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

Impact of route of reconstruction of gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: A prospective randomized study

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.

Stapler insertion angle toward the esophagus reduces the incidence of early postoperative Roux stasis syndrome after distal gastrectomy in minimally invasive surgery

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.

Subtotal gastrectomy pancreaticoduodenectomy versus conventional pancreaticoduodenectomy in the incidence of delayed gastric emptying: single-center retrospective cohort study

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.

Comparison between laparoscopic uncut Roux-en-Y and Billroth II with Braun anastomosis after distal gastrectomy: A meta-analysis

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.

The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis

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.

A Modified Billroth-II with Braun Anastomosis in Totally Laparoscopic Distal Gastrectomy: Initial Experience Compared with Roux-en-Y Anastomosis

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.

Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying

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.

Previous upper abdominal surgery is a risk factor for nasogastric tube reinsertion after pancreaticoduodenectomy

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.

Comparison of the Clinical Outcomes Between Isoperistaltic and Antiperistaltic Anastomoses After Laparoscopic Distal Gastrectomy for Patients With Gastric Cancer

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.

Easy fixation effects the prevention of Peterson’s hernia and Roux stasis syndrome

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.

Effect of Standardizing the Incision Line on Delayed Gastric Emptying After Laparoscopic Gastrectomy: A Retrospective Preliminary Analysis

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 &lt; 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.

Four reconstruction methods after laparoscopic distal gastrectomy: A systematic review and network meta-analysis

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.

Two cases of a perforated duodenal diverticulum after gastrectomy with Roux-en-Y reconstruction

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.

Comparison of Billroth I, Billroth II, and Roux-en-Y Reconstruction After Totally Laparoscopic Distal Gastrectomy: A Randomized Controlled Study

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.

Use of Video Review to Investigate Technical Factors That May Be Associated With Delayed Gastric Emptying After Pancreaticoduodenectomy

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.

Roux-en-Y or Billroth II Reconstruction After Radical Distal Gastrectomy for Gastric Cancer: A Multicenter Randomized Controlled Trial

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.

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

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.

Predictive Factors for Delayed Gastric Emptying after Distal Gastrectomy with Roux-en-Y Reconstruction

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.

Comparative study of outcomes of Roux-en-Y reconstruction and Billroth Ⅰ reconstruction performed after radical distal gastrectomy

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.

Antecolic reconstruction is a predictor of the occurrence of roux stasis syndrome after distal gastrectomy

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.

Optimal Roux-en-Y reconstruction after distal gastrectomy for early gastric cancer as assessed using the newly developed PGSAS-45 scale

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.

Roux-en-Y limb motility after total gastrectomy

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.

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.