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