide gastric feedings, jejunal access usually requires laparotomy. We have developed a technique for placing a laparoscopic guided jejunostomy. Twenty-three patients have undergone this procedure without complication. We believe this technique will be a valuable addition to the surgeon's options for obtaining enteral access.

Percutaneous endoscopic gastrostomy.

The development of an endoscopic procedure for the placement of a gastrostomy feeding tube has revived interest in the use of this technique for nutritional support. The medical literature has reported a considerable amount of experience which attests to its ease of placement and low incidence of complications associated with placement. The "push" and "pull" techniques both have been used effectively to establish access to the stomach. Innovations by numerous practitioners have helped reduce some of the minor complications associated with percutaneous endoscopic gastrostomy (PEG) placement. Serious complications from pulmonary aspiration and stomal infection remain important management issues after gastrostomy placement and initiation of feeding. The adequacy of nutritional support should be the final measure of successful PEG placement.