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The placement of a jejunostomy catheter during esophagectomy may cause postoperative bowel obstruction. The proximity of the jejunostomy site to the midline might be associated with bowel obstruction, and we have introduced laparoscopic jejunostomy (Lap-J) to reduce jejunostomy’s left lateral gap. We evaluated 92 patients who underwent esophagectomy for esophageal cancer between February 2013 and August 2022 to clarify the benefits of Lap-J compared to other methods. The patients were classified into two groups according to the method of feeding catheter insertion: jejunostomy via small laparotomy (J group, n = 75), and laparoscopic jejunostomy (Lap-J group, n = 17). Surgery for bowel obstruction associated with the feeding jejunostomy catheter (BOFJ) was performed on 11 in the J group. Comparing the J and Lap-J groups, the distance between the jejunostomy and midline was significantly longer in the Lap-J group (50 mm vs. 102 mm; P < 0.001). Regarding surgery for BOFJ, the distance between the jejunostomy and midline was significantly shorter in the surgery group than in the non-surgery group (43 mm vs. 52 mm; P = 0.049). During esophagectomy, Lap-J can prevent BOFJ by placing the jejunostomy site at the left lateral position to the midline and reducing the left lateral gap of the jejunostomy.

BackgroundRobotic suturing training is in increasing demand and can be done using suture-pads or robotic simulation training. Robotic simulation is less cumbersome, whereas a robotic suture-pad approach could be more effective but is more costly. A training curriculum with crossover between both approaches may be a practical solution. However, studies assessing the impact of starting with robotic simulation or suture-pads in robotic suturing training are lacking.MethodsThis was a randomized controlled crossover trial conducted with 20 robotic novices from 3 countries who underwent robotic suturing training using an Intuitive Surgical® X and Xi system with the SimNow (robotic simulation) and suture-pads (dry-lab). Participants were randomized to start with robotic simulation (intervention group, n = 10) or suture-pads (control group, n = 10). After the first and second training, all participants completed a robotic hepaticojejunostomy (HJ) in biotissue. Primary endpoint was the objective structured assessment of technical skill (OSATS) score during HJ, scored by two blinded raters. Secondary endpoints were force measurements and a qualitative analysis. After training, participants were surveyed regarding their preferences.ResultsOverall, 20 robotic novices completed both training sessions and performed 40 robotic HJs. After both trainings, OSATS was scored higher in the robotic simulation-first group (3.3 ± 0.9 vs 2.5 ± 0.8; p = 0.049), whereas the median maximum force (N) (5.0 [3.2–8.0] vs 3.8 [2.3–12.8]; p = 0.739) did not differ significantly between the groups. In the survey, 17/20 (85%) participants recommended to include robotic simulation training, 14/20 (70%) participants preferred to start with robotic simulation, and 20/20 (100%) to include suture-pad training.ConclusionSurgical performance during robotic HJ in robotic novices was significantly better after robotic simulation-first training followed by suture-pad training. A robotic suturing curriculum including both robotic simulation and dry-lab suturing should ideally start with robotic simulation.

Direct percutaneous endoscopic jejunostomy (DPEJ) provides post-pyloric enteral access in patients unable to meet long-term nutritional needs per os in situations where gastric feeding is neither tolerated nor feasible. Specific conditions associated with feeding intolerance due to due to nausea, vomiting, or ileus include gastric outlet obstruction, gastroparesis, or complications of acute or chronic pancreatitis; infeasibility may be due to high aspiration risk or prior gastric surgery. Since performing DPEJ is not an ACGME requirement for GI fellows or early career gastroenterologists, not all trainees are taught this technique. Hence, provider expertise for teaching and performing this technique varies widely across centers. In this article, we provide top tips for successful performance of DPEJ.

BackgroundThe main treatment of choledochal cysts is the complete resection of the cyst with Roux-en-Y hepaticojejunostomy, which includes open procedures, laparoscopic procedures, and robot-assisted procedures using a da Vinci surgical system. The aim of this current study was to investigate the safety and effectiveness of these three different surgical methods in pediatric choledochal cyst excisions.MethodsBetween January 2015 and December 2018, patients with choledochal cysts treated with open procedures, laparoscopic procedures, or robot-assisted procedures were retrospectively analyzed. The data collected included demographic information of all patients, type and size of cyst, operative details, and postoperative outcomes.ResultsA total of 371 episodes of patients were enrolled which consist of the open procedures group (n = 226), laparoscopic procedures group (n = 104), and robot-assisted procedures group (n = 41). The operation time was significantly longer in the laparoscopic procedures group (212.79 ± 34.94) than open procedures group (115.88 ± 13.50) and robot-assisted procedures group (180.61 ± 14.07) (p < 0.001). The volume of intraoperative bleeding were higher in the open procedures group (40.12 ± 55.51) than in the laparoscopic procedures group (21.73 ± 11.44) and robot-assisted procedures group (21.34 ± 9.42), while there was no significant difference between the latter groups. The time to taking water, time to starting liquid diet, and the average length of postoperative hospital stay were similar between the laparoscopic and robot-assisted procedures group, which are shorter than the open procedures group with significant differences. There was no signifcant difference in complications among the three groups.ConclusionCholedochal cyst excision with robotic-assisted procedures had identical surgical effects as open procedures and had lower technical requirements. But it had higher medical cost and better cosmetic effects. Open procedures had largely positive surgical outcomes with fewest complications but poor cosmetic effects. Laparoscopic procedures were the most technique-demanding approaches with positive cosmetic and economic effect. The incidence of complications of laparoscopic procedures decreased with the learning curve.

AimWe compared robotic hepaticojejunostomy anastomosis (RHJA) with laparoscopic hepaticojejunostomy anastomosis (LHJA) in children undergoing complete excision of choledochal cyst.MethodsDifficulty of suturing (DOS) during anastomosis was scored blindly, from intraoperative video recordings, using: 5 = impossible; 4 = difficult; 3 = tedious; 2 = slow; and 1 = easy. A panel of fiveindependent surgeons was also asked to compare RHJA with matched LHJA and score + 1 if RHJA appeared superior to LHJA, 0 if RHJA appeared equivalent to LHJA, and − 1 if RHJA appeared inferior to LHJA.ResultsRHJA (n = 10) was performed between 2017 and 2019; LHJA (n = 27) was performed between 2009 and 2018. LHJA cases were matched for age, weight, and anastomosis diameter to RHJA cases. Complete excision was performed laparoscopically in both groups. DOS was lower in RHJA with less variance. The panel all scored RHJA as + 1. Total anastomotic time (TAT) and TAT per suture were significantly shorter for RHJA. Times taken to ambulate and for return of bowel sounds postoperatively were significantly shorter for RHJA. There was one anastomotic leak with LHJA (3.7%) and no anastomotic complications with RHJA.ConclusionsRHJA is a more stable anastomosis that can be performed quicker, and thus, would appear to be superior to LHJA.

Roux-en-Y hepaticojejunostomy is a crucial procedure for treating biliary diseases, especially in patients with recurrent hepatolithiasis. However, the safety and efficacy of repeat laparoscopic Roux-en-Y hepaticojejunostomy(R-LRHJS) remain controversial due to the complexity of hepatobiliary stones and the potential for complications. A total of 41 patients admitted to the Department of Hepatobiliary Surgery at the Second Affiliated Hospital of Kunming Medical University from June 2019 to December 2023 were reviewed. 20 patients who underwent repeat R-LRHJS were included in the final analysis. Surgical techniques emphasized meticulous dissection of intra-abdominal adhesions, precise identification of the hepatic hilum bile duct, and careful reconstruction of the biliary-enteric anastomosis. The mean patient age was 54.6 ± 10.7 years. Operative time ranged from 120 to 378 min, with intraoperative blood loss between 10 and 200 ml. Postoperative complications included anastomotic bleeding (2 cases), pancreatic stump bleeding (1 case), duodenal fistula (1 case), and biliary leakage (5 cases). No perioperative deaths occurred. During a 1- to 3-year follow-up, no recurrence of anastomotic stenosis or stone formation was observed on MRCP. The study concludes that R-LRHJS is a feasible and effective treatment for recurrent biliary strictures or stones following initial choledochojejunostomy.

Enteral feeding is a common problem in children with gastric emptying disorders. Traditional feeding methods in these patients often show a high rate of complications and maintenance issues. Laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) has been described in a few patients as a minimal invasive option for enteral access in these children. The aim of this study is to evaluate the outcomes of the LRFJ procedure in our tertiary referral center. We conducted a retrospective case-series including all patients, aged 0–18 years old, that underwent a LFRJ procedure between August 2011 and December 2020 for the indication of oral feeding intolerance due to delayed gastric emptying. Outcomes evaluated were complications (short and long term) and parenteral satisfaction. In total, 12 children were identified that underwent LRFJ for the indication of oral feeding intolerance due to delayed gastric emptying. A total of 16 complications were noted in 8/12 patients (67%). Severity classified by Clavien-Dindo were grade I ( n  = 13), grade II ( n  = 1), and grade IIIB ( n  = 2). In 11/12 patients, parents were satisfied with the results. Conclusions : Although minor complications after LRFJ are common in our patients, this technique is a safe solution in patients with gastric emptying disorders leading to a definitive method of enteral feeding and high parenteral satisfaction. What is Known: • Traditional tube feeding in children (duodenal, PEG-J-tubes) with severe delayed gastric emptying can be challenging with a high rate of complications and maintenance issues. • Open loop jejunostomy and Roux-en-Y jejunostomy are alternative, permanent methods of feeding but either invasive or are accompanied by severe complications. Little is known in the literature about laparoscopic Roux-en-Y feeding jejunostomy. What is New: • Laparoscopic Roux-en-Y feeding jejunostomy is a permanent, safe and minimal invasive alternative option for enteral feeding in children with severe delayed gastric emptying..

BackgroundLaparoscopic intracorporeal esophagojejunostomy (EJ) is a useful method in totally laparoscopic total gastrectomy (TLTG) for treating upper-third gastric cancer. The two methods of laparoscopic intracorporeal EJ—functional and overlap—have not been compared side-by-side in terms of safety and feasibility.MethodsRetrospective review and analysis of the data of 490 consecutive patients who underwent TLTG by either functional method (n = 365) or overlap (n = 125) method for upper- or middle-third gastric cancer was conducted between January, 2011 and May, 2018 at Asan Medical Center (Seoul, Korea). One-to-one propensity score matching (PSM) was performed to compare age, sex, body mass index, American Society of Anesthesiologist score, the presence of comorbidity, number of comorbidities, clinical T stage, clinical nodal stage, clinical TNM stage, history of previous abdominal surgery, and combined surgery. After PSM, 244 patients were divided into functional method group and overlap method group (n = 122, each). The surgical outcomes and EJ-related complications were compared between the two groups.ResultsNo significant difference was found between the two groups in terms of early surgical outcomes such as operative time, time to first flatus, postoperative hospital stay, transfusion during surgery, transfusion after surgery, and administration of analgesics. However, the pain score was significantly lower in overlap method group (6.21 ± 1.83) than functional method group (6.97 ± 2.09, p < 0.05). The overlap method was also associated with significantly fewer late complications (3.28% vs. 12.30%; p < 0.05), lower Clavien–Dindo classification grade (p < 0.05), and fewer EJ-related complications (0.82% vs. 6.56%; p < 0.05), as compared with the functional method.ConclusionThe overlap method was safer and more feasible than the functional method for TLTG in gastric cancer patients, based on the finding of significantly lower incidence of EJ-related complications.

Background Feeding jejunostomy (JT) tubes are often utilized as an adjunct to optimize nutrition for successful esophagectomy; however, their utility has come into question. The aim of this study was to evaluate utilization and outcomes associated with JTs in a nationwide cohort of patients undergoing esophagectomy. Methods The NSQIP database was queried for patients who underwent elective esophagectomy. JT utilization was assessed between 2010 and 2019. Post-operative outcomes were compared between those with and without a JT on patients with esophagectomy-specific outcomes (2016–2019), with results validated using a propensity score-matched (PSM) analysis based on key clinicopathologic factors, including tumor stage. Results Of the 10,117 patients who underwent elective esophagectomy over the past decade, 53.0% had a JT placed concurrently and 47.0% did not. Utilization of JTs decreased over time, accounting for 60.0% of cases in 2010 compared to 41.7% in 2019 ( m  = − 2.14 95%CI: [− 1.49]–[− 2.80], p  < 0.01). Patients who underwent JT had more composite wound complications (17.0% vs. 14.1%, p  = 0.02) and a higher rate of all-cause morbidity (40.4% vs. 35.5%, p  = 0.01). Following PSM, 1007 pairs were identified. Analysis of perioperative outcomes demonstrated a higher rate of superficial skin infections (6.1% vs. 3.5%, p  = 0.01) in the JT group. However, length of stay, reoperation, readmission, anastomotic leak, composite wound complications, all-cause morbidity, and mortality rates were similar between groups. Conclusions Among patients undergoing elective esophagectomy, feeding jejunostomy tubes were utilized less frequently over the past decade. Similar perioperative outcomes among matched patients support the safety of esophagectomy without an adjunct feeding jejunostomy tube.

Aim The aim of this study was to introduce the Esophagus-Sparing Anastomotic Narrowing Revision (ESANR) technique for the intraoperative management of anastomotic narrowing and to conduct a literature review to provide an algorithm for the management of narrowing and strictures that may develop secondary to esophagojejunostomy. Methods Three patients with anastomotic narrowing during esophagojejunostomy were analyzed between September 2019 and June 2024. The anastomotic narrowing was detected by intraoperative gastroscopy after reconstruction. The ESANR technique was performed for the management of anastomotic narrowing. We conducted a systematic search of PubMed, Embase, and Web of Science databases for studies published up to June 2024 related to the treatment of anastomotic stricture. Data on the number of patients, sex, age, type of anastomosis, treatment, and outcomes were collected. Results The ESANR technique proved effective for the management of anastomotic narrowing in patients who underwent esophagojejunostomy during gastric cancer surgery. No anastomotic stricture or leakage was found following ESANR, and all three patients recovered without complications. 12 studies with a total of 174 patients were analyzed. The management of anastomotic stricture, which included Balloon Dilation (BD), Endoscopic Incision Therapy (EIT), stent placement, Endoscopic combination therapy (Needle-Knife stricturotomy NKS, Balloon Dilation with Triamcinolone Injection TAC), and re-do laparoscopic esophagojejunostomy. Conclusions In conclusion, the ESANR technique demonstrates potential advantages in addressing anastomotic narrowing in esophagojejunostomy. However, further clinical data and analyses are necessary to verify its effectiveness and establish robust statistical support.