A Short Term Outcome of Laparoscopic Hand Sewn and Stapled Gastrojejunostomy in Gastric Outlet Obstruction - An Observational Study

Zubair GL and Aabid RB

surgeon, Government Medical College Srinagar, Email: mushtaq_chalkoo@rediffmail.com operative complications and total hospital stay.

complication rate was 10%.

Conclusion: Stapling devices in surgery are a versatile tool in the armamentarium of a surgeon. Anastomosis in laparoscopic stapled group took less time and thus decreased total operative time.

Keywords: Laparoscopy; Gastrojejunostomy; Techniques

Abbreviations: GOO: Gastric Outlet Obstruction; PUD: Peptic Ulcer Disease; QOL: Quality of Life.

Introduction

Gastric outlet obstruction (GOO) is a term used to describe a condition characterized by the inability of gastric contents to go beyond the proximal duodenum. Gastric outlet obstruction (GOO) is a misnomer expression as numerous cases include duodenal or extra luminal disease, rather than an isolated gastric disease. The obstruction may be partial or complete [1, 2, 3]. Apart from the mechanical impediment of the flow of gastric contents, there are other concerns in patients with GOO, such as malnutrition and electrolyte imbalance [4]. The incidence of GOO is not precisely known. Until the discovery of proton pump inhibitors and H2 blockers, the major cause of GOO was peptic ulcer disease (PUD). The discovery of Helicobacter pylori and developing an effective treatment for the same has resulted in fewer cases of PUD presenting with GOO (<5%); however, in the modern era, the major cause is known to be malignancy, especially in the developed world [5]. The causes of gastric outlet obstruction can be categorized as gastric and extra gastric in origin. Chronic peptic ulceration, gastric adenocarcinoma, GIST, gastric lymphoma, tuberculosis and amyloidosis comprise gastric causes. While as periampullary carcinoma, hepato-biliary cancer, pancreatic cancer, pancreatic pseudo cyst, colon cancer and neuroendocrine tumors are extra-gastric causes that can present with gastric outlet obstruction. Malignant GOO is a common condition among locally advanced gastric cancer patients and can lead to significant morbidity, including nausea, vomiting, abdominal pain, dehydration, malnutrition, and weight loss. Not surprisingly, these clinical symptoms have a negative impact on quality of life (QOL) [6]. To avoid the disastrous consequences of malignant GOO, appropriate treatment is indispensable, which enables not only an amelioration of the patient’s QOL but also the commencement of chemotherapy [7]. These treatments are included in the first-line regimen for unrespectable gastric cancer recommended in the Japanese gastric cancer treatment guidelines [8]. The most common surgical procedures performed for GOO related to PUD are vagotomy and antrectomy, vagotomy and pyloroplasty, truncalvagotomy and Gastrojejunostomy, pyloroplasty, and laparoscopic variants of the afore mentioned procedures [9]. The role of the laparoscopic approach in the treatment of GOO is under investigation and may represent a valid form of therapy with low morbidity. The experience of several international centers has been published. One group in China performed laparoscopic truncalvagotomy and Gastrojejunostomy for GOO related to PUD, with nearly complete resolution of symptomatology. The investigators reported no conversions to open procedure or mortalities. Twenty-seven percent of patients did experience transiently delayed gastric emptying, which resolved with conservative measures [10]. The gastric outlet obstruction bypass (Gastrojejunostomy) can be performed by both open and laparoscopic technique. Gastrojejunostomy is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum. This is usually done either for the purpose of draining the contents of the stomach or to provide a bypass for the gastric contents. Gastrojejunostomy can be done via either an open or a laparoscopic approach. The ante colic position may be preferred because it is technically easy. However, when Gastrojejunostomy is performed for malignant disease, whether after gastrectomy or in a palliative setting, the ante colic position is preferred to the retro colic position. When the retro colic position is used, the anastomosis is at risk of obstruction owing to enlargement of the lymph nodes or serosal implants in the transverse mesocolon. In a retrocolic gastro jejunostomy, there is potential to form a gastrojejuno-colic fistula. At present, laparoscopic gastrojejunostomy is preferred to open gastrojejunostomy whenever possible and feasible, especially in a palliative setting for advanced malignancy.

Aims and Objectives

Patients were divided into two groups and surgical outcome of laparoscopic hand sewn anastomosis and stapled anastomosis in gastric outlet obstruction was evaluated. The present study was prospective in nature and aimed to observe the following parameters in either group. a) Operative time of procedure b) Time for making anastomosis. c) Total hospital stay. d) Return of bowel sound. e) Post-operative complications.

Materials and Methods

This study was prospective, observational, hospital based study conducted in the department of general surgery government medical college, Srinagar between June 2014 to September 2016. It was undertaken after getting a clearance by our college ethical committee board. All the cases were performed by a single surgeon. Forty patients were selected randomly, who were admitted for elective surgery for gastric outlet obstruction and after proper evaluation, build up and after anesthetic clearance these patients were posted for diagnostic laparoscopy and subsequent laparoscopic Gastrojejunostomy. Forty patients of gastric outlet obstruction were randomly divided into two groups. These were labeled as group A and group B without giving any choice to the patient. Group A consisted of 20 patients and group B consisted of 20 patients. The Patients in group A were subjected to laparoscopic Gastrojejunostomy with hand sewn anastomosis (Extracorporeal suture anastomosis). Those in group B were subjected to laparoscopic gastrojejunostomy with stapled anastomosis. If intraoperatively, the tumor was found to be respectable, then bilroth II operation was done laparoscopically in both groups and anastomosis done according to the group to which the patient was assigned. However those patients where resection was done were not included in the study.

Discussion

With the advent of laparoscopic and minimal access techniques different modalities are in use for the treatment of gastric outlet obstruction from advanced malignancies and benign disorders. Open gastrojejunostomy used to be the only method to relieve gastric outlet obstruction. Owing to the introduction of endoscopic stenting and laparoscopic surgery, lesser and lesser invasive approaches are now more commonly being used. Diagnostic laparoscopy is gaining momentum and acceptance as preliminary modality to be followed in all cases of gastrointestinal malignancy especially carcinoma stomach. It provides a gamut of information about the extent of tumor, biopsy of tumor, MNT staging of the tumor and analysis of malignant ascites if present. In our study, our aims and objectives were defined and conclusive. We routinely followed laparoscopy as a modality for diagnosis and even treatment for unresectable distal gastric tumors. The patients having gastric outlet obstruction with stage 4 disease were taken up for laparoscopic gastrojejunostomy. It was decided to use two techniques of laparoscopic gastrojejunostomy. In one of the techniques we used barbed sutures; co- polymer of glycolic acid and trimethylene carbonate (v- loc, stratafix), vicryl for creating laparoscopic hand sewn anastomosis. In other technique, we used laparoscopic linear stapler with 60 mm mounted cartridge for creating 6cm anastomosis and results were observed keeping in aims and objectives of our study in consideration. While surveying the literature, we found a very few work is published in this concern. In this study, we reviewed our institution's experience of laparoscopic gastrojejunostomy as a treatment modality for GOO. The results were analyzed and compared with published literature both in India and abroad. Various parameters were observed. In our study Group A (Laparoscopic hand sewn anastomosis) comprised of 20 patients between the ages of 50 and 70 years (mean age: 59.6±6.29 years) while Group B (Laparoscopic stapled anastomosis) comprised of 20 patients in age range of 50 to 70 years (mean age: 60.9±6.77 years).Most of the patients were in age range of 50-59 years of age in both groups. Study done by Vivek, et al. [12] showed the majority of the study population was between the age group of 40 and 80 years with a maximum number of individuals falling in the group of 51-60 years In study by Linda P. Zhang, et al. [13] in a study a total of 28 patients were reviewed. Average age was 68 (range, 25 to 99). In study by Su Hyun Seo, et al. [14] the mean age of patients in stapled group was 60.1 +/- 11.7, the mean age of patients in stapled group was 60.4 +/- 12. In our study the majority of the study population was males in both groups. The study sample showed 17 males and 3 females in Group A (Laparoscopic hand sewn anastomosis) and 15 males and 5 females in Group B (Laparoscopic stapled anastomosis) The P-value was 0.695. In a study done by Hyasinta Jaka, et al. [15] the male female ratio was 3.2: 1 for the malignant gastric outlet obstruction. This difference was statistically significant (P < 0.001). In study done by Vivek, et al. Gender distribution of the study sample. The majority of the study population was males with a male to female ratio of 3.2:1. The finding was concurrent with studies which suggested males are more commonly affected with GOO and the outnumber females [16]. Laparoscopic Gastrojejunostomy is technically more difficult than open Gastrojejunostomy in creating bypass. Laparoscopy is a less invasive procedure than open surgery. In this study total operative time was taken in minutes. The time was taken from introduction of ports to removal of all ports. In Gastrojejunostomy group, the mean operating time was shortened in the stapler group and the difference was statistically significant (p- value<0.001). In study done by Choi YB, et al. [17] on Laparoscopic Gastrojejunostomy for palliation of gastric outlet obstruction in unrespectable gastric cancer the mean operative time for stapled laparoscopic Gastrojejunostomy was 100.5 +/- 9.8. In a study done by Higa, et al. [18] the total operative time for creating laparoscopic Gastrojejunostomy hand sewn anastomosis was 60-90 minutes.+/- 9.8 min. In a study done by Linda P. Zhang, et al. the average operative time for laparoscopic stapled Gastrojejunostomy was 170 minutes. Prior studies have shown that operative time decreases as the individual surgeons become more experienced [19]. The operative time is also likely surgeon and patient dependent. In our study the mean time taken for creating anastomosis was 22.3 +/- 1.86 minutes in hand sewn anastomosis and 17.4+/- 2.48 minutes and p – value was <0.001 which was significant difference for creating anastomosis. In a study done by Su Hyun Seo, et al. time taken for creating anastomosis by hand sewn method was 15.2+/- 2.2 and stapled anastomosis was 5.7±0.7 the p value between hand sewn and stapled anastomosis was <0.001 which was significant difference. The hospital length of stay can be as low as 3 days and as high as 14 days [20, 21] in laparoscopic Gastrojejunostomy. In our study the mean postoperative hospital stay for hand sewn anastomosis was 8.4 +/- 0.89 and in stapled group was 7.9 +/- 0.91 and p-value was 0.067 which was insignificant. This total postoperative hospital stay is shorter than the reported length of stay for open cases. Jeurnink, et al. [22] performed a systemic review of published series on GJ between 1996 and 2006. Of the 297 cases of GJ (Gastrojejunostomy), 226 patients had open GJ, and their average length of stay ranged from 8.5 days to 24 days. In a study done by Su Hyun Seo, et al. the mean post- operative hospital stay in hands sewn 8.0 +/-3.8 and stapled anastomosis was 7.4 +/- 1.9 and P- Value was 0.497 this study showed no significant difference between hospital stay in stapled and hand sewn anastomosis. In a study done by Linda P, et al. the median length of postoperative hospital stay found in this study was 8 days. In our study the mean time of appearance of bowel sounds in hand sewn group was 2.6 +/- 0.59 and stapled group was 2.3 +/- 0.47 and P-value was 0.076 which was insignificant. In a study by Su Hyun Seo, et al. appearance of bowel sound was found to be 2.8 +/- 0.9 in hand sewn anastomosis and 2.4 +/- 0.9 in stapled anastomosis group and p – value was 0.104 and was insignificant. In a study by Linda P et al. the appearance of bowel sound in stapled anastomosis was found to be 3 days. Resumption of orals in hand sewn anastomosis was 4.3 +/- 0.71 and in hand sewn anastomosis was 3.9 +/- 0.72 and p- value was 0.089 which was insignificant difference between two groups (Table 7). In a study done by Linda et al the mean days for resumption or orals in laparoscopic Gastrojejunostomy (stapled anastomosis) was found to be 3 days. In a study by Alam, et al. [23] and Kazanjian, et al. [24] both reviewed patients with GOO secondary to inoperable cancer and found the median time to solid food after laparoscopic Gastrojejunostomy to be 4 days. In contrast, open Gastrojejunostomy generally required 7 days before a patient could resume solid food. As we understand the complications are part of any surgery performed. Surprisingly in our study we observed complication rate on a lesser ebb than mentioned in the literature. Among the various complications of laparoscopic Gastrojejunostomy, we found intra operative anastomosis site hemorrhage to the tune of 15%; total of 3 cases, 10 % in laparoscopic stapled anastomosis; total of 2 patients. P-value between two groups was 0.633 which was insignificant difference between two groups. In a study by Rodrigo Gonzalez, et al. [25] in their study of 108 patients with eighty seven patients had hand sewn anastomosis and 21 had stapled anastomosis there was no significant difference in anastomosis related hemorrhage with p value 0.34 (hand sewn = 2, stapled = 1 ). The anastomosis leak is one of the complications of Gastrojejunostomy hand sewn or stapled. It was observed that our study group of patients did not have any anastomosis leakage in contrast to the literature mentioned leak rate of 3.57 % by Linda P. Zhang, et al. in his study, 1.0% in laparoscopic stapled anastomosis and 1.1% in laparoscopic hand sewn anastomosis by Frank P. Bendewald [26]. This we possibly attribute to the surgeon expertise and optimum preoperative preparation. Intra-abdominal abscess and fistula formation is also complication of laparoscopic Gastrojejunostomy mentioned in the literature. However, in our study we did not find any such case with intra-abdominal abscess or fistula formation in our follow-up. It is important to mention that we observed contrast results as regards with complications of the procedure mentioned in the literature. This is possibly because the single surgeon performed all the procedures both laparoscopic hand sewn and stapled anastomosis. The patients were properly optimized with a special reference to the clinical built, hemoglobin level, plasma proteins and preparation of stomach and small bowel.

Summary

This Prospective study was observational and was aimed to observe the laparoscopic Gastrojejunostomy hand sewn and stapled anastomosis on the basis of various parameters.

• There was no significant difference between the two groups in terms of age.
• Majority of the patients in our study were males in both groups.
• Total operative time was significantly less in laparoscopic Gastrojejunostomy (stapled anastomosis).
• In our study time taken for anastomosis was less in stapled Gastrojejunostomy.

• There was no significant difference in hospital stay, appearance of bowel sounds, and resumption of orals on both groups.
• The main Intraoperative / postoperative complication were suture line hemorrhage.

Conclusion

• Stapling devices in surgery are a versatile tool in the armamentarium of a surgeon.
• Anastomosis in stapled gastrojejunostomy takes less time and thus decreases total operative time.
• Laparoscopic hand sewn(suture)anastomosis avoids the use of staplers and suits to the patients from developing countries