Abstract: Objective:To investigate the clinical value of semi-end-to-end esophagojejunal anastomosis versus side-to-side esophagojejunal anastomosis in laparoscopic total radical gastrectomy for adenocarcinoma of esophagogastric junction.
Methods:The retrospective cohort study was conducted. The clinical data of 85 patients with adenocarcinoma of esophagogastric junction who were admitted to the First Hospital Affiliated to Army Medical University from January 2016 to January 2019 were collected. There were 65 males and 20 females, aged (58± 10)years, with a range of 36 to 84 years. Of the 85 patients, 46 patients undergoing laparoscopic total gastrectomy+D₂ lymphadenectomy+semi-end-to-end esophagojejunal anastomosis were allocated into semi-end-to-end anastomosis group, and 39 patients undergoing laparoscopic radical total gastrectomy+D₂ lymphadenectomy+side-to-side esophagojejunal anastomosis were allocated into side-to-side anastomosis group. Observation indicators: (1) surgical situations; (2) postoperative situations; (3) follow-up. Follow-up was performed by outpatient examination and telephone interview to detect the survival, anastomotic stenosis and tumor recurrence at postoperative one year up to January 2020. Measurement data with normal distribution were expressed as Mean±SD, and comparison between groups was analyzed using the t test. Count data were expressed as absolute numbers, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Comparison of ranked data was analyzed using the nonparametric rank sum test.
Results:(1) Surgical situations: patients of two groups successfully underwent laparoscopic total gastrectomy with D₂ lymph node dissection, without conversion to open surgery or perioperative death. The proximal length between tumor and surgical margin, time of esophagojejunal anastomosis, length of auxiliary incision were (2.3±0.9)cm, (32±3)minutes, (7.5±1.6)cm for the semi-end-to-end anastomosis group, respectively, versus (1.6±1.0)cm, (42±5)minutes, (4.8±1.2)cm for the side-to-side anastomosis group, showing significant differences between the two groups (t=3.334, 10.177, 8.734, P<0.05). During the esophageal jejunal anastomosis, one patient in the side-to-side anastomosis group had proximal jejunum punctured by a linear cutting stapler resulting in jejunal rupture. The ruptured segment of jejunum was resected and the mesojejunum was freed to perform side-to-side anastomosis. (2) Postoperative situations:there was 1 and 7 patients with postoperative anastomotic bleeding in the semi-end-to-end anastomosis group and side-to-side anastomosis group, respectively, showing a significant difference (x²=4.449, P<0.05). Patients with postoperative anastomotic bleeding in the semi-end-to-end anastomosis group and side-to-side anastomosis group were cured after conservative treatment including blood transfusion and endoscopic hemostasis. One patient with esophagojejunal fistula in the side-to-side anastomosis group was cured after conservative treatment including puncture drainage and anti-infective treatment. Two patients with duodenal stump fistula in side-to-side anastomosis group were cured by anti-infection, puncture drainage and nutritional support. Eight patients with pulmonary infection (5 cases in semi-end-to-end anastomosis group and 3 cases in side-to-side anastomosis group) were cured by anti-infection, atomization and expectorant therapy. Three patients with abdominal infection (2 cases in semi-end-to-end anastomosis group and 1 case in side-to-side anastomosis group) were cured by anti-infection and abdominal puncture drainage. One case with incisional infection in semi-end-to-end anastomosis group was cured by dressing change and anti-infective treatment. (3) Follow-up: all the 85 patients were followed up for 1 year. During the follow-up, 3 and 2 patients died in semi-end-to-end anastomosis group and side-to-side anastomosis group, 0 and 2 patients had anastomotic stricture. There was no anastomotic recurrence.
Conclusion:In laparoscopic total gastrectomy of adenocarcinoma of esophagogastric junction, semi-end-to-end esophagojejunal anastomosis has the advantages of higher proximal surgical magin from the tumor, shorter anastomosis time, less postoperative anastomotic bleeding, while side-to-side anastomosis anastomosis has shorter length of auxiliary incision.