Surgical tips and innovations for esophagojejunostomy in totally laparoscopic total gastrectomy: a retrospective study

Background Various intracorporeal reconstruction methods have been developed for esophagojejunostomy following laparoscopic total gastrectomy. Although the linear stapler technique has progressed, the circular stapler technique requires specific devices to complete intracorporeal anastomosis. However, high-resolution laparoscopy and improved surgical skills have enabled many surgeons to perform laparoscopic esophagojejunostomy without these devices. The aim of this study was to identify the problems and complications associated with laparoscopic esophagojejunostomy and examine the feasibility of reconstruction methods and their innovations in our facility. Methods We retrospectively examined eight cases that underwent laparoscopic esophagojejunostomy after laparoscopic total gastrectomy, focusing on surgical outcomes and anastomosis-related complications. Results Eight patients were diagnosed with esophagogastric junction cancer or gastric cancers, including 5 males and 3 females, with a median age of 77 years. Five patients had advanced tumors invading deeper than the seromuscular layer. Esophagojejunostomy was performed using linear staplers in 3 patients and circular staplers in 5 patients. The anastomosis, reconstruction, and total operative times were 64.5, 106.9, and 404 min with linear staplers and 67.2, 97.1, and 379 min with circular staplers, respectively. One pseudo-lumen anastomosis occurred with the linear stapler and required mediastinal re-anastomosis during the operation, resulting in anastomotic leakage on postoperative day 7; no leakage occurred after modifying the stapler-handling method. Circular stapler techniques were also introduced, though the initial case with esophagogastric junction cancer was complicated by difficulty inserting the anvil head in a narrow mediastinal space, which required a longer operative time. Therefore, anvil insertion was improved by pulling the stomach before transecting the esophagus, incising the right esophageal wall, inserting the anvil head toward the oral side, and completing esophageal transection with a linear stapler to adjust the orifice size. Hand-sewn purse-string suturing was later introduced to complete the single-stapler technique, which reduced insertion time. Estimated blood loss and postoperative hospital stay were lower with the circular stapler technique. Conclusions Laparoscopic esophagojejunostomy using a circular stapler is a safe treatment option that can minimize mediastinal disruption, particularly during proximal mediastinal anastomosis.