An Effective Duodenum Bulb Mobilization for Extracorporeal Billroth I Anastomosis of Laparoscopic Gastrectomy

Background Data  Extracorporeal circular-stapled Billroth I (B-I) anastomosis is difficult in patients with obesity, a large body shape, or small remnant stomach, as it requires the duodenal stump to be lifted outside of the wound. The aim of this study was to evaluate the feasibility of circular-stapled B-I reconstruction for laparoscopy-assisted distal gastrectomy (LADG) with effective duodenal mobilization. Methods  Between March 2005 and December 2007, 199 patients with early gastric cancer underwent LADG with B-I reconstruction in the Department of Gastrointestinal Surgery at the Cancer Institute. The greater omentum, comprised of four membrane layers, was completely dissected for effective duodenal bulb mobilization to allow easy performance of extracorporeal end-to-end gastroduodenostomy. Several clinicopathophysiological features relating to anastomosis complications, including anastomotic leakage, stenosis, bleeding, and ulcers, were evaluated. Results  The success rate of extracorporeal circular-stapled B-I anastomosis was 100% for the 199 patients, 24% of whom had a body mass index greater than 25. The rate of anastomosis-related postoperative complications was 2%. Anastomotic leakage was not observed in this study. Anastomotic stenosis was observed in 2 (1%) patients, anastomotic bleeding was observed in 1 (0.5%) patient, and anastomotic ulcer was diagnosed in 1 (0.5%) patient. All these complications were managed conservatively. There was no postoperative mortality. Conclusions  Feasible duodenal bulb mobilization by complete dissection of the greater omentum allows easy performance of extracorporeal B-I anastomosis and minimizes complications related to anastomosis in LADG.