OGT-assisted Overlap Esophagojejunostomy Versus Traditional Overlap Method (OGT)

Comparison Of Short-term Outcomes Between OGT-assisted Overlap Esophagojejunostomy And Traditional Overlap Method In Patients With Siewert III/II Esophagogastric Junction Cancer Or Gastric Cancer

Abstract Background Our previous studies have shown OGT method significantly simplified overlap esophagojejunostomy with good short-term outcomes, and provided new perspectives for optimizing esophagojejunostomy. However, the safety and efficiency of OGT method still need evidence of randomized controlled trial.

Methods: This trial is a prospective, multicenter, randomized, controlled, open, and superiority trial. Three hundred and forty-four patients who met the inclusion criteria and did not accord with the exclusion criteria will be randomly divided into OGT group(n=172) and traditional group(n=172). The primary purpose of this study is to evaluate time of oesophagojejunostomy of OGT method compared with traditional method for Siewert III/II esophagogastric junction cancer and gastric cancer. The second purpose is to evaluate the success rate of inserting anvil fork into esophageal lumen at first attempt, attempts of inserting anvil fork into esophagus, early postoperative complications,recovery course and compare the postoperative hospital stay of the patients enrolled in this study.

Discussion: This trial is the first prospective randomized two-arm controlled study to determine the safety and efficiency of OGT method compared with traditional overlap method. Through this trial, we hope to show that experienced surgeons can safely perform OGT-assisted overlap esophagojejunostomy for Siewert III/II esophagogastric junction cancer and gastric cancer.

Study Overview

• Status: Recruiting
• Conditions: Gastric Cancer
• Intervention / Treatment: Procedure: OGT group; Procedure: Overlap group

Detailed Description

Methods Objectives This trial is a prospective, multicenter trial for OGT-assisted overlap esophagojejunostomy and traditional overlap method during totally laparoscopic total gastrectomy for Siewert III/II esophagogastric junction cancer and gastric cancer. The primary purpose of this study is to evaluate the time of oesophagojejunostomy of OGT method compared with traditional overlap method for Siewert III/II esophagogastric junction cancer and gastric cancer. The second purpose is to evaluate the success rate of inserting anvil fork into esophageal lumen at first attempt, attempts of inserting anvil fork into esophagus, early postoperative complications,recovery course and compare the postoperative hospital stay of the patients enrolled in this study.

Study design This trial is a prospective, multicenter, randomized, controlled, open, and superiority trial comparing the safety of OGT method during TLTG for Siewert III /II esophagogastric junction cancer and gastric cancer compared with traditional overlap method .

Participating surgeons To participate in this trial, the responsible surgeons should meet the following qualifications: first, completing at least 50 cases of TLTG with D2 lymphadenectomy;second, passing the blind review of surgery video. Briefly, the applicants should provide the videos of TLTG with traditional overlap and OGT method in recent 3 months (three cases each) to the CLASS Research Council.CLASS Research Council will select two videos of traditional overlap and OGT method separately, and randomly appoint three experts to peer review blindly. When three experts unanimously approved it, the applicant will be permitted to participate in this study as a researcher.

Sample size calculation This is a superiority verification study on clinical efficiency, with the time of oesophagojejunostomy as the main index for efficiency evaluation. Our center's early OGT Overlap esophagojejunal anastomosis takes only 21 minutes, compared to 30-32 minutes for the conventional technique. The experimental group has a mean standard deviation of 6, while the control group has a mean standard deviation of 8. The ratio of the two groups is 1:1, and the superiority threshold is set at 7. With a one-sided error of 0.05 and a power test of 0.8, we calculated the required sample size for each group as 156 cases. Given a maximum dropout rate of about 10%, the final sample size for each group was set at 172 cases, totaling 344 cases.

Inclusion criteria Aged 18-75 years; Primary lesion is pathologically diagnosed as gastric adenocarcinoma; Expected to live more than 1 year; Tumor located located in gastroesophageal junction (GEJ) involve esophagus no more than 2cm, or in the upper, upper to middle, or entire stomach, and intend to perform laparoscopic total gastrectomy with D2 lymphadenectomy No history of upper abdominal surgery (except for laparoscopic cholecystectomy); Preoperative performance status (ECOG, Eastern Cooperative Oncology Group) of 0 or 1; Preoperative ASA (American Society of Anesthesiologists) scoring: I-III; Sufficient organ functions; Written informed consent.

Exclusion criteria Women during pregnancy or breast-feeding; Body temperature ≥ 38 °C before surgery or infectious disease with a systemic therapy indicated; Severe mental disease; Confirmed stage IV (AJCC 8th) during surgery Severe respiratory disease; Severe hepatic and renal dysfunction; Unstable angina pectoris or history of myocardial infarction within 6 months; History of cerebral infarction or cerebral hemorrhage within 6 months; Gastric cancer complications (bleeding, perforation, obstruction) that requiring emergency surgery.

Randomized grouping In this study, the central dynamic, stratified randomization method is adopted, and the factors including age, TNM stage, tumor location, neoadjuvant, BMI, and investigators, are considered. After each case is enrolled, the research center will arrange the research assistant to send the information of included cases (age,TNM stage, tumor location, neoadjuvant, and BMI) to the data center. After analyzing the case information by the center randomization department, the case grouping will be determined.

Quality control To ensure the rationality of the ESJ procedure, a series of photographs of ESJ (traditional and OGT) are taken for assessment. All photographs will be saved and submitted to CLASS data center within 1 week after the operation. The CLASS Research Committee will monitor and review regularly to ensure the quality of operation.

Outcome measurements

Primary endpoint:

Time of oesophagojejunostomy: time starts from making the entry hole for the anastomosis on the oesophagealstump, to the end of the common entry hole was closed using barbed threads.

The secondary endpoint of this study is early postoperative complications, the success rate of inserting anvil fork into oesophagal lumen at first attempt, the number of attempts to insert anvil fork into oesophagus and postoperative recovery course, which is assessed by time to first ambulation, flatus, liquid diet, soft diet, etc. In addition, the length of postoperative hospital stay will be recorded.

Follow-up The patients in both groups will be followed up 6 months after operation. A physical examination, a complete blood count, blood biochemical examination (albumin, prealbumin, total bilirubin, direct bilirubin, AST, ALT, creatinine, blood urea nitrogen, and blood glucose), and serum tumor markers (AFP, CEA, CA19-9, CA12-5, and CA72-4) analyses will be performed. In addition, imageological examination (total abdominal and pelvic enhanced CT, chest X-ray, upper gastrointestinal tract iodine imaging, gastroscopy, ultrasonography, whole body bone scan, PET-CT, etc.) will also be performed if needed. All the results will be recorded and evaluated by the specialist.

Statistical analysis Statistical analysis will be performed with SPSS 25.0 (SPSS Inc., Chicago, IL, USA). Continuous variables with normal distribution are expressed as the mean ± standard deviation, and continuous variables with a skewed distribution are expressed as the median (interquartile range [IQR]) and were compared across groups using. Continuous variables were compared across groups using the independent t-test or Mann-Whitney U test if the data were highly skewed. Categorical variables are expressed as the number and percentage and were compared with the chi-square test or Fisher's exact test(if a variable's exact theory frequency was less than 1). P < 0.05 was considered statistically significant.

• Study Type: Interventional
• Enrollment (Estimated): 344
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Xinhua Chen, Ph.D; Phone Number: +8615626452302; Email: xinhuachen03@163.com

Study Locations

• China
  • Fujian
    • Quanzhou, Fujian, China
      • Recruiting
      • Fujian Medical University 2nd Affiliated Hoapital
      • Contact: Kai Ye, Ph.D; Phone Number: 15159514641
  • Guangdong
    • Guangzhou, Guangdong, China
      • Recruiting
      • Guangdong Provincial People's Hospital
      • Contact: Junjiang Wang; Phone Number: 13650719255
    • Guangzhou, Guangdong, China, 510515
      • Completed
      • Nanfang Hospital
    • Guangzhou, Guangdong, China
      • Completed
      • Sixth Affiliated Hospital of Sun Yat-sen University
    • Guangzhou, Guangdong, China
      • Recruiting
      • The First Affiliated Hospital, Guangzhou University of Traditional Chinese Medicine
      • Contact: Wei Wang, Ph.D; Phone Number: 139 2225 5515
    • Shantou, Guangdong, China
      • Recruiting
      • The First Affiliated Hospital of Shantou University Medical College
      • Contact: Feirang Zhang; Phone Number: 13809293958
  • Guangxi
    • Ganzhou, Guangxi, China
      • Recruiting
      • Ganzhou City People Hospital
      • Contact: Chuanfa Fang; Phone Number: 15679777532
  • Hunan
    • Changsha, Hunan, China, 410013
      • Completed
      • The Third Xiangya Hospital of Central South University
    • Hengyang, Hunan, China, 421001
      • Completed
      • The First Affiliated Hospital of Nanhua University
  • Jilin
    • Changchun, Jilin, China
      • Completed
      • The First Hospital of Jilin University
  • Liaoning
    • Shenyang, Liaoning, China, 110001
      • Completed
      • The First Hospital of China Medical University
  • Shanxi
    • Changzhi, Shanxi, China
      • Completed
      • The People's Hospital of Changzhi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Aged 18-75 years;
• Primary lesion is pathologically diagnosed as gastric adenocarcinoma;
• Expected to live more than 1 year;
• Tumor located located in gastroesophageal junction (GEJ) involve esophagus no more than 2cm, or in the upper, upper to middle, or entire stomach, and intend to perform laparoscopic total gastrectomy with D2 lymphadenectomy
• No history of upper abdominal surgery (except for laparoscopic cholecystectomy);
• Preoperative performance status (ECOG, Eastern Cooperative Oncology Group) of 0 or 1;
• Preoperative ASA (American Society of Anesthesiologists) scoring: I-III;
• Without preoperative radiotherapy;
• Did not found metastasis preoperatively and intraoperatively;
• Sufficient organ functions;
• Written informed consent.

Exclusion Criteria:

• Women during pregnancy or breast-feeding;
• Body temperature ≥ 38 °C before surgery or infectious disease with a systemic therapy indicated;
• Severe mental disease;
• Confirmed stage IV (AJCC 8th) during surgery
• Severe respiratory disease;
• Severe hepatic and renal dysfunction;
• Unstable angina pectoris or history of myocardial infarction within 6 months;
• History of cerebral infarction or cerebral hemorrhage within 6 months;
• Gastric cancer complications (bleeding, perforation, obstruction) that requiring emergency surgery;
• Performing hyperthermic intraperitoneal chemotherapy (HIPEC) after surgery.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Arm A; In OGT group,After the enterotomy was made, the nasogastric tube was pulled out 3 cm from the oesophagal lumen to connect with the OGT. Next, the anvil fork sleeved with OGT insert into the oesophageal mucosa canal by movement of the connection of fork -OGT -gastric tube. Then, the anaesthesiologist continued to pull back the nasogastric tube for 10 cm to ensure that the stapler would not clamp the nasogastric tube. After that, the surgeon began to fire the stapler to perform side-to-side esophagojejunostomy.	Procedure: OGT group; In OGT group,the nasogastric tube was pulled out 3 cm from the oesophagal lumen to connect with the OGT. Meanwhile, the OGT was sleeved on anvil fork extracorporeally and the linear stapler was put into abdomen through trocar on the right side and then cartridge fork was inserted through jejunum opening towards the oral side of the lumen. Next, the anvil fork sleeved with OGT insert into the oesophageal mucosa canal by movement of the connection of fork -OGT -gastric tube.
Active Comparator: Arm B; In overlap group, the oesophagojejunostomy was performed as reported by Inaba et al. After firing the stapler, two openings were converted into a single entry hole to create an end-to-side oesophagojejunostomy, and the entry hole was closed with full-thickness running suture using barbed sutures intracorporeally.	Procedure: Overlap group; In overlap group, the oesophagojejunostomy was performed as reported by Inaba et al.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time of oesophagojejunostomy	Time starts from making the entry hole for the anastomosis on the oesophagealstump, to the end of the common entry hole was closed using barbed threads.	1 Days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time of oesophagojejunostomy	Time of esophagojejunostomy was defined as the time from making the entry hole for the anastomosis on the esophageal stump to the time the common entry hole was closed and reinforced using barbed threads	Surgery
The success rate of inserting anvil fork into oesophagal lumen at first attempt	Inserting anvil fork into esophageal lumen at first attempt: when inserting the anvil fork into the esophageal hole, the anvil fork can be correctly placed in a satisfactory position and at a satisfactory angle into the esophageal mucosa canal to be fired for esophagojejunostomy by inserting it only once.	Surgery
The number of attempts to insert anvil fork into oesophagus	The number of times required to try to insert the anvil fork in a satisfactory position and at a satisfactory angle into the esophageal mucosa canal to be fired for esophagojejunostomy.	Surgery

Collaborators and Investigators

• Sponsor: Nanfang Hospital, Southern Medical University
• Investigators: Principal Investigator: Jiang Yu, Ph.D, Nanfang Hospital, Southern Medical University; Principal Investigator: Quan Wang, Ph.D, The First Hospital of Jilin University; Principal Investigator: Kai Ye, Ph.D, Fujian Medical University 2nd Affiliated Hoapital; Principal Investigator: Chuanfa Fang, Ph.D, Ganzhou City People Hospital; Principal Investigator: Feirang Zhang, Ph.D, First Affiliated Hospital of Shantou University Medical College; Principal Investigator: Wei Wang, Ph.D, The First Affiliated Hospital, Guangzhou University of Traditional Chinese Medicine; Principal Investigator: Wenqing Hu, Ph.D, The People's Hospital of Changzhi; Principal Investigator: Junjiang Wang, Ph.D, Guangdong Provincial People's Hospital; Principal Investigator: Lei Lian, Ph.D, Sixth Affiliated Hospital of Sun Yat-sen University; Principal Investigator: Jiaquan Zhu, Ph.D, First Hospital of China Medical University; Principal Investigator: Yi Zhang, Ph.D, The Third Xiangya Hospital of Central South University; Principal Investigator: Shuai Xiao, Ph.D, The First Affiliated Hospital of Nanhua University

Study record dates

Study Major Dates

• Study Start (Actual): September 1, 2022
• Primary Completion (Actual): May 26, 2025
• Study Completion (Estimated): December 30, 2025

Study Registration Dates

• First Submitted: July 1, 2022
• First Submitted That Met QC Criteria: July 7, 2022
• First Posted (Actual): July 11, 2022

Study Record Updates

• Last Update Posted (Actual): May 31, 2025
• Last Update Submitted That Met QC Criteria: May 26, 2025
• Last Verified: May 1, 2025

More Information

Terms related to this study

• Keywords: Gastric/gastroesophageal junction (G/GEJ) tumors; Laparoscopy total gastrectomy; Overlap esophagojejunostomy; OGT
• Additional Relevant MeSH Terms: Neoplasms by Site; Neoplasms; Gastrointestinal Neoplasms; Digestive System Neoplasms; Digestive System Diseases; Gastrointestinal Diseases; Stomach Diseases; Stomach Neoplasms
• Other Study ID Numbers: NFEC-2022-202

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The IPD will be available for the investigation.
• IPD Sharing Time Frame: August, 2022-August, 2025
• IPD Sharing Access Criteria: All the accession for research will be admitted.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No