Laparoscopic total gastrectomy (LTG) has not become as popular as laparoscopic distal gastrectomy (LDG) because of the more difficult reconstruction technique. Despite various modifications of reconstruction methods after LTG, an optimal procedure has yet to be established. The authors report the newly developed reconstruction technique after LTG: intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil™; Covidien, Mansfield, MA, USA).
After full mobilization of the abdominal esophagus, the esophagus is transected with an endoscopic linear stapler. The anvil is then transorally inserted into the esophagus by using the OrVil™ system. After jejunojejunostomy is performed through a 4-cm midline minilaparotomy, preparing a 50-cm Roux-en-Y jejunal limb, a circular stapler is inserted into the jejunum and introduced into the abdominal cavity. Pneumoperitoneum is established by sealing off the laparotomy wound retractor with a surgical glove attached to the circular stapler. Double-stapling esophagojejunostomy with a circular stapler is performed intracorporeally, and the jejunal stump is closed with an endoscopic linear stapler.
Of the 16 patients who underwent this operation, there was no intraoperative complication or conversion to open surgery, and no patient required an extension of the initial incision for anastomosis. Mean operation time and blood loss were 194 min and 272 ml, respectively. One patient developed an intra-abdominal abscess postoperatively. Postoperative fluorography revealed no anastomosis leakage or stenosis in any of the patients. Patients resumed an oral liquid diet on postoperative day 3-5, and the mean postoperative hospital stay was 11 days.
We have successfully performed LTG with Roux-en-Y reconstruction using our technique in 16 patients without any anastomosis complications. We believe that our procedure is a secure and reliable reconstruction method after LTG, which is especially useful in obese patients, in whom conventional extracorporeal anastomosis often is difficult.
Laparoscopy-assisted total gastrectomy (LATG) is not a commonly performed procedure due to the surgical difficulty associated with reconstruction. Although various reconstruction methods have been reported, a standard technique has not yet been established. In this study, we compared the short-term outcomes of LATG reconstructed by mini-laparotomy and by the newly developed transorally inserted anvil (OrVil).
From April 2006, a series of 45 patients underwent LATG. Of these, 15 were reconstructed by mini-laparotomy and 30 by OrVil. Short-term outcomes were compared between the two groups.
Operation time was significantly shortened and intraoperative blood loss significantly reduced by the use of OrVil. The postoperative course, including morbidity, did not differ between the two groups.
LATG using OrVil for the treatment of early gastric cancer is a technically feasible surgical procedure with sufficient lymph node dissection, satisfactory early recovery, and acceptable morbidity. It will be necessary to perform this novel technique in a large number of patients to confirm its feasibility.
George, the Liberal Chancellor, fervently believed that a radical
improvement to the munitions industry was not only possible but thoroughly
necessary if the British were to compete with Germany in a long war.
He did not however believe that the war secretary,
under whom responsibility for munitions production fell, was up to the task
of delivering the required production overhaul.
Lloyd George therefore
encouraged the proprietor of the powerful Times and Daily Mail
Northcliffe, in the latter’s determination to publish details of the
‘shell scandal’ in his newspapers. Northcliffe duly published an
article by Repington on 14 May 1915 claiming that the fault of the matter
lay with the War Office and in particular with Lord Kitchener. The
resultant uproar was not restricted to the political elite.
spite of a growing view in the Cabinet that Lord Kitchener was not well
suited to his political role, he was revered in the country at large.
Regarded with awe, ‘K of K’ (Kitchener of Khartoum) the country was not yet
ready to believe ill of Kitchener of Khartoum. Circulation of
Northcliffe’s newspaper consequently dipped.
Nevertheless Lloyd George
achieved his aim. Even though by this time the bottleneck in shell
production was opening up and supplies were increasing, the Liberal
government fell on 25 May 1915 and a new coalition established (under the
continuing Prime Minister
Lord Kitchener remained as minister for war.