Ingenuity of overlap esophagojejunostomy using a linear stapler in laparoscopic total or proximal gastrectomy

Abstract

Background: Intracorporeal esophagojejunostomy in laparoscopy-assisted total or proximal gastrectomy is highly difficult. We developed ingenuity of overlap esophagojejunostomyusing a linear stapler to avoid stapler-related intraoperative complications. Methods: After lymph node dissection was completed, the esophagus was transected in the anterior-posterior direction. The jejunum was divided with a linear stapler approximately 20 cm distal to the ligament of Treitz. A small enterotomy was then created at 5 cm distal from the elevated jejunal stump to insert the linear stapler cartridge. A full-thickness incision was created with an electric knife using the tip of the nasogastric tube (NGT) pressed against the posterior wall side of the esophageal stump as a guide. Full-thickness sutures were applied on both the anterior and posterior walls of the entry hole in the esophageal stump to prevent mis-insertion of the anvil fork into the submucosal layer of esophagus. The thread on the posterior wall side was guided to the outside of the abdominal cavity through the port, into which the linear stapler was inserted to perform side-to-side anastomosis. A 45-mm cartridge fork and an anvil fork were inserted to the entry holes of the elevated jejunum and the esophageal stump, respectively. The esophageal stump was gently grasped. The thread on the posterior wall side was pulled from outside of the abdominal cavity through the port to eliminate the gap between the esophageal wall and the jejunal wall. The linear stapler was fired to create anastomosis after confirming that the anvil fork was not mis-inserted into the submucosal layer of esophagus and there was no gap between the esophagus and the elevated jejunum. The insertion hole was closed with hand-sewn sutures or linear staples to complete the esophagojejunostomy. Results:Seven patients received this procedure with no stapler-related complications. Conclusions: This method enables us to perform an easier and more stable esophagojejunostomy.