[Surgical safety of laparoscopic total gastrectomy with intracorporeal esophagojejunostomy via transoral anvil versus mini-laparotomy anastomosis: a propensity score matching analysis].

Objective To evaluate the feasibility and safety of intracorporeal Roux-en-Y esophagojejunostomy via the transoral anvil (OrVilTM) by mini-laparotomy anastomosis during laparoscopic total gastrectomy (LTG) for gastric cancer. Methods From March 2010 to December 2016, 414 consecutive gastric adenocarcinoma patients underwent either intracorporeal Roux-en-Y esophagojejunostomy (n=43) via the OrVilTM or extracorporeal circular anastomosis (n=371) via auxiliary incision during LTG. After generating propensity scores with six covariates, including gender, age, body mass index (BMI) , neoadjuvant chemotherapy, tumor location, and tumor size, 43 patients undergoing OrVilTM method (OrVilTM group) were matched with 43 patients undergoing extracorporeal circular anastomosis approach (extracorporeal anastomosis group) . Operation-associated parameters and safety were compared between the two groups. Results Both groups were balanced regarding baseline variables (all P > 0.05) . The total operative time[ (235.6±49.8) minutes vs. (221.1±46.5) minutes, t=1.397, P=0.166] and anvil insertion time [ (10.0±3.2) minutes vs. (10.6±4.5) minutes, t=-0.671, P=0.504] were not significantly different between the two group, whereas the duration of reconstruction and the mean length of minilaparotomy [ (48.3±12.0) minutes vs. (55.9±12.3) minutes, t=-2.899, P=0.005; (5.6±0.6) cm vs. (8.1±2.2) cm, t=-7.118, P=0.001] in the OrVilTM group were significantly shorter. The number of retrieved lymph nodes, mean blood loss and proximal resection margin were not significantly different between two groups (all P > 0.05) . As a whole, OrVilTM group had advantages over extracorporeal anastomosis group during the postoperative recovery course. The time to liquid intake [ (3.7±1.8) days vs. (6.2±7.2) days, t=-2.236, P=0.030], time to fluid diet [ (4.8±2.3) days vs. (7.2±7.1) days, t=-2.013, P=0.048], and time to semi-fluid diet [ (6.7±2.9) days vs. (10.2±9.6) days, t=-2.245, P=0.029] were significantly shorter in the OrVilTM group. The first ambulatory time, time to first flatus and length of hospital stay were not significantly different between two groups (all P>0.05) . The morbidity of intraoperative complication [ (7.0% (3/43) vs. 4.7% (2/43) , χ2=0.000, P=1.000] and postoperative complication [30.2% (13/43) vs. 20.9% (9/43) , χ2=1.484, P=0.223], and even the distribution of severity (χ2=0.013, P=0.990) between the two groups were not significantly different. The incidence of anastomotic leakage (AL) was 9.3% (4/43) and 18.6% (8/43) in the OrVilTM group and extracorporeal anastomosis group respectively without significant difference (χ2=1.550, P=0.213) . Multivariate analysis showed that the OrVilTM anastomosis was not a risk factor of AL (HR=0.663, 95%CI: 0.120-3.674, P=0.638) . Conclusions Intracorporeal esophagojejunostomy using the OrVilTM system is more minimally invasive and convenient to operate without increasing the risk of operation-related complication. Thus it may be a potential safe approach to optimize the reconstruction for LTG. Key words: Gastric neoplasms; Laparoscopic total gastrectomy; Esophagojejunostomy; Anastomotic leakage