Reframing self-pulling and latter transection as a traction concept to de-risk overlap esophagojejunostomy in totally laparoscopic total gastrectomy

Dear Editor, Intracorporeal esophagojejunostomy remains a pivotal technical bottleneck in totally laparoscopic total gastrectomy (TLTG). Among commonly adopted approaches, linear-stapled overlap reconstruction was originally introduced as a practical intracorporeal option that is less constrained by esophageal diameter[1]. However, in a deep and narrow operative field, conventional overlap can still be challenged by proximal stump retraction after early transection and technically demanding closure of the common entry hole. We propose that self-pulling and latter transection (SPLT) should be reframed less as a single “named technique” and more as a transferable traction concept: defer esophageal transection while maintaining controlled traction to preserve exposure throughout key reconstructive steps. The original SPLT framework and subsequent variants share the same logic – “transection later, traction first” – aiming to prevent a “lost stump,” stabilize stapler introduction, and facilitate subsequent entry-hole closure[2,3]. First, the traction concept addresses the core ergonomic problem of overlap esophagojejunostomy in TLTG: exposure control. By keeping esophageal continuity until the anastomosis is established, SPLT-style traction helps maintain a stable operative window and reduces the risk of high mediastinal retraction, which is particularly relevant in patients with limited working space (e.g., obesity or a short abdominal esophagus)[2]. Meanwhile, by reducing repeated grasping and compression of the esophageal wall during manipulation, traction may theoretically mitigate tissue injury during reconstruction[3]. Second, emerging comparative evidence suggests that integrating SPLT into overlap reconstruction may streamline operative workflow and improve key short-term intraoperative metrics. In a recent retrospective comparison of SPLT-overlap versus traditional overlap during TLTG, the SPLT-overlap approach was associated with significantly shorter operation and esophagojejunal anastomosis times, lower intraoperative blood loss (80.29 ± 36.36 vs 101.40 ± 46.68 ml), and a higher proximal cutting edge, without an apparent increase in short-term postoperative complications[4]. These observations support the view that the main contribution of SPLT lies in traction-enabled exposure and procedural simplification rather than in introducing additional instruments. Moreover, the available evidence remains heterogeneous, and results may depend on how traction is created and controlled, what exactly constitutes “latter transection,” the orientation of stapling, and the strategy for entry-hole closure. In addition, not all comparative studies use the same control procedures; for example, SPLT-TLTG has also been compared with laparoscopic-assisted total gastrectomy and shown broadly similar short-term outcomes while emphasizing incision advantages and reconstruction simplification[5]. Long-term endpoints – clinically meaningful stricture, reflux-related symptoms, nutritional recovery, and oncologic outcomes – are still insufficiently established across consistent definitions and follow-up durations. In conclusion, SPLT is best understood as a traction concept for de-risking overlap esophagojejunostomy in TLTG, rather than an eponym that should proliferate into multiple near-duplicate “new techniques.” To translate promising feasibility into generalizable practice, we suggest that future studies standardize reporting of four concept-defining items: (1) traction creation (where/how the self-pulling point is established), (2) traction control (how excessive pull and mucosal injury are avoided), (3) an explicit, reproducible definition of “latter transection,” and (4) entry-hole closure strategy and leak testing. Multicentre prospective registries and pragmatic trials with a core outcome set would clarify whether the traction concept yields reproducible benefit across centers and patient subgroups.