Prospective Randomized Trial Comparing Billroth I and Roux-en-Y Procedures after Distal Gastrectomy for Gastric Carcinoma

To determine the clinical efficacy of Roux-en-Y reconstruction (RY) after distal gastrectomy, we compared postoperative outcomes of patients who underwent RY or conventional Billroth I reconstruction (B-I). A total of 50 patients were prospectively randomized to either B-I or RY reconstruction, and complications, postoperative course, and nutritional status were compared. Bile reflux and inflammation in the remnant stomach and lower esophagus were evaluated by postoperative follow-up endoscopy at 6 months. Operative time and blood loss as well as postoperative nutrition did not show significant differences between the two groups. As anticipated, 5 of 24 patients with RY reconstruction developed gastrojejunal stasis in the early postoperative period, which led to a longer postoperative hospital stay as compared with the B-I group (mean ± S.D; B-I; 19.0 ± 6.2, RY; 31.8 ± 21.7 days) (P < 0.05). Endoscopic examination revealed that the frequency of bile reflux (P < 0.01) and degree of inflammation in the remnant stomach (P < 0.05) were less in the RY group than in the B-I group. However, inflammatory findings in the lower esophagus were observed in 7 (27%) of B-I, and 8 (35%) of the RY group, suggesting that late phase esophagitis was not improved in the RY group. Roux-en-Y reconstruction was effective in preventing duodenogastric reflux and resulting gastritis, but it did not prevent esophagitis. Because RY reconstruction induces the frequent complication of Roux-en-Y stasis, causing longer postoperative hospital stay, this method has limited advantages over B-I anastomosis after distal gastrectomy.     

Clinical Outcome of Pylorus-preserving Gastrectomy in Gastric Cancer in Comparison with Conventional Distal Gastrectomy with Billroth I Anastomosis

BACKGROUND: Pylorus-preserving gastrectomy (PPG) was originally a treatment option in gastric ulcer surgery and is now being performed as a limited surgery in some early gastric cancer cases. This study was designed to evaluate the postoperative functional characteristics of PPG versus conventional distal gastrectomy with Billroth I anastomosis (BI). METHODS: Patients who underwent PPG (study group) between November 1999 and April 2003 were enrolled and BI patients (control group) were matched for number, gender, age, weight, height, stage, and follow-up period. We evaluated postprandial symptoms and nutritional status. Gastric emptying studies with a 99mTc gamma camera, follow-up endoscopies with random biopsies of remnant gastric mucosa to evaluate bile reflux gastritis, and ultrasonography to detect gallbladder stones were performed. Recurrence and survival also were investigated. RESULTS: Twenty-two PPG patients (study group) and 17 BI patients (control group) were enrolled. Overall modified Visick scores of postprandial symptoms were lower in PPG patients than in BI patients (0.9 +/- 0.7 vs. 2.3 +/- 1.4; p = 0.018). Gastric emptying was delayed in PPG patients versus BI patients for solids (p < 0.05). Moderate gastritis, bile reflux, and gallbladder stone were observed only in BI patients. Remnant stomach pathologic findings corresponding to bile reflux gastritis in the two groups were similar, except for Helicobacter pylori colonization. No recurrence occurred in either group (mean follow-up period = 41 +/- 9.5 months). CONCLUSIONS: PPG patients had fewer subjective postprandial symptoms than BI patients. The present study also suggests that PPG has advantages over BI in terms of the avoidance of bile reflux and gallbladder stones.     

Randomized Controlled Trial of Roux-en-Y Versus Rho-Shaped-Roux-en-Y Reconstruction After Distal Gastrectomy for Gastric Cancer

Background  The main advantage of the Roux-en-Y (RY) operation is that it prevents bile and pancreatic juice from reaching the gastric mucosa, although the gastrojejunostomy may cause functional delayed gastric emptying (DGE), known as RY stasis syndrome. Rho-shaped Roux-en-Y reconstruction (rRY), an RY reconstruction with a rho-shaped anastomosis, is an established operation that has been found to be effective in preventing DGE. Methods  We conducted the randomized trial of RY versus rRY reconstruction after gastric cancer resection. The primary endpoint was the frequency of DGE, and secondary endpoints were the length of postoperative hospital stay, morbidity, and nutritional status. Seventy patients were enrolled, with 35 in each group. Results  The incidences of postoperative mortality and morbidity did not differ significantly between the two groups. There were no significant differences in nutritional status between the two groups after discharge. Delayed gastric emptying occurred in two patients (6%) in the RY group and four patients (11%) in the rRY group (P = 0.67). Logistic regression analysis revealed that truncal vagotomy was significantly associated with DGE inhibition. Conclusions  Our findings showed that RY reconstruction after gastrectomy may be as simple and sufficient as conventional reconstruction.     

Morbidity and Mortality Results From a Prospective Randomized Controlled Trial Comparing Billroth I and Roux-en-Y Reconstructive Procedures After Distal Gastrectomy for Gastric Cancer

Background  

Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed after distal gastrectomy. Which reconstruction procedure is superior remains controversial. We conducted a randomized controlled trial to compare the clinical efficacy of B-I and R-Y.     

Assessment of Postoperative Symptoms After Laparoscopy-Assisted Distal Gastrectomy for Stage I Gastric Cancer

Laparoscopic gastrectomy has the advantage of early recovery at the initial phase after surgery. However, there are only few reports of mid- or long-term observations of patients'' quality of life. In all, 254 Stage IA or IB [laparoscopy-assisted distal gastrectomy (LADG): 177, open distal gastrectomy (ODG): 77] patients were enrolled. Heart burn, diarrhea, abdominal pain, amount of food intake, and body weight of each patient were investigated at 1 month, 3 months, 6 months, and 1 year after surgery. Recovery of the amount of oral intake for the LADG group occurred earlier than for the ODG group; significant differences were seen at months 1 and 6 postoperatively. A significantly lower incidence of diarrhea was observed in the LADG group at months 6 and 12 postoperatively. Early recovery of the amount of food intake and fewer incidences of diarrhea were shown to have mid-term merits for postgastrectomy symptoms.Key words: Laparoscopy, Gastrectomy, Gastric cancer, Postoperative symptomsLaparoscopic gastrectomy is well known as a less invasive surgery, which provides an early recovery from the pain, bowel paralysis, and hematologic parameters. However, these well-examined objects belong to the recovery by the day.¹⁻³ On the other hand, the fluctuation of the frequency of heart burn, diarrhea and abdominal pain after eating, amount of oral intake, and body weight loss persist for months. So these subjects belong to the recovery by the month. And only a few studies about these subjects after laparoscopic gastrectomy compared with open gastrectomy.^4,5 Therefore, it is unclear whether laparoscopic gastrectomy has merits for improved mid- or long-term quality of life (QOL). In this study, we observed these postgastrectomy symptoms during the first year after surgery, and compared the changeover between laparoscopy-assisted distal gastrectomy (LADG) and open distal gastrectomy (ODG).     

Billroth I Gastrectomy Using a Circular Stapler to Treat Gastric Cancer

We describe herein our technique of performing gastrectomy followed by side-to-end gastroduodenostomy. Because the clamp is removed at the resection line of the greater curvature, there is no need to perform an additional gastrotomy for insertion of the instrument. This feature differentiates our technique from previous methods of anastomosis using the circular stapler. We believe that our technique is superior in simplicity and security to the traditional hand-sewn anastomosis. Moreover, it allows for a shorter operative time. This technique is recommended for practical surgery over conventional techniques. Received: February 23, 2000 / Accepted: July 25, 2000     

Short-term Outcomes of Roux-en-Y Stapled Anastomosis after Distal Gastrectomy for Gastric Adenocarcinoma

Background

Since 2003, we have begun to perform gastrojejunostomy by mechanical stapling for Roux-en-Y reconstruction in distal gastrectomy. We performed a retrospective study to compare the short-term outcomes of anastomosis by mechanical stapling and hand suturing.

Methods

We evaluated the data of 701 consecutive patients of gastric adenocarcinoma who underwent conventional open distal gastrectomy with Roux-en-Y reconstruction. The data collected included details on the method used for the Roux-en-Y reconstruction, the disease stage, extent of lymph node dissection, performance rate of truncal vagotomy, operation time, operative blood loss, length of hospital stay, and postoperative complications.

Results

The operation time was significantly shorter in the group in which mechanical stapling was used for the anastomosis (MS group) than in the group in which anastomosis was performed by hand suturing (HS group; 241.1?±?56.8 vs. 166.4?±?48.3 min; p?<?0.05). Postoperatively, delayed gastric emptying occurred in 14 (1.9%) patients, including seven (4.2%) from the MS group and seven (1.3%) from the HS group (p?=?0.038).

Conclusion

There were no significant disadvantages of employing mechanical stapling for anastomosis, except for the high rate of delayed gastric emptying. More consideration therefore needs to be given to decreasing the frequency of gastric emptying disturbance post surgery using mechanical staples.     

Roux-en-Y Reconstruction is Superior to Billroth I Reconstruction in Reducing Reflux Esophagitis After Distal Gastrectomy: Special Relationship with the Angle of His

Background  

The aim of the present study was to evaluate the relationship between the angle of His in Roux-en-Y (RY) or Billroth I (BI) reconstruction and reflux esophagitis after distal gastrectomy for gastric cancer.     

Roux-en-Y 胃空肠吻合术在远端胃切除消化道重建中的应用

目的 评价Roux-en-Y胃空肠吻合术在远端胃大部切除消化道重建中的临床价值。方法 对笔者所在医院科室2009年1月至2012年7月期间31例远端胃癌行Roux-en-Y消化道重建患者的临床资料进行回顾性分析。结果 全组病例无围手术期死亡,无吻合口漏、十二指肠残端瘘、输入空肠段梗阻及倾倒综合征发生。28例（90.3%） 患者术后半年进食3～4次/d,每餐量150～400 g;血红蛋白110～150 g/L,血清白蛋白38～50 g/L;24例 （77.4%） 患者体质量恢复或超过术前水平。胃镜检查未发现反流性食管炎,有残胃炎表现者3例,但无临床症状。结论 Roux-en-Y胃空肠吻合术可成为远端胃大部切除消化道重建的主要术式。     

Comparison Between Billroth-II with Braun and Roux-en-Y Reconstruction After Laparoscopic Distal Gastrectomy

Purpose

This study aims to compare the effectiveness of Billroth-II with Braun and Roux-en-Y reconstruction after laparoscopic distal gastrectomy.

Methods

From April 2010 to August 2012, 66 patients underwent laparoscopic distal gastrectomy (Billroth-II with Braun reconstruction, 26; Roux-en-Y, 40). The patients’ data were collected prospectively and reviewed retrospectively.

Results

The mean operation and reconstruction times were statistically shorter for Billroth-II with Braun reconstruction than Roux-en-Y (198.1?±?33.0 vs. 242.3?±?58.1 min, p?=?0.001). One case of postoperative stricture was observed in each group. One case each of intra-abdominal abscess and delayed gastric emptying occurred in the Billroth-II with Braun group. At 1 year postoperatively, gastric residue and reflux esophagitis were not significantly different between the groups. Gastritis and bile reflux were more frequently observed in the Billroth-II with Braun group (p?=?0.004 and p?<?0.001, respectively). At 2 years postoperatively, gastric residue was not significantly different, but gastritis, bile reflux, and esophagitis were more frequent in the Billroth-II with Braun group (p?=?0.029, p?<?0.001, and p?=?0.036, respectively).

Conclusion

The postoperative effectiveness of Roux-en-Y reconstruction may be superior to Billroth-II with Braun reconstruction after laparoscopic distal gastrectomy.

     

A Modified Stapling Technique for Performing Billroth I Anastomosis after Distal Gastrectomy

Autosuture staplers have provided various operative and postoperative benefits in gastrointestinal surgery. We describe herein our technique of performing distal gastrectomy followed by side-to-end gastroduodenostomy. Eighteen consecutive patients with gastric cancer underwent distal gastrectomy by the staple technique. We propose a modification of the stapling technique to reduce the number of devices used. In our technique, side-to-end anastomosis is performed first, followed by gastric resection just distal to the anastomosis. By introducing the stapler through the area to be resected, we can eliminate the need to close the gastrostomy. Anastomotic stricture occurred in only 1 (5.5%) of 18 cases. There have been no other postoperative complications related to the anastomosis. We believe that our technique is superior in simplicity and security to the conventional techniques.     

腹腔镜下早期胃癌手术的消化道重建

随着内窥镜技术的飞速发展和高危人群对胃镜检查的普遍接受,越来越多的胃癌患者获得早期诊断、及时治疗及长期生存。近20年来,腹腔镜胃癌根治术得到蓬勃发展,使早期胃癌患者在获得根治性疗效的前提下,获得了微创的手术效果和快速的康复,提升了生命质量,其已成为治疗早期胃癌的金标准手术。     

Postoperative Evaluation of Pylorus-Preserving Procedures Compared with Conventional Distal Gastrectomy for Early Gastric Cancer

We evaluated postoperative function in 98 patients who underwent surgery for early gastric cancer between 1995 and 1998 to compare the results of pylorus-preserving procedures to those of conventional distal gastrectomy with Billroth I (B-I). The pylorus-preserving procedures included endoscopic mucosal resection (EMR), performed in 12 patients; local resection (Local), performed in 14 patients; segmental resection (Seg), performed in 8 patients; and pylorus-preserving gastrectomy (PPG), performed in 19 patients. B-I was performed in 45 patients. The nutritional status and serum albumin (Alb) levels after PPG, the hemoglobin (Hb) levels after EMR, Local, and PPG, and the present/preoperative body weight ratios after EMR, Local, Seg, and PPG were superior to those after B-I. The time before oral intake was recommenced after EMR and Local, the volume of oral intake tolerated after EMR, Local, Seg, and PPG, and the postoperative hospital stay after EMR were all superior to those after B-I. Moreover, significantly fewer patients suffered reflux symptoms after EMR, Local, and PPG, abdominal fullness after EMR, and early dumping syndrome after EMR, Local, and PPG than after B-I. There was also less evidence of gastritis after EMR, Local, and PPG, and of bile reflux after EMR, Local, and PPG, than after B-I. These findings indicate that pylorus-preserving procedures may result in a better postoperative quality of life for selected patients with early gastric cancer. Received: September 28, 2000 / Accepted: March 6, 2001     

Outcome of Segmental Gastrectomy versus Distal Gastrectomy for Early Gastric Cancer

Background Because of the frequent occurrence of postgastrectomy disturbances after distal gastrectomy (DG), segmental gastrectomy (SG) has recently been applied to early gastric cancer (EGC). Outcomes of SG and DG in patients with EGC were compared to clarify the usefulness of SG as a treatment for EGC. Methods This retrospective study involved 61 patients with EGC: 28 patients who underwent DG before March 1996 and 33 patients who underwent SG after April 1996 during the period April 1991 through March 2002. Patient and tumor characteristics, operative results, and postoperative outcomes were compared between the two groups. Results The postoperative/preoperative body weight ratio was higher in the SG group than in the DG group. Early dumping syndrome and reflux gastritis occurred less frequently after SG than after DG. The incidence of postoperative complications was similar in the two groups. All patients remained alive without recurrence during a mean follow-up period of 54.7 months in the SG group and 99.9 months in the DG group. Conclusions In comparison to DG, SG is associated with improved postoperative quality of life with no decrease in operative curability of EGC. Thus, SG is a feasible treatment for EGC.     

Postoperative Pancreatic Fistula and the Risk Factors of Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer

Background  

Laparoscopy-assisted distal gastrectomy (LADG) was introduced as minimally invasive surgery for early gastric cancer (EGC) in Japan. This study investigated postoperative pancreatic fistula (POPF) and associated risk factors of the procedure.     

Oncologic Outcomes of Laparoscopy-Assisted Distal Gastrectomy for Gastric Cancer

Background

In both advanced and early gastric cancer with preoperatively suspected lymph node metastasis, extended lymph node dissection is needed to achieve R0. Since extended lymph node dissection is difficult to perform laparoscopically, few reports have reported long-term outcomes in large numbers of patients. The purpose of this study was to investigate oncologic outcomes after laparoscopy-assisted distal gastrectomy (LADG) with extended lymph node dissection.

Methods

Between April 2004 and March 2010, LADG with extended lymph node dissection was performed at our hospital for 880 patients diagnosed with T1N0-1 or T2N0 (N is classified by Japanese topographic classification) gastric cancer in the lower or middle body of the stomach. D2 lymph node dissection was performed for stage IB (T1N1, T2N0) cancers. Modified D2 lymph node dissection was performed for stage IA (T1N0). Overall survival (OS), disease-free survival (DFS), and form of tumor recurrence at 4 years were investigated retrospectively.

Results

Median follow-up was 42 months. The 4-year OS was 98.2 % for all patients. By stage, OS/DFS were 99.0/99.0 % in stage IA patients, 95.9/95.9 % in stage IB, 92.6/92.0 % in stage IIA, and 90.0/92.9 % in stage IIB. A total of 11 patients died, including 4 deaths from recurrence (liver metastasis, n = 1; peritoneal dissemination, n = 2; distant lymph node and bone metastases, n = 1). There is 1 patient is alive with recurrence (liver). Mean time until recurrence was 14 months.

Conclusions

Oncologic outcomes were good in patients with T1N0-1 and T2N0 gastric cancer who underwent LADG with extended lymph node dissection. This approach appears effective for treating T1N0-1 and T2N0 gastric cancer.     

Spleen-Preserving Distal Pancreatectomy Combined with Distal Gastrectomy for Distal Pancreatic Lesion and Gastric Cancer: Report of a Case

Spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein was recently devised as a feasible operation. We report the case of a patient who underwent spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, combined with distal gastrectomy, for gastric cancer and a distal pancreatic lesion. Thus, unnecessary total gastrectomy was avoided. The operative blood loss and operative time were 630 ml and 465 min, respectively. The patient's postoperative course was complicated by a minor pancreatic fistula, which required daily irrigation and drainage, but she recovered and was discharged from hospital. This case report demonstrates that spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein combined with distal gastrectomy can be performable synchronously and is a feasible alternative to avoid unnecessary total gastrectomy.     

Laparoscopy-Assisted Distal Gastrectomy for Early Gastric Cancer: A Video Demonstration

Background  

Laparoscopic gastrectomy with lymph node dissection, such as laparoscopy-assisted distal gastrectomy (LADG), has been widely accepted as the treatment for early gastric cancer with the risk of lymph node metastasis, especially in Asia since 1991.1 ^– 3