Abstract: Objective:To investigate the application value of the modified Overlap method in digestive tract reconstruction of totally laparoscopic total gastrectomy (TLTG).
Methods:The retrospective cohort study was conducted. The clinicopathological data of 50 patients with gastric cancer who underwent TLTG with Overlap anastomosis between January 2016 and December 2016 in the Tangdu Hospital of the Fourth Military Medical University were collected. Twentysix patients using classic Overlap method and 24 patients using modified Overlap method were respectively allocated into the classic Overlap group and modified Overlap group. All the patients underwent D₂ lymph node dissection. Patients in the classic Overlap group underwent totally laparoscopic catastalsis sidetoside esophagojejunostomy. During digestive tract reconstruction in the modified Overlap group,there was no esophageal transection before anastomosis, and gastric fundus traction fully exposed to the lower esophagus. Esophagus was spun anticlockwise, and a hole was opened at the left posterior esophageal wall. Transection of jejunum was 25 cm away from Treitz ligment, and opening a hole at mesenteric margin was 6 cm away from distal jejunum to transected end of jejunum. Esophagusdistal jejunum sidetoside anastomosis was done using 60 mm linear stapler, and then laterally closing openings and transecting esophagus. Observation indicators: (1) intraand postoperative recovery: total operation time, time of esophagus-jejunum anastomosis, volume of intraoperative blood loss, number of lymph node dissected, time to anal exsufflation, cases with complications and duration of postoperative hospital stay; (2) followup and survival. Followup using outpatient examination and telephone interview was performed to detect the postoperative tumorfree survival and tumor recurrence or metastasis up to March 2017. Measurement data with normal distribution were represented as ±s and comparison between groups was analyzed using the independentsample t test. Comparison of count data was analyzed using the chisquare test or Fisher exact probability.
Results:(1) Intra and postoperative recovery: all the 50 patients underwent successful TLTG using Overlap method, without conversion to open surgery. Total operation time and time of esophagusjejunum anastomosis were respectively (278.6±14.9)minutes, (46.5±4.4)minutes in the classic Overlap group and (253.3±12.8)minutes, (20.4±2.3)minutes in the modified Overlap group, with statistically significant differences between the 2 groups (t=5.459, 22.482, P<0.05). Volume of intraoperative blood loss, number of lymph node dissected, time to anal exsufflation, cases with complications and duration of postoperative hospital stay were respectively (73±25)mL, 34±6, (2.7±1.0)days, 2, (9.7±1.6)days in the classic Overlap group and (71±22)mL, 35±5, (2.6±1.3)days, 2, (9.8±1.5)days in the modified Overlap group, with no statistically significant difference between the 2 groups (t=0.175,-0.616, 0.293,-0.217, P> 0.05). Two patients in the classic Overlap group were respectively complicated with esophagusjejunum anastomotic fistula and pancreatic leakage, 2 patients in the modified Overlap group were respectively complicated with pulmonary infection and subcutaneous emphysema, and they were improved by symptomatic treatment. (2) Followup and survival: 41 of 50 patients were followed up for 3-15 months, with a median time of 7 months, including 20 in the classic Overlap group and 21 in the modified Overlap group. During followup, patients had tumorfree survival, without tumor recurrence and metastasis.
Conclusion:Compared with classic Overlap method, the modified Overlap method can simplify the anastomotic procedures, shorten operation time and achieve similar efficacy, and it is also a simple and effective method for digestive tract reconstruction after TLTG.