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Impact of Falciform Ligament Reinforcement in Esophagojejunostomy Leakage After Total Gastrectomy: A Pilot Study

This pilot study suggests that reinforcing esophagojejunostomy with the falciform ligament during total gastrectomy significantly reduces the incidence of anastomotic leakage and shortens hospital stays, despite not remaining a statistically significant protective factor in multivariable analysis.

Original authors: Qayom Khan Dawlatzay, Ahmet Akmercan, Şakir Karpuz, Tevfik Kıvılcım Uprak

Published 2026-10-12

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CC BY 4.0

Original authors: Qayom Khan Dawlatzay, Ahmet Akmercan, Şakir Karpuz, Tevfik Kıvılcım Uprak

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

When a surgeon removes a stomach to treat cancer, the body must be reconnected so that food can travel from the esophagus directly into the small intestine. This connection, known as an anastomosis, is one of the most critical and delicate steps in the entire operation. If this junction fails to heal properly, it can leak, allowing digestive fluids to escape into the abdominal cavity. Such a leak is a serious complication that often leads to severe infection, requires additional surgeries, prolongs hospital stays, and can even be fatal. Because the risk of this happening is a constant concern for surgeons, the medical community has long searched for ways to strengthen these connections. One approach involves using the body's own tissues to wrap around the new junction, providing extra support and blood flow to help it heal. While surgeons have used various tissues for this purpose in other parts of the body, a specific piece of tissue called the falciform ligament had never been tested for this specific job in stomach surgery until recently.

A team of researchers at Marmara University in Turkey set out to investigate whether using this ligament could make a difference. The falciform ligament is a thin, fan-shaped sheet of tissue that connects the liver to the front wall of the abdomen. It is rich in blood vessels and can be easily moved during surgery without causing harm to the patient. In this study, the researchers looked back at the records of 106 patients who had undergone total stomach removal for cancer. All of these patients had their digestive tracts reconnected by hand, using a single layer of stitches. The surgeons had chosen to use the falciform ligament reinforcement in 51 of these cases, wrapping the mobilized tissue around the new connection, while the other 55 patients received the standard procedure without this extra layer.

The results of this comparison were striking. Among the patients who did not receive the reinforcement, 14.5 percent developed a leak at the surgical site. In contrast, only 2.0 percent of the patients who had the ligament wrapped around their connection experienced this complication. This difference was statistically significant in the initial analysis, suggesting that the extra layer of tissue provided a potential protective benefit. The benefits extended beyond just preventing leaks. Patients who received the reinforcement also spent less time in the hospital, with a median stay of five days compared to six days for those who did not. Furthermore, the severity of the leaks that did occur was lessened; in the group with the reinforcement, the single patient who leaked was treated successfully without further surgery, whereas several patients in the other group required invasive interventions, and two unfortunately passed away.

The researchers also examined what factors made a leak more likely to happen in the first place. They found that patients who were older, had lower levels of a specific blood protein called albumin before surgery, or experienced greater blood loss during the operation were at higher risk. Interestingly, while the use of the ligament appeared to be a strong protective factor in the initial analysis, it did not remain a statistically independent predictor when the data was adjusted for these other risk factors. This likely happened because the study included a relatively small number of patients and a low number of leak events, which can make it difficult to prove a cause-and-effect relationship with absolute certainty. However, the clear reduction in leak rates and the shorter hospital stays observed in the reinforced group suggest that the technique is promising.

The study concludes that using the falciform ligament is a safe, simple, and potentially effective way to reinforce the connection after stomach removal. Because the tissue is taken from the patient's own body, it requires no special materials and carries no risk of rejection. The surgeons noted that the procedure did not cause any new problems, such as narrowing of the connection or other complications, during the follow-up period. While the authors caution that larger studies are needed to confirm these findings definitively, their work provides the first clinical evidence regarding the potential efficacy of this simple, low-cost technique to improve outcomes for patients facing one of the most challenging aspects of stomach cancer surgery.

Technical Summary: Impact of Falciform Ligament Reinforcement in Esophagojejunostomy Leakage After Total Gastrectomy

Problem Statement
Anastomotic leakage following total gastrectomy for gastric cancer remains a severe complication associated with high morbidity, mortality, and prolonged hospitalization. While patient-related factors (e.g., malnutrition, comorbidities) and surgical factors (e.g., tension, inadequate perfusion) contribute to leakage, the incidence of esophagojejunostomy leakage varies widely (3–15%). Although reinforcement of the anastomosis with autologous vascularized tissue (such as the omentum) is a known strategy to improve healing, the omentum is often unavailable or unsuitable for esophagojejunostomy reinforcement after total gastrectomy. The falciform ligament, a well-vascularized autologous tissue, has been utilized in various reconstructive procedures but has not previously been reported as a reinforcement material for esophagojejunostomy.

Methodology
This retrospective cohort study analyzed data from 106 consecutive patients with stage I–III gastric adenocarcinoma who underwent open total gastrectomy with hand-sewn esophagojejunostomy between January 2023 and December 2025 at a single institution.

Grouping: Patients were stratified into two groups based on whether the operating surgeon utilized falciform ligament reinforcement (FLR) for the anastomosis: the FLR group ( $n=51$ ) and the control group ( $n=55$ ).
Surgical Technique: In the FLR group, the falciform ligament was mobilized as a pedicled flap (20–30 cm) from the umbilical level to the diaphragm, ensuring adequate vascularity. Following the construction of a single-layer, full-thickness, hand-sewn esophagojejunostomy, the ligament was wrapped circumferentially around the anastomosis and secured with absorbable sutures, ensuring no luminal narrowing or torsion.
Outcomes: The primary outcome was the incidence of esophagojejunostomy leakage, defined by clinical signs, radiological evidence of contrast extravasation, or endoscopic confirmation. Secondary outcomes included anastomotic stricture, length of hospital stay, and risk factors associated with leakage.
Analysis: Statistical comparisons were performed using chi-square/Fisher's exact tests for categorical variables and Mann-Whitney U tests for continuous variables. Multivariable regression analysis was employed to identify independent risk factors.

Key Results

Leakage Rates: The overall leakage rate was 8.5%. The FLR group demonstrated a significantly lower leakage rate compared to the control group (2.0% vs. 14.5%; $p=0.020$ ).
Clinical Severity: In the FLR group, the single leakage case was managed conservatively. In contrast, the control group had eight leakage cases, requiring invasive interventions (stents, drainage) in several instances, and resulting in two deaths.
Hospital Stay: The median length of hospital stay was significantly shorter in the FLR group (5 days) compared to the control group (6 days; $p=0.017$ ).
Strictures: No benign anastomotic strictures were observed in either group during follow-up.
Risk Factors: Univariable analysis identified older age, lower preoperative hemoglobin, lower preoperative albumin, increased intraoperative blood loss, and the absence of FLR as significant factors associated with leakage. However, in multivariable analysis, only lower preoperative albumin levels (OR 1.48) and increased intraoperative blood loss (OR 1.03) remained independent risk factors. FLR did not retain statistical significance as an independent protective factor in the multivariable model ( $p=0.454$ ), likely due to the limited sample size and low event count.

Significance and Claims
The authors claim that this study provides the first clinical evidence regarding the use of falciform ligament reinforcement for esophagojejunostomy. The paper posits that FLR is a feasible, safe, and technically simple adjunctive technique that utilizes readily available autologous tissue without additional morbidity.

While the multivariable analysis did not confirm FLR as an independent protective factor—attributed by the authors to the study's pilot nature, small sample size, and low number of leakage events—the observed reduction in leakage incidence (from 14.5% to 2.0%) and the associated decrease in hospital stay suggest a potential clinical benefit. The authors conclude that FLR may be a promising strategy for reinforcing esophagojejunostomy, warranting further investigation in larger, prospective multicenter studies to validate these findings and overcome the statistical limitations of the current pilot data.

Technical Summary: Impact of Falciform Ligament Reinforcement in Esophagojejunostomy Leakage After Total Gastrectomy

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