Page 110 - Read Online

Page 8 of 10 Mazzola et al. Mini-invasive Surg 2019;3:12 I http://dx.doi.org/10.20517/2574-1225.2019.05

however several authors reported important limits of this approach due to the difficulty to use a purse-string
instrument in a very narrow space, and to place a suture without clear visualization [24,25] . Actually various
[7]
totally laparoscopic techniques are used, based on circular or linear staplers ; some authors achieved excellent
[1]
results independently from the technique, without a clear superiority of a particular model , even if leakage
[8]
and stenosis seemed to occur more frequently using circular stapler compared to linear ones . However the
incidence of anastomotic-related complications widely varied among the studies with anastomotic leakage
[1]
and stricture rate of 3.5% (0.9%-8.5%) and 2.2% (0%-9%) respectively . Differences between laparoscopic
total gastrectomies with open ones were not found, neither regarding anastomotic-related complications,
[26]
with a slightly, but not significantly, disadvantage of laparoscopy in term of stenosis . The feasibility and
good outcomes of totally laparoscopic reconstruction were supported by our data; in the majority of patients,
anastomosis was performed laparoscopically, under pneumoperitoneum, with a good visualization; just in one
case an esophageal disruption occurred during linear stapler insertion needing laparotomic conversion to re-
do the anastomosis. With a mean follow up of 16 month, only 1 anastomotic-related complication occurred:
anastomotic leakage diagnosed at imaging on 6th postoperative day and treated by means of endoscopically
positioned stent with good recovery. As reported in literature, overlap technique is quite easy to perform and
not demanding a long time; in addition it seemed to have lower incidence of anastomotic stenosis compared
[27]
to Orvill technique ; on the other hand it doesn’t allow ability to check for malignancy with frozen section
[6]
the esophageal margin and can be very challenging in obese patients with thickened and fixed mesentery, as
the patient in our series who experienced esophageal injury. For patients with these anthropometric features,
we used a modified E-S double stapling technique using 25 mm circular stapler, introduced in the peritoneal
cavity via a wound sealing device in the place of the left hemi-clavear trocar, reproducing the same familial
anastomosis usually used in the open total gastrectomy. This technique, although perceived as more time-
consuming and technically challenging, allowed to perform a tension-free anastomosis in obese patients
too, overcoming the problem of the deep and dorsal position of the anastomotic site and the hindering
visualization and manipulation.

Small sample size, retrospective and non comparative analysis constitute the main limits of this study, and
firm conclusions cannot be drawn, but it adds to a still lacking amount of literature, especially in Western
countries, some results confirming the feasibility and the safety of totally laparoscopic total gastrectomy in
the hands of experienced surgeons with a steep learning curve.

In conclusion, totally laparoscopic total gastrectomy is a feasible option in the treatment of gastric cancer.
The choice about the method for E-J reconstruction should be based on the individual patient’s features
and on the dexterity of the surgeon, which should be able to perform more than one option for a tailored
approach.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study: Mazzola M., Gualtierotti M, De
Martini P, Ferrari G
Performed data analysis and interpretation: Mazzola M, Gualtierotti M
Performed data acquisition: Morini L, Achilli P, Zironda A

Availability of data and materials
Not appliable.

Financial support and sponsorship
None.