Modified technique for esophagojejunostomy after total gastrectomy.
Machado, M.A.C. ; Herman, P.; Montagnini, A.L.; Costa, M.L.; Machado, M.C.C.
J. Surg. Oncol. 78(2):148-50, 2001.



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Gastric cancer is worldwide one of the most common causes of cancer death. Total gastrectomy is the gold standard treatment for gastric carcinomas originating in the gastric body or fundus. There have been important decrease in surgical morbidity and mortality after total gastrectomies. However, some major complications are related to the surgical technique. Esophagojejunostomy leaks are serious complications that, if not recognized and managed expeditiously, can be life-threatening. Esophagojejunostomy is the most common type of reconstruction after total gastrectomy but there are several ways to perform it. The authors describe a modified technique for an easier esophagojejunostomy after total gastrectomy.
The esophagus is not transected prior to performance of the anastomosis. A transversal incision on the anterior esophageal wall, at the point of the transection, is made. The stomach is used as a ``handle'' during mobilization and placement of stay sutures at terminal esophagus. A purse string suture (manual or with a purse string instrument) can be easily performed with gentle gastric traction, avoiding the use of crushing clamps at the distal esophagus. The partial esophageal transection facilitates the placement of the stapler at the distal esophagus, enabling the anvil to slip on the intact posterior mucosa. Following the anvil placement at the distal esophagus, the purse sting suture is tied and the posterior esophageal wall is then transected. The trocar tip of the main instrument, that had been introduced in the open end of the Roux, is now advanced through the side of the Roux limb. The anvil is inserted into the main instrument, the ends are brought together, the stapler device is fired and an end-to-side anastomosis is completed. The open end of the Roux is closed by a linear stapler. The last mesenteric vessels of the open end had been ligated before construction of the esophagojejunostomy in order to facilitate the insertion of the linear stapler.We believe that this technical variation facilitates the construction of esophagojejunostomy. It may reduce the
need to manipulate the distal esophagus and its mucosa, minimizing risk for suture line leaks complications.