| Background:Laparoscopic technology has been widely used in the treatment of gastric cancer in multiple centers,among which esophagojejunal anastomosis technology is the main content of laparoscopic total gastrectomy and proximal gastrectomy,and is also the main focus of research in gastrointestinal surgery.As one of the main methods of complete laparoscopic esophagojejunal anastomosis in recent years,π-type esophagojejunostomy technology has been controversial.Currently,there are still significant technical challenges and to some extent,it is also a bottleneck that restricts the development of total laparoscopic upper gastric cancer radical surgery.Howπ-type anastomosis technology can complete digestive tract reconstruction faster and better needs to be further explored.Objective:This study aims to compare and analyze the advantages and disadvantages ofπ-type anastomosis and laparoscopic assisted circular incision anastomosis in total gastrectomy.It also explores the application ofπ-type esophagojejunostomy technology in proximal resection and dual channel anastomosis.At the same time,it conducts a hierarchical analysis of the currentπ-type anastomosis technology,such as its application in Siewert II esophageal gastric junction adenocarcinoma and obese patients.Finally,clinical research is conducted,optimize and improve theπtype anastomosis technique to verify its safety,effectiveness,and short-term efficacy.Methods:A retrospective case study method was used to collect clinical case data from 256 patients with gastric cancer who underwent laparoscopic total gastrectomy(TG,total or endoscopic assistance)and 63 patients with proximal gastric resection and dual channel anastomosis(DRT,total or open)in our hospital’s gastroenterology department from January 2018 to January 2023.Different groups were designed according to the required research content,and corresponding testing methods were used to verify the safety and effectiveness of theπ-type esophagojejunostomy technology in total gastrectomy,proximal resection,also in Siewert type II AEG subgroup,and obesity subgroup,while analyzing the feasibility of improvingπanastomosis technology.Result1.In a comparative study between total laparoscopic total gastrectomy(TLTG)and laparoscopic assisted total gastrectomy(LATG)with Roux-en-Y esophagojejunal anastomosis,there was no significant difference in preoperative baseline data,intraoperative complications,postoperative complications,including complications related to esophagojejunal anastomosis and perioperative mortality rate between theπanastomosis group and the assisted circular anastomosis group.However,in terms of incision length(π-type anastomosis group vs assisted circular anastomosis group:4.37cm±0.93cm vs 6.57cm±2.44cm,P=0.000),first time to ground activity(1.20d±0.40d vs 1.94d±0.41d,P=0.000),first time to exhaust(2.35d±0.70d vs 2.86d±0.48d,P=0.000),and time to restore full fluid feeding(5.48d±1.30d vs 6.19d±1.49d,P=0.000),NRS pain score on the first day after surgery(1.42±0.90 vs 2.27±1.25,P=0.000)On the second day after surgery,there were statistical differences in NRS pain scores(0.92±1.46 vs 2.53±0.80,P=0.000),indicating that theπ-type anastomosis group had less pain,faster recovery,and early eating in the early postoperative period,which was beneficial for rapid recovery.According to the survival curve plotted,there was no statistically significant difference in survival time between the two groups.2、In the comparative study of double channel anastomosis(TLPG-DT)and esophagojejunalπ-type anastomosis in the proximal resection of total endoscopic gastrectomy with open approach(PG-DT),there were no differences between the two groups in terms of preoperative baseline data,number of lymph nodes cleaned during surgery,positive surgical margin and distance,intraoperative bleeding volume,surgical time and anastomosis time,WBC and HB on the first day after surgery,and postoperative related complications.However,there are significant statistical differences in the length of the first incision(4.92cm±0.53cm vs 14.33cm±1.80cm,P=0.000)downtime activity time(1.07d±0.27d vs 2.91d±0.58d,P=0.000),first exhaust time(2.17d±0.38d vs 2.91d±0.58d,P=0.039),time to resume full fluid feeding(5.07d±0.27d vs 6.70d±2.45d,P=0.033),postoperative hospitalization time(11.05d±3.83d vs 13.66d±6.47d,P=0.048),NRS score on the 3rd day after surgery(1.23±1.15 vs 2.33±1.46,P=0.002),NRS score on the 5th day after surgery(0.05±0.32 vs 0.70±1.39,P=0.006)Incision infection(P=0.036),overall grading of postoperative complications(P=0.023)and other aspects.It suggests thatπ-type anastomosis has minimal trauma,fast recovery,and minimal stress,which is beneficial for recovery.3、In the descriptive study ofπ-type esophagojejunostomy and dual channel andπ-type anastomosis for total endoscopic total gastrectomy and total endoscopic proximal resection in Siewert type II AEG:1)Thirty one patients with SiewertⅡAEG underwent total gastrectomy,22men and 9 women,with an average age of 63.93years±8.92 years and an average BMI of 23.79kg/m~2±3.37 kg/m~2,and 8 patients with hypertension,diabetes,and lung diseases.The average surgical time was 298.35min±47.81 minutes,the average intraoperative blood loss was 39.77 ml±23.87 ml,the number of lymph nodes cleaned was 16.08±4.36,the average proximal margin distance was 2.04cm±0.55cm,the lower margin distance was 6.12 cm±0.99cm,the esophagojejunal anastomosis time was 41.45min±6.53 minutes,the postoperative hospital stay was 11.48d±4.49 d,and the maximum diameter of the tumor was 2.58cm±0.91cm.2)37 Siewert type II AEG patients underwent proximal gastrectomy,consisting of 29 males and 8 females,with an average age of 64.66years±7.26 years,the average BMI was 21.23kg/m ~2±3.75 kg/m ~2,and 9 cases were complicated with hypertension,diabetes,lung disease,etc.The average surgical time was 275.59minutes±47.65minutes,the average intraoperative bleeding volume was 44.59ml±28.63 ml,the number of lymph nodes cleaned was 16.77±5.42,the average proximal margin distance was 2.11cm±0.43cm,the lower margin distance was 5.54cm±0.63cm,the esophagojejunal anastomosis time was 39.75 minutes±7.16 minutes,the postoper-ative hospital stay was 11.02 d±3.93d,and the maximum diameter of the tumor was2.77 cm±0.62cm.4、In the study of total or proximal gastric patients undergoingπ-type esophagojejunostomy technology in obese patients:1)49 obese patients with gastric cancer underwent total gastrectomy andπ-type esophagojejunostomy under total endoscopy(π-type anastomosis group)in 19 cases,and laparoscopic assisted total gastrectomy and Roux en Y anastomosis(assisted circular anastomosis group)in 30 cases.There were no differences between the two groups in terms of baseline data,number of lymph nodes cleaned during surgery,positive surgical margin and distance,surgical time,intraoperative bleeding volume,postoperative WBC and HB levels,and early postoperative related complications,And in terms of esophagojejunal anastomosis time(36.89minutes±7.30minutes vs41.53minutes±8.04minutes,P=0.047),incision length(6.70cm±2.74cm vs 4.21cm±0.97cm,P=0.000),first ground activity time(1.26d±0.45d vs 1.93d±0.25d,P=0.000),first exhaust time(2.47d±0.84d vs 2.90d±0.30d,P=0.015),time to restore total fluid diet(5.36d±0.59d vs 6.63d±2.61d,P=0.045),postoperative hospitalization time(12.94d±2.24d vs 14.86d±3.55d,P=0.041)There were differences in NRS pain score on the first postoperative day(1.36±0.95 vs 2.16±1.08,P=0.012),NRS pain score on the third postoperative day(0.42±0.83 vs 2.56±0.81,P=0.000),and overall postoperative complication grading(P=0.032).This indicates that in obese patients,πanastomosis technology has shorter anastomosis time,faster postoperative recovery,less postoperative pain,and shorter hospital stay compared to endoscopic assistance,reflecting the minimally invasive advantages ofπanastomosis technology.2)17 obese patients with gastric cancer underwent proximal gastrectomy(open or endoscopic),and the results are for reference only.5.Programmed improvements and optimizations forπ-type esophagojejunostomy process design can increase the small intestine’s degree of freedom without affecting the blood supply of the small intestine after cutting the small intestine mesentery and disconnecting the jejunum;Partial resection of the right diaphragmatic foot increased the anastomosis space and adjusted the anastomosis angle,making the anastomosis smoother;The intraoperative dual mirror combined localization makes it easier to locate the upper margin of the tumor,ensuring its integrity.Other methods such as suspending the anastomotic site have also effectively avoided anastomotic site torsion,and there are currently no reports of related cases of anastomotic site torsion.conclusions1.The use of this improvedπ-type esophagojejunostom in total laparoscopic gastrectomy is safe,feasible,and worthy of application.The short-term efficacy is good,similar to laparoscopic assisted total gastrectomy.2.The programmedπ-type esophagojejunostom expands the scope of application of this surgery,making the operation simple and safe,while also reducing trauma and postoperative complications.3.The improvement ofπ-type esophagojejunostom at the technical level has made it a safe and feasible method for gastrointestinal reconstruction in Siewert type II esophageal gastric junction cancer,which is safer and more convenient.4.This improvedπ-type esophagojejunostom can reduce the difficulty of surgery while ensuring the safety and overall recovery effect in obese patients,and is worthy of clinical application.5.The programmatic improvement ofπ-type esophagojejunostom is safe and feasible,which can effectively reduce the difficulty of laparoscopic surgery,shorten surgical time,and expand the indications ofπ-type anastomosis,which is conducive to further promotion and application.This provides a certain technical research foundation for future diversified surgeries,including the widely studied Da Vinci robot radical gastrectomy for gastric cancer. |
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