Modified Entry Hole Closure Method for Esophagojejunostomy in Totally Laparoscopic Total Gastrectomy: A Safe, Repeatable Method Using a Barbed Suture

Summary

The clinical use of totally laparoscopic total gastrectomy (TLTG) is limited by high complications and reconstruction difficulty. This article presents a modified method for closing the entry hole of esophagojejunostomy in TLTG, which has been verified to be safe and reproducible.

Abstract

Totally laparoscopic total gastrectomy (TLTG) has not been widely used to date because of the risk of postoperative complications and difficulty in reconstructing the digestive tract. To address these issues, a modified esophagojejunostomy technique in TLTG was developed. This technique reduced the need for linear staplers by effectively using a barbed suture and made closing the entry hole faster and safer. It was referred to as the modified esophagojejunostomy entry hole suture technique. A knot-free automatic suture device made of barbed suture material is used. This barbed suture was used to close the full thickness of the common opening, reinforce the seromuscular layer, and embed the esophageal stump, serving as a modified method of closing the entry hole of esophagojejunostomy in TLTG. Retrospectively, data, including surgical results and postoperative outcomes, were collected from 38 patients who underwent TLTG at the First Affiliated Hospital of Soochow University between January 2017 and December 2024. All surgeries were performed successfully. The mean operation time was 221.03 min (range 170-360 min), the mean suture time for closing the entry hole of esophagojejunostomy was 13.15 min (range 9.25-19.22 min), and the mean estimated blood loss was 96.05 mL (range 50-300 mL). The patients tolerated a liquid diet for 4.50 days (±1.87 days) after surgery, and the mean total hospital stay was 12.54 days (range 10-59 days). Overall, 6 patients underwent postoperative blood transfusion. No anastomotic-related complications or surgical complications occurred, and only 1 patient developed pneumonia after surgery. In conclusion, this modified overlap method in TLTG provides satisfactory surgical results and overcomes several technical difficulties, which is encouraging and worth expanding. This indicates that the modified method for closing the entry hole of esophagojejunostomy (E-J) in TLTG is a safe and reproducible technique.

Introduction

Gastric cancer is one of the most prevalent malignant tumors in the world, and it is more common in East Asian countries, such as China and Japan¹. Laparoscopic technology and equipment have tremendously developed after laparoscopy-assisted distal gastrectomy (LADG) was reported in 1994. The safety and feasibility of laparoscopic surgery have been confirmed during continuous practice^2,3,4,5,6. In recent years, total laparoscopic distal gastrectomy (TLDG) has been widely used in the treatment of distal gastric cancer, and totally laparoscopic total gastrectomy (TLTG) has become more and more popular in the treatment of proximal gastric cancer and gastroesophageal conjunction cancer. However, given the difficulty of gastrointestinal tract reconstruction and the occurrence of postoperative complications, the operational requirements for this procedure have accordingly increased for surgeons^6,7. In general, the reconstruction of the gastrointestinal tract after TLTG, involves completing the esophagojejunostomy, which can be performed in three ways, hand-stitching, the use of circular staplers, and the use of linear staplers. At present, this procedure is most commonly accomplished by employing a linear stapler, followed by closure of the stapler entry hole^8,9. After the side-to-side anastomosis is completed, there are two ways to close the entry hole: either by using a linear stapler or by hand stitching¹⁰. Since 2017, we have been using a barbed suture to close the stapler entry hole, which can facilitate laparoscopic sutures during laparoscopic surgery¹¹. During this period, the use of linear staplers and barbed sutures for TLTG with different suture methods had also been reported^12,13.

Stratafi-Spiral PGA-PCL (SXMD1B405) knot-free automatic suture device is made of barbed suture material; one end is connected with a surgical needle, and the other end is a ring. Because the belt is inverted, the tissue can be closed without knotting. SXMD1B405 is a sterile synthetic absorbable single-strand suture made from a copolymer of glycolide and e-caprolactone. The tensile strength of the barbed structure on SXMD1B405 is lower than that of the same-sized suture material without a barbed structure. However, the effective tensile strength of the barbed structure-free suture material is reduced after knotting. Accordingly, the strength of SXMD1B405 is comparable to that of knotless sutures that meet the requirements of the United States Pharmacopeia (USP). In vivo studies show that the tensile strength of SXMD1B405 7 days after implantation is 62% of its original strength, and the tensile strength 14 days after implantation is approximately 27% of its original strength. Studies have found that the copolymer has no antigenicity and pyrogenicity, and only a slight tissue reaction occurs during absorption. SXMD1B405 is generally absorbed between 90 and 120 days after implantation.

The barbed sutures, the two ends of which consist of one needle and one loop, are barbed absorbable threads. Barbs and the loop make sewing easier and faster because no surgical knots are needed, which greatly reduces the difficulty of laparoscopic suturing, shortens operative time, and improves operative efficiency.

At present, TLTG remains a challenging procedure in the surgical management of gastric cancer, primarily for the reason of the complexity of completing gastrointestinal tract reconstruction^2,14,15. In this study, we introduce a modified method for completing intracorporeal anastomosis using a linear stapler and barbed suture and consider its impact on surgery and postoperative complications. In our study, this method is demonstrated to be particularly applicable to patients with restricted operative space at the esophagojejunal common opening. Similarly, it is well-suited for surgeons who are accustomed to the left-sided standing position and experienced in laparoscopic suturing. Meanwhile, several potential limitations are identified: excessive suturing of esophagojejunal tissues, most notably the jejunum, should be avoided due to the risk of potential stenosis. Besides, owing to the fixed length of the barbed suture, this method is not suitable for patients with relatively thick esophageal or jejunal tissues. We hope that it can be a safe and practical way to complete esophagojejunostomy, and TLTG can be more widely accepted as a common surgical method for gastric cancer surgery.

Protocol

This study was approved by the hospital's institutional review board. The Independent Ethics Committee of the First Affiliated Hospital of Soochow University (2025748) approved the study, and it was performed in accordance with the principles of the Declaration of Helsinki. All patients or their family members were fully informed preoperatively and signed the informed consent form.

1. Patient selection and clinical data collection

1. Inclusion and exclusion criteria
   1. Inclusion Criteria: Include patients who meet the following criteria:
      1. Patients aged between 18 and 80 years.
      2. Patients who have a preoperative diagnosis of Siewert type II-III adenocarcinoma of the esophagogastric junction confirmed by digestive endoscopy and histopathological examination.
      3. Patients who are classified as American Society of Anesthesiologists (ASA) physical status I-III.
      4. Patients who are undergoing total laparoscopic-assisted radical total gastrectomy.
      5. Patients who have an Esophagojejunal anastomosis performed using the Overlap technique.
      6. Patients who have complete clinical data available.
   2. Exclusion Criteria: Exclude patients with the following criteria:
      1. Patients who have a preoperative diagnosis of Siewert type I carcinoma of the esophagogastric junction confirmed by digestive endoscopy and histopathological examination.
      2. Patients who have a history of preoperative radiotherapy or chemotherapy.
      3. Patients who have positive intraoperative frozen pathological results of esophageal resection margins, requiring combined thoracoabdominal surgery.
      4. Patients who have a history of abdominal surgery that makes laparoscopic surgery inappropriate.
         NOTE: Data from 38 patients (25 men and 13 women) who underwent TLTG + D2 lymph node dissection at The First Affiliated Hospital of Soochow University between January 2017 to December 2024 were collected. The diagnosis of gastric cancer in all patients was confirmed via pathological or auxiliary examinations, and all patients' surgeries, including gastric resection and lymph node dissection, were performed according to the treatment guidelines to achieve R0 resection.
2. Data collection: Record the following data for all eligible patients: gender, age, BMI, pathological data, surgical results (operation time, estimated blood loss, vascular invasion, and neural invasion) and postoperative outcomes (postoperative time to first flatus, defecation, and liquid diet; duration of hospitalization; blood transfusion status; anastomotic leakage; anastomotic stricture; and other complications).

2. Surgical operation

1. Preoperative preparation
   1. Ensure the patients undergo blood tests, including a complete blood count, blood biochemistry, coagulation function tests, blood type determination, and blood transfusion compatibility testing, as well as imaging examinations such as gastroscopy and/or computed tomography (CT) scan of the abdomen.
   2. Instruct all patients to remain Nil Per Os (NPO) for 8 h (solid food) and 4 h (clear liquids) prior to surgery.
   3. Induce general anesthesia and perform tracheal intubation according to institutionally approved protocols.
   4. Disinfect the surgical field with 0.5% iodine-based antiseptic scrub (500 mL) in three sequential passes from the incision outward, then apply sterile towel drapes to expose the surgical site.
2. General operative procedures
   NOTE: The procedures included gastrectomy, lymphadenectomy, specimen extraction, and the lateral jejunal anastomosis.
   1. Place patients in the supine position with legs abducted after endotracheal intubation and induction of general anesthesia.
   2. Position the operator on the left side of the patient, assign one assistant to the contralateral side, and place the second assistant between the patient's legs.
      NOTE: All surgeries were performed by one surgical team consisting of an operator and two assistants.
   3. Establish pneumoperitoneum at 10-15 mm Hg, then insert 5 percutaneous trocars (B12LT, B5LT) according to the standardized abdominal trocar layout.
   4. Perform laparoscopic total gastrectomy with D2 lymph node dissection in all patients to achieve R0 resection.
   5. Make a 5-7 cm abdominal mini-laparotomy incision to extract the specimen after gastrectomy and lymphadenectomy. Immediately submit the gastric specimen for intraoperative pathological examination to confirm negative resection margins.
   6. Transect the jejunum 20 cm distal to the ligament of Treitz using a linear stapler.
   7. Create a side-to-side jejunal anastomosis 40 cm distal to the jejunal stump with a 60 mm linear stapler (see Table of Materials) by a powered plus articulating endoscopic linear cutter. Close the jejunal mesentery with silk braided non-absorbable sutures (4-0) to prevent internal hernia.
   8. Mobilize the mesentery and make a small enterotomy on the distal jejunum in preparation for esophagojejunostomy.
      ​NOTE: Perform all procedures (steps 2.2.5-2.2.8) under open laparotomy conditions, then re-establish pneumoperitoneum using rubber gloves (see Table of Materials).
3. Reconstruction procedures: Perform the intracorporeal anastomosis followed by the reconstruction of pneumoperitoneum (Figure 1 to Figure 7).
   1. Make two incisions: Make an incision on the intestinal wall 6 cm distal to the distal jejunal stump, then elevate the jejunum. Create a second incision at the left corner of the esophageal stump to align both openings at approximately the same horizontal level.
   2. Place a stapler: Introduce a 60-mm linear stapler by a powered plus articulating endoscopic linear cutter into the abdominal cavity via the left trocar channel. Insert one fork of the stapler proximally through the jejunal opening and the other through the esophageal incision. Adjust the stapler to an anastomotic length (about 5 cm), clamp for 15 s, and fire to complete the side-to-side anastomosis (Figure 1).
   3. Form an anastomotic entrance: Divide the common wall between the esophagus and jejunum using the stapler. Remove the stapler and fully expose the anastomosis site to visualize the resection margins (Figure 2).
   4. Perform a suture with a barbed suture: Using a barbed suture, perform a full-thickness continuous suture from the anterior to the posterior wall of the common opening, starting at the esophageal stump and extending to the jejunum (10-15 stitches). Ensure the spacing between stitches is maintained at 0.3-0.5 cm, with suture depth reaching the full layer (avoiding penetration into the muscular layer). When pulling the suture, standard practice should ensure no tissue blanching or significant tension. Secure the initial knot using the loop at the end of the barbed suture; subsequent knots are unnecessary (Figure 3).
   5. Reinforce by the same barbed suture: Without changing the suture for completing the full-thickness suture, perform a seromuscular layer reinforcement suture in the opposite direction (from jejunum to esophagus) to bury the common opening (Figure 4).
   6. Bury the stump: Suture the seromuscular layer over the esophageal stump to bury it completely (Figure 5).
   7. Add an additional suture: Add a purse-string suture around the anastomosis to secure the barbed suture and prevent slippage (Figure 6).
   8. Check and place drainage tubes: Verify the integrity of the anastomosis, ensuring no tension. The appearance of the anastomosis should show good blood circulation, no mucosal prolapse, and no active bleeding. Close all trocar sites and place two drainage tubes (see Table of Materials) adjacent to the anastomosis (Figure 7).
   9. Process specimens: Immerse the resected tissue specimens during surgery in 10% neutral buffered formalin solution after the family members have reviewed for confirmation, then send them to the pathology department for examination.
   10. Manage medical wastes: Package other medical wastes generated during surgery uniformly, then transport them to designated locations for disposal.

3. Postoperative management

NOTE: Ensure all patients undergo successful surgery and are safely transferred to the general ward for subsequent treatment.

1. Administer parenteral nutritional support to patients until they can tolerate a liquid diet.
2. Initiate a semi-liquid diet after patients have tolerated a liquid diet for three consecutive days without complications.
3. Discharge patients once they can tolerate a regular semi-liquid diet. In the event of postoperative complications, extend hospital stay and provide symptomatic treatment as indicated.
4. Advise patients to undergo routine gastroscopy within one year postoperatively (Figure 8).
5. Record the time of first postoperative flatus and the time of first postoperative liquid diet intake, respectively. On postoperative day 7, perform upper gastrointestinal iodine (32% iodine-based Ioversol, 50 mL: 33.9 g) contrast imaging for all patients to assess recovery of the postoperative anastomosis.

4. Statistical analysis

1. Analyze all data using SPSS 22.0 and GraphPad Prism 8. For measurement data following a normal distribution, present as mean ± standard deviation (X ± SD); for non-normally distributed data, report as median (range) [M (range)]; and for categorical data, express as frequency (percentage) [n (%)].

Results

Statistical Analysis: Data on clinical features
This study included 38 patients (25 men and 13 women) who underwent treatment with our new surgical technique. The average patient age was 64.18 years (± 8.98 years), and the median BMI was 22.27 kg/m² (± 2.51kg/m²). Postoperative pathological results showed that only 2 patients had a T-stage of T 1-2, whereas the remaining 36 patients were at a T-stage of T 3-4, likewise, the NM stage showed that 2 patients were at an early stage ...

Discussion

The safety and short-term benefits of laparoscopic gastrectomy (LG) over open surgery have been proven in previous studies¹⁸. The application of laparoscopy in the treatment of gastric cancer has been extremely extensive, and many different surgical methods have gradually been developed, depending on the different locations where gastric cancer occurs. Most studies on LG have focused on Laparoscopic Distal Gastrectomy (LDG) because gastric cancer in East Asia mostly occurs in the lower third of th...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Disposable Laparoscopic Trocar	ETHICON	B12LT, B5LT
Drainage Tubes	Suzhou Jingle Polymer Medical Apparatus Co., Ltd	F28
Electrocautery Hook	Zhejiang Shuyou Instrument Co., Ltd.	SY-IIIa-1	voltage: 220V
Iodine-based Antiseptic Scrub	Shanghai Likang Disinfectant Hi-Tech Co., Ltd	500ml
Iodine-based Ioversol	Jiangsu Hengrui Medicine Co., Ltd.	50ml: 33.9g
Linear Stapler	ETHICON	GST60B
Powered Plus Articulating Endoscopic Linear Cutter	ETHICON	PSEE60A
Rubber gloves	Ansell	MEDI-GRIP
Silk Braided Non-absorbable Sutures	ETHICON	4-0 SA84G
Stratafi-Spiral PGA-PCL Knotless Tissue Control Device	ETHICON	SXMD1B405
Ultrasonic Dissector	ETHICON	HARHD36
3D Laparoscopic System	KARL STORZ	TC200