[Abstract] Objective To investigate the feasibility of ENDO STITCH? for lumpectomy jejunostomy. Methods From November 2010.to January 2011, laparoscopic jejunostomy was performed by using ENDO STITCH for 4 patients with esophageal cancer, 3 of whom were patients with metastatic esophageal cancer with dysphagia and 1 of whom was a step of total lumpectomy for radical esophageal cancer. Results All four patients were successfully treated with jejunostomy using ENDO STITCH? with no serious surgery-related complications intraoperatively or postoperatively. There was venting and bed movement on the first postoperative day, and enteral nutrition was started 24 hours after surgery. At postoperative follow-up, all patients with metastatic esophageal cancer received enteral nutrition with jejunostomy tubes during chemotherapy, and their weight remained stable. Conclusion ENDO STITCH is safe and feasible for lumpectomy jejunostomy, with the advantages of less trauma and faster postoperative recovery, and is suitable for frail patients with esophageal cancer.
[Keywords] ENDO STITCH? laparoscopic jejunostomy
Several studies have confirmed that weight loss and reduced albumin levels are closely associated with poor prognosis of GI tumors [1, 2]. If the patient requires only short term enteral nutrition, the nasal feeding tube has the advantage of being simple and does not require anesthesia. If the patient requires longer-term enteral nutrition or if the patient cannot tolerate the discomfort associated with a nasal feeding tube, gastrostomy or jejunostomy may be considered. Laparoscopic jejunostomy was first reported by O’Regan and Scarrow in 1990 [3]. The ENDO STITCH? automatic suture tying device, manufactured by Covidien Ltd, has been widely used abroad for interrupted and continuous suturing of soft tissues under various lumpectomy operations. We report 4 patients with esophageal cancer who underwent laparoscopic jejunostomy using ENDO STITCH?
1. Patients and methods
1.1 Patients and surgical procedures
From November 2010 to January 2011, we performed laparoscopic jejunostomy in four patients with esophageal cancer, three of whom had metastatic esophageal cancer with dysphagia and one of whom was a step of total laparoscopic radical esophageal cancer surgery, three were male and one was female, aged 56-61 years. Surgical steps.
1.The patient was placed in supine position, and the first 11 mm trocar incision was made at the glabella and inferior 1/3 of the umbilicus, and the first 11 mm trocar incision was made at the right two fingers as the laparoscopic access hole.
2, Under direct laparoscopic view, three additional trocar incisions were made, two 5-mm trocar incisions were made under the right and left costal arches, and the other 11-mm trocar incisions were made in the right lower abdomen, and the trocar was inserted using versa-stepTM followed by the ultrasonic knife and Snowden, respectively.
3. After locating the TRIS ligament, a small 0.8 cm incision was made 30 cm downward with the ultrasonic knife and a jejunostomy tube was inserted with 20 ml of air to help ensure the position and adequate length of the tube in the jejunum.
4. A loop of ENDO STITCH is made, and then the jejunum is retracted to the left lower abdominal wall. 4 stitches are fixed to the abdominal wall with ENDO STI- TCH.
5. 5 cm from the jejunostomy fixation site, the jejunum is fixed to the anterior abdominal wall with one more stitch using ENDO STITCH® to form the Witzel tunnel.
1.2 Composition and use of ENDO STITCH?
The main features of the 10 mm ENDO STITCH are: 1. operating handle for needle installation, needle change and withdrawal; 2. 36 cm shank length for lumpectomy and depth scale for in-situ measurement; 3. integrated needle and suture; 4. needle position switching lever for switching the needle position between the two teeth (see Figure 1A). The specific operation steps of the ENDO STITCH are as follows
1. Needle installation: Open the two teeth of the head end of the suture by pressing the black button in the middle of the handle, place the head end into the disposable needle and suture installation box to achieve accurate alignment, press the handle to bring the two teeth together again, while pulling the switching lever longitudinally towards the proximal end until the position of the switching lever is fixed, and withdraw the suture from the installation box.
2. ENDO STITCH is mainly used for laparoscopic ports with a diameter close to the diameter of the rod, and the author uses either the pen-held or palm-held type depending on the suture position.
3. Once the ENDO STITCH has entered the body cavity, the suture can be opened by squeezing the handle again with the palm of the hand while pushing the switching lever forward or backward on either side. The suture needle can then be exposed for use after the two teeth are opened.
4. When suturing, pressing the handle to the end while pushing the toggle bar backwards until it cannot be pushed will allow the needle to pass through the tissue to be sutured and simultaneously complete the switching of the needle between the two teeth. In this way, the suture needle can be switched to the opposite side of the tooth.
5. Relax the handle so that the two teeth open and pull the suture through the suture tissue, leaving a thread to complete the interrupted suture or continuous suture after tying the knot, I like to form a “D” or reverse “D” when tying the knot and tie 3 knots, which is fast and safe. Safe and reliable.
6. ENDO STITCH: When exiting the lumpectomy trocar, it is also necessary to keep the handle and the two teeth in a closed position.
7. Withdrawal of the suture: After the suture is tied, turn the switching lever to the horizontal position and press the black button in the middle of the handle forward again to withdraw the suture.
2. Results
The operative time in this study was 55-120 min, with intraoperative bleeding of approximately 10 ml. 5F “needle” fistula (Compat Biosystems, Minneapolis MN, Figure 1B, C) was used in one patient, and a conventional 22F thick fistula was used in the other three patients (Figure 1D).
All three patients with laparoscopic jejunostomy did not use morphine-based analgesics postoperatively, and were discharged from the hospital on the first day of surgery with venting and bedtime exercise. All patients with metastatic esophageal cancer received enteral nutrition through jejunostomy tubes during chemotherapy, and their weight remained stable. We routinely performed laparoscopic staging to detect liver metastases (superficial lesions) and abdominal metastases before the fistula, and if we found suspected nodules, we performed laparoscopic biopsy and sent them for intraoperative freezing.
3. Discussion
There are many reports of laparoscopic jejunostomy abroad. Allen et al [5] reported 35 cases of laparoscopic jejunostomy with 16F fistula tubes, and there were no serious complications except for one person with unexplained pain. edelman et al [6] reported 22 cases of laparoscopic gastrostomy and jejunostomy, and the authors preferred jejunostomy if the patients were prone to aspiration. jenkinson et al [ 7] reported 35 cases of laparoscopic placement of jejunostomy tubes before neoadjuvant chemotherapy for esophageal cancer, and the patients had significantly better albumin levels and body weight than those without the placement of a fistula, and they concluded that laparoscopic placement of jejunostomy tubes allowed patients to better receive neoadjuvant chemotherapy without compromising esophagectomy after chemotherapy.Han- Geurts et al [8] systematically reviewed 23 cases of total laparoscopic or laparoscopic-assisted Han-Geurts et al [8] systematically reviewed 23 total or laparoscopic-assisted jejunostomies with complications similar to those of conventional open surgery, including wound infection and blockage of the fistula, with 1.8% of patients requiring reopening to manage the complications. Therefore, the authors concluded that this minimally invasive technique can safely and effectively provide enteral nutrition to patients. We performed laparoscopic jejunostomy using ENDO STITCH in 4 patients with esophageal cancer. None of them used morphine analgesics after surgery, and they had venting and got out of bed on the first day.
In recent years, there are some reports of thoracoscopic and/or laparoscopic radical esophageal cancer surgery in China, but the step of jejunostomy is often omitted, and there are no reports of laparoscopic jejunostomy using ENDO STITCH. On the contrary, jejunostomy with the ENDO STITCH has become a routine step in minimally invasive radical esophageal cancer surgery abroad [9, 10]. This device allows a rapid needle transition from one side of the suture to the other, and the needle can be automatically adjusted to the next suture position. It has been reported in foreign literature that the speed of lumpectomy ENDO STITCH? knot tying (114 ± 64 s) is significantly faster than that of conventional instruments (206 ± 107 s, P < 0.05) [11], so it is very practical but difficult to learn (learning curve). Depending on the suture position, the author used either the pen-held or palm-held type. When suturing, the handle is pressed to the end and the switching lever is pushed backwards until it cannot be pushed, which allows the needle to pass through the tissue to be sutured and simultaneously switches the needle between the two teeth. In this way, the suture needle can be switched to the opposite tooth. When tying the knot, the author prefers to form a "D" or reverse "D" with 3 knots, which is fast, safe and reliable.
Besides nasogastric tube and PEG, laparoscopic jejunostomy is also suitable for patients with advanced esophageal cancer who have feeding obstruction or weight loss.
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