The gastric cancer (GC) is the fifth most common cancer and the third most common cause of cancer-related mortality in the world.
Many current areas of research seek to identify the best treatment strategies. GC patients demonstrate reliable survival results due to the implementation of D2 lymphadenectomy, which has become the cornerstone of GC treatment in the past decades. Thanks to our continuously evolving technology, the minimally invasive surgery has become of increasing interest. Kitano et al. first reported a case of laparoscopic-assisted distal gastrectomy in 1994. GC surgery has gradually changed from open to laparoscopic-assisted and ultimately to total laparoscopic during the past 20 years. At present, the main indication for laparoscopic gastrectomy (LG) is early GC, but recent randomized clinical trials had showed that the oncologic outcomes of LG were comparable to those of open surgery for treatment also of advanced GC.
In addition to the improved survival, quality of life attracted more attention, total laparoscopic surgery has gained widespread global popularity owing to its well-known benefits, such as reduced surgical trauma, decreased pain, low rates of morbidities and complications and a shorter length of hospital stay.
This study aims to describe for the first time the laparoscopic distal and total gastrectomy with a double-loop mechanical intracorporeal reconstruction conceived at our general surgery unit and described as a robotic technique only by Parise et al. for robotic reconstruction after total gastrectomy but not described by any author after LG for GC.
Completed the total or distal LG with extended lymphadenectomy D2, a selected intestinal segment coming from the ligament of Treitz moved transmesocolic: it must be free of tension or torsion. The small intestine is joined to the oesophagus or stomach with two stitches to the selected loop so as to locate the biliary side to the left and the alimentary side to the right. This represents the first loop [Figure 1].
The first anastomosis is performed between the first loop and the oesophagus or stomach. In particular, we perform a mechanical gastro-jejunum anastomosis with linear stappler (60 mm) in case of a subtotal gastrectomy while we perform an oesophagus-jejunum anastomosis with circular stappler (25 mm) introduced through a minilaparotomy performed for the extrinsection of the stomach in the case of total gastrectomy. All the breaches made are closed with absorbable closure barbed suture [Figure 2].
At the end of the procedure, just with a single fire of the mechanical stapler, the jejunum is dissected on the left side thuse dividing the two anastomosis. In this way, after division, the ‘‘cul de sac’’ is minimal [Figure 3].
The route of the alimentary limb is followed upward to reach a distance of about 30–40 cm from the esophago or gastric-jejunal anastomosis. In this way, the bowel that will form the second loop is identified. It is carried upward, avoiding intestinal twisting, and placed close to the first anastomosis. The J-J anastomosis is performed between the second loop and the biliary limb with mechanical linear stappler (60 mm) and the opening is closed with absorbable closure barbed suture [Figure 4]. This procedure represents a variant of the traditional Roux-en-Y reconstruction and was planned to overcome the difficulties that may be encountered in a full intracorporeal reconstruction after total or distal gastrectomy.
PATIENTS AND RESULTS
Between August 2019 and June 2021, 45 patients underwent the laparoscopic double-loop reconstruction method after performing a total or distal gastrectomy with extended lymphadenectomy D2 for histologically proven GC. In particular, we performed 37 subtotal gastrectomies and 8 total gastrectomies. The characteristics of the enrolled patients are described in Table 1. The inclusion criteria of patients’ enrolment for this intervention were histologically proven GC, pre-operative staging work-up performed by upper endoscopy, computed tomographic scan, both early gastric cancer and advanced gastric cancer and patients treated with curative intent in accordance to international guidelines. The exclusion criteria were locally advanced, tumor-infiltrating neighbouring organs, distant metastases, patients with a high operative risk as defined by the American Society of Anaesthesiologists score > 4, history of gastric surgery, remnant GC, synchronous other major abdominal surgery, synchronous malignancy in other organs and palliative surgery cases [Table 1].
The median operative time was 140 min (130–175 min) for distal gastrectomy and 225 min (170–275 min) for total gastrectomy thus improving the timing on the reconstructive part of our centre which will be followed by further comparative studies. No procedures were converted. The median hospital stay was 5.5 days (range: 4–17 days) and we observed only one post-operative complication represented by a small dehiscence of the duodenal stump treated conservatively. Thirty-day mortality was 0%. All patients were re-evaluated 30 days after surgery and we did not observe any distant complications. The patients were subsequently re-evaluated clinically at 60 days, 6 months and 1 year and no complications were noted in terms of functional and dietary outcome. We did not also observe the differences in terms of oncological outcome and we will perform comparative studies in the future to evaluate any differences.
Digestive tract reconstruction is a key technique in laparoscopic gastric surgery. In the current literature, an interesting aspect is that the way to perform the reconstructive phase is not properly discussed and it seems to take a second place, even more regarding the total gastrectomy. However, surgeons well know that the anastomosis execution method has the most important impact on peri-operative outcomes, such as hospital stay and surgical complications. Studies do not explain how this phase of the intervention is run or study groups were made up of mixed procedures without subgroup analysis. Surely, the advent of robotic surgery has stimulated the need to develop anastomotic techniques which, respecting the physiology of the Roux technique, could overcome the obstacle represented by the anastomosis, allowing it to be packaged intracorporeally.
Laparoscopic double-loop technique advantages can be highlighted, which are as follows. The surgeon can easily adjust the tension of the two loops of bowel obtaining a floppy restoration of the digestive continuity. There is no confusion in bowel orientation, reducing the risks of swapping the intestinal tract. The double loop allows the surgeon to keep the biliary limb separate from the alimentary limb. It is not necessary to interrupt the mesentery, reducing the risk of bleeding, devascularisation of anastomosis or internal hernias. The surgery takes place entirely intracorporeally in a single abdominal quadrant, minimising instruments movements thus saving time and performing the various movements with greater ergonomics. In our technique, the reconstruction takes place only in the supramesocolic space facilitating the implementation of the intervention and reducing the risk of twisting the mesentery. Both anastomoses are located in the sovramesocolic compartment and are very close to each other. In fact, the simple separation of the alimentary loop from the biliary limb without separating the mesentery fixes the jejunojejunostomy very close to the oesophagus-jejunal or gastro-jejunal anastomosis.
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Conflicts of interest
There are no conflicts of interest.
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