Double stapling Roux-en-Y reconstruction in a laparoscopy-assisted distal gastrectomy

Three-Port Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy for Uncut Roux-en-Y Reconstruction

BACKGROUND

This study presents the initial feasibility of three-port right-side approach-duet totally laparoscopic distal gastrectomy (R-duet TLDG) with uncut Roux-en-Y (R-Y) reconstruction for the treatment of lower- or middle-third gastric cancer.

METHODS

A total of 30 patients who underwent R-duet TLDG with uncut R-Y reconstruction for gastric cancer were enrolled. All patients were treated at the Catholic Medical Center. Reconstructions were performed intracorporeally without special instruments. The clinicopathological characteristics, operative details, postoperative short-term outcomes, and postoperative follow-up endoscopy results were analyzed retrospectively.

RESULTS

All operations were performed by three-port R-duet TLDG. There were no conversions to an open approach, and no additional ports were placed. The mean operating time was 170 minutes, and the mean number of retrieved lymph nodes was 44. Three patients experienced mild postoperative complications, including small bowel ileus and pneumonia. Follow-up endoscopy was carried out at 3 months. No patients had experienced moderate-or-severe food stasis, alkaline gastritis, or bile reflux during the follow-up period. Recanalization of the biliopancreatic limb was not observed.

CONCLUSIONS

R-duet TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery without special instruments.

Right-Side Approach-Duet Totally Laparoscopic Distal Gastrectomy (R-Duet TLDG) Using a Three-Port to Treat Gastric Cancer

BACKGROUND

Gastric cancer is commonly treated via minimally invasive surgery. The present study explored the feasibility of right-side approach-duet (R-duet) totally laparoscopic distal gastrectomy using a three-port compared with a four- or five-port.

METHODS

A total of 251 patients who underwent curative totally laparoscopic distal gastrectomy for gastric cancer (72 R-duet, 74 four-port, and 105 five-port) at the Catholic Medical Center were enrolled. All operations were performed using conventional laparoscopic instruments. The clinicopathological characteristics, operative details, and postoperative short-term outcomes were analyzed retrospectively.

RESULTS

The clinicopathological characteristics did not differ significantly among the groups, except that the N stage was higher in the five-port group. The operating time was significantly longer in the four-port than the R-duet group (R-duet, four-port, and five-port 148.2 ± 30.7, 162.4 ± 30.6, and 159.9 ± 31.5 min, respectively; p = 0.024). The estimated blood loss did not differ significantly. Postoperatively, the times to flatus and to soft diet consumption and the hospital stay were significantly longer in the five-port group. The extent of postoperative complications did not differ among the groups.

CONCLUSIONS

R-duet totally laparoscopic distal gastrectomy is a reliable form of reduced-port surgery when used to treat gastric cancer; no special instruments are required.

Totally laparoscopic Roux-en-Y gastrojejunostomy after laparoscopic distal gastrectomy: analysis of initial 50 consecutive cases of single surgeon in comparison with totally laparoscopic Billroth I reconstruction

PURPOSE

Roux-en-Y reconstruction (RY) in laparoscopic distal gastrectomy for gastric cancer is a more complicated procedure than Billroth-I (BI) or Billroth-II. Here, we offer a totally laparoscopic simple RY using linear staplers.

MATERIALS AND METHODS

Each 50 consecutive patients with totally laparoscopic distal gastrectomy with RY and BI were enrolled in this study. Technical safety and surgical outcomes of RY were evaluated in comparison with BI.

RESULTS

In all patients, RY gastrectomy using linear staplers was safely performed without any events during surgery. The mean operation time and anastomosis time were 177.0±37.6 min and 14.4±5.6 min for RY, respectively, which were significantly longer than those for BI (150.4±34.0 min and 5.9±2.2 min, respectively). There were no differences in amount of blood loss, time to flatus passage, diet start, length of hospital stay, and postoperative inflammatory response between the two groups. Although there was no significant difference in surgical complications between RY and BI (6.0% and 14.0%), the RY group showed no anastomosis site-related complications.

CONCLUSION

The double stapling method using linear staplers in totally laparoscopic RY reconstruction is a simple and safe procedure.

Retrocolic roux-en-Y anastomosis for total laparoscopic distal gastrectomy: fix-the-remnant-first technique

INTRODUCTION

Herein we report our retrocolic Roux-en-Y anastomosis for laparoscopic distal gastrectomy and its feasibility.

MATERIALS AND SURGICAL TECHNIQUE

After laparoscopic distal gastrectomy with lymphadenectomy, the gastric remnant was fixed through the mesentery of the transverse colon. The gastrojejunostomy was performed with linear stapling devices at an angle that allowed for easy application. The jejunojejunostomy was also performed with linear stapling devices. All spaces between the mesentery were hand-sewn closed. This procedure was performed laparoscopically without additional incisions in all 34 patients. The median operative time was 365 min and the median blood loss was 50 mL. All patients started liquid intake the day after gastrectomy. There were three cases of Grade 1 complications and one Grade 2 complication per the Clavien-Dindo Classification. Patients' weights after surgery were stable at the 36-month follow-up.

DISCUSSION

The advantages of Roux-en-Y reconstruction have been reported to include less frequent anastomotic leakage, less gastritis and less bile reflux over the long term. The retrocolic reconstructions were performed in a manner similar to open surgery but under a laparoscopic view. The mesentery closure stitches to prevent internal herniation did not require as many stitches as the antecolic route and were easier to place. Our anastomosis for laparoscopic distal gastrectomy showed acceptable short-term results, with patients maintaining up to 91.0% of their preoperative weight and nutritional input. By fixing the remnant stomach to the mesentery of the transverse colon before the anastomosis, we easily completed the retrocolic Roux-en-Y anastomosis under laparoscopic view.

Use of fibrin glue sealant with polyglycolic acid sheets to prevent pancreatic fistula formation after laparoscopic-assisted gastrectomy

PURPOSE

A pancreatic fistula is a serious postoperative complication that can occur after gastrectomy with lymphadenectomy for gastric cancer. The aim of this prospective study was to analyze the usefulness of the local application of fibrin glue sealant (FG) and polyglycolic acid sheets (PAS) in preventing pancreatic fistula formation after gastrectomy.

PATIENTS AND METHODS

The surface of the pancreas was covered with FG and PAS after peri-pancreatic lymph node dissection in 34 patients (F/P group). The postoperative outcome was compared with historical control subjects who did not receive the same application (control group, 64 patients).

RESULTS

A pancreatic fistula occurred in three patients in the control group but in none the F/P group (P = 0.049). The volume of drainage fluid on postoperative day (POD) 1 and 3 was smaller in the F/P group than in the control group (POD1: F/P group, 80 ml; control: 150 ml, P < 0.001; POD3: 60 vs. 120 ml, P < 0.001). The amylase levels in the drainage fluid on POD1 and 3 were also significantly lower in the F/P group than in the control group (POD1: F/P group, 660 U/L; control: 1220 U/L, P = 0.030; POD2: 270 vs. 830 U/L, P = 0.038; POD3, 160 vs. 630 U/L, P = 0.041).

CONCLUSION

The application of FG and PAS after LAG helps to prevent pancreatic fistula formation.