TLTG is a widely known procedure in recent years due to its own advantages, such as better visual field, shorter operation time, and shorter hospital stay.[9–11] During the TLTG procedure, esophagojejunostomy is even more important as its complications may cause high morbidity rate and poor prognosis. In this study, a modified π-shaped esophagojejunostomy has been used to complete this procedure, showing esophagojejunal anastomosis-related complications as 2.5%, which is comparable to that of previous published studies,[9, 13, 14] initially proving the safety of this procedure.
In esophagojejunostomy using the linear stapler, overlap and functional method were the two major approaches.[15, 16] Several studies have shown that the esophagojejunal anastomotic complication ranged from 0 to 6.45% in the functional method,[17, 18] whereas few reports have illustrated the use of the overlap method.[19, 20] In our perspective, modified π-shaped anastomosis, an alternative form of the functional method, has its own advantages theoretically. First, during the common entry hole closure, hand-sewing technique was usually practiced in overlap method, which may result not only in the increasing risk of anastomotic leakage and bleeding but also extend the learning curve. In modified π-shaped anastomosis, after closing the common entry using linear staplers, several additional sutures were added at the stapling line to prevent minor bleeding and potential leakage due to overlapped stapling. Second, the functional method or the original π-shaped anastomosis results in kinking or narrowing of the lifted efferent loop just below the anastomotic site, which may result in increased incidence of esophagojejunal anastomotic stricture. In our modified approach, the jejunal mesentery at 50 cm distal to the ligament of Treitz was adequately divided to prevent possible tension during esophagojejunostomy, thus avoiding possible anastomotic stricture. Besides, adequate mesentery division can also ensure a tension-free anastomosis to prevent possible leakage.
In our study, the operative time was 264.6 ± 56.9 min, which is slightly longer than that of previously published studies,[13, 21, 22] mainly because dividing the jejunal mesentery is time consuming. Besides, the estimated blood loss, postoperative flatus, and postoperative hospital stays were all comparable to that of the above-mentioned previous studies, which also initially proved that this approach is feasible. Anastomotic stenosis is a common complication in esophagojejunal anastomosis, especially when using a circular stapler. In our modified π-shaped anastomosis, 60-mm linear stapler was used both for the anastomosis and common entry hole closure as in the traditional π-shaped anastomosis. This procedure can prevent the stenosis maximally, which was also confirmed in our findings that no stenosis was observed in postoperative radiography. Several studies have also reported that surgeon’s experiences is also an important factor in the incidence of complications.[23–25] In this study, only one well-experienced surgeon with similar surgical team performed surgeries for all 40 patients. This quality control may be a possible reason for the low incidence of complications, especially for esophagojejunal anastomotic complications. Based on this viewpoint, we recommend that the surgeon and the surgical team who perform this approach should be well experienced.
However, this approach also has some drawbacks. First, the division of jejunal mesentery in some patients with high BMI are difficult and inefficient. Second, jejunal mesenteric division may result in inadequate blood supply at the proximal part of the division area, i.e., the anastomotic site in the next step. The application of indocyanine green injection to examine the blood supply in the jejunal loop may help prevent this situation.[26, 27]
This study also has limitations associated with its retrospective, small-volume, and single-arm design. Well-designed studies are needed to confirm the application of this approach in TLTG in the future.