[Delayed esophagojejunostomy as a damage control principle]. / Otsrochennyi ezofagoeyunoanastomoz kak printsip «Damage Control¼.

The authors describe 2 patients with rare gastric diseases and indications for gastrectomy with delayed esophagojejunostomy for objective causes. In one case, they could not determine extent of resection, and other patient had hemorrhagic shock. Damage control principle was applied in both cases.

Comparison of surgical outcomes among different methods of esophagojejunostomy in laparoscopic total gastrectomy for clinical stage I proximal gastric cancer: results of a single-arm multicenter phase II clinical trial in Korea, KLASS 03.

BACKGROUND: Laparoscopic distal gastrectomy for early gastric cancer has been widely accepted, but laparoscopic total gastrectomy has still not gained popularity because of technical difficulty and unsolved safety issue. We conducted a single-arm multicenter phase II clinical trial to evaluate the safety and the feasibility of laparoscopic total gastrectomy for clinical stage I proximal gastric cancer in terms of postoperative morbidity and mortality in Korea. The secondary endpoint of this trial was comparison of surgical outcomes among the groups that received different methods of esophagojejunostomy (EJ). METHODS: The 160 patients of the full analysis set group were divided into three groups according to the method of EJ, the extracorporeal circular stapling group (EC; n = 45), the intracorporeal circular stapling group (IC; n = 64), and the intracorporeal linear stapling group (IL; n = 51). The clinicopathologic characteristics and the surgical outcomes were compared among these three groups. RESULTS: There were no significant differences in the early complication rates among the three groups (26.7% vs. 18.8% vs. 17.6%, EC vs. IC vs. IL; p = 0.516). The length of mini-laparotomy incision was significantly longer in the EC group than in the IC or IL group. The anastomosis time was significantly shorter in the EC group than in the IL group. The time to first flatus was significantly shorter in the IL group than in the EC group. The long-term complication rate was not significantly different among the three groups (4.4% vs. 12.7% vs. 7.8%; EC vs. IC vs. IL; p = 0.359), however, the long-term incidence of EJ stenosis in IC group (10.9%) was significantly higher than in EC (0%) and IL (2.0%) groups (p = 0.020). CONCLUSIONS: The extracorporeal circular stapling and the intracorporeal linear stapling were safe and feasible in laparoscopic total gastrectomy, however, intracorporeal circular stapling increased EJ stenosis.

21- versus 25-mm Circular Staplers for Cervical Anastomosis: A Propensity-Matched Study.

BACKGROUND: The use of a small circular stapler (CS) has been reported to increase the incidence of benign anastomotic stricture of the intrathoracic anastomosis after esophagectomy, but no study has evaluated the effects of the CS size on cervical esophagogastrostomy. Based on a propensity-matched comparison, the present study was designed to determine whether the perioperative outcomes differ between 21- and 25-mm CSs after minimally invasive esophagectomy with cervical anastomosis. METHODS: From January 2015 to December 2017, 162 patients who received CS cervical esophagogastric anastomosis after minimally invasive esophagectomy for esophageal cancer were identified from our surgical database. A propensity-matched analysis was used to compare the outcomes between the 21- and 25-mm CS groups. Endpoints included anastomotic leak, dysphagia, reflux, stricture, and other major postoperative outcomes within 6 postoperative months. RESULTS: There were 69 and 93 patients in the 21- and 25-mm CS groups, respectively. Propensity matching produced 57 patients in each group. The two groups were not remarkably different in benign anastomotic stricture rate (P = 0.528). All strictures were resolved by balloon dilatation. The 25-mm CS group had a significantly longer operative time in cervical anastomosis than the 21-mm group (P = 0.005). No statistically significant differences in anastomotic leak rates, dysphagia scores, reflux scores, or other postoperative complications were noted between the two groups. CONCLUSIONS: The use of a 21-mm CS in minimally invasive esophagectomy with cervical esophagogastric anastomosis did not result in greater anastomotic stricture as compared with a 25-mm CS. The 21-mm CS was associated with a significantly shorter operative time.

Stenosis after esophagojejunostomy with the hemi-double-stapling technique using the transorally inserted anvil (OrVil™) in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following laparoscopic total gastrectomy.

BACKGROUND: The drawback of intracorporeal esophagojejunostomy with the double-stapling technique (DST) using a transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA) following laparoscopic total gastrectomy (LTG) is not only the high incidence of stenosis but also the presence of intractable stenosis that is refractory to endoscopic treatments. METHODS: From November 2013 to December 2016, 24 patients with gastric cancer underwent intracorporeal circular-stapled esophagojejunostomy with the hemi-double-stapling technique (hemi-DST) using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient following LTG to prevent twisting of the esophagojejunostomy and lifted jejunum, which might cause intractable stenosis of the esophagojejunostomy. RESULTS: In this patient series, no twisting of the esophagojejunostomy and lifted jejunum was encountered intraoperatively or postoperatively. Two stenoses of the esophagojejunostomy occurred. Because neither was involved with twisting and both were localized at the anastomotic plane, endoscopic treatments including balloon dilation and electrocautery incisional therapy were successful in both cases. There were no patients with intractable stenosis in this series. CONCLUSIONS: Intracorporeal esophagojejunostomy with the hemi-DST using the OrVil™ in antecolic Roux-en-Y reconstruction with its efferent loop located on the left side of the patient can be one option for a circular stapling technique in LTG due to its prevention of intractable stenosis of the esophagojejunostomy that is refractory to endoscopic treatments.

The crossover technique for intracorporeal esophagojejunostomy following laparoscopic total gastrectomy: a simple and safe technique using a linear stapler and two barbed sutures.

BACKGROUND: Totally laparoscopic gastrectomy (LG) is preferred over open gastrectomy because it allows safe anastomosis, a small wound, and early bowel recovery. However, esophagojejunostomy (EJS) following laparoscopic total gastrectomy (LTG) remains technically challenging. To popularize LTG, a secure method of reconstruction must be developed. We present a simple and safe technique for intracorporeal EJS following LTG. METHODS: Our modified technique for intracorporeal EJS as a part of Roux-en-Y reconstruction following LTG incorporates an isoperistaltic stapled EJS with closure of the entry hole using two unidirectional barbed sutures. First, a side-to-side isoperistaltic EJS is created between the dorsal and left side of the esophagus and the jejunal arm. Second, the opening for the stapler is closed with a two-layer continuous suture using two 15-cm 3-0 V-Loc suture devices. The full-thickness inner layer closure commences from the sides of the staple lines and progresses toward the center of the enterotomy. During suturing, the remaining thread is utilized to apply tension and lift the enterotomy. Once the full-thickness layer closure is complete at the center of the enterotomy, suturing of the second seromuscular layer is started in the forward direction toward each corner to give a crossover-shaped suturing line. RESULTS: From February 2012 to October 2017, 27 patients with gastric cancer underwent LTG with intracorporeal stapled EJS as a part of Roux-en-Y reconstruction. All procedures were successfully performed without any intra- or postoperative anastomosis-related complications. No conversion to other procedures was required. The mean suturing time was 19.1 ± 9.5 min. The mean postoperative time to tolerating a liquid diet was 3.3 days, and the mean hospital stay was 12.1 days. CONCLUSIONS: We herein report our procedure for intracorporeal EJS using a linear stapler and barbed sutures. This technique is simple and feasible and has acceptable morbidity.

The Impact of the Location of Esophagogastrostomy on Acid and Duodenogastroesophageal Reflux After Transthoracic Esophagectomy with Gastric Tube Reconstruction and Intrathoracic Esophagogastrostomy.

BACKGROUND: The aim of this study was to evaluate the impact of the location of esophagogastrostomy on acid and duodenogastroesophageal reflux (DGER) in patients undergoing gastric tube reconstruction and intrathoracic esophagogastrostomy. METHODS: Thirty patients receiving transthoracic esophagectomy without cervical lymph node dissection and gastric tube reconstruction by intrathoracic anastomosis were enrolled. All patients underwent 24-h pH and bilirubin monitoring and gastrointestinal endoscopy one year after surgery. Patients were divided into three groups according to esophagogastrostomy location: group A (n = 9), above the top of the aortic arch; group B (n = 15), between the top and bottom of the aortic arch; and group C (n = 6), below the bottom of the aortic arch. The relations among the esophagogastrostomy location, 24-h pH and bilirubin monitoring results, endoscopic findings, and reflux symptoms were investigated. RESULTS: No acid reflux into the remnant esophagus was observed in group A, whereas it was observed in three of 15 patients (20%) in group B and in two of six patients (33%) in group C (P = 0.139). No DGER was found in group A, whereas DGER was observed in eight (53%) patients in group B and all patients in group C (P < 0.001). Reflux esophagitis was observed in one patient (11%) in group A, five patients (33%) in group B, and all patients in group C (P = 0.002). CONCLUSION: In gastric tube reconstruction via intrathoracic anastomosis, esophagogastrostomy should be performed above the top of the aortic arch to prevent postoperative DGER and reduce the incidence of reflux esophagitis.

Utilization of Gastric Conduit in the Management of Combined Corrosive Esophageal and Stomach Stricture.

BACKGROUND: Corrosive stricture of esophagus may be associated with variable involvement of stomach. We analyzed the outcome of gastric conduit used in the management of corrosive esophageal stricture with concomitant antro-pyloric stricture. STUDY DESIGN: Among 101 esophageal replacements performed, 53 patients had combined esophagus and stomach strictures. Colon was used as a conduit in 43 patients, while stomach was used in ten patients. Indications, perioperative complications and early/late outcomes of patients with gastric pull-up were reviewed and compared with those undergone colon pull-up. RESULTS: The indications of using gastric conduit were impromptu in four patients [colonic conduit ischemia (n = 2) and an oversight of antro-pyloric stricture after forming the gastric conduit (n = 2)]. Six patients had preconceived gastric conduit (distal antro-pyloric stricture with distended stomach). The median age was 29 years (range 16-50), and median BMI was 15.4 kg/m2 (range 14.5-20.1). The stomach was drained using loop gastrojejunostomy (n = 7) or Roux-en-Y gastrojejunostomy (n = 3). One patient died due to sepsis secondary to anastomotic leak. Median hospital stay was 9 days (range 7-22). At median follow-up of 25 months (range 14-80), the remaining nine patients are able to have solid diet and have gained weight. The level of esophageal stricture was low (p = 0.01), and duration of surgery (p = 0.02) and median hospital stay (p = 0.04) were significantly less in patients with gastric conduit plus drainage as compared to patients undergone colonic pull-up. CONCLUSION: Gastric conduit in a subject with distal antro-pyloric stricture can be used safely along with gastrojejunostomy in selected patients of corrosive esophageal stricture.

Early Postoperative Endoscopy for Evaluation of the Anastomosis after Esophageal Reconstruction.

BACKGROUND: Anastomotic leaks significantly affect hospital stay after esophageal surgery. Here, we investigated the efficacy of early endoscopy for predicting anastomotic healing and leaks after esophageal reconstruction. METHODS: A total of 65 consecutive esophageal cancer patients treated by cervical esophagogastrostomy underwent routine endoscopy between postoperative days 5 and 7. The anastomosis was scored for the degree of ischemia, stenosis, and torsion of the anastomotic axis. Independent associations between ischemia, stenosis, and torsion of the proximal esophagus and the risk of the anastomotic leak were examined using Spearman's rank correlation method. RESULTS: Assessment of the degree of mucosal ischemia in 65 patients shows well healing in 35, patch ischemia in 20, diffuse ischemia in 10, no necrosis in any patient. Stenosis was classified as 0 to 10% in 40 patients, 11 to 20% in 12, 21 to 80% in 11, and 81 to 100% in 2. The degree of torsion of the anastomotic axis was classified as 0 to 10 degrees in 52 patients, 11 to 90 degrees in 8, and 91 to 180 degrees in 5. With rising endoscopy scores, there was an increase in risk for leaks (score > 4.5, sensitivity 100%, and specificity 83.8%). CONCLUSIONS: Early postoperative endoscopy facilitates the management of esophagogastrostomy anastomosis to predict leaks.

Endoscopic suturing as a less invasive approach for the treatment of anastomotic leakage after esophagogastrostomy - a case report.

Anastomotic leakage is a frequent complication after gastrointestinal (GI) surgery and is associated with high morbidity and mortality. Endoluminal therapy offers numerous advantages compared to surgical revision. We present the case of a 74-year-old female patient with anastomotic leakage after esophagogastrostomy. The defect was closed using the OverStitch endoscopic suturing system with immediate technical and clinical success. Hereby, an example of the feasibility of this novel technique in a case of anastomotic leakage is presented and provides an outlook for the rising importance of endoscopic therapy.

Esophagojejunostomy Using the Purse-String Suturing Device After Laparoscopic Total or Proximal Gastrectomy for Gastric Cancer.

BACKGROUND: Performing a safe esophagojejunostomy is important for the standardization of laparoscopic total gastrectomy. We have performed intracorporeal esophagojejunostomy by a circular stapler using the purse-string suturing device that we co-developed. The advantage of this device is that it makes use of the same surgical procedure as open surgery, but it does not depend on the surgeon's technical skills since this device does not require the laparoscopic hand-sewn technique. Furthermore, we have also adapted this device for double-tract reconstruction after laparoscopic proximal gastrectomy. In this study, we present the surgical procedures and postoperative short-term outcomes that were obtained using this novel technique. METHODS: We enrolled 94 patients that underwent intracorporeal esophagojejunostomy by circular stapler using our device after laparoscopic total or proximal gastrectomy for gastric cancer between November 2009 and October 2016. RESULTS: Postoperative complications related to esophagojejunostomy were due to anastomotic stenosis in two cases (2.1%) and leakage of the jejunum stump in one case (1.1%). CONCLUSIONS: Intracorporeal esophagojejunostomy by circular stapler using the purse-string suturing device is safe and feasible. This method can be one of the standard procedures for performing intracorporeal esophagojejunostomy.

Stability of cervical esophagogastrostomy via hand-sewn anastomosis after esophagectomy for esophageal cancer.

The aim of the present study is to evaluate the outcome of hand-sewn esophagogastric anastomosis during radical esophagectomy for esophageal cancer. The outcomes of 467 consecutive esophageal cancer patients who underwent cervical esophagogastric anastomosis using interrupted and double-layered sutures after radical esophagectomy via right thoracotomy or thoracoscopic surgery were retrospectively reviewed. Anastomotic leakage, including conduit necrosis, occurred in 11 of 467 patients (2.4%); 7 of 11 (63.6%) cases experienced only minor leakage, whereas the other four (36.4%) patients had major leakage that required surgical or radiologic intervention, including two patients of conduit necrosis. Anastomotic leakages were more frequently observed after retrosternal reconstruction compared with the posterior mediastinal route (P < 0.0001). The median time to healing of leakage was 40 days (range: 14-97 days). Two patients (2/467, 0.4%) died in the hospital due to sepsis caused by the leakage and conduit necrosis. Twelve patients (2.6%) developed anastomotic stenosis, which was improved by dilatation in all patients. Hand-sewn cervical esophagogastric anastomosis is a stable and highly safe method of radical esophagectomy for esophageal cancer.

Comparing the short-term outcomes of intracorporeal esophagojejunostomy with extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer.

BACKGROUND: Totally laparoscopic distal gastrectomy (TLDG) using intracorporeal anastomosis has gradually developed due to advancements in laparoscopic surgical instruments. However, totally laparoscopic total gastrectomy (TLTG) with intracorporeal esophagojejunostomy (IE) is still uncommon because of technical difficulties. Herein, we evaluated various types of IE after TLTG in terms of the technical aspects. We compared the short-term operative outcomes between TLTG with IE and laparoscopy-assisted total gastrectomy (LATG) with extracorporeal esophagojejunostomy (EE). METHODS: Between March 2006 and December 2014, a total of 213 patients with gastric cancer underwent TLTG and LATG. Overall, 92 patients underwent TLTG with IE, and 121 patients underwent LATG with EE. Generally, there are two methods of IE: mechanical staplers (circular or linear staplers) and hand-sewn sutures. Surgical efficiencies and outcomes were compared between two groups. We also described various types of IE using a subgroup analysis. RESULTS: The mean operation times were similar in the two groups, as was the number of retrieved lymph nodes. However, the mean estimated blood loss of TLTG was statistically lower than LATG. There were no significant differences in time to first flatus, the time to restart oral intake, the length of the hospital stay after operation, and postoperative complications. Four types of IE have been applied after TLTG, including 42 cases of hand-sewn IE. The overall mean operation time and the mean anastomotic time in TLTG were 279.5 ± 38.4 min and 52.6 ± 18.9 min respectively. There was no case of conversion to open procedure. Postoperative complication occurred in 16 patients (17.4%) and no postoperative mortality occurred. CONCLUSIONS: IE is a feasible procedure and can be safely performed for TLTG with the proper laparoscopic expertise. It is technically feasible to perform hand-sewn IE after TLTG, which can reduce the cost of the laparoscopic procedure.

A new option for intracorporeal circular-stapled esophagojejunostomy in laparoscopic total gastrectomy: Roux-en-Y reconstruction with its efferent loop located at the left side of the patient to prevent twisting of the esophagojejunostomy.

BACKGROUND/AIMS: Laparoscopic total gastrectomy (LTG) has not gained widespread acceptance because of the difficult reconstruction technique, especially for esophagojejunostomy. Although various modified procedures using a circular stapler for esophagojejunostomy have been reported, an optimal technique has not yet been established. In addition, in intracorporeal techniques, twisting of the esophagojejunostomy, which might be the cause of stenosis, is often encountered because application of the shaft is restricted. To prevent twisting of the esophagoejunostomy, we underwent LTG with Roux-en-Y reconstruction with its efferent loop located at the left side of the patient. METHODOLOGY: From November 2013 to November 2014, a series of 9 patients underwent LTG with Roux-en-Y reconstruction using the transorally inserted anvil (OrVil™, Covidien, Mansfield, MA, USA), whose efferent loop was located at the left side of the patient. RESULTS: No twisting of the esophagojejunostomy was encountered in all cases. In addition, no stenosis or leakage of the esophagojejunostomy occurred. CONCLUSIONS: This reconstruction system may be a feasible surgical procedure in LTG.

Esophagojejunostomy reconstruction using a robot-sewing technique during totally robotic total gastrectomy for gastric cancer.

BACKGROUND/AIMS: The aim of this study was to report on the feasibility of esophagojejunostomy reconstruction using a robot-sewing technique during a completely robotic total gastrectomy for gastric cancer. METHODOLOGY: Between May 2011 and July 2012, 65 patients in whom gastric adenocarcinoma was diagnosed underwent a completely robotic total gastrectomy, including a robot-sewing esophagojejunal anastomosis. We demonstrated the surgical techniques with analysis of clinicopathologic data and short-term surgical outcomes. RESULTS: All robotic surgeries were successfully performed without conversion. Among the 65 patients, 46 were men and 19 were women. The mean age (± SD) was 57.8 ± 6.5 y. The mean total operative time (± SD), EJ anastomosis time (± SD), and blood loss (± SD) were 245 ± 53 min, 45 ± 26 min, and 75 ± 50 ml, respectively. The mean (± SD) post-operative hospital stay was 5.4 ± 2.5 d. One patient was readmitted for an intestinal obstruction and underwent re-operation 14 d post-operatively; he recovered uneventfully and was discharged 10 d post- operatively. During the follow-up, no patients developed an esophgojejunostomy stricture. CONCLUSIONS: A robot-sewing anastomosis for esophagojejunostomy reconstruction during robotic total gastrectomy for gastric cancer is feasible. Indeed, a robot-sewing anastomosis for esophagojejunostomy reconstruction may become a standard surgical technique during completely robotic total gastrectomy for gastric cancer.

Evaluation of the safety and efficacy of esophagojejunostomy after totally laparoscopic total gastrectomy using a trans-orally inserted anvil: a single-center comparative study.

BACKGROUND: Although laparoscopic surgery is frequently performed for the treatment of gastric cancer, laparoscopic total gastrectomy is not widely performed because of its technical difficulty. Since December 2007 we have performed esophagojejunostomy after totally laparoscopic total gastrectomy (TLTG) in more than 110 cases in our institution by using a circular stapler with a trans-orally inserted anvil. We performed a single-center comparative study to evaluate the safety and efficacy of esophagojejunostomy using a trans-orally inserted anvil in patients who underwent TLTG for the treatment of gastric cancer. METHODS: In the present study, we examined 329 patients with gastric cancer who underwent esophagojejunostomy using a circular stapler after total gastrectomy. Data on the clinicopathological features, operative time, amount of intraoperative blood loss, and incidence of anastomosis-related complications among the surgical groups were obtained by reviewing the medical records, which were then analyzed. RESULTS: Approximately 67% of the patients were men, and the average patient age was 64.0 years (range 26-93 years). In addition, 166 (50.5%) and 163 (49.5%) patients underwent open and laparoscopic surgery, respectively. Leakage following esophagojejunostomy was noted in 7 (4.2%) of 166 patients who underwent total gastrectomy with open laparotomy, and 0 of 46 patients who underwent laparoscopic-assisted total gastrectomy (LATG). However, only 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil exhibited leakage following esophagojejunostomy. Anastomotic stenosis of the esophagojejunostomy was observed in 5 (3.0%) of 166 patients who underwent total gastrectomy with open laparotomy, 2 (4.3%) of 46 patients who underwent LATG, and 2 (1.7%) of 117 patients who underwent TLTG using a trans-orally inserted anvil. CONCLUSIONS: We believe that esophagojejunostomy using a trans-orally inserted anvil after TLTG for gastric cancer is a safe and useful surgical procedure.

Phase II study of percutaneous transesophageal gastrotubing for patients with malignant gastrointestinal obstruction; JIVROSG-0205.

PURPOSE: This multicenter, prospective study was conducted to evaluate the efficacy of percutaneous transesophageal gastrotubing (PTEG) as an esophagostomy procedure for bowel decompression in patients with malignant bowel obstruction. MATERIALS AND METHODS: The study subjects were patients with malignant bowel obstruction treated with a nasogastric tube (NGT). After receiving PTEG, efficacy evaluations were conducted, with NGT designated as the control state. The procedure was considered effective only when discomfort in the nasopharynx was improved for at least 2 weeks. Safety was evaluated by using National Cancer Institute Common Toxicity Criteria, version 2.0. PTEG was performed by using a PTEG kit. RESULTS: From February 2003 to December 2005, 33 patients were enrolled. The technical success rate was 100%, and the procedure was considered effective in 30 of 33 cases. The three cases in which the procedure was ineffective could not be evaluated as a result of deterioration of general status or early death. The one recorded complication was a tracheoesophageal fistula that caused grade 2 aspiration pneumonia. CONCLUSIONS: PTEG is an effective technique to relieve discomfort in the nasopharynx caused by NGT in patients with terminal malignant tumors. PTEG should be considered an efficacious method for bowel decompression in patients who are ineligible for surgical procedures, percutaneous gastrostomy, or percutaneous enterostomy.

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas.

PURPOSE: The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy-esophagojejunostomy (EJ) operations. MATERIALS AND METHODS: Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality-morbidity, and mortality related with factors other than the procedure were noted. RESULTS: Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months). CONCLUSION: From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure.

Clinical outcome of esophagogastrostomy after proximal gastrectomy for gastric cancer.

BACKGROUND/AIMS: In order to prevent reflux esophagitis after proximal gastrectomy, reconstruction by jejunal interposition (EJ) is often performed; however, this procedure is considered to be extremely complex. The purpose of this research is to consider the indication and usefulness of esophagogastrostomy (EG), as a less-invasive method of reconstruction. METHODOLOGY: From 1999, 64 proximal gastrectomy cases have been reviewed. In 46 cases, EG combined with a reflux prevention procedure was performed while in the remaining 18 cases, EJ was performed. An endoscopic examination was conducted 1 year after surgery in all cases. RESULTS: Compared to EJ, EG required less surgical time, thus resulting in less blood loss. Reflux esophagitis was frequently present in the EG cases (22 vs. 11%). In the EG group, 36 cases involving abdominal esophagus (AE) conservation due to the site of the cancer in comparison to the resection group (10), experienced a lower probability of reflux esophagitis (5.6 vs. 60%) and endoscopic examinations showed a lower severity (Grade B,C,D; 0 vs. 50%). CONCLUSIONS: EG combined with a reflux prevention procedure is simple and less invasive. In cases in which the conservation of AE is possible, less reflux esophagitis is observed and EG is therefore recommended as an appropriate reconstruction method.

Novel fundoplication for esophagogastrostomy after proximal gastrectomy.

BACKGROUND/AIMS: Stapled esophagogastrostomy is simple and safe reconstruction after proximal gastrectomy. However, this reconstruction is often concomitant with severe reflux esophagitis because of the loss of cardiac function; simple esophagogastrostomy is not preferred reconstruction after proximal gastrectomy. To prevent reflux esophagitis, we established the fundoplication under the endoscopic stent after proximal gastrectomy. METHODOLOGY: After proximal gastrectomy with lymph node dissection, end-to-side esophago-gastrostomy was done with circular suturing instrument. To prevent gastric juice reflux from the remnant stomach, the stomach was rolling around the abdominal esophagus and tightly under the endoscopical stenting. To make renewal His angle and fornix, the stump of greater curvature was fixed to the left side of diaphragmatic crus with some sutures. RESULTS: We performed this type of fudplication for 18 patients with early gastric cancers and gastric submucosal tumors. Almost all patients postoperative course was uneventful. Three patients needed an endoscopic dilatation for the stricture of esophago-gastrostomy. One case revealed asymptomatic reflux esophagitis because of the looseness of the anastomosis. Weight loss was limited, almost all patients recovered preoperative weight. CONCLUSIONS: Simple esophagogastrostomy plus this fundoplication with endoscopic stent is safe and satisfactory reconstruction procedure after proximal gastrectomy.