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 t....

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. ....

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