Surgical safety and technical optimization of arch-bridge anastomosis after laparoscopy-assisted proximal gastrectomy: An IDEAL stage 2a prospective cohort study

To the Editor: Gastric cancer (GC) is one of the most common digestive system malignancies, and the incidences of proximal gastric cancer (PGC) and adenocarcinoma of esophagogastric junction (AEG) have recently increased.[1] Compared to total gastrectomy (TG), proximal gastrectomy (PG) preserves more of the stomach’s volume and function and is increasingly used in clinical practice. However, PG disrupts the anatomical antireflux barrier, often leading to reflux esophagitis. To reduce complications and improve patients’ quality of life (QOL), various reconstruction methods have been proposed. However, an optimal reconstruction method has not been established. Valvuloplastic esophagogastrostomy (vEG) can increase the lower esophagus pressure, helping to prevent reflux esophagitis. Shaibu et al[2] demonstrated that vEG reduced the complications compared to double tract reconstruction and jejunal interposition. Based on the vEG, we developed a modified esophagogastric reconstruction method called arch-bridge anastomosis.[3] The IDEAL provides a systematic approach to establish a scientific evaluation pathway for surgical innovations.[4] It categorizes surgical innovation into five stages: idea, development, exploration, assessment, and follow-up. IDEAL stage 2a represents the “development” stage, which involves enrolling no more than 30 patients in a single center to assess surgical safety and refine the technical approach. Further details of the IDEAL framework are provided in Supplementary Table 1, https://links.lww.com/CM9/C695. According to the IDEAL framework, we conducted this prospective cohort study on 30 patients who underwent arch-bridge anastomosis in the Department of Gastrointestinal Surgery, Peking University Cancer Hospital between November 2021 and July 2023. Eligible patients had histologically confirmed cT1–3N0–1M0 PGC or AEG, a tumor diameter ≤4 cm, esophageal invasion length ≤2 cm, and no metastatic signs of No. 4d, 5, 6, and 12a lymph nodes as assessed by computed tomography (CT). This study was approved by the institutional review board of the Peking University Cancer Hospital medical ethics committee (No. 2023YJZ11), and written informed consent was obtained from each patient. This study was registered on the ClinicalTrials (No. NCT05829213). The procedures arch-bridge anastomosis were as follows [Figure 1]:Figure 1: : The procedures of LAPG and arch-bridge anastomosis. (A) Two barbed threads were sutured. (B) PG was performed extracorporeally. (C) A single seromuscular flap (3 × 4 cm) was created. (D) The opening of the single flap was closed, forming an arch-bridge structure. (E) A hole was created on the anterior wall, and four stitches were sewed around the hole. (F) The two barbed threads were pulled downward to guide the esophageal stump through the arch-bridge to anastomotic site. (G) The anastomosis of posterior wall. (H) The anastomosis of anterior wall. LAPG: Laparoscopy-assisted proximal gastrectomy; PG: proximal gastrectomy. (1) Lymph node dissection was performed according to the Japanese Gastric Cancer Treatment Guidelines 2018 (5th edition).[5] (2) The esophagus was transected using a linear stapler. Two barbed threads were sutured 0.5 cm from the stapled line of esophageal stump [Figure 1A]. (3) An auxiliary incision was made, and PG was performed extracorporeally [Figure 1B]. (4) Creation of the “arch-bridge”. A single seromuscular flap (3 × 4 cm) was created on the anterior wall of the remnant stomach, 1 cm from the top [Figure 1C]. The opening of the flap was towards the lesser curvature. The opening of the single flap was closed with 4-0 absorbable sutures under direct vision, forming an arch-bridge structure [Figure 1D]. A 2 cm diameter hole was created on the anterior wall, 1 cm below the flap. Four stitches of the 4-0 absorbable sutures were sewed around the hole to secure mucosal and seromuscular layers together [Figure 1E]. (5) Pneumoperitoneum was re-established, and the remnant stomach was lifted to the hiatus. The two presutured barbed threads were pulled downward to guide the esophageal stump through the arch-bridge to the anastomotic site- the hole [Figure 1F]. (6) The stapled line of the esophageal stump was cut using an ultrasonic shear. The posterior wall anastomosis was performed by continuous suture between the posterior wall of the esophageal stump and the proximal side of the hole using one barbed thread [Figure 1G]. The anterior wall anastomosis was completed by suturing the anterior wall of the esophageal stump, the distal side of the hole and the arch-bridge with another thread [Figure 1H]. Continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range, [IQR]). Categorical variables are presented as frequency (percentage). The technical optimization for arch-bridge anastomosis was developed through qualitative analysis using postoperative interview recordings. After each surgery, a semistructured interview was conducted in which the chief surgeon responded to the following questions: (1) Technical modifications made compared to the previous surgery, (2) analysis of intraoperative conditions and (3) identification of intraoperative technical errors. P value <0.05 was considered statistically significant. Statistical analyses were performed using SPSS, Version 26.0 (IBM Corporation, Armonk, NY, USA). Qualitative analysis was performed using the Nvivo, Version 12 (QSR International, Melbourne, Australia). A total of 25 male and 5 female patients were enrolled, with a mean age of 63.6 ± 9.8 years and mean body mass index (BMI) of 25.1 ± 3.0 kg/m2. The mean tumor size was 2.6 ± 1.1 cm. Thirteen patients (43.3%) had tumors located at the esophagogastric junction, whereas 17 patients (56.7%) were diagnosed with PGC. Six patients (20.0%) received preoperative treatment. The patients’ detailed characteristics are presented in Supplementary Table 2, https://links.lww.com/CM9/C695. All 30 patients successfully completed the surgery without conversion to laparotomy. The mean total operation time was 189.0 ± 32.1 min, with a median time for anastomosis was 20.0 (18.0, 25.0) min, and the median time for creating the arch-bridge was 14.5 (12.0, 15.0) min. The median number of lymph nodes retrieved was 29 (23, 36). The detailed surgical outcomes are provided in Supplementary Table 3, https://links.lww.com/CM9/C695. Postoperative complications occurred in five (16.7%, 5/30) patients. Two patients (6.7%, 2/30) developed anastomotic stricture and were successfully treated with endoscopic balloon dilatation. The complications in the other three patients were managed conservatively. There were no cases of postoperative anastomotic leakage. The detailed complication outcomes are listed in Supplementary Table 4, https://links.lww.com/CM9/C695. The median postoperative hospital stays were 9 days. The postoperative recovery outcomes are shown in Supplementary Table 5, https://links.lww.com/CM9/C695. In total, 24 postoperative interviews were recorded. Through the qualitative analysis, a technical framework for arch-bridge anastomosis was developed, comprising three major components: Creating the arch-bridge, pulling the esophageal stump through the arch-bridge, and performing the esophagogastrostomy. Each component was organized into four aspects: Procedure, analysis, decision-making, and error. The technical optimization scheme of arch-bridge anastomosis is summarized in Supplementary Table 6, https://links.lww.com/CM9/C695. In this study, all patients successfully completed the surgery without conversion to laparotomy. The overall complication rate was 16.7%, with 6.7% of patients experiencing anastomotic stricture, all of which were successfully treated with balloon dilatation. The incidence of stricture was slightly lower than the conventional double-flap technique (DFT).[6] This difference may contribute to the improved controllability of suturing the seromuscular flap under direct vision, which enhanced the suturing quality. In terms of postoperative recovery, the median postoperative length of stay was 9 days, and all patients were able to pass gas, defecate, and start a liquid diet shortly after surgery, indicating favorable recovery outcomes. In this study, a qualitative analysis was conducted to develop the technical optimization scheme for arch-bridge anastomosis. The scheme includes three main components: (1) Creating the arch-bridge, (2) pulling the esophageal stump through the arch-bridge, and (3) performing the esophagogastrostomy. Creating the arch-bridge was the core procedure. A 3 cm × 4 cm seromuscular flap was created for all patients. Because the average width of the esophagus is 1.5–2.5 cm, an arch-bridge width of 3.0 cm is sufficient. In addition, the previous study reported that the length of the flap was not important for reflux control. Therefore, the length of the arch-bridge was set at 4 cm, similar to the DFT. In this study, none of the patients experienced postoperative reflux symptoms, suggesting that the single flap had favorable short-term antireflux efficacy. The flap’s opening was closed using absorbable sutures under direct vision, replacing the conventional laparoscopic manual suturing and thereby reducing technical difficulty. The median time required to create the arch-bridge was 14.5 min, indicating that the procedure is both feasible and time efficient. According to the postoperative interviews, pulling the esophageal stump through the arch-bridge was the most complex step in the arch-bridge anastomosis, requiring close coordination between the chief surgeon and assistants. First, careful attention should be paid to the alignment of the esophagus to prevent esophageal rotation. We reported a case in which the esophagus rotated 180°, making it difficult to pass through the arch-bridge. Second, the remnant stomach should be lifted to the esophageal hiatus before pulling the pre-sutured barbed threads to guide the esophagus through the arch-bridge. In addition, longitudinally enlarging the hiatus can facilitate this procedure. For esophagogastrostomy, we used a modified overlap method using knotless barbed sutures. The presutured barbed threads facilitated manual suturing while also providing traction and fixation of the esophagus during the procedure. The median time for esophagogastrostomy was 20 min, significantly shorter than the conventional DFT, highlighting the advantage of barbed threads. Qualitative analysis identified the “cutting and suturing simultaneously” method as the optimal technique, which helps reduce intraoperative bleeding and improves the accuracy of suturing. In conclusion, arch-bridge anastomosis is a safe, time-saving, and feasible procedure that can lower the incidence of postoperative anastomotic anastomotic complications. Further research is needed to assess the long-term anti-reflux efficacy and postoperative QOL of the arch-bridge anastomosis. Acknowledgements We thank Angela Morben from Liwen Bianji (Edanz) (www.liwenbianji.cn) for editing a draft of this manuscript. Funding This study was supported by grants from Capital’s Funds for Health Improvement and Research (No. 2024-1-2152), the Beijing Nova Program (No. 20220484111), Beijing Hospitals Authority Innovation Studio of Young Staff Funding Support (No. 202123), Science Foundation of Peking University Cancer Hospital (No. PY202335), Clinical Research Fund for Distinguished Young Scholars of Peking University Cancer Hospital (No. QNJJ2022016), and Clinical Research United Fund of Peking University Cancer Hospital (No. LHJJ2023003). Conflicts of interest None.