Application value of hand-sewn anastomosis in totally laparoscopic total gastrectomy for gastric cancer

Background Digestive tract reconstruction in totally laparoscopic total gastrectomy can be divided into two types: instrument anastomosis and hand-sewn anastomosis. This study explored the feasibility and safety of hand-sewn sutures in esophagojejunostomy of totally laparoscopic total gastrectomy, compared with instrument anastomosis using an overlap linear cutter. Methods This retrospective cohort study was conducted from January 2017 to January 2020 at one institution. The clinical data of 50 patients who underwent totally laparoscopic total gastrectomy, with an average follow-up time of 12 months, were collected. The clinicopathologic data, short-term survival prognosis, and results of patients in the hand-sewn anastomosis (n=20) and the overlap anastomosis (n=30) groups were analyzed. Results There were no significant differences between the groups in sex, age, body mass index, American Society of Anesthesiologists score, tumor location, preoperative complications, abdominal operation history, tumor size, pTNM stage, blood loss, first postoperative liquid diet, exhaust time, or postoperative length of hospital stay. The hand-sewn anastomosis group had a significantly prolonged operation time (204±26.72min versus 190±20.90min, p=0.04) and anastomosis time (58±22.0min versus 46±15.97min, p=0.029), and a decreased operation cost (CNY 77,100±1700 versus CNY 71,900±1300, p<0.0001). Postoperative complications (dynamic ileus, abdominal infection, and pancreatic leakage) occurred in three patients (15%) in the hand-sewn anastomosis group and in four patients (13.3%) in the overlap anastomosis group (anastomotic leakage, anastomotic bleeding, dynamic ileus, and duodenal stump leakage). Conclusion The hand-sewn anastomosis method of esophagojejunostomy under totally laparoscopic total gastrectomy is safe and feasible and is an important supplement to linear and circular stapler anastomosis. It may be more convenient regarding obesity, a relatively high position of the anastomosis, edema of the esophageal wall, and short jejunal mesentery.

Intestine wall histostructure peculiarities with peritonitis and mechanical intestine obstruction (experimental study)

Today, the histological criteria for differential diagnosis of dynamic ileus due to peritonitis and mechanical obstruction of the intestine remain undeveloped. In this regard, the aim of the work was to establish the difference in morphological changes occurring in the intestinal wall during dynamic and mechanical ileus in the experiment. The experiment was conducted on 33 sexually mature Wistar rats. In 15 animals of the first group, mechanical ileus was modeled by ligation of the lumen of the small intestine at the middle of the distance between the duodenojejunal junction and the ileocecal angle. In 15 rats of the second group, a dynamic ileus model was formed in the form of peritonitis by introducing fecal suspension into the lumen of the abdominal cavity. The control group included 3 animals who underwent laparotomy without the formation of mechanical ileus and peritonitis. For histological examination, fragments of the intestinal wall were sampled 1 cm above the site of the obstruction with mechanical ileus and the portion of the small intestine with peritonitis. Statistical processing was performed in an Excel package using parametric statistics methods. It was stated that with mechanical ileus purulent inflammation develops in the intestine wall beginning from the mucous membrane spreading over wall thickness which can cause its destruction within 48 hours; with dynamical ileus purulent inflammation develops in the intestine wall, it captures particularly serous and muscle layers without causing violations of mucosa cover structure and without intestine wall destruction within 48 hours. Under experimental dynamic ileus, changes in the mucous membrane were reactive in nature and consisted of manifestations of compensatory-adaptive and regenerative processes in response to a violation of the trophism of various structures of the intestinal wall.

Differential diagnostics and treatment of post-operative dynamic ileus

Annotation. Diagnostics and treatment of patients with long-term existing intestinal paresis in post-operative period with the frequency from 3.5 to 75% is an actual problem of abdominal surgery. Functional violations of intestinal motility demanding conservative therapy can be in one of case the cause of prolonged paresis, in other case – complications of surgery itself or pathologic state appearing independently but demanding relaparotomy. The objective criteria of differential diagnostics of prolonged paresis and dynamic ileus as a consequence of complications demanding surgery are absent by now. Aim of the study — identification and determination of reliable diagnostic criteria of differential diagnostics of “prolonged paresis” and other complications demanding surgery in the way of relaparotomy. 52 patients of the main group with dynamic ileus and its causes confirmed by ultrasound were included into the study; 50 patients with diagnosed dynamic ileus by combination of clinical and radiological methods of study were included into the comparison group. The study demonstrated that ultrasound method is most significant in differential diagnostics of dynamic ileus and its causes. Radiological study is uninformative in early post-operative period as it is done in horizontal position and the abdomen in these terms contains free gas (relaparotomy, presence of drainages). The use of the suggested method in the main group allowed determination of the causes of prolonged paresis and indications for relaparotomy: in 9 (17.2%) patients BO was found on the 3-4th day, post-operative peritonitis — in 3 (5.7%) cases, interstitial abscess — in 1 (1.9%). In 38 (73%) cases dynamic ileus was resolved conservatively. In the comparison group BO was found in 8 (16%) patients on the 7th day, post-operative peritonitis — in 4 (8%) cases, in 5 (10%) cases of the comparison group relaparotomy was done in vain. Thus ultrasound method is the main diagnostic method in early post-operative period in patients with prolonged paresis with the help of which differential diagnostics of mechanical and dynamic ileus can be done and indications for relaparotomy in the given category of patients can be determined. Decrease of post-operative mortality from 6 to 0% was the result of ultrasound method.