Alimentary tract obstruction attributed to use of barbed suture for double tract reconstruction after robot-assisted proximal gastrectomy: a case report

Background Anastomotic stenosis following esophagojejunostomy reconstruction by the overlap method with absorbable barbed sutures occurs only rarely in patients who have undergone laparoscopic surgery. We report anastomotic stenosis by the overlap method that we attributed to the lack of tactile sensation during robot-assisted surgery. Case presentation An 83-year-old man underwent robot-assisted laparoscopic proximal gastrectomy and lymph node dissection at our hospital for treatment of gastric cancer. Double tract reconstruction followed with side-to-side esophagojejunostomy (overlap method) performed with an endoscopic linear stapler. On completion of the anastomosis, the enterotomy was closed under robotic assistance with absorbable barbed suture. Once solid foods were introduced, the patient had difficulty swallowing and felt as though his digestive tract was stopped up. When upper gastrointestinal endoscopy was performed, we found the anastomotic lumen to be coated with food residue. After rinsing off the residue with water, we could see barbed suture protruding into the anastomotic lumen that had become entangled upon itself, which explained how the food residue had accumulated. We cut the entangled suture under endoscopic visualization using a loop cutter. Conclusion This case highlights a stricture caused by insufficiently tensioning barbed suture, which subsequently protruded into the anastomotic lumen and became entangled upon itself. We believe this occurrence was associated with the lack of tactile sensation in robot-assisted surgery.

A safe and simple technique for nasogastric tube insertion in patients with thoracic esophageal cancer surgery

Background Risk factors for anastomotic leakage include local factors such as excessive tension across anastomosis and increased intraluminal pressure on the gastric conduit; therefore, we consider the placement of a nasogastric tube to be essential in reducing anastomotic leakage. In this study, we devised a safe and simple technique to place an NGT during an end-to-side, automatic circular-stapled esophagogastrostomy. Methods First, a 4-0 nylon thread is fixed in the narrow groove between the plastic and metal parts of the tip of the anvil head. After dissecting the esophagus, the tip of the NGT is guided out of the lumen of the cervical esophageal stump. The connecting nylon thread is applied to the anvil head with the tip of the NGT. The anvil head is inserted into the cervical esophageal stump, and a purse-string suture is performed on the esophageal stump to complete the anvil head placement. The main unit of the automated stapler is inserted through the tip of a reconstructed gastric conduit, and the stapler is subsequently fired and an end-to-side esophagogastrostomy is achieved. The main unit of the automated stapler is then pulled out from the gastric conduit, and the NGT comes out with the anvil head from the tip of the reconstructed gastric conduit. Subsequently, the nylon thread is cut. After creating an α-loop with the NGT outside of the lumen, the tip of the NGT is inserted into the gastric conduit along the lesser curvature toward the caudal side. Finally, the inlet of the automated stapler on the tip of the gastric conduit is closed with an automated linear stapler, and the esophagogastrostomy is completed. Results We utilized this technique in seven patients who underwent esophagectomy for esophageal cancer; smooth and safe placement of the NGT was accomplished in all cases. Conclusion Our technique of NGT placement is simple, safe, and feasible.

P021 OUTCOME AFTER USE OF THE STAPLED MIDLINE CLOSURE TECHNIQUE AND SELF-FIXATING MESH FOR ABDOMINAL WALL RECONSTRUCTION

Aim To evaluate surgical outcomes after introduction to our unit of the stapled opening and closure of the linea alba in reconstruction of the abdominal wall using the GIA linear stapler (linea alba stapling – LAS) and self-fixating mesh for medium and large defects. Material and Methods Since 2018, we have transitioned from the Rives – Stoppa (with or without component separation) (R-S) to the LAS technique for abdominal wall reconstruction. We compared our outcomes with the LAS technique with matched historic R-S controls (in terms of defect size, duration of surgery and skin related complications). Results Thirty-three cases of LAS reconstruction have been performed in our unit: 15 with defects larger than 10 cm. After exclusion of patients who underwent additional procedures such as adhesiolysis and bowel resection, the mean duration of surgery was 165 min. There were no skin related complications. Comparable cases who underwent R-S reconstruction took 213 min; and, wound infection developed in one patient and skin necrosis in two. Conclusions Provisional results indicate significantly lower operative times and incidence of wound complications (including infections and fluid collections). Notable advantages include a shorter skin incision, a small incision in the anterior rectus sheath to introduce the linear stapler rather than the standard laparotomy and lateral abdominal wall dissection (with ligation of perforators) necessary in the R-S method. Self-fixating mesh eliminates the requirement of sutured mesh fixation which may also be associated with more extensive dissection and longer operative times.

Safety and Feasibility of Novel Reconstruction Method Using Long and Narrow Cobra- Head- Shaped Gastric Tube in Laparoscopic Proximal Gastrectomy for Cancer

Background. To clarify the safety and feasibility of laparoscopic proximal gastrectomy (LPG) with our novel reconstruction methods, clinical outcomes of this LPG were evaluated and compared to those of LPG with our conventional method. Methods. Novel method is a reconstruction with a long and narrow gastric tube with widening of the proximal side of the gastric tube created by linear stapler. Esophagogastrostomy is performed by direct anastomosis with overlap method between the posterior wall of the esophagus and anterior wall of the gastric tube using a linear stapler. In conventional method, direct anastomosis between the esophagus and a gastric tube by a circular stapler was performed. Short- and long-term outcomes of a novel method were compared with those of conventional method. Results. A total of 39 patients whom LPG was performed were enrolled in this retrospective study. The amount of blood loss in the Novel method group (n=30) was significantly less than those in the Conventional method group (n=9) (40 vs. 110 ml, p<0.01). No cases of anastomotic leakage and stenosis were observed in both groups. The cases of postoperative reflux esophagitis at 1 year after operation in the Novel group were less than those in the Conventional group (10% vs. 33%). In the Novel group, postoperative recurrence was observed in 2 patients (7%). Conclusions. LPG with novel reconstruction method using long and narrow cobra- head-shaped gastric tube can be easily performed, and may be feasible for the treatment of gastric cancer in the upper third of the stomach.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

Perineal stapled prolapse resection in combination with Thiersch operation for relapsed rectal prolapse: a case report

Background Treatment options for complete rectal prolapse include over 100 procedures. In previous reports, operative rectal prolapse repair, regardless of the technique by perineal approach, was associated with high recurrence rates. However, there is no consensus on the optimal surgical procedure for relapsed rectal prolapse. Case presentation A 97-year-old woman was admitted to our hospital with a chief complaint of complete rectal prolapse measuring > 5 cm. The patient had a history of laparoscopic anterior suture rectopexy without sigmoid resection under general anesthesia for complete rectal prolapse one year prior. The patient’s postoperative course was uneventful. However, her dementia worsened (Hasegawa’s dementia scale: 5/30 points) after the first operation. Further, moderate-to-severe aortic valve stenosis was first diagnosed with heart failure 6 months after the operation. Nine months after the initial surgery, she experienced a recurrence of complete rectal prolapse measuring approximately 5 cm. Considering the coexistence of advanced age, severe dementia, and aortic valve stenosis, surgery under general anesthesia was not indicated. Perineal stapled prolapse resection in combination with the t operation was planned because of its minimal invasiveness and shortened hospital stay. The procedure was performed by a team of two surgeons in the jack knife position, under spinal anesthesia. The prolapse was cut along the long-axis direction with three linear staplers and resected along the short-axis direction with four linear staplers. The cross-section of the linear stapler was reinforced with 3-0 Vicryl sutures. After rectal resection, the Thiersch operation using 1-0 nylon thread 1 cm away from the anal verge was additionally performed. The operative time was 24 min, and intraoperative blood loss was 1 mL. The postoperative course was uneventful. Three months after the operation, no recurrence was observed, and defecation function was good with improvements of Wexner score. Conclusions Perineal stapled prolapse resection in combination with the Thiersch operation could be a useful option for patients with relapsed rectal prolapse and with poor general condition, who are not indicated for other surgical procedures.