Objective: Traditional Kamikawa anastomosis in digestive tract reconstruction after proximal
gastrectomy can greatly decrease the anastomosis-related complications and reduce the incidence of
reflux esophagitis, but its complexity limits the wide application. To decrease the complexity of Kamikawa anastomosis, the surgical team of Changzhi People's Hospital of Shanxi Changzhi Medical College improved this technique by using novel notion and reduced
surgical procedures. This study aims to evaluate the efficacy and safety of modified Kamikawa anastomosis in digestive tract reconstruction after proximal
gastrectomy. Methods: A descriptive cohort study was carried out. Case enrollment criteria: (1) upper gastric
carcinoma or esophagogastric junction
carcinoma without distant
metastasis was confirmed by preoperative gastroscopic biopsy and imaging examination; (2)
tumor diameter was less than 4 cm; (3) preoperative clinical staging was cT1-3N1M0. Exclusion criteria: (1) patients received preoperative
neoadjuvant chemotherapy; (2) patients had severe heart or
lung disease, or poor nutritional status so that they could not tolerate surgery. Clinical data of 25 patients with upper gastric
carcinoma or esophagogastric junction
carcinoma who underwent modified Kamikawa anastomosis in digestive tract reconstruction in Heji Hospital (8 cases) and Changzhi People's Hospital (17 cases) from April 2019 to December 2020 were retrospectively collected. Of 25 patients, 21 were male and 4 were female, with mean age of 63.0 (49 to 78) years; 3 underwent open surgery and 22 underwent laparoscopic surgery. The modified Kamikawa anastomosis was as follows: (1) the novel notion of total mesangial resection of the esophagogastric junction was applied to facilitate the thorough removal of lymph nodes and facilitate hand-sewn anastomosis and embedding; (2) the diameter of the anastomotic stoma was selected according to the diameter of the esophageal stump, between 2.5 and 3.5 cm, to reduce the occurrence of anastomotic
stenosis; (3) an ultrasonic scalpel was used to incise the esophageal stump, which could not only prevent
bleeding of the esophageal stump, but also closely seal the esophageal mucosa, muscle layer and serosa to prevent esophageal mucosa retraction; (4) barbed
suture was used to
suture the remnant stomach fundus and esophagus to fix the stomach fundus in order to reduce the cumbersome and difficult intermittent
sutures in a small space; (5) two barbed
sutures were used to continuously
suture the front and back walls of the anastomosis and complete the
suture and fixation of the muscle flap. Relevant indicators of surgical safety, postoperative complications (using the Clavien-Dindo classification),
esophageal reflux symptoms and the occurrence of
esophagitis (using Los Angeles classification) were analyzed. The
gastroesophageal reflux disease (
GERD) score, gastroscopy, multi-position digestive tract radiography during postoperative follow-up were used to evaluate the residual gastric motility and anti-reflux efficacy. Results: Modified Kamikawa anastomosis in digestive tract reconstruction after proximal
gastrectomy was successfully performed in 25 patients. The
surgical time was (5.8±1.8) hours, the intraoperative blood loss was (89.2±11.8) ml, and the average
hospital stay was (13.8±2.9) days. Three cases (12.0%) developed postoperative anastomotic
stenosis as Clavien-Dindo grade III and were healed after endoscopic dilation treatment. Postoperative upper gastrointestinal radiography showed 1 case (4.0%) with reflux symptoms as Clavien-Dindo grade I. Gastroscopy showed no signs of
reflux esophagitis, and its Los Angeles classification was A grade. No anastomotic
bleeding, local
infection and death were found in all the patients. At postoperative 6-month of follow-up,
GERD score showed no significant difference compared to pre-operation (2.7±0.6 vs. 2.4±1.0, t=-1.495, P=0.148). Conclusion: Modified Kamikawa anastomosis in digestive tract reconstruction after proximal
gastrectomy is safe and feasible with good anti-reflux efficacy.