Long-term outcomes of Roux-en-Y and Billroth-I reconstruction after laparoscopic distal gastrectomy

Background

Laparoscopic distal gastrectomy (LDG) is an established procedure for the treatment of early gastric cancer. Roux-en-Y (R-Y) or Billroth-I (B-I) reconstruction is generally performed after LDG in Japan. The aim of this retrospective cohort study was to compare the effectiveness of R-Y and B-I reconstructions and thereby determine which has better clinical outcomes.

Methods

We analyzed data from 172 patients with gastric cancer who underwent LDG. Reconstruction was done by R-Y in 83 patients and B-I in 89. All patients were followed up for 5 years. Evaluated variables included symptoms, nutritional status, endoscopic findings, gallstone formation, and later gastrointestinal complications.

Results

Scores for the amount of residue in the gastric stump, remnant gastritis, and bile reflux, calculated according to the “residue, gastritis, bile” scoring system, were significantly lower in the R-Y group (score 0 vs. 1 and more; p = 0.027, <0.001, and <0.001, respectively). The proportion of patients with reflux esophagitis was significantly lower in the R-Y group (p < 0.001). Relative values (postoperative 5 years/preoperative) for body weight, serum albumin level, and total cholesterol level were similar in the two groups (p = 0.59, 0.56, and 0.34, respectively). Gallstone formation did not differ between the groups (p = 0.57). As for later complications, the incidence of gastrointestinal ulcer was 4.5 % in the B-I group, and that of ileus was 3.6 % in the R-Y group, but differences between the groups were not significant (p = 0.12, 0.11, respectively).

Conclusions

As compared with B-I, R-Y was associated with lower long-term incidences of both bile reflux into the gastric remnant and reflux esophagitis.     

Laparoscopy-assisted uncut Roux-en-Y operation after distal gastrectomy for gastric cancer

In order to prevent the Roux stasis syndrome that sometimes follows Roux-en-Y gastrojejunostomy after distal gastrectomy, a new type of reconstruction, called the uncut Roux-en-Y technique, has been reported. We successfully performed 42 laparoscopy-assisted uncut Roux-en-Y gastrojejunostomies. Here we describe our technique and the initial outcome.     

The flow angle beneath the gastrojejunostomy predicts delayed gastric emptying in Roux-en-Y reconstruction after distal gastrectomy

Background

Delayed gastric emptying without mechanical obstruction after Roux-en-Y reconstruction has been defined as Roux stasis syndrome. It occurs in 10–30% of patients after such reconstruction. So far, the cause of this stasis has not been completely identified. This study aimed to reduce Roux stasis using surgical techniques.

Methods

From November 2007 to October 2010, we performed 101 distal gastrectomies with Roux-en-Y reconstruction. All the gastrojejunostomies were performed with end-to-end anastomoses. Roux stasis was analyzed with respect to tumor location, extent of the dissection, tumor progression, operation time, antecolic/retrocolic reconstruction, and the shape of the gastrojejunostomy. The shape of the gastrojejunostomy was evaluated by contrast gastroradiography 4?days after the operation.

Results

Roux stasis syndrome was observed in 17 of the 101 patients. There was no relationship between the extent of the dissection, tumor progression, or operation time and the occurrence of Roux stasis. There was no difference in the incidence of Roux stasis between antecolic and retrocolic reconstructions. However, the group that displayed a straight anastomotic shape on contrast radiography demonstrated an apparently lower incidence of Roux stasis (p?=?0.0003). In addition, Roux-en-Y reconstruction following gastric cancer was more frequently followed by Roux stasis in the antrum than in the midstomach (p?=?0.0036). Cases of Roux stasis occurred 11.8?days after surgery on average and resolved within 2?weeks on average.

Conclusions

Our findings demonstrate the substantial benefits of a straight anastomosis of the gastrojejunostomy for the prevention of Roux stasis syndrome.     

Comparison of delta-shaped anastomosis and Billroth I reconstruction after laparoscopic distal gastrectomy for gastric cancer

BackgroundThis study intends to compare the short-term effects and long-term survival of gastric cancer patients who underwent delta-shaped anastomosis (DA) and Billroth I reconstructions after laparoscopic distal gastrectomy.MethodsWe retrospectively collected data from 257 patients with gastric cancer who underwent laparoscopic distal gastrectomy between January 2013 and December 2017. Patients were classified into 2 groups according to the reconstruction method used: the DA group (n=91) and the Billroth I group (n=166). The clinical data, short-term efficacy, and long-term results were compared between the 2 groups.ResultsThe operation time (P<0.001) and the post-operative length of hospital stay (P<0.001) were shorter in the DA group than in the Billroth I group. The time to the first oral intake of a soft diet after surgery was earlier in the DA group than in the Billroth I group (P=0.014). Kaplan-Meier (log-rank test) analysis showed no significant difference in the 5-year survival rates between the 2 groups for patients at the same pathological stage. Multivariate analysis showed that abnormal carcinoembryonic antigen (CEA) (P=0.006), chemotherapy (P<0.001), T stage (P<0.001), and N stage (P<0.001) were independent prognostic factors for survival.ConclusionsDA and Billroth I are feasible and safe reconstruction methods of the digestive tract after gastric cancer. DA is the recommended reconstruction method for laparoscopic distal gastrectomy.     

Long-term effects of jejunal pouch added to Roux-en-Y reconstruction after total gastrectomy

Background. Jejunal pouch reconstruction after total gastrectomy has been demonstrated to ameliorate postgastrectomy symptoms, with the process of adaptation taking several months. In contrast to the short-term effects of pouch reconstruction, there are few reports about the long-term consequences (more than 2 years after surgery). Methods. In this study, 22 patients with jejunal pouch (PRY group) and 12 patients without jejunal pouch (RY group) who survived for more than 2 years without any recurrence and were available for follow-up were compared. Patients in the two groups were compared 2 years after surgery in terms of postgastrectomy symptoms, and improvements in body weight and nutritional parameters. Results. Eating capacity at a single meal compared with that in the pre-illness state was significantly better in the PRY group than in the RY group. The total score on the gastrointestinal symptom rating scale (GSRS) in the PRY group was less than that in the RY group (3.17 vs 5.25). The GSRS score for reflux syndrome in the PRY group was significantly better than that in the RY group. Assessment according to Cuschieri's gradings revealed that the total score in the PRY group was lower than that in the RY group (2.73 vs 5.92). Among the various symptoms examined, the incidence of dietary restriction and that of heartburn were significantly lower in the PRY group. Conclusion. We conclude that, 2 years after total gastrectomy, the pouch reconstruction had alleviated postgastrectomy symptoms to a greater extent than simple Roux-en-Y reconstruction, but the effectiveness could be improved. The long-term effects of pouch reconstruction should be examined more precisely with an adequate and valid scoring system for determining quality of life. Received: May 15, 2001 / Accepted: August 29, 2001     

Open distal gastrectomy versus laparoscopic distal gastrectomy for early gastric cancer: a retrospective study

BackgroundLaparoscopic distal gastrectomy (LDG) is gaining popularity because its early postoperative effect has been shown to be better than open distal gastrectomy (ODG). However, to our knowledge, there are no studies demonstrating ODG is oncologically equivalent to LDG.MethodsThis is a retrospective study based on the prospectively maintained database of the People’s Hospital of Jinan City. Patients with operable, pathologically confirmed early-stage gastric cancer were included, while those with advanced disease or carcinoma in situ were excluded. Extracted data included age, body mass index (BMI), sex, clinical TNM stage, and pathologic stage. The primary outcome was 5-year overall survival, and the secondary outcomes included cancer-specific survival, cost-effectiveness, and quality of life.ResultsA total of 126 patients were finally enrolled and included 61 in the ODG group and 65 in the LDG group. Baseline clinical and pathological characteristics were generally balanced between the two groups. After a median follow-up of 8.31 years, the 5-year overall survival rate was estimated to be 82.8% (95% CI: 69.4–90.7%) for the ODG group and 86.7% (95% CI: 73.9–93.5%) for the LDG group and the recurrence patterns were similar between the two groups.ConclusionsOur data showed that the surgical results of both approaches are satisfactory, and LDG offers a reasonable option to ODG in patients with early gastric cancer.     

A novel procedure for Roux-en-Y reconstruction following laparoscopy-assisted distal gastrectomy: transoral placement of anvil and intracorporeal gastrojejunostomy via umbilical mini-laparotomy

We describe herein our procedures for Roux-en-Y reconstruction using a transoral anvil following laparoscopy-assisted distal gastrectomy (LADG). The procedure consists of three technical processes: transoral placement of the anvil with the head pre-tilted, extracorporeal preparation of the Roux-en-Y limb, and intracorporeal gastrojejunostomy with a circular stapler introduced via an umbilical mini-laparotomy. We applied the procedure to 33 patients with early gastric cancer between December 2008 and June 2010. None of the patients suffered from surgical complications related either to the transoral placement of the anvil or the anastomoses. The postoperative wound appearance was much less conspicuous than that of conventional laparoscopic distal gastrectomy, because our procedure needed only a 4-cm mini-laparotomy on the umbilicus, except for the trocar ports. This technique involving transoral anvil placement enables intracorporeal anastomosis for gastrojejunostomy via an umbilical mini-laparotomy, and may be one of the surgical choices for anastomosis and Roux-en-Y reconstruction following LADG.     

“Tornado Roux-en-Y” anastomosis in laparoscopy-assisted distal gastrectomy

The use of laparoscopy-assisted distal gastrectomy has been gradually spreading and it has become one of the standard treatment options for early gastric cancer in Japan. But anastomotic problems are still frequent with this procedure, because of its technical difficulty. We have developed a simple, safe, and speedy Roux-en-Y anastomosis for use in laparoscopy-assisted distal gastrectomy. Here, we describe our technique and the short-term results.     

Digestive tract reconstruction options after laparoscopic gastrectomy for gastric cancer

In addition to the popularity of laparoscopic gastrectomy (LG), many reconstructive procedures after LG have been reported. Surgical resection and lymphatic dissection determine long-term survival; however, the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer (GC). Presently, no consensus exists regarding the optimal reconstructive procedure. In this review, the current state of digestive tract reconstruction after LG is reviewed. According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction, we divide these reconstruction procedures into three categories consistent with the resection procedures. We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes (length of surgery and blood loss) and postoperative complications (anastomotic leakage and stricture) to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.     

Total laparoscopic-assisted radical gastrectomy (D2+) with jejunal Roux-en-Y reconstruction

Total laparoscopic-assisted radical gastrectomy and the jejunal Roux-en-Y anastomosis were performed to treat cancer of the upper gastric body and fundic region. In the case of open anastomosis during total laparoscopic-assisted radical gastrectomy, an incision of 6-8 cm would be required due to the need for placing the stapler anvil. If using the Roux-en-Y procedure, however, the incision could be reduced to as small as 4-5 cm without increasing the length of operation and intraoperative bleeding that favors postoperative recovery.Key Words: Gastric cancer, laparoscopy, gastrectomy, gastrointestinal anastomosisA 42-year-old woman was admitted for “repeated abdominal pain and discomfort for more than a month.” Gastroscopic pathology showed adenocarcinoma of the “gastric angle and gastric body” (NO: 13-10963). CT indicated gastric cancer and abdominal lymph node metastases. Ultrasound showed a solid mass in the lower gastric body and the lesser curvature side of the gastric angle (gastric cancer was suspected, which had protruded the serosal layer, Borrmann III type), complicated with multiple enlarged lymph nodes close to the lesser curvature suspected of metastases. The preoperative diagnosis was gastric cancer, stating T3N1M0IIB. “Total laparoscopic-assisted radical gastrectomy (D2+) and jejunal Roux-en-Y reconstruction” was performed under general anesthesia on May 3, 2013.In this surgery (Video 1), the patient is placed in supine position with legs apart. Routine disinfection and draping of the surgical area is performed after successful endotracheal and intravenous anesthesia. The surgeon stands on the left side of the patient, the first assistant on the right side, and the camera assistance between the patient’s legs. A 1-cm incision is made above the umbilicus for placement of a trocar. Pneumoperitoneum of 12 mmHg is established, and a 30-degree laparoscope is inserted. Abdominal exploration shows no ascites, and no evident mass of the liver, parietal peritoneum, or greater omentum. An infiltrative, ulcerative tumor is visible at the lesser curvature of the gastric body (Borrmann III), about 5 cm × 3 cm in size, which is solid and invading the serosa. Stations 1, 2, 7, 8, 11 and 12 lymph nodes are enlarged in a diameter of about 0.8 cm, which are moderately solid without fusion. Trocars are inserted using the 5-port technique. An ultrasonic scalpel is used to cut the greater omentum and the anterior lobe of the transverse mesocolon. The right gastroepiploic artery and vein are ligated at their roots and cut. Station number 6 lymph nodes are dissected, and the pancreatic capsule to the upper left area is cut. The left gastric vein and artery are successively transected. Stations number 7, 9 and 8 lymph nodes are dissected, through to the station 11d, and the dissection is continued to stations 4sh, 10, 4sa and 2 lymph nodes at the left upper region. In the anterior region, the small omentum is resected, and stations 3 and 1 lymph nodes are dissected. The duodenum is transected using a linear stapler, and stations 12p and 8p lymph nodes are dissected. The abdominal segment of the esophagus is cut with the linear stapler, and one suture is made for retraction. The transverse mesocolon is open, and the jejunum is dissociated by an ultrasonic scalpel 20 cm away from the Treitz ligament. The wall at the mesangial side is denuded. A hole is made to the esophagus with the scalpel, and a 60 mm linear stapler is inserted with the two ends at the distal stumps of the esophagus and the jejunum to establish the end-to-side anastomosis. Two sutures are made to the common opening at the side of the anastomosis for retraction, and the 60 mm linear stapler is again inserted to cut the tissue to complete the anastomosis. The stomach and the omental bursa are completely resected. A small hole is made using the ultrasonic scalpel about 40 cm below the opening of the anastomosis at the mesenteric edge for placement of the two firings of a 60 mm linear stapler through the proximal stump. Upon completion of the anastomosis, the two jejunal segments with a common opening are held with harmless forceps, and a 60 mm linear stapler is inserted to complete the jejunal Roux-en-Y anastomosis. When no anastomosis stenosis and bleeding is detected, a central incision of 4 cm is made to the upper abdomen to collect the total gastrectomy specimen, and the laparoscopic resection and anastomoses are completed.Open in a separate windowVideo 1Laparoscopic-assisted radical gastrectomy (D2+) with jejunal Roux-en-Y reconstructionThe surgery was uneventful. The operation time was 192 minutes, with intraoperative blood loss of about 60 mL. A feeding tube was inserted, in conjunction with antibiotics and nutritional support. A small dose of Peptison was administered through the nasogastric tube on the first day. Flatus and little bowel movement occurred on the morning of the third day. As the blood testing results and temperature gradually returned to normal, the nasogastric amount was increased as well. Semi-liquid food was given from the fifth day, and the patient was discharged on the eighth day after surgery. No obvious complication was observed after 30 days. Postoperative pathology showed: total gastrectomy specimen: (gastric lesser curvature) ulcerated moderately differentiated adenocarcinoma (tumor size 5.5 cm × 4 cm), involving the serosal fat and nerve; tumor vascular thrombosis was found; the upper and lower margins of the specimens, as well as the separate “upper resected margin” were negative for tumor tissue. Metastases were observed in the lesser curvature LN2/2, greater curvature LN1/3,“Station 1” LN0/8, “Station 2” LN0/2, “Station 3” LN0/14, “Station 6” LN0/4, “Station 7” LN0/2, “Station 8” LN1/3, “Station 9” LN0/2, and “Station 10” LN0/1. No LN was detected in “stations 5, 11 and 12.” IHC: tumor cells CgA (-), Syn focal (+), CD56 (-), CK8/18 (+), CK7 (-), Ki-67 20% (+). Pathologic staging was T4aN2MoIIIB.     

An additional suture secures against pitfalls in delta-shaped gastroduodenostomy after laparoscopic distal gastrectomy

Abstract  

Laparoscopic gastrectomy is widely used as a minimally invasive surgery for gastric cancer. Laparoscopic distal gastrectomy must be followed by either a gastroduodenostomy or gastrojejunostomy to restore continuity of the alimentary tract. The intraabdominal delta-shaped gastroduodenostomy using endoscopic linear staplers, which was developed by Kanaya et al., is one of the feasible reconstructive procedures. However, the clinical results still remain uncertain. In 71 patients treated between February 2008 and February 2009, we found that anastomotic failure occurred in six patients and there was an intraabdominal abscess around the anastomosis in two patients, findings which might be associated with technical pitfalls in the procedure. After considering the mechanisms underlying these unfavorable complications, we developed a modification of the procedure to successfully overcome these complications by reinforcement of the anastomosis using simple suturing at the closed common channel on the greater curvature. This modified Kanaya’s procedure will be safer and should provide a better intracorporeal gastroduodenostomy after laparoscopic distal gastrectomy.     

A comparison of postoperative quality of life and dysfunction after Billroth I and Roux-en-Y reconstruction following distal gastrectomy for gastric cancer: results from a multi-institutional RCT

Background

Both Billroth I (B-I) and Roux-en-Y (R-Y) reconstructions are commonly performed as standard procedures, but it has yet to be determined which reconstruction is better for patients. A randomized prospective phase II trial with body weight loss at 1?year after surgery as a primary endpoint was performed to address this issue. The current report delivers data on the quality of life and degree of postoperative dysfunction, which were the secondary endpoints of this study.

Methods

Gastric cancer patients who underwent distal gastrectomy were intraoperatively randomized to B-I or R-Y. Postsurgical QOL was evaluated using the EORTC QLQ-C30 and DAUGS 20.

Results

Between August 2005 and December 2008, 332 patients were enrolled in a randomized trial comparing B-I versus R-Y. A mail survey questionnaire sent to 327 patients was completed by 268 (86.2%) of them. EORTC QLQ-C30 scores were as follows: global health status was similar in each group (B-I 73.5?±?18.8, R-Y 73.2?±?20.2, p?=?0.87). Scores of five functional scales were also similar. Only the dyspnea symptom scale showed superior results for R-Y than for B-I (B-I 13.6?±?17.9, R-Y 8.6?±?16.3, p?=?0.02). With respect to DAUGS 20, the total score did not differ significantly between the R-Y and B-I groups (24.8 vs. 23.6, p?=?0.41). Only reflux symptoms were significantly worse for B-I than for R-Y (0.7?±?0.6 vs. 0.5?±?0.6, p?=?0.01).

Conclusions

The B-I and R-Y techniques were generally equivalent in terms of postoperative QOL and dysfunction. Both procedures seem acceptable as standard reconstructions after distal gastrectomy with regard to postoperative QOL and dysfunction.     

Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomy

With less injury and faster postoperative recovery, laparoscopic techniques have been widely applied in D2 radical gastrectomy for distal gastric cancer. Billroth I anastomosis is a common reconstruction procedure in D2 radical gastrectomy for distal gastric cancer. The delta-shaped anastomosis, an intra-abdominal Billroth I reconstruction, has been increasingly applied by gastrointestinal surgeons. This surgical video demonstrates the delta-shaped anastomosis in laparoscopic-assisted D2 radical gastrectomy for distal gastric cancer.Key Words: Gastric cancer, delta-shaped anastomosis, laparoscopyIn 2002, Professor Seiichiro Kanaya from Japan Himeji Medical Center first introduced the delta-shaped anastomosis (1), which was a Billroth I side-to-side anastomosis of the posterior walls of the remnant stomach and the duodenum using a laparoscopic linear stapler. During the anastomosis, the staple line was in a “V” shape, which would turn into a triangular shape after the anastomosis was closed, hence the name “delta-shaped anastomosis”. With increasing application of laparoscopic techniques in the D2 radical treatment of distal gastric cancer, the delta-shaped reconstruction has been gradually adopted in China.In April 2013, a 54-year-old woman presented with dull abdominal pain for three months was diagnosed with adenocarcinoma of the gastric angle by gastroscopic biopsy. The lesion had a diameter of about 3 cm. After routine preoperative preparation, total laparoscopic D2 distal gastrectomy was performed; the delta-shaped anastomosis was used to reconstruct the gastrointestinal tract during operation. An ultrasonic scalpel (Johnson & Johnson, U.S.) was used for anatomical separation, and the anastomosis was completed with a gastroscopic linear stapler (Tri-Staple).After general anesthesia, the patient was put in supine position with the head elevated and legs apart. During the surgery (Video 1), five trocars were inserted. CO₂ pneumoperitoneum of 12 mmHg was established. Standing on the left side of the patient, the surgeon divided the stomach and duodenum using an ultrasonic scalpel, and dissected the related lymph nodes according to the 2002 edition of the Gastric cancer treatment guidelines in Japan (2). A 60 mm gastroscopic linear stapler was inserted through the left upper trocar, which was used to transect the duedenum by rotating 90° from back to front. This would help to ensure the blood supply for anastomotic stoma. The stomach was then resected by successively transecting from the greater curvature to the lesser curvature with the stapler. A small incision was made to the remnant stomach and the edge of the duodenum respectively by the ultrasonic scalpel. The upper and lower anvils of a 60 mm linear stapler were inserted into one end respectively to close the posterior walls of the stomach and the duodenum. The stapling length was adjusted to 45 mm. Then the anastomosis of both ends was triggered. Upon confirmation of no leakage and bleeding of the anastomosis, the gastric tube was inserted into the distal anastomotic end of the duodenum. Finally, the common opening of the stomach and the duodenum was closed with the linear stapler.Open in a separate windowVideo 1Delta-shaped anastomosis in totally laparoscopic D2 radical distal gastrectomyThroughout the surgery, the delta-shaped anastomosis procedure lasted about more than 10 minutes. Both resected specimens had negative margins. A total of 30 lymph nodes were dissected. Pathological staging was T2N0M0. Flatus occurred three days after the surgery. Liquid diet was started on the fourth day, and the patient was discharged on the eighth day. Based on the follow-up so far, the patient has been free of postoperative complications.In short, the application of delta-shaped anastomosis with a linear stapler as part of the intraperitoneal Billroth I reconstruction is safe and feasible (3), allowing satisfying postoperative recovery and outcomes.     

Esophagojejunostomy through minilaparotomy after laparoscopic total gastrectomy

Although laparoscopic distal gastrectomy (LDG) has been accepted as a surgical option for the treatment of early gastric cancer, laparoscopic total gastrectomy (LTG) has been adopted less often, because a more difficult surgical technique is required for reconstruction. To reduce the technical difficulties, we made some modifications to the functional end-to-end anastomosis technique and performed esophagojejunal anastomosis through a minilaparotomy. First, for easier handling of the esophagus, the first application of the linear stapler to create the esophagojejunal anastomosis was performed before transection of the esophagus. Second, the jejunal limb was anastomosed to the left side of the esophagus, which, compared with the right side, made available more free space, sufficient to operate the stapling device. Third, to close the entry hole and complete the gastrectomy concurrently, a linear stapler was applied through the left lower trocar. With this technique, the closure of the access opening was performed easily and was monitored directly through the minilaparotomy. We successfully performed LTG with Roux-en-Y reconstruction using our modified procedure in seven patients without any anastomotic complications. We believe our procedure is a secure and reliable method for reconstruction after LTG and will facilitate adoption of LTG as a surgical option for patients with early upper gastric cancers.     

Non-exposed endoscopic wall-inversion surgery as a novel partial gastrectomy technique

In gastric full-thickness resection employing both endoscopy and laparoscopy, intraabdominal contamination or even possibly tumor seeding is unavoidable as a result of iatrogenic perforation and the resultant spread of gastric juice. To minimize contamination and resected tissue volume, we developed a new technique without perforation termed non-exposed endoscopic wall-inversion surgery (NEWS), and present here the preliminary results. In a clinical observation cohort study, NEWS was attempted in six patients with gastric SMT to investigate the procedure, mortality, and morbidity. NEWS consists of several steps: marking around a tumor on the mucosal as well as the serosal surface, submucosal injection of sodium hyaluronate with indigo carmine dye, circumferential seromuscular dissection with suture closure under laparoscopy, and circumferential mucosubmucosal incision under gastric endoscopy. The resected specimen is then retrieved perorally. Perforation occurred as a result of misidentification and technical inadequacy in the first three patients. After modification of the devices, the entire procedure was successfully achieved in the latter three. There were no complications in any of our six cases. NEWS allows en bloc full-thickness resection, theoretically avoiding contamination and tumor dissemination into the peritoneal cavity.