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Arora L, Reddy VV, Gavini SK, Chandrakasan C. Impact of route of reconstruction of gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A prospective randomized study. Ann Hepatobiliary Pancreat Surg 2023; 27:287-291. [PMID: 37066756 PMCID: PMC10472118 DOI: 10.14701/ahbps.22-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 04/18/2023] Open
Abstract
Backgrounds/Aims Pancreaticoduodenectomy (PD) is commonly performed pancreatic procedure for tumors of periampullary region. Delayed gastric emptying (DGE) and pancreatic fistula are the most common specific complications following PD. DGE can lead to significant morbidity, resulting in prolonged hospital stay and increased cost. Various factors might influence the occurrence of DGE. We hypothesized that kinking of jejunal limb could be a cause of DGE post PD. Methods Antecolic (AC) and retrocolic (RC) side-to-side gastrojejunostomy (GJ) groups in classical PD were compared for the occurrence of DGE in a prospective study. All patients who underwent PD between April 2019 and September 2020 in a tertiary care center in south India were included in this study. Results After classic PD, RC GJ was found to be superior to AC in terms of DGE rate (26.7% vs. 71.9%) and hospital stay (9 days vs. 11 days). Conclusions Route of reconstruction of GJ can influence the occurrence of DGE as RC anastomosis in classical PD provides the most straight route for gastric emptying.
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Affiliation(s)
- Lokesh Arora
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
| | - Vutukuru Venkatarami Reddy
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
| | - Sivarama Krishna Gavini
- Department of Surgical Gastroenterology, Sri Venkateswara Institute of Medical Sciences (SVIMS), Tirupati, India
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Yoshikawa K, Shimada M, Tokunaga T, Nakao T, Nishi M, Takasu C, Kashihara H, Wada Y, Yoshimoto T. Stapler insertion angle toward the esophagus reduces the incidence of early postoperative Roux stasis syndrome after distal gastrectomy in minimally invasive surgery. BMC Surg 2023; 23:54. [PMID: 36906525 PMCID: PMC10007757 DOI: 10.1186/s12893-023-01954-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 03/06/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Roux stasis syndrome (RSS) after Roux-en-Y (RY) reconstruction significantly prolongs the hospital stay and decreases the quality of life. The purpose of the present study was to evaluate the incidence of RSS in patients who underwent distal gastrectomy for gastric cancer and to identify the factors related to the development of RSS after mechanical RY reconstruction in minimally invasive surgery (MIS). METHODS This study included 134 patients who underwent distal gastrectomy in MIS with mechanical RY anastomosis. RSS was defined as the presence of symptoms such as nausea, vomiting, or abdominal fullness, and the confirmation of delayed gastric emptying on imaging or gastrointestinal fiber testing. Clinical data were checked, including body mass index, operative procedure, age, sex, operative time, blood loss volume, extent of lymph node dissection, final stage, stapler insertion angle, method of entry hole closure. The relationship between the incidence of RSS and these factors was analyzed. RESULTS RSS occurred in 24 of 134 patients (17.9%). RSS occurred significantly more frequently in patients with D2 lymphadenectomy than in patients with D1 + lymphadenectomy (p = 0.04). All patients underwent side-to-side anastomosis via the antecolic route. The incidence of RSS was significantly greater in patients with a stapler insertion angle toward the greater curvature (n = 20, 22.5%) versus the esophagus (n = 4, 8.9%) (p = 0.04). The multivariate logistic regression model revealed that the stapler insertion angle to the greater curvature is identified as independent risk factor for RSS (OR 3.23, 95%Cl 1.01-10.3, p = 0.04). CONCLUSION Stapler insertion angle toward the esophagus may reduce the incidence of early postoperative RSS rather than toward the greater curvature.
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Affiliation(s)
- Kozo Yoshikawa
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan.
| | - Mitsuo Shimada
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Takuya Tokunaga
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Toshihiro Nakao
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Masaaki Nishi
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Chie Takasu
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Hideya Kashihara
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Yuma Wada
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
| | - Toshiaki Yoshimoto
- The Department of Surgery, The University of Tokushima, 3-18-15 Kuramoto-cho, Kuramoto-Cho, Tokushima, 770-8503, Japan
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Zhang J, Li S, Zhu W, Leng X, Gao J, Zhang D. Subtotal gastrectomy pancreaticoduodenectomy versus conventional pancreaticoduodenectomy in the incidence of delayed gastric emptying: single-center retrospective cohort study. BMC Surg 2022; 22:376. [PMID: 36329420 PMCID: PMC9635176 DOI: 10.1186/s12893-022-01824-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). There is currently no widely accepted procedure for PD to reduce the incidence of DGE. Our institution attempts to perform subtotal gastrectomy in patients undergoing PD to reduce DGE. Here we aimed to evaluate the effectiveness and safety of PD with subtotal gastric resection. Methods Patients who underwent PD between January 2014 and December 2021 were reviewed. They were stratified by extent of gastrectomy into a conventional PD group (PD that resected approximately 1/3 of the distal stomach) and a subtotal gastrectomy PD group (PD that resected approximately 3/4 of the distal stomach), which were compared in terms of intraoperative and postoperative parameters. Result From January 2014 to December 2021, a total of 512 patients underwent PD in the Department of Hepatobiliary Surgery, Peking University People’s Hospital. Nineteen patients were excluded from this study due to benign disease. A total of 493 patients were included, with 378 in the conventional PD group and 115 in the subtotal gastrectomy PD group. Compared with the conventional PD group, the subtotal gastrectomy PD group had a lower incidence of DGE (8.7% vs. 17.7%, p = 0.019), and a shorter hospital stay. Multivariate analysis showed that conventional PD and higher body mass index were independent risk factors for grade B/C DGE. Conclusion This study showed that, compared with conventional PD, subtotal gastrectomy PD can reduce the incidence of DGE and shorten the length of hospital stay. At the same time, subtotal gastrectomy PD is comparable to conventional PD in terms of surgical safety. Furthermore, high BMI is an independent risk factor for postoperative DGE.
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Affiliation(s)
- Jinzhu Zhang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Shu Li
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Weihua Zhu
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xisheng Leng
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jie Gao
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
| | - Dafang Zhang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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Jiao YJ, Lu TT, Liu DM, Xiang X, Wang LL, Ma SX, Wang YF, Chen YQ, Yang KH, Cai H. Comparison between laparoscopic uncut Roux-en-Y and Billroth II with Braun anastomosis after distal gastrectomy: A meta-analysis. World J Gastrointest Surg 2022; 14:594-610. [PMID: 35979420 PMCID: PMC9258235 DOI: 10.4240/wjgs.v14.i6.594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/09/2022] [Accepted: 05/14/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Conventional Billroth II (BII) anastomosis after laparoscopic distal gastrectomy (LDG) for gastric cancer (GC) is associated with bile reflux gastritis, and Roux-en-Y anastomosis is associated with Roux-Y stasis syndrome (RSS). The uncut Roux-en-Y (URY) gastrojejunostomy reduces these complications by blocking the entry of bile and pancreatic juice into the residual stomach and preserving the impulse originating from the duodenum, while BII with Braun (BB) anastomosis reduces the postoperative biliary reflux without RSS. Therefore, the purpose of this study was to compare the efficacy and safety of laparoscopic URY with BB anastomosis in patients with GC who underwent radical distal gastrectomy.
AIM To evaluate the value of URY in patients with GC.
METHODS PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Wanfang, Chinese Biomedical Database, and VIP Database for Chinese Technical Periodicals (VIP) were used to search relevant studies published from January 1994 to August 18, 2021. The following databases were also used in our search: Clinicaltrials.gov, Data Archiving and Networked Services, the World Health Organization International Clinical Trials Registry Platform Search Portal (https://www.who.int/clinical-trials-registry-platform/the-ictrp-search-portal), the reference lists of articles and relevant conference proceedings in August 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). We cited high-quality references using its results analysis functionality. The methodological quality of the eligible randomized clinical trials (RCTs) was evaluated using the Cochrane Risk of Bias Tool, and the non-RCTs were evaluated using the Newcastle-Ottawa scale. Statistical analyses were performed using Review Manager (Version 5.4).
RESULTS Eight studies involving 704 patients were included in this meta-analysis. The incidence of reflux gastritis [odds ratio = 0.07, 95% confidence interval (CI): 0.03-0.19, P < 0.00001] was significantly lower in the URY group than in the BB group. The pH of the postoperative gastric fluid was lower in the URY group than in the BB group at 1 d [mean difference (MD) = -2.03, 95%CI: (-2.73)-(-1.32), P < 0.00001] and 3 d [MD = -2.03, 95%CI: (-2.57)-(-2.03), P < 0.00001] after the operation. However, no significant difference in all the intraoperative outcomes was found between the two groups.
CONCLUSION This work suggests that URY is superior to BB in gastrointestinal reconstruction after LDG when considering postoperative outcomes.
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Affiliation(s)
- Ya-Jun Jiao
- School of Clinical Medicine, Ningxia Medical University, Yinchuan 750000, Ningxia Province, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Ting-Ting Lu
- Institution of Clinical Research and Evidence Based Medicine, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - De-Ming Liu
- School of Clinical Medicine, Ningxia Medical University, Yinchuan 750000, Ningxia Province, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Xue Xiang
- School of Clinical Medicine, Ningxia Medical University, Yinchuan 750000, Ningxia Province, China
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Liu-Li Wang
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Shi-Xun Ma
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Yong-Feng Wang
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Ya-Qiong Chen
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
| | - Ke-Hu Yang
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui Cai
- General Surgery Clinical Medical Center, Gansu Provincial Hospital, Lanzhou 730000, Gansu Province, China
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The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis. HPB (Oxford) 2022; 24:654-663. [PMID: 34654621 DOI: 10.1016/j.hpb.2021.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 07/14/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. METHODS One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. RESULTS Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p = 0.02). V-GJ was also associated to a less severe DGE manifestation (p = 0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p = 0.002). At the multivariate analysis, ASA score≥3 (p = 0.02), H-GJ (p = 0.03), flow angle>30°(p = 0.004) and Clavien-Dindo≥3 (p = 0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. CONCLUSION VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.
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Yalikun A, Aikemu B, Li S, Zhang T, Ma J, Zheng M, Zang L. A Modified Billroth-II with Braun Anastomosis in Totally Laparoscopic Distal Gastrectomy: Initial Experience Compared with Roux-en-Y Anastomosis. Ann Surg Oncol 2022; 29:2359-2367. [PMID: 34994886 DOI: 10.1245/s10434-021-11187-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND This retrospective study aimed to compare the feasibility and effectiveness of a modified Billroth-II with Braun (B-II Braun) reconstruction and those of a Roux-en-Y (R-Y) reconstruction after laparoscopic distal gastrectomy. METHODS From January 2016 to December 2019, 247 patients underwent total laparoscopic distal gastrectomy (TLDG), with B-II Braun reconstruction for 145 patients and R-Y reconstruction for 102 patients. The patients' data were collected prospectively and reviewed retrospectively. RESULTS In this study, the median times of the operation were statistically shorter for B-II Braun than for R-Y (167 min [range, 110-331 min] vs 191 min [range, 123-384 min]; p = 0.001), including anastomotic times (33 min [range, 30-42 min] vs 42 min [range, 40-48 min]; p = 0.001). After a short-term follow-up period, endoscopy showed 31 cases of bile reflux (21.4%), 15 cases of grade 2 gastritis (10.3%), and 6 cases of grade 2 food residue (4.1%) in the B-II Braun group after 6 months. After 1 year, 10 patients (6.9%) had grade 2 gastritis and 2 patients (1.4%) had grade 3 gastritis. However, the remnant stomach of the two groups did not differ significantly in the rate of gastric residue (p = 0.112 after 6 months; p = 0.579 after 1 year, respectively), gastritis (p = 0.726 after 6 months; p = 0.261 after 1 year, respectively), or bile reflux (p = 0.262 after 6 months; p = 0.349 after 1 year, respectively). CONCLUSIONS For gastric cancer patients, TLDG with modified B-II Braun reconstruction could be technically feasible. It has an acceptable range of postoperative complications and is effective in preventing bile reflux into the gastric remnant.
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Affiliation(s)
- Abudushalamu Yalikun
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Batuer Aikemu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Shuchun Li
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Tao Zhang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Minimally Invasive Surgery Center, Shanghai, China
| | - Junjun Ma
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, China.
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, China.
| | - Lu Zang
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai Minimally Invasive Surgery Center, Shanghai, China.
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Arango NP, Prakash LR, Chiang YJ, Dewhurst WL, Bruno ML, Ikoma N, Kim MP, Lee JE, Katz MHG, Tzeng CWD. Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying. J Gastrointest Surg 2021; 25:2221-2230. [PMID: 33236322 DOI: 10.1007/s11605-020-04877-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period. METHODS A single-institution, prospective database was queried for consecutive PDs during July 2011-November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets. RESULTS Among 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] - 1.84; p < 0.001), postoperative abscess (OR - 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR - 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR - 1.46, p = 0.042). CONCLUSION Our data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.
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Affiliation(s)
- Natalia Paez Arango
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Laura R Prakash
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Yi-Ju Chiang
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Whitney L Dewhurst
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Morgan L Bruno
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Michael P Kim
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler St., Unit 1484, Houston, TX, 77030, USA.
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Miyazawa M, Kawai M, Hirono S, Okada KI, Kitahata Y, Kobayashi R, Ueno M, Hayami S, Miyamoto A, Yamaue H. Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy. Surgery 2021; 170:1223-1230. [PMID: 33958204 DOI: 10.1016/j.surg.2021.03.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/28/2021] [Accepted: 03/30/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Pancreaticoduodenectomy without subsequent nasogastric tube management has not been widely adopted due to delayed gastric emptying, the specific and frequent morbidity associated with this surgical procedure. We assessed the feasibility of pancreaticoduodenectomy without use of nasogastric tubes and the risk factors for subsequent nasogastric tube reinsertion. METHODS We retrospectively reviewed 465 patients who underwent pancreaticoduodenectomy at a single institution between 2010 and 2019. Primary endpoint was the rate of nasogastric tube reinsertion. Logistic regression analysis was used to determine independent risk factors of nasogastric tube reinsertion and delayed gastric emptying. RESULTS The rate of nasogastric tube reinsertion was 10.1% (47/465). The rate of delayed gastric emptying was 9.5% (44/465). Logistic regression analysis identified 4 independent risk factors for nasogastric tube reinsertion: male sex (odds ratio = 4.42; 95% confidence interval 1.50-13.0, P = .007), comorbidity of cardiac ischemia (odds ratio = 3.04; 95% confidence interval 1.05-8.79, P = .041), preoperative cholangitis or cholecystitis (odds ratio = 2.21; 95% confidence interval 1.02-4.76, P = .044), and previous upper abdominal surgery (odds ratio = 8.34; 95% confidence interval 3.07-22.7, P < .001). Independent risk factors for delayed gastric emptying were male sex (odds ratio = 3.20; 95% confidence interval 1.11-9.21, P = .031), comorbidity of cardiac ischemia (odds ratio = 3.81; 95% confidence interval 1.34-10.8, P = .012), concomitant organ resection (odds ratio = 3.99; 95% confidence interval 1.10-14.4, P = .035), and previous upper abdominal surgery (odds ratio = 7.21; 95% confidence interval 2.68-19.4, P < .001). CONCLUSION Pancreaticoduodenectomy without use of nasogastric tubes is feasible, but patients with previous upper abdominal surgery require careful postoperative nasogastric tube management.
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Affiliation(s)
- Motoki Miyazawa
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Manabu Kawai
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan.
| | - Seiko Hirono
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ken-Ichi Okada
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuji Kitahata
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Ryohei Kobayashi
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masaki Ueno
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Shinya Hayami
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Atsushi Miyamoto
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
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Lee Y, Lee CM, Park S, Kim JH, Park SH. Comparison of the Clinical Outcomes Between Isoperistaltic and Antiperistaltic Anastomoses After Laparoscopic Distal Gastrectomy for Patients With Gastric Cancer. Front Oncol 2020; 10:1237. [PMID: 32850372 PMCID: PMC7411350 DOI: 10.3389/fonc.2020.01237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/16/2020] [Indexed: 12/24/2022] Open
Abstract
Background: No consensus exists regarding the superiority of either of the two types of gastrointestinal anastomosis, which are isoperistaltic and antiperistaltic. This study aimed to compare the clinical outcomes between isoperistaltic and antiperistaltic anastomoses after total laparoscopic distal gastrectomy (TLDG) in patients with gastric cancer. Methods: We retrospectively reviewed the medical records of patients with gastric cancer who underwent TLDG with Billroth II anastomosis between January 2014 and December 2018. The patients were divided into two groups according to the peristaltic direction of gastrointestinal anastomosis after TLDG. One group underwent isoperistaltic anastomosis (Iso group), and the other underwent antiperistaltic anastomosis (Anti group). Clinical outcomes were compared between the groups. Results: Of the 148 patients who underwent TLDG with Billroth II anastomosis, 124 were included in the Iso group and 24 were included in the Anti group. The Anti and Iso groups showed no significant difference with regard to the incidence of internal hernia (0.0 vs. 6.5%, respectively; p = 0.355). The incidence of bile reflux was more frequent in the Iso group than in the Anti group (p = 0.010), but food stasis was more common in the Anti group than in the Iso group (p = 0.006). Conclusion: In gastric cancer patients who underwent TLDG in which postoperative adhesion was minimized, antiperistaltic anastomosis may have created a physiologic barrier in gastrointestinal continuity. However, a large-scale study is necessary to validate the relationship between the digestive stream and the peristaltic direction.
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Affiliation(s)
- Yoontaek Lee
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Chang Min Lee
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Sungsoo Park
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Jong-Han Kim
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Seong-Heum Park
- Department of Surgery, Korea University College of Medicine, Seoul, South Korea
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10
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Wu JZ, Orita H, Zhang S, Egawa H, Yube Y, Kaji S, Oka S, Fukunaga T. Easy fixation effects the prevention of Peterson’s hernia and Roux stasis syndrome. World J Gastrointest Surg 2020; 12:346-354. [PMID: 32904043 PMCID: PMC7448210 DOI: 10.4240/wjgs.v12.i8.346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/31/2020] [Accepted: 07/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Laparoscopic distal gastrectomy (LDG) for gastric cancer has been progressed and popular in Japan, since it was first described in 1994. Several reconstruction methods can be adopted according to remnant stomach size, and balance of pros and cons. Roux-en-Y (R-Y) reconstruction is a one of standard options after LDG. Its complications include Petersen’s hernia and Roux stasis syndrome. Here we report our ingenious attempt, fixation of Roux limb and duodenal stump, for decreasing the development of Petersen’s hernia and Roux stasis syndrome.
AIM To develop a method to decrease the development of Petersen’s hernia and Roux stasis syndrome.
METHODS We performed ante-colic R-Y reconstruction after LDG. After R-Y reconstruction, we fixed Roux limb onto the duodenal stump in a smooth radian. Via this small improvement in Roux limb, Roux limb was placed to the right of the ligament of Treitz. This not only changed the anatomy of the Petersen’s defect, but it also kept a fluent direction of gastrointestinal anastomosis and avoided a cross-angle after jejunojejunostomy. 31 patients with gastric cancer was performed this technique after R-Y reconstruction. Clinical parameters including clinicopathologic characteristics, perioperative outcomes, postoperative complication and follow-up data were evaluated.
RESULTS The operative time was (308.0 ± 84.6 min). This improvement method took about 10 min. Two (6.5%) patients experienced pneumonia and pancreatitis, respectively. No patient required reoperation or readmission. All patients were followed up for at least 3 year, and none of the patients developed postoperative complications related to internal hernia or Roux stasis syndrome.
CONCLUSION This 10 min technique is a very effective method to decrease the development of Petersen’s hernia and Roux stasis syndrome in patients who undergo LDG.
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Affiliation(s)
- Jian-Zhong Wu
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
- Department of Gastroenterology Surgery, Suzhou Ninth People’s Hospital, Nantong University, Suzhou 215000, Jiangsu Province, China
| | - Hajime Orita
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
| | - Shun Zhang
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
- Department of Surgery, Tongji University, Shanghai 200000, China
| | - Hiroyuki Egawa
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
| | - Yukinori Yube
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
| | - Sanae Kaji
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
| | - Shinichi Oka
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
| | - Tetsu Fukunaga
- Department of Gastroenterology and Minimally Invasive Surgery, Juntendo University School of Medicine, Juntendo University, Tokyo 1638001, Japan
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Effect of Standardizing the Incision Line on Delayed Gastric Emptying After Laparoscopic Gastrectomy: A Retrospective Preliminary Analysis. Int Surg 2020. [DOI: 10.9738/intsurg-d-16-00062.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
The use of totally laparoscopic surgery with Billroth-I reconstruction (delta-shaped anastomosis) has rapidly become widespread in recent years. However, we experienced delayed gastric emptying (DGE) in the early period after introduction of this technique. To the best of our knowledge, there are no reports that mention the incision line when discussion prevention of DGE in distal gastrectomy. In the present study, we standardized the surgical techniques, including the gastric incision line, and compared the short-term results before and after standardization.
Methods
A total of 86 patients were enrolled in this study. Twenty-eight procedures were performed in the early period, 58 procedures were performed in the late period, and the 2 groups were compared retrospectively.
Results
The operation time decreased significantly after standardization from 288 to 224 minutes (P < 0.001). The median value of perioperative bleeding volume decreased from 22.5 to 12.5 mL (P = 0.060). There were no postoperative complications related to the site of anastomosis in either group. Five cases of DGE (17.8%) were noted in the early period, but only 2 cases (3.4%) were noted in the late period (P = 0.022).
Conclusions
Standardization of the incision line after laparoscopic gastrectomy resulted in a decrease in the incidence of DGE.
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Ma Y, Li F, Zhou X, Wang B, Lu S, Wang W, Yu S, Fu W. Four reconstruction methods after laparoscopic distal gastrectomy: A systematic review and network meta-analysis. Medicine (Baltimore) 2019; 98:e18381. [PMID: 31860999 PMCID: PMC6940138 DOI: 10.1097/md.0000000000018381] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND There is no consensus regarding which reconstruction methods are superior after laparoscopic distal gastrectomy (LDG). This study compared four reconstruction methods after LDG for gastric cancer. METHODS Literature in EMBASE, PubMed, and the Cochrane Library was screened to compare Billroth I (B-I), Billroth II (B-II), Roux-en-Y (RY), and uncut Roux-en-Y (URY) anastomoses after LDG for gastric cancer. A Bayesian network meta-analysis (NMA) was conducted to compare these methods. RESULTS Eighteen studies involving 4347 patients were eligible for our NMA. The operative time in RY anastomosis was longer than that in B-I and B-II anastomoses. Blood loss and risk of gastrointestinal motility dysfunction were greater with RY anastomosis than with URY or B-I anastomosis. Furthermore, URY anastomosis was superior to the other 3 reconstruction methods for preventing food residue. For remnant gastritis, RY anastomosis was significantly superior to B-I and B-II anastomoses, whereas URY anastomosis was significantly superior to B-II anastomosis. In addition, RY and URY anastomoses were better than B-I and B-II anastomoses for preventing bile reflux. CONCLUSIONS URY anastomosis tended to be a more favorable reconstruction method after LDG due to its operative simplicity and reduced long-term complications.
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Yagi S, Ida S, Ohashi M, Kumagai K, Hiki N, Sano T, Nunobe S. Two cases of a perforated duodenal diverticulum after gastrectomy with Roux-en-Y reconstruction. Surg Case Rep 2019; 5:169. [PMID: 31691035 PMCID: PMC6831787 DOI: 10.1186/s40792-019-0738-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 10/22/2019] [Indexed: 02/08/2023] Open
Abstract
Background What type of reconstruction procedure should be applied is one of the important issues in surgery for gastric cancer. We have several options for reconstruction procedure after distal gastrectomy. The Billroth II and Roux-en-Y reconstruction have a duodenal stump while the Billroth I does not have it, which is the biggest structural difference in these procedures. An increase in intraduodenal pressure due to the formation of duodenum stump occasionally causes severe complication such as duodenal stump leakage; however, a duodenal diverticulum perforation after the Roux-en-Y reconstruction has not yet been reported. Herein, we report two cases of a perforated duodenal diverticulum after gastrectomy with the Roux-en-Y reconstruction. Case presentation The first case was a 66-year-old man who presented to our hospital with an acute onset right-upper-quadrant abdominal pain. He had undergone laparoscopic distal gastrectomy with the Roux-en-Y reconstruction for the early gastric cancer 15 months before. A large periampullary diverticulum had been detected during the checkup before the gastrectomy. Abdominal contrast-enhanced CT showed a retroperitoneal fluid collection with gas present at the second part of the duodenum. Therefore, a perforated duodenal diverticulum with abdominal abscess was diagnosed, and an emergency laparotomy was performed. Pancreaticoduodenectomy was performed because of severe duodenal inflammation and surrounding tissue damage. The second case was a 52-year-old man who had undergone open distal gastrectomy for locally advanced gastric cancer. Multiple non-ampullary duodenal diverticula had also been identified during the preoperative checkup. On the 2nd postoperative day, he presented with a sudden-onset abdominal pain with peritoneal irritation signs, and intestinal fluid was identified through the intraperitoneal drainage tube placed in a suprapancreatic site during his previous gastrectomy. Therefore, an emergency laparotomy was performed. During laparotomy, a perforated diverticulum at the second part of the duodenum was detected. The perforated duodenum diverticulum was directly sutured with drainage of the retroperitoneal space. Conclusions It is necessary to recognize that the Roux-en-Y reconstruction after gastrectomy for gastric cancer patients with duodenal diverticulum might cause a perforation of the diverticulum.
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Affiliation(s)
- Shusuke Yagi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Satoshi Ida
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Manabu Ohashi
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Koshi Kumagai
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Naoki Hiki
- Department of Upper Gastrointestinal Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Takeshi Sano
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Souya Nunobe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.
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14
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Rosa F, Quero G, Fiorillo C, Doglietto GB, Alfieri S. Billroth II reconstruction in gastric cancer surgery: A good option for Western patients. Am J Surg 2019; 218:940-945. [DOI: 10.1016/j.amjsurg.2019.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/19/2019] [Accepted: 03/07/2019] [Indexed: 12/15/2022]
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15
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Ren Z, Wang WX. Comparison of Billroth I, Billroth II, and Roux-en-Y Reconstruction After Totally Laparoscopic Distal Gastrectomy: A Randomized Controlled Study. Adv Ther 2019; 36:2997-3006. [PMID: 31605307 DOI: 10.1007/s12325-019-01104-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION This study aimed to explore the efficacy of delta-shaped Billroth I anastomosis in totally laparoscopic distal gastrectomy for digestive tract reconstruction, and provide clinical data for determining the most appropriate digestive tract reconstruction method after distal gastrectomy. METHODS This was a prospective randomized controlled study. A total of 180 patients were randomly and prospectively selected from Renmin Hospital of Wuhan University by random number table. These patients were randomly divided into three groups: Billroth I group, Billroth II group, and Roux-en-Y (RY) group. RESULTS There were significant differences in resection margin, blood nutrition, and the number of postoperative complications among these three groups (P < 0.05). Furthermore, the resection margin, blood nutrition status, and immunization of patients in these three groups were determined. Compared to the other groups, the RY group was better in terms of hematologic status, immunological index, and postoperative complications. CONCLUSION Delta-shaped Billroth I anastomosis in totally laparoscopic distal gastrectomy for digestive tract reconstruction is simple and easy to perform, and has an advantage in postoperative gastrointestinal function recovery. RY reconstruction is superior to Billroth I and Billroth II in terms of postoperative complications.
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Jung JP, Zenati MS, Dhir M, Zureikat AH, Zeh HJ, Simmons RL, Hogg ME. Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy. JAMA Surg 2019; 153:918-927. [PMID: 29998288 DOI: 10.1001/jamasurg.2018.2089] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Importance Technical proficiency at robotic pancreaticoduodenectomy (RPD) and video assessment are promising tools for understanding postoperative outcomes. Delayed gastric emptying (DGE) remains a major driver of cost and morbidity after pancreaticoduodenectomy. Objective To determine if technical variables during RPD are associated with postoperative DGE. Design, Setting, and Participants A retrospective study was conducted of technical assessment performed in all available videos (n = 192) of consecutive RPDs performed at a single academic institution from October 3, 2008, through September 27, 2016. Exposures Video review of gastrojejunal anastomosis during RPD. Main Outcomes and Measures Delayed gastric emptying was classified according to International Study Group of Pancreatic Surgery criteria. Video analysis reviewed technical variables specific in the construction of the gastrojejunal anastomosis. Using multivariate analysis, DGE was correlated with known patient variables and technical variables, individually and combined. Results Of 410 RPDs performed, video was available for 192 RPDs (80 women and 112 men; mean [SD] age, 65.7 [11.1] years). Delayed gastric emptying occurred in 41 patients (21.4%; grade A, 15; grade B, 14; and grade C, 12). Patient variables contributing to DGE on multivariate analysis were advanced age (odds ratio [OR] 1.11; 95% CI, 1.05-1.16; P < .001), small pancreatic duct size (OR, 0.84; 95% CI, 0.72-0.98; P = .03), and postoperative pseudoaneurysm (OR, 17.29; 95% CI, 2.34-127.78; P = .005). However, technical variables contributing to decreased DGE on multivariate analysis included the flow angle (within 30° of vertical) between the stomach and efferent jejunal limb (OR, 0.25; 95% CI, 0.08-0.79; P = .02), greater length of the gastrojejunal anastomosis (OR, 0.40; 95% CI, 0.20-0.77; P = .006), and a robotic-sewn anastomosis (robotic suture vs stapler: OR, 0.30; 95% CI, 0.09-0.95; P = .04). Conclusions and Relevance This study examines modifiable technical factors through the use of review of video obtained at the time of operation and suggests ways by which the surgical construction of the gastrojejunal anastomosis during RPD may reduce the incidence of DGE as a framework for prospective quality improvement.
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Affiliation(s)
- Jae Pil Jung
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mazen S Zenati
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mashaal Dhir
- Department of Surgery, State University of New York Upstate Medical University, Syracuse
| | - Amer H Zureikat
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Richard L Simmons
- Division of Surgical Research, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Division of Surgical Oncology, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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So JBY, Rao J, Wong ASY, Chan YH, Pang NQ, Tay AYL, Yung MY, Su Z, Phua JNS, Shabbir A, Ng EKW. Roux-en-Y or Billroth II Reconstruction After Radical Distal Gastrectomy for Gastric Cancer: A Multicenter Randomized Controlled Trial. Ann Surg 2019; 267:236-242. [PMID: 28383294 DOI: 10.1097/sla.0000000000002229] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of the study was to compare the clinical symptoms between Billroth II (B-II) and Roux-en-Y (R-Y) reconstruction after distal subtotal gastrectomy (DG) for gastric cancer. BACKGROUND Surgery is the mainstay of curative treatment for gastric cancer. The technique for reconstruction after DG remains controversial. Both B-II and R-Y are popular methods. METHODS This is a prospective multicenter randomized controlled trial. From October 2008 to October 2014, 162 patients who underwent DG were randomly allocated to B-II (n = 81) and R-Y (n = 81) groups. The primary endpoint is Gastrointestinal (GI) Symptoms Score 1 year after surgery. We also compared the nutritional status, extent of gastritis on endoscopy, and quality of life after surgery between the 2 procedures at 1 year. RESULTS Operative time was significantly shorter for B-II than for R-Y [mean difference 21.5 minutes, 95% confidence interval (95% CI) 3.8-39.3, P = 0.019]. The B-II and R-Y groups had a peri-operative morbidity of 28.4% and 33.8%, respectively (P = 0.500) and a 30-day mortality of 2.5% and 1.2%, respectively (P = 0.500). GI symptoms score did not differ between R-Y versus B-II reconstruction (mean difference -0.45, 95% CI -1.21 to 0.31, P = 0.232). R-Y resulted in a lower median endoscopic grade for gastritis versus B-II (mean difference -1.32, 95% CI -1.67 to -0.98, P < 0.001). We noted no difference in nutritional status (R-Y versus B-II mean difference -0.31, 95% CI -3.27 to 2.65, P = 0.837) and quality of life at 1 year between the 2 groups too. CONCLUSION Although BII is associated with a higher incidence of heartburn symptom and higher median endoscopic grade for gastritis, BII and RY are similar in terms of overall GI symptom score and nutritional status at 1 year after distal gastrectomy.
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Affiliation(s)
- Jimmy Bok-Yan So
- Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Jaideepraj Rao
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Yiong-Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ning Qi Pang
- Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Amy Yuh Ling Tay
- Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Man Yee Yung
- Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
| | - Zheng Su
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Janelle Niam Sin Phua
- Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Asim Shabbir
- Department of Surgery, National University Hospital, National University of Singapore, Singapore, Singapore
| | - Enders Kwok Wai Ng
- Department of Surgery, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong
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Kitano T, Yasukawa D, Aisu Y, Hori T. Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb. Surg Res Pract 2018; 2018:4938341. [PMID: 30345344 PMCID: PMC6174744 DOI: 10.1155/2018/4938341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/30/2018] [Indexed: 12/16/2022] Open
Abstract
Laparoscopic gastrectomy is a treatment for gastric cancer, and isoperistaltic side-to-side reconstruction is called "overlap anastomosis." The physiological advantages of preserving the autonomic nerves in the jejunal limb for digestive reconstruction are well known. Here, we focused on overlap anastomosis with autonomic nerve-preserved mesojejunum of the lifted jejunal limb for laparoscopic distal gastrectomy with intentional lymph node dissection. Our surgical techniques and technical pitfalls were described in detail. The jejunum was partially sacrificed to preserve the autonomic nerves in the lifted jejunal limb. The length of the staple line was 35 - 40 mm. The endostapler entry was carefully closed to avoid even subtle stenosis. Twelve patients were retrospectively evaluated with a follow-up of 5.0 ± 0.6 years. Histological findings according to the Japanese classification were stage IA or IB. Dietary intake and postoperative ambulation occurred at 3.3 ± 1.0 and 1.3 ± 0.5 days after surgery, respectively. Postoperative complications according to Clavien-Dindo classification were one each of grade I and grade II. Postoperative hospital stay was 6.7 ± 1.6 days. Five patients were medication-free at final follow-up, with no recurrence in any patient. Overlap anastomosis with autonomic nerve-preserved jejunal limb was safe and feasible for laparoscopic distal gastrectomy with lymph node dissection.
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Affiliation(s)
- Taku Kitano
- Department of Digestive Surgery, Tenri Hospital, Tenri, Japan
| | - Daiki Yasukawa
- Department of Digestive Surgery, Tenri Hospital, Tenri, Japan
| | - Yuki Aisu
- Department of Digestive Surgery, Tenri Hospital, Tenri, Japan
| | - Tomohide Hori
- Department of Digestive Surgery, Tenri Hospital, Tenri, Japan
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Matsumoto S, Wakatsuki K, Migita K, Ito M, Nakade H, Kunishige T, Kitano M, Nakatani M, Sho M. Predictive Factors for Delayed Gastric Emptying after Distal Gastrectomy with Roux-en-Y Reconstruction. Am Surg 2018. [DOI: 10.1177/000313481808400670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Delayed gastric emptying (DGE) after distal gastrectomy (DG) followed by Roux-en-Y (R-Y) reconstruction is one of the most worrisome complications, and the course of DGE has not been completely elucidated. This retrospective study aimed to evaluate the frequency of DGE after DG followed by R-Y reconstruction for gastric cancer and identify the risk factors for its development. This study included 266 patients with gastric cancer who underwent DG followed by R-Y reconstruction between 2005 and 2016. We compared clinicopathological characteristics and surgical procedures between the DGE group and non-DGE group. DGE occurred in 24 of the 266 patients. There were no relationships of gender, age, TNM stage, historical grade, surgical approach, extent of lymphadenectomy, preservation of the vagal nerve, and reconstruction route with DGE development. Body mass index (BMI) was higher in DGE patients than in non-DGE patients (P = 0.053). Univariate analysis revealed that a tumor located in the lower third of the stomach (P = 0.005) and isoperistaltic reconstruction (P = 0.043) were significant factors for DGE. Multivariate analysis showed that a tumor located in the lower third of the stomach (P = 0.007), isoperistaltic reconstruction (P = 0.044), and BMI (P = 0.034) were significant predictors of DGE. Our findings suggest that tumor location, the direction of peristalsis for gastrojejunostomy, and BMI are associated with DGE after R-Y reconstruction.
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Affiliation(s)
- Sohei Matsumoto
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Kohei Wakatsuki
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Kazuhiro Migita
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Masahiro Ito
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Hiroshi Nakade
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Tomohiro Kunishige
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Mutsuko Kitano
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Mitsuhiro Nakatani
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
| | - Masayuki Sho
- From the Department of Surgery, Nara Medical University School of Medicine, Nara, Japan
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20
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Comparative study of outcomes of Roux-en-Y reconstruction and Billroth Ⅰ reconstruction performed after radical distal gastrectomy. Asian J Surg 2018; 42:379-385. [PMID: 29804711 DOI: 10.1016/j.asjsur.2018.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 04/11/2018] [Accepted: 04/26/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Billroth Ⅰ (BⅠ) reconstruction and Roux-en-Y (RY) reconstruction are both commonly performed after distal gastrectomy (DG). We conducted a retrospective study to evaluate which is the better option. METHODS Included in our study were 162 patients who, between April 2011 and October 2015, underwent DG followed by BⅠ reconstruction (n = 93) or RY reconstruction (n = 69). All patients were followed up for at least 1 year. We compared perioperative outcomes, postoperative complications, gastrointestinal (GI) symptoms, endoscopic findings, and nutritional status between the 2 groups of patients. RESULTS Patient characteristics did not differ between the 2 groups, with the exception of the incidence of gastric body tumors, which was significantly higher in the RY group (73.9% vs. 19.4%; p < 0.001). Operation time was significantly longer in the RY reconstruction group (p < 0.001). There was no significant between-group difference in the grades of GI dysfunction (p = 0.122).The endoscopically determined RGB (Residual food, Gastritis, Bile reflux)scores were significantly better in the RY reconstruction group than in the BI reconstruction group (p = 0.027, p < 0.001,p < 0.001,respectively).There was also no significant between-group difference in the change (1-year postoperative value/preoperative value) in body weight, body mass index, serum albumin concentration, or total cholesterol concentration (p = 0.484,p = 0.613,p = 0.760,p = 0.890, respectively). CONCLUSIONS RY reconstruction appears not to be advantageous over BⅠ reconstruction in terms of GI function or nutritional status 1 year after surgery. RY reconstruction does appear to be superior in terms of preventing bile reflux but takes more operation time.
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21
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Gong JQ, Cao YK, Zhang GH, Wang PH, Luo GD. Uncut Esophagojejunostomy with Double Jejunal Pouch: An Alternative Reconstruction Method that Improves the Quality of Life of Patients after Total Gastrectomy. J INVEST SURG 2016; 30:125-132. [DOI: 10.1080/08941939.2016.1230249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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22
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Otsuka R, Natsume T, Maruyama T, Tanaka H, Matsuzaki H. Antecolic reconstruction is a predictor of the occurrence of roux stasis syndrome after distal gastrectomy. J Gastrointest Surg 2015; 19:821-4. [PMID: 25693423 DOI: 10.1007/s11605-015-2770-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 02/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Roux-en-Y reconstruction after distal gastrectomy can result in delayed gastric emptying, called Roux stasis syndrome (RSS). The cause of RSS has not been completely identified. This study retrospectively investigated the development of RSS. METHODS Between April 2008 and March 2014, we performed 138 procedures with distal gastrectomy using Roux-en-Y reconstruction. The development of RSS was analyzed and examined for correlations with the length of the operation, amount of blood loss, and surgical procedure. RESULTS RSS was observed in 16 of the 138 patients. There were no relationships between the length of the operation or amount of blood loss and the development of RSS according to the Mann-Whitney U test. There were also no significant differences in the development of RSS between the patients treated with laparotomy and laparoscopic surgery, end-to-side, side-to-side, or end-to-end anastomosis or isoperistaltic or antiperistaltic anastomosis, as determined using the chi-square test. However, the development of RSS tended to lower in the patients who underwent laparoscopic surgery, side-to-side anastomosis, and isoperistaltic anastomosis. In addition, there was a significant difference between the patients who received antecolic and retrocolic reconstruction (p=0.005). CONCLUSIONS Our findings suggest that antecolic reconstruction correlates with a lower likelihood of developing RSS.
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Affiliation(s)
- Ryota Otsuka
- Department of Surgery, Funabashi Municipal Medical Center, 1-21-1, Kanasugi, Funabashi-shi, Chiba, 273-8588, Japan,
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23
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Kawahira H, Kodera Y, Hiki N, Takahashi M, Itoh S, Mitsumori N, Kawashima Y, Namikawa T, Inada T, Nakada K. Optimal Roux-en-Y reconstruction after distal gastrectomy for early gastric cancer as assessed using the newly developed PGSAS-45 scale. Surg Today 2015; 45:1307-16. [PMID: 25631461 DOI: 10.1007/s00595-015-1111-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 12/25/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE The optimal surgical procedure for distal gastrectomy with Roux-en-Y reconstruction (DGRY) remains to be determined. Recently, a self-report assessment instrument, the Postgastrectomy Syndrome Assessment Scale-45 (PGSAS-45), was compiled to evaluate symptoms, the living status and the quality of life of patients who have undergone gastrectomy. We used this scale to evaluate procedures used for DGRY. METHODS The subjects included 475 patients who underwent DGRY for stage IA/IB gastric cancer. We evaluated whether the size of the remnant stomach, length of the Roux limb, reconstruction route and anastomotic procedure affected the patients' symptoms, living status and quality of life assessed using the PGSAS-45. RESULTS Patients with a residual stomach of more than half had significantly worse esophageal reflux scores than the patients with a smaller residual stomach (P = 0.0462); a residual stomach of one-third or one-fourth was favorable. A shorter length of the Roux limb was shown to be preferable to a longer Roux limb based on the results of the PGSAS-45. In addition, antecolic reconstruction and the anastomotic procedure using a linear stapler were found to be more favorable. CONCLUSIONS The size of the remnant stomach and the length and route of the Roux limb significantly influence the patient-reported DGRY outcomes.
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Affiliation(s)
- Hiroshi Kawahira
- Department of Frontier Surgery, Center for Frontier Medical Engineering, Chiba University, Graduate School of Medicine, 1-33, Yayoi-cho, Inage-ku, Chiba, 263-8522, Japan.
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Hiki
- Department of Gastroenterological Surgery, Gastroenterological Center, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masazumi Takahashi
- Division of Gastroenterological Surgery, Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | - Seiji Itoh
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Norio Mitsumori
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
| | | | | | - Takao Inada
- Department of Surgery, Tochigi Cancer Center, Utsunomiya, Japan
| | - Koji Nakada
- Department of Surgery, Jikei University School of Medicine, Tokyo, Japan
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24
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Herbella FAM, Silva LC, Vicentine FPP, Patti MG. Roux-en-Y limb motility after total gastrectomy. J Gastrointest Surg 2014; 18:906-10. [PMID: 24496746 DOI: 10.1007/s11605-014-2473-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/23/2014] [Indexed: 01/31/2023]
Abstract
The Roux-en-Y stasis syndrome is a troublesome postgastrectomy syndrome. Although the era of gastric resection for peptic ulcer disease has almost come to an end, the increasing incidence of proximal gastric cancer and the outbreak of bariatric operations make the study of the motility of the Roux-en-Y limb (RYL) after gastric resection or gastroplasty very relevant.This study aims to evaluate the motility of the RYL after total gastrectomy using high-resolution manometry (HRM). We performed an HRM on 8 patients after total gastrectomy for proximal gastric cancer and Roux-en-Y reconstruction, 74 ± 111 months after the operation. At the time of the study, all patients were asymptomatic without evidence of cancer recurrence.Peristaltic waves were noticed at the RYL in 3 (37%) of the patients. The mean wave amplitude of the peristaltic waves was 63 ± 29 (37-94) mmHg and 83 ± 35 (42-104) mmHg at 3 and 7 cm below the esophagojejunal junction, respectively. Simultaneous waves were noticed in 6 (75%) of the patients in 80 ± 32 % (30-100) of the swallows of these patients. No patient presented with absence of motor activity detectable at the HRM. Our results show that: (1) esophageal motility is normal after total gastrectomy with Roux-en-Y reconstruction; (2) motor activity is always detectable at the proximal RYL, but peristalsis is abnormal in most patients; and (3) absence of peristalsis does not translate into symptoms.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil,
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Iida A, Hirono Y, Fujimoto D, Koneri K, Goi T, Katayama K, Yamaguchi A. Retrocolic roux-en-Y anastomosis for total laparoscopic distal gastrectomy: fix-the-remnant-first technique. Asian J Endosc Surg 2013; 6:333-7. [PMID: 24308598 DOI: 10.1111/ases.12054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 05/07/2013] [Accepted: 06/23/2013] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Atsushi Iida
- Department of Gastroenterological Surgery, University of Fukui, Fukui, Japan
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