A comparative study on short-term outcomes and quality of life for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic-assisted total gastrectomy using a circular stapler / 中华胃肠外科杂志

Objective: To explore the differences of short-term outcomes and quality of life (QoL) for gastric cancer patients between totally laparoscopic total gastrectomy using an endoscopic linear stapler and laparoscopic-assisted total gastrectomy using a circular stapler. Methods: A retrospective cohort study was conducted. Clinicopathological data of patients with stage I to III gastric adenocarcinoma who underwent laparoscopic total gastrectomy from January 2017 to January 2020 were retrospectively collected. Those who were ≥80 years old, had serious complications that could affect the quality of life, underwent multi-organ resections, palliative surgery, emergency surgery due to gastrointestinal perforation, obstruction, bleeding, died or lost to follow-up within 1 year after surgery were excluded. A total of 130 patients were enrolled and divided into circular stapler group (CS group, 77 cases) and linear stapler group (LS group, 53 cases) according to the surgical method. The differences of age, gender, body mass index, number of comorbidities, history of abdominal surgery, ASA, tumor location, degree of differentiation, tumor length, tumor T stage, tumor N stage, tumor pathological stage and preoperative quality of life between the two groups were not statistically significant (all P>0.05). The observation indicators: (1) Surgery and postoperative conditions. (2) Postoperative complications: Any adverse conditions that require conservative treatment or surgical intervention after surgery were defined as postoperative complications, of which, complications occurring within 30 days after surgery were defined as early complications; complications occurring within 30 days to 1 year after surgery were defined as late complications. (3) Postoperative quality of life was assessed by the quality of life core scale (QLQ-C30) and gastric cancer specific module scale (QLQ-STO22). The higher the scores of functional scales and global health status, the better the corresponding quality of life. The higher the scores of symptoms scales, the worse the corresponding quality of life. Results: (1) Surgery and postoperative conditions: Compared with the CS group, the LS group presented less intraoperative blood loss [50.0 (50.0-100.0) ml vs. 100.0 (100.0-100.0) ml, Z=-3.111, P=0.002] and earlier time to flatus [(3.1±0.8) days vs. (3.5±1.1) days, t=-2.490, P=0.014]. However, there were no statistically significant differences between two groups of patients in terms of operation time, time to start a liquid diet and postoperative hospital stay (all P>0.05). (2) Postoperative complications: The early complication rates of the CS group and the LS group were 22.1% (17/77) and 18.9% (10/53), respectively, while the late complication rate were 18.2% (14/77) and 15.1% (8/53), respectively, whose differences were not statistically significant (all P>0.05). (3) Postoperative quality of life: After 1-year follow-up, 7 (5.4%) patients were lost, including 5 in CS group and 2 in LS group. One year after operation, the QLQ-C30 scale showed that the score of financial difficulty of the LS group was significantly higher than that of the CS group [33.3 (0 to 33.3) vs.0 (0 to 33.3), Z=-1.972, P=0.049] with statistically significant difference, and there were no statistically significant differences in the scores of other functional fields and symptom fields between the two groups (all P>0.05). The QLQ-STO22 scale showed that the scores of dysphagia [0 (0 to 5.6) vs. 0 (0 to 11.1), Z=-2.094, P=0.036] and eating restriction were significantly lower [0 (0 to 4.2) vs. 0 (0 to 8.3), Z=-2.011, P=0.044] in patients of the LS group than those of the CS group. There were no significant differences in scores of other symptoms between two groups (all P>0.05). Conclusions: Compared with the circular stapler, the esophagojejunostomy with linear stapler for gastric cancer patients can reduce intraoperative blood loss, shorten the time to flatus after operation, alleviate the symptoms of dysphagia and eating restriction but increase the economic burden to a certain degree.

Laparoscopic circular stapled gastrointestinal anastomosis using novel device of sealed cap access after total laparoscopic gastrectomy / 中华胃肠外科杂志

Intracorporeal classic gastrointestinal anastomosis using circular stapler in totally laparoscopic gastrectomy (TLG) for gastric cancer requires intracorporeal anvil placement and suitable access for introduction of the circular stapler to the abdominal cavity without gas leak. The novel techniques for anvil placement have been updated, but there is no progress for proper access for circular stapler. In the study, intracorporeal circular-stapled gastrointestinal anastomosis were successfully accomplished using a novel device of sealed cap access with a central hole (WLB-60/70-60/100, Wuhan Widerep Medical Instrument Co.,Ltd, China) customized to the incision protection retractor for the simple and accessible introduction of the circular stapler and anvil under the optimal maintenance of pneumoperitoneum pressure in TLG. In these 3 cases, there was no gas leakage and the pneumoperitoneum was well maintained when performing the gastrointestinal anastomosis, and there was no transition to laparotomy or other anastomosis techniques. The result suggests that the sealed cap access could be a novel choice for introduction of the circular stapler to the abdominal cavity in order to obtain laparoscopic circular-stapled gastroin-testinal anastomosis in TLG.

A Novel Roux-en-Y Reconstruction Involving the Use of Two Circular Staplers after Distal Subtotal Gastrectomy for Gastric Cancer

PURPOSE: Although Roux-en-Y (R-Y) reconstruction after distal gastrectomy has several advantages, such as prevention of bile reflux into the remnant stomach, it is rarely used because of the technical difficulty. This prospective randomized clinical trial aimed to show the efficacy of a novel method of R-Y reconstruction involving the use of 2 circular staplers by comparing this novel method to Billroth-I (B-I) reconstruction. MATERIALS AND METHODS: A total of 118 patients were randomly allocated into the R-Y (59 patients) and B-I reconstruction (59 patients) groups. R-Y anastomosis was performed using two circular staplers and no hand sewing. The primary end-point of this clinical trial was the reflux of bile into the remnant stomach evaluated using endoscopic and histological findings at 6 months after surgery. RESULTS: No significant differences in clinicopathological findings were observed between the 2 groups. Although anastomosis time was significantly longer for the patients of the R-Y group (P<0.001), no difference was detected between the 2 groups in terms of the total surgery duration (P=0.112). Endoscopic findings showed a significant reduction of bile reflux in the remnant stomach in the R-Y group (P<0.001), and the histological findings showed that reflux gastritis was more significant in the B-I group than in the R-Y group (P=0.026). CONCLUSIONS: The results of this randomized controlled clinical trial showed that compared with B-I reconstruction, R-Y reconstruction using circular staplers is a safe and feasible procedure. This clinical trial study was registered at www.ClinicalTrials.gov (registration No. NCT01142271).

Utilidad de los dispositivos de sutura mecánica circular para técnicas endoanales / Circular staplers devices in endoanal techniques

INTRODUCCION: entre las técnicas descriptas para corregir defectos del piso pelviano, el uso de suturas mecánicas circulares se plantea como una opción con fundamentos anatómicos y funcionales, con bajos índices de complicaciones. OBJETIVO: analizar las indicaciones y técnicas utilizando suturas mecánicas circulares por vía Endoanal, su factibilidad y resultados inmediatos. DISEÑO: estudio prospectivo, consecutivo, no randomizado. MATERIAL Y METODO: entre Junio de 2007 y Diciembre de 2010 se utilizaron los dispositivos PPH 03 y PPH 01 en 62 pacientes. Se analizan: indicaciones, técnica, tiempo operatorio, morbilidad, internación y resultados funcionales inmediatos. RESULTADOS: con el procedimiento PPH fueron intervenidos 40 pacientes. Con la técnica STARR fueron operadas 22 mujeres. Para el procedimiento PPH el tiempo operatorio promedio fue de 30 minutos y la morbilidad 15%. Para STARR el tiempo operatorio promedio fue de 40 minutos y la morbilidad 4,5%. Con la técnica PPH se obtuvo 100% de corrección de prolapso. Con STARR se observó disminución del ODS Score en todos los casos. Internación promedio: 1 día. CONCLUSIONES: el uso de los dispositivos de sutura mecánica circular por vía endoanal es factible y seguro. Utilizados por coloproctólogos con experiencia ofrecen una alternativa válida en los pacientes que cumplan los requisitos para indicarlos.

BACKGROUND: several techniques have been described for the treatment of pelvic floor diseases. The circular stapler devices are advocated as a safety and effectiveness option, with anatomical and physiological basis. OBJECTIVE: The aim of this study was to demonstrate the feasibility, effectiveness and reliability of the circular staplers devices for endoanal techniques. DESIGN: non-randomized, prospective study. MATERIAL AND METHODS: since June 2007 up to December 2010 we have applied the PPH 03 and PPH 01 devices to 60 patients. We analyzed indications, surgical techniques mean operative time, complications, mean length of stay and immediate functional results. RESULTS: we have applied the PPH procedure to 40 patients and the STARR procedure to 22 female patients. To PPH procedure the mean duration of the operation was 30 minutes and we registered a rate of complications to 15%. To STARR procedure the mean operative time was 40 minutes and the morbidity was 4,5%. Mean length of stay was 1 day. CONCLUSIONS: the circular stapler devices trough endoanal techniques are feasible, safe and effective with low morbidity. Colorectal surgeons might implement them in the use of them in order to optimize results. Further investigation is required to optimize patient selection and reduce potential complications.

Intracorporeal Anastomosis in Laparoscopic Gastric Cancer Surgery

Laparoscopic gastrectomy has become widely used as a minimally invasive technique for the treatment of gastric cancer. When it was first introduced, most surgeons preferred a laparoscopic-assisted approach with a minilaparotomy rather than a totally laparoscopic procedure because of the technical challenges of achieving an intracorporeal anastomosis. Recently, with improved skills and instruments, several surgeons have reported the safety and feasibility of a totally laparoscopic gastrectomy with intracorporeal anastomosis. This review describes the recent technical advances in intracorporeal anastomoses using circular and linear staplers that allow for totally laparoscopic distal, total, and proximal gastrectomies. Data that demonstrate advantages in early surgical outcomes of a total laparoscopic method compared to laparoscopic-assisted operations are also discussed.

Circular Stapled Gastrojejunostomy after Radical Subtotal Gastrectomy: Anastomotic Bleeding and Prevention

PURPOSE: Circular stapled gastrectomy has been the favored procedure with its feasibility and the shortened operative time, but anastomotic leakage, stenosis and bleeding have been reported as problems. The aim of this study was to identify what can be done to supplement the safety of this technique by examining the potential complications of performing circular stapled gastrojejunosomy after radical subtotal gastrectomy. MATERIALS AND METHODS: As subjects, this study selected 1,391 patients who underwent gastrojejunostomy after radical subtotal gastrectomy because of gastric cancer at our Department of Surgery from Jan. 1998 to Dec. 2007. The patients were divided into Group I (n=479) who underwent hand-sewn gastrojejunostomy, Group II (n=48) who underwent linear stapled gastrojejunostomy and Group III (n=864) who underwent circular stapled gastrojejunostomy. Group III was re-divided into two subgroups on the basis of the point of time that a visual check was intraoperatively performed at the anastomotic site: Group III-A (n=198) before and Group III-B (n=666) after. The characteristics and complications of the patients were then compared. RESULTS: For the comparison of the complications between Group I, Group II and Group III, anastomotic leakage was found in 7 cases (1.5%) in Group I, in 1 case (2.0%) in Group II and in 10 case (1.2%) in Group III, and anastomotic stenosis were found in 4 cases (0.8%) in Group I, 1 case (2.0%) in Group II and 5 case (0.6%) in Group III. Anastomotic bleeding was found in 32 cases (6.7%) in Group I, in 5 cases (10.4%) in Group II and in 67 cases (7.7%) in Group III. For the comparison of complications between Group III-A and Group III-B, anastomotic bleeding was found in 57 cases (28.8%) in Group III-A and 10 cases (1.5%) in Group III-B and the difference was statistically significant (P=0.037). CONCLUSION: Circular stapled gastrojejunostomy after radical subtotal gastrectomy is recommended because of the safety and feasibility of this technique, but bleeding at the anastomotic site may be the critical issue. In conclusion, direct inspection for bleeding at the anastomotic site during the operation will improve the safety of performing circular stapler anastomosis.

Forte and technique of circular stapler application in radical correction of gastric eardia carcinoma / 国际外科学杂志

Objective To investigate forte and technique in radical correction of gastric eardia carcinoma (esophagojejunostomy and gastric stump esophago anastomosis). Methods 753 Patients with gastric cardia carcinoma admitted to our hospital from 1998 to 2007 treated with radical correction by jejuno-osophagus an-astomosis and esophagogastric anastomosis to digestive tract reconstruction, circular staplers were used in all cases. Results There was no death (no leakage、bleeding and stricture of anastornotic entrance stenosis)in these cases by thoracoabdominal approach 6 cases, anastomotic leakage 0 case, pero-eutting 2 cases, steno-sis 4 cases, infection of abdominal cavity 1 case, diaphragmatic hernia 1 case, pathologic diagnosis of exam-ple after operation , the upper cut positive 1 case, the lower cut negative in all cases. Conclusions in rad-ical correction gastric cardia carcinoma, the application of circular stapler makes this procedure simple, reli-ability, safety and time saving, descends the ratio of radical correction of gastric cardia carcinoma by thora-coabdominal approach, decreases surgical trauma, decurtate the period of recovery following an illness, pre-vent the complications of post-operation such as the leakage and stricture of anastomotic entrance. But the applieation of circular stapler is not absolutely trustworthy, there are also any ratio of leakage ,haemorrhage and stricture of anastomotic entrance, the technique worth summarizing and investgating in the future.

Circular Stapled Billroth I Anastomosis after Distal Subtotal Gastrectomy : Anastomotic Complications and Prevention

PURPOSE: The circular stapled Billroth I gastrectomy has been gradually popularized because of several advantages. Thus, this study aims to identify what to be supplemented for the safety of this technique by examining the potential complication after the circular stapled Billroth I gastrectomy. MATERIALS AND METHODS: This study selected 594 patients who underwent the circular stapled Billroth I gastrectomy because of the gastric cancer in our department of surgery from Jan. 1998 to Dec. 2004 as the subjects. As of Jan. 2001 when the bleeding on the anastomosis site was visually checked through the small incision at the opposite curvature to the lesion of the stomach to be resected and so the operation was completed, the patients were divided into the Group I (n=219) and Group II (n=375), which were the patients before and after Jan. 2001, respectively. Then, the clinical characteristics and postoperative anastomotic complications of both groups were compared. RESULTS: For the comparison of complications between two groups, the anastomotic leakage was found in four cases in Group I and three cases in Group II (p=0.196). The stenosis on the anastomosis region was not observed in both groups. The bleeding on the anastomosis region illustrates the statistically significant difference between Group I and Group II, with 43 cases and 2 cases, respectively (P=0.019). CONCLUSION: The circular stapled Billroth I gastrectomy is recommended because of several advantages of this technique. However, the bleeding on the anastomosis site may be indicated as the critical issue. Accordingly, the visual check on the bleeding on the anastomosis site during the operation will improve the safety of circular stapler.

Clinical Study of Circular Stapler Hemorrhoidectomy

PURPOSE: A circular stapler hemorrhoidectomy is widely used to treat hemorrhoids and has the advantages of less pain and an earlier return to work compared with a conventional excisional hemorrhoidectomy. This study examined the clinical significance and efficacy of a circular stapled hemorrhoidectomy. METHODS: One hundred eighty-six (186) patients with prolapsed hemorrhoids underwent surgery using a circular stapler. The patients' characteristics, the operation time, the postoperative course, the procedure- related factors, the pain, and the complications were analyzed. All the patients received a follow-up examination at the outpatient clinic, including the time to return to work, and the degree of satisfaction was analyzed. RESULTS: Grade-III hemorrhoids were the most common complaint (74.1%), followed by grade-IV hemorrhoids (23.7%). Twenty-one cases (11.3%) had undergone previous anal operations: hemorrhoids, fissure, and fistula. Regarding the anesthetic method, caudal anesthesia was used in 59.7% of the cases, and spinal or saddle anesthesia was used in 39.2%. The mean operation time was 19.1 minutes (range: 8~50). The postoperative pain scores were 3.4 on the operation day, 2.1 on the postoperative 3rd day, and 0.9 on the postoperative 7th day. During the operation, a hemostatic suture was made at the suture line in 72.0% of the cases. Muscle involvement was detected at a donut specimen grossly in 9% of cases and microscopically in 48.9%. The mean thickness of muscle involvement was 2.5 mm. In the postoperative course, the time for the first bowel movement was 1.2 days, and the mean hospital stay was 2.1 days. The mean time needed for the patient to return to work was 6.2 days. The most common complication encountered was urinary problems (34.9%). The incidence of postoperative bleeding was 2.2%. Postoperative follow- up revealed one case of a hemorrhoids recurrence and one case of temporary fecal incontinence. CONCLUSIONS: The circular stapler hemorrhoidectomy has no disadvantage in terms of operation time and operative course, and has an advantage in terms of operative pain and an earlier return to normal work without any significant or serious complications. Moreover, it has minimal long-term complications. Therefore, a circular stapler hemorrhoidectomy can be performed safely and is recommended as a useful method for treating hemorrhoids.

Complications after Stapled Hemorrhoidopexy

PURPOSE: While conventional hemorrhoidectomy is notorious for postoperative pain, stapled hemorrhoidopexy has been reported less painful because it has no anal wound. However, the safety of stapled hemorrhoidopexy is not established completely yet. Therefore, the purpose of this study is to evaluate the safety of stapled hemorrhoidopexy through analyzing the postoperative complications. METHODS: The author analyzed the complications of 63 patients treated with stapled hemorrhoidopexy by reviewing the medical records. All of the operations were performed by one surgeon. RESULTS: There were 39 men and 24 women with a mean age of 47.7 years. The majority of cases were carried out under spinal anesthesia except 4 cases of general anesthesia. The combined operations were performed in 16 cases (25.4%) including skin tag excision, external hemorrhoid excision, and polypectomy. The postoperative complications were 2 cases (3.2%) of rectal stenosis, 1 case (1.6%) of thrombosis, 1 case (1.6%) of abscess, and 1 case (1.6%) of late bleeding. Three patients were needed to rehospitalized and reoperation was needed in 1 case of thrombosis. One case of rectal stenosis was treated easily by manual dilatation. However, the other rectal stenosis was treated by Hega dilatation. CONCLUSION: Complications after stapled hemorrhoidopexy may be different from complications after conventional hemorrhoidectomy. However, most of the complications after stapled hemorrhoidopexy can be avoided by respecting the rectal wall anatomy during the procedure. Therefore, in terms of postoperative complications, the stapled hemorrhoidopexy may be a safe procedure.