With the increasing incidence of adenocarcinomas of the esophagogastric junction worldwide, developing TLTG with minimal invasiveness is essential. However, esophagogastric anastomosis in TLTG remains a significant clinical challenge . At present, mechanical anastomosis is widely used in TLTG for gastric cancer. Even the circular stapler technique does not require the exposure of a large portion of the esophagus, and the blood supply of the anastomosis is sufficient, especially on the side of the esophageal stump, which can still be disconnected at a relatively high position . However, it is still rarely used in TLTG, mainly because it is difficult to insert the anvil in the esophageal cavity under endoscopy and is easily affected by the patient’s body size. When using the linear stapler, it is necessary to free at least 5 cm of the healthy esophageal stump before the side-to-side esophagojejunostomy is feasible. In principle, the criteria for successful reconstruction of esophageal jejunal anastomosis include sufficient blood supply and tension-free anastomosis. Nevertheless, too much free esophagus will affect the blood supply of the anastomosis. At the same time, the linear stapler is needed to cut the esophagus longitudinally for 3–5 cm, which will aggravate the blood supply of the esophageal stump. After the anastomosis is completed, the anastomotic stoma will generally retract to the mediastinum, and its tension distribution will be unbalanced. Meanwhile, TLTG has been promoted by the increasing incidence of tumors at the esophagogastric junction, especially for Siewert II patients, due to their lower esophageal availability, high anastomotic position, and difficult mechanical anastomosis, which can easily cause inaccurate anastomosis and increase the risk of anastomotic leakage. In some cases, the anastomosis needs to be resected after the failure of the mechanical anastomosis. Thus, hand-sewn anastomosis becomes an important option for re-anastomosis. Therefore, mechanical anastomosis is not optimal for patients with high lesion locations, considering the high tension, blood supply, and proximal margin safety. In contrast, hand-sewn anastomosis does not need a long esophageal stump and is easy to inspect. Herein, in the manual suture group, the operator tended to resect more esophagus to ensure that the margin was negative while ensuring that no tension could reduce the disconnection of the small intestinal vascular arch and the risk of small intestinal ischemia. During suture, the whole process could be viewed directly to avoid the hidden injury of the machine to the esophagus and jejunum. Furthermore, for the high position or invasive tumors, mechanical anastomosis has higher requirements for the length of the esophageal broken end and jejunum, and the cutting edge is often reserved when leaving the broken esophagus. On the other hand, the hand-sewn suture does not require a high esophageal length, so the average distance between tumor margins is longer. Therefore, we recommend hand-sewn sutures for patients with possible tension of linear anastomosis. In the present study, during jejunoesophageal anastomosis, the distance between the jejunal opening and the jejunal stump in the hand-sewn suture group was significantly shorter, which is particularly important for patients with obesity and short mesentery of the small intestine. For early GEJ cancer, proximal gastrectomy and double flap esophagogastrostomy is a good choice, however, in our retrospective study, the surgeon has chosen total gastrectomy according to his own experience and current consensus, so the advantages of manual suture in proximate gastronomy and double flap esophagogastrostomy are not discussed. However, from a technical point of view, the improvement of this technology may help the operators to improve their experience in manual suture and is more conducive to their later development of totally laparoscopic proximate gastronomy and double flap esophagogastrostomy.
Hand-sewn is considered more time-consuming and challenging to learn than mechanical anastomosis . Our team has performed total laparoscopic gastrectomy for 10 years. Some of them have performed about 800 and 2000 gastric cancer operations respectively. Because we often use barbed wire to close the common opening in gastric colorectal cancer, we have accumulated a lot of experience in laparoscopic surgical anastomosis, so esophagojejunostomy is relatively easy for us. This learning curve may varies greatly depending on the amount of surgery performed in each center. The common opening in esophagojejunostomy and duodenal stump was routinely sutured with barbed wire during total laparoscopic surgery for gastric cancer, so based on our experience, skilled suture can be achieved average time after completing about 9 cases.
Additionally, the requirements for assistants are lower. For example, as long as the suture on both sides was pulled at a fixed angle, the operator could use barbed suture for continuous full-thickness suture from left to right, so the average operation time was shorter than in the mechanical group.
Moreover, the 30 hand-sewn esophagojejunostomy was accomplished except for one grade 2 anastomotic leakage case. This patient was the fifth case of hand-sewn esophagojejunostomy. We believe that the barbed suture damaged the esophageal wall at the beginning of the exercise due to improper strength and direction. Hence, we suggest that the barbed suture should not be excessively tightened, which requires experience from a certain number of cases. Thus, attention should be paid to the barbed wire strength and direction of pulling and the needle distance grasp, especially the needle entry distance of the mucosal layer. Otherwise, it may cause anastomotic stenosis, incomplete anastomosis, poor appearance, and other consequences.
In summary, our current method has the following advantages: (1) it is simple and convenient, with full-thickness suture with barbed thread, which does not affect the blood supply and is conducive to the healing of anastomotic stoma; (2) it can increase the margin distance and reduce the risk of positive margin; (3) less proximal jejunal distance is required to reduce the risk of anastomotic tension; (4) it is still applicable when there is a high risk of machine anastomoses, such as a high tumor, intestinal wall thickening, and edema; (5) the anastomosis time is significantly reduced.
However, our current study also has limitations. The number of patients was small and led to a significant bias. Thus, further multicenter randomized controlled trials are needed to confirm the safety and effectiveness of the new manual suture method.
In conclusion, we provided a new anastomotic method as a choice for surgeons, which may benefit from specific patient populations. Experienced surgeons can try to carry it out, even if its safety and effectiveness still need further verification.