Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China.
Langenbecks Arch Surg. 2022 Dec;407(8):3397-3406. doi: 10.1007/s00423-022-02694-3. Epub 2022 Sep 27.
Totally laparoscopic total gastrectomy has been developed with difficulty in intracorporeal esophagojejunostomy. Although mechanical stapling has been widely used for intracorporeal esophagojejunostomy, manual suture holds great promise with the emergence of high-resolution 3D vision and robotic surgery. After exploration of how to improve the safety and efficiency of intracorporeal suture for esophagojejunostomy, we recommended the technique of single-layer running "trapezoid-shaped" suture. The cost-effectiveness was analyzed by comparing with conventional mechanical stapling.
The study retrospectively reviewed the patients undergoing laparoscopic gastrectomy for gastric cancer from January 2010 to December 2021. The patients were divided into two cohorts based on the methods of intracorporeal esophagojejunostomy: manual suture versus stapling suture. Propensity score matching was performed to match patients from the two cohorts at a ratio of 1:1. Then group comparison was made to determine whether manual suture was non-inferior to stapling suture in terms of operation time, anastomotic complications, postoperative hospital stay, and surgical cost.
The study included 582 patients with laparoscopic total gastrectomy. The manual and stapling suture for esophagojejunostomy were performed in 50 and 532 patients, respectively. In manual suture cohort, the median time for the whole operation and digestive tract reconstruction were 300 min and 110 min. There was no anastomotic bleeding and stenosis but two cases of anastomotic leak which occurred at 3 days after surgery. The median length of postoperative hospital stay was 11 days. After propensity score matching, group comparison yielded two variables with statistical significance: time for digestive tract reconstruction and surgery cost. The manual suture cohort spent less money but more time for esophagojejunostomy. Intriguingly, the learning curve of manual suture revealed that the time for digestive tract reconstruction was declined with accumulated number of operations.
Laparoscopic single-layer running "trapezoid-shaped" suture appears safe and cost-effective for intracorporeal esophagojejunostomy after total gastrectomy. Although the concern remains about prolonged operation time for beginners of performing the suture method, adequate practice is expected to shorten the operation time based on our learning curve analysis.
全腹腔镜全胃切除术在进行腔内食管空肠吻合时存在困难。尽管机械吻合已广泛应用于腔内食管空肠吻合，但随着高分辨率 3D 视觉和机器人手术的出现，手工缝合具有很大的前景。在探索如何提高腔内食管空肠吻合安全性和效率之后，我们推荐了单层连续“梯形”缝合技术。通过与传统机械吻合进行比较，分析了其成本效益。
本研究回顾性分析了 2010 年 1 月至 2021 年 12 月期间接受腹腔镜胃癌切除术的患者。根据腔内食管空肠吻合的方法，将患者分为两组：手工缝合组和吻合器缝合组。采用倾向评分匹配将两组患者以 1:1 的比例进行匹配。然后进行组间比较，以确定手工缝合在手术时间、吻合口并发症、术后住院时间和手术费用方面是否不劣于吻合器缝合。
本研究共纳入 582 例行腹腔镜全胃切除术的患者。50 例患者行食管空肠吻合术采用手工缝合，532 例患者采用吻合器缝合。在手工缝合组中，整个手术和消化道重建的中位时间分别为 300 分钟和 110 分钟。无吻合口出血和狭窄，但有 2 例吻合口漏发生在术后 3 天。术后中位住院时间为 11 天。经过倾向评分匹配后，组间比较有两个变量具有统计学意义：消化道重建时间和手术费用。手工缝合组花费较少，但进行食管空肠吻合术的时间较长。有趣的是，手工缝合的学习曲线显示，随着手术次数的增加，消化道重建的时间减少。
腹腔镜单层连续“梯形”缝合用于全胃切除术后的腔内食管空肠吻合是安全且具有成本效益的。尽管对于初学者来说，进行缝合方法的手术时间可能较长，但根据我们的学习曲线分析，充分的实践有望缩短手术时间。
