J Gastric Cancer.  2017 Dec;17(4):354-362. 10.5230/jgc.2017.17.e40.

Laparoscopic Reinforcement Suture (LARS) on Staple Line of Duodenal Stump Using Barbed Suture in Laparoscopic Gastrectomy for Gastric Cancer: a Prospective Single Arm Phase II Study

• Kim MC
• Kim SY
• Kim KW

• KMID: 2398801
• DOI: http://doi.org/10.5230/jgc.2017.17.e40

Abstract

PURPOSE
Laparoscopic gastrectomy is accepted as a standard treatment for patients with early gastric cancer in Korea, Japan, and China. However, duodenal stump leakage remains a fatal complication after gastrectomy. We conducted a prospective phase II study to evaluate the safety of the new technique of laparoscopic reinforcement suture (LARS) on the duodenal stump.
MATERIALS AND METHODS
The estimated number of patients required for this study was 100 for a period of 18 months. Inclusion criteria were histologically proven gastric adenocarcinoma treated with laparoscopic distal or total gastrectomy and Billroth II or Roux-en-Y reconstruction. The primary endpoint was the incidence of duodenal stump leakage within the first 30 postoperative days. The secondary endpoints were early postoperative outcomes until discharge.
RESULTS
One hundred patients were enrolled between February 2016 and March 2017. The study groups consisted of 65 male and 35 female patients with a mean age (years) of 62.3. Of these, 63 (63%) patients had comorbidities. The mean number of retrieved lymph nodes was 38. The mean operation time was 145 minutes including 7.8 minutes of mean LARS time. There was no occurrence of duodenal stump leakage. Thirteen complications occurred, with one case of reoperation for splenic artery rupture and one case of mortality.
CONCLUSIONS
Based on the results of this prospective phase II study, LARS can be safely performed in a short operation period without development of duodenal stump leakage. A future randomized prospective controlled trial is required to confirm the surgical benefit of LARS compared to non-LARS.

Keyword

Stomach neoplasms; Laparoscopy; Gastrectomy; Reinforcement; Duodenum; Leakage

MeSH Terms

Adenocarcinoma
Arm*
China
Comorbidity
Duodenum
Female
Gastrectomy*
Gastroenterostomy
Humans
Incidence
Japan
Korea
Laparoscopy
Lymph Nodes
Male
Mortality
Prospective Studies*
Reoperation
Rupture
Splenic Artery
Stomach Neoplasms*
Sutures*

Figure

• 

  Fig. 1 Continuous LARS with invagination. At the upper end of the duodenal stump, a triangular suture with a barbed suture is performed (A). Then, a reinforcement suture with invagination of the staple line is continued up to the lower end of the duodenal stump (B). At the lower end, a triangular suture with invagination is performed once again (C). After the continuous suture with invagination ends, the duodenal stump staple line is buried under the barbed suture (D). LARS = laparoscopic reinforcement suture.

• 

  Fig. 2 Interrupted LARS without invagination. From one end of the duodenal stump, interrupted sutures using barbed sutures are performed 2 or 3 times to cover the whole staple line. LARS = laparoscopic reinforcement suture.

• 

  Fig. 3 Operation time of LARS in 100 patients. The mean time for LARS is 7.8 minutes. The 95% confidence interval for the mean is 7.3674 to 8.2106. LARS = laparoscopic reinforcement suture.

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