Braun Anastomosis Research Articles

098. Report in Emergency repair for Duodenum Part 1 Perforation in Referral Hospital Banyumas

Introduction: Duodenal perforation was frequent cause of hollow viscus perforation beside to gastric perforation. Immediate source control properties, reproducibility, simplicity and applicability was the prefer method in emergency setting to repair this perforation. Case: We present one case of female, 46 years old patient with duodenal part 1 perforation with Boey Score 1, where we performed repair with primary suturing, gastrojejunal – braun anastomosis and omental patch. We found part 1 duodenal perforation 1.5cm in diameter. Patient was in hospital for 5 days before being discharged. Conclusions: Primary suturing, gastrojejunal – braun anastomosis and omental patch applicable in referral hospital, were preferable method that has best result and easy repair technique based on this report.

Comparison Between Billroth II and Billroth II + Braun Anastomosis in Gastrectomy for Gastric Cancer

IntroductionDistal gastrectomy remains the predominant therapeutic approach for gastric cancer, with digestive tract reconstruction as an integral procedure. The implementation of Braun anastomosis following Billroth II anastomosis is common in distal gastrectomy. This retrospective cohort study evaluated the clinical utility of Braun anastomosis by comparing the outcomes and quality of life between Billroth II (B-II) and Billroth II with Braun (B-IIB) anastomosis in the treatment of gastric cancer. MethodsA retrospective cohort study examined clinical and pathological data from 377 patients who underwent distal gastrectomy for gastric cancer treatment at The Affiliated Lihuili Hospital, Ningbo University, from October 2016 to October 2021.185 patients received B-II anastomosis, while the other 192 received B-IIB anastomosis, forming the B-II and B-IIB groups, respectively. Baseline characteristics, perioperative variables, short-term and long-term complications, and nutritional indicators at 1 mo and 1 y postsurgery were compared across both groups. Additionally, gastric endoscopy results at 6 mo and 1 y postsurgery were evaluated. Quality of life at 1 y postsurgery was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30. ResultsBaseline characteristics between the two groups revealed no statistically significant differences (all P > 0.05), confirming their equivalence. All 377 patients successfully underwent curative distal gastrectomy for gastric cancer without intraoperative procedural modifications. No intraoperative complications or perioperative mortality occurred. Notable differences included extended operative time (222.1 ± 41.0 vs. 199.4 ± 24.9 min, P < 0.001), reduced postoperative nasogastric tube removal time (1.8 ± 0.9 vs. 2.2 ± 1.1 d, P < 0.001), decreased average gastric drainage volume (100.7 ± 35.2 vs. 112.2 ± 32.0 mL, P = 0.001), and increased incidence of internal hernia and ileus (4.7% vs. 1.1% and 8.3% vs. 3.2%, P = 0.038 and P = 0.035) in the B-IIB group compared to the B-II group. No significant differences were observed in estimated blood loss, lymph node dissection, postoperative flatus time, transition to a semiliquid diet, length of hospital stay, or short-term and long-term complications (all P > 0.05). Nutritional assessments conducted 1 mo and 1 y postsurgery indicated no statistically significant differences in body mass index, total protein, and serum albumin levels between the two groups (all P > 0.05). Gastric endoscopy evaluations at 6 mo and 1 y postsurgery, including food residue grade, gastritis severity, extent of gastritis, and bile reflux, demonstrated no significant discrepancies between the groups (all P > 0.05). At the 1-y follow-up, neither group exhibited tumor recurrences, deaths from tumor-related diseases, postoperative complications, or other diseases. Additionally, quality of life assessments using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core revealed no significant differences across various domains or items between the groups (all P > 0.05). ConclusionsA comparative analysis between B-II and B-IIB anastomosis demonstrated no notable variations in intraoperative parameters, postoperative nutritional outcomes, gastric endoscopic results, or postoperative quality of life. Nevertheless, incorporating Braun anastomosis can extend the duration of surgery and may elevate the likelihood of postoperative internal hernia.

Application and research progress of Billroth-II combined with Braun anastomosis in laparoscopic radical gastrectomy of distal gastric cancer.

Application and research progress of Billroth-II combined with Braun anastomosis in laparoscopic radical gastrectomy of distal gastric cancer.

Dunking Pancreaticojejunostomy With Braun's Jejunojejunostomy: Perioperative Outcomes of a Hundred Pancreaticoduodenectomies.

Background The optimal surgical technique for pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD) is still debated. Dunking and duct-to-mucosa PJ are the most commonly adopted techniques. Incorporating Braun's jejunojejunostomy (JJ) could reducetheincidence and severity of delayed gastric emptying (DGE). This retrospective descriptive study seeks to clarify the outcomes of dunking PJ with Braun's JJ in 100 PD patients. Methodology We retrospectively reviewed 100 patients who underwent PDs in a single unit of the Department of Surgical Gastroenterology of Tribhuvan University Teaching Hospital from October 2012 to February 2023. Demographic and historical data, indications, procedure-related data, complications, and mortality data were collected and analyzed. Results The mean age was 50.96 ± 14.97 years, and 64 (64%) were males. The most common indication was ampullary carcinoma (53, 53%) followed by distal cholangiocarcinoma (18, 18%) and pancreatic ductal adenocarcinoma (7, 7%). Operative time was 5.83 ± 1.09 hours, intraoperative blood loss was 515 ± 194 mL, and the average time for PJ and Braun's JJ was 22 ± 6 and 15 ± 3 minutes, respectively. Soft pancreas was encountered in 52 (52%) patients and clinically significant postoperative pancreatic fistula (Grade B, C) was seen in 23 (23%). Postpancreatectomy hemorrhage was seen in 21 (21%) patients (Grades A: 3, B: 12, C: 6). DGE (Grade B) occurred in two (2%) patients, and bile leak was observed in 4% of patients (Grades A: 1, B: 2, C: 1). Major complications (Clavien-Dindo ≥IIIA) occurred in 24%, and 11 patients died. Conclusions The dunking technique is easily adaptable, less time-consuming, and can be performed in the pancreas of any texture or duct size but is associated with an increased incidence of post-pancreatectomy hemorrhage. Incorporation of Braun's anastomosis lowers DGE, allows early initiation of feeding, and reduces complication rates.

Analysis of Clinical Efficacy and Quality of Life of Braun Anastomosis in Gastrointestinal Reconstruction in Totally Laparoscopic Distal Gastrectomy: A Single-Center Retrospective Study.

This study aimed to compare the clinical efficacy and quality of life of B-IIB (Billroth-II with Braun anastomosis) and B-II (Billroth-II anastomosis) in the alimentary tract reconstruction postoperative totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. From February 2016 to January 2022, 158 patients underwent totally laparoscopic distal gastrectomy and D2 lymphadenectomy in Northern Jiangsu People's Hospital, with Billroth-II with Braun anastomosis for 93 patients and Billroth-II anastomosis for 65 patients. The patients' data were collected prospectively and reviewed retrospectively. In this study, the post-op hospital stay of B-IIB group were shorter than B-II group (12.70 ± 3.08 days in the B-IIB group versus 14.12 ± 4.90 days in the B-II group, p < 0.05) and the first post-op flatus time of the B-IIB group were shorter than B-II group (3.49 ± 1.02days versus 4.08 ± 1.85days, p < 0.05). Twogroupsdiddiffersignificantly inhemoglobin on postoperative 3months, albumin at 3months after operation, and serum sodium on postoperative 3daysand3months(p < 0.05), and the B-IIB had an advantage; the complications incidence (Clavien-Dindo grade II or even a higher grade) of the B-IIB group and B-II group were 10.75% and 29.23%, respectively. There being a statistical difference between the two groups. The B-IIB group and the B-II group both had different degrees of weight loss at 3months after operation compared with preoperative weight. The weight of B-IIB group was 4.04 ± 1.33kg, which was less than B-II group (8.08 ± 1.47kg). The difference was statistically significant (p < 0.05). According to the PGSAS (Postgastrectomy Syndrome Assessment Scale), the score of the B-IIB group is lower than that of the B-II group for esophageal reflux gastritis, dyspepsia, and dumping syndrome group (1.84 ± 0.92 VS 2.15 ± 0.85, P = 0.031; 1.86 ± 1.10 VS 2.22 ± 0.91, P = 0.034; 1.98 ± 1.06 VS 2.32 ± 0.94, P = 0.037, respectively). Totally laparoscopic distal gastrectomy with Billroth-II Braun reconstruction is a safe and technically feasible method for gastric cancer patients, which can reduce the incidence of postoperative reflux esophagitis and dumping syndrome. Compared with Billroth-II reconstruction, it has advantages in maintaining postoperative nutritional status and electrolyte balance and improving quality of life.

Management Modalities of Pancreatic Cancer and Surgical Outcomes of Braun's Anastomosis Addition in Whipple's Procedure: A Single-center Prospective Study

Background: Pancreatic cancer is an aggressive malignancy with high mortality rate. Many morbidities associated with Whipple's procedure that endanger patients’ life which need updated surgical techniques to lower these morbidities. The aim of this study is to determine management modalities of pancreatic cancer and surgical outcomes of adding Braun's jejunojejunostomy to Whipple's procedure for reduction of postoperative risks in Sudanese patients to reach excellent surgical practice. Subjects and Methods: This is a prospective-cohort study conducted during the period between January 2022 and July 2023 at Ibn Sina specialized hospital, Khartoum, Sudan, on sixty-three patients diagnosed with resectable pancreatic cancer. Addition of Braun’s jejunojejunostomy to elective open Whipple’s surgery was performed. Results: Seventy-three percent of patients diagnosed with pancreatic cancer were males with the ratio (3:1). Patients’ distribution according to age ranged between 46 and 60 years representing (41.3%). The significant reported comorbidities that associated with PC were diabetes mellitus (30.2%) and businessmen (39.7%). Most of patients were lived in rural areas (57.1%). Abdominopelvic CT-scan revealed stage (II) of pancreatic cancer in (68.2%) of patients. The predominant morbidity after addition of Braun's jejunojejunostomy was wound infections noticed in (17.5%) of patients. Moreover, other complications were categorized as follows: pulmonary infections in (6.35 %) of cases, postoperative diabetes mellitus in (4.76 %) of cases, entero-cutaneous fistula in (4.76 %) of cases, delayed gastric emptying in (3.17%) of cases, biliary leak in (3.17%) of cases, (3.17%) of cases, pancreatic fistula in one case (1.58%), gastric outlet obstruction in one case (1.58%) and postoperative GIT bleeding in one case (1.58%). Postoperative hospital stay of patients were ranged between 8-15 days for (66.7%) of cases. The mortality rate was zero. Conclusions: To reduce the rate of lethal surgical morbidities of Whipple's procedure, we recommend addition of Braun's jejunojejunostomy as useful technique. Moreover, it will potentially help in improving the quality of surgical practice and survival outcomes of patients who diagnosed with pancreatic cancer.

Comparison of uncut Roux-en-Y anastomosis and Billroth-II with Braun anastomosis after distal gastrectomy.

This study aimed to compare the clinical outcomes and patient benefits of uncut Roux-en-Y (URY) anastomosis and Billroth-II with Braun (BB) anastomosis after distal gastrectomy. We retrospectively reviewed the data of patients who underwent URY or BB anastomosis after distal gastrectomy between March 2015 and December 2017. Clinical characteristics, survival data, postoperative recovery data, and long-term outcomes were recorded and compared between the two groups. A total of 231 patients were included, with 167 in the URY group and 64 in the BB group. Kaplan-Meier curves for overall survival showed no differences after propensity score matching (p = 0.488). Long-term postoperative quality of life evaluation also showed no significant differences. Compared to the BB group, patients in the URY group had a significantly shorter time to start a liquid diet after propensity score matching (67.6 h vs. 46.5 h, p = 0.003), and a lower occurrence of bile reflux on follow-up gastroscopy (p < 0.001). The URY anastomosis appears to be a feasible method for digestive tract reconstruction after distal gastrectomy, resulting in less bile reflux and better postoperative recovery. However, there is no significant difference between URY and BB anastomosis in terms of overall survival and long-term quality of life.

Billroth II anastomosis combined with brown anastomosis reduce reflux gastritis in gastric cancer patients.

The surgeon performing a distal gastrectomy, has an arsenal of reconstruction techniques at his disposal, Billroth II among them. Braun anastomosis performed during a Billroth II procedure has shown evidence of superiority over typical Billroth II, in terms of survival, with no impact on postoperative morbidity and mortality. To compare Billroth II vs Billroth II and Braun following distal gastrectomy, regarding their postoperative course. Patients who underwent distal gastrectomy during 2002-2021, were separated into two groups, depending on the surgical technique used (Billroth II: 74 patients and Billroth II and Braun: 28 patients). The daily output of the nasogastric tube (NGT), the postoperative day that NGT was removed and the day the patient started per os feeding were recorded. Postoperative complications were at the same time noted. Data were then statistically analyzed. There was difference in the mean NGT removal day and the mean start feeding day. Mean total postoperative NGT output was lower in Braun group (399.17 mL vs 1102.78 mL) and it was statistically significant (P < 0.0001). Mean daily postoperative NGT output was also statistically significantly lower in Braun group. According to the postoperative follow up 40 patient experienced bile reflux and alkaline gastritis from the Billroth II group, while 9 patients who underwent Billroth II and Braun anastomosis were presented with the same conditions (P < 0.05). There was evidence of superiority of Billroth II and Braun vs typical Billroth II in terms of bile reflux, alkaline gastritis and NGT output.

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis.

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness. Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups. During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively. R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

Surgical management of Stapfer Type 2 ERCP perforations.

While numerous studies have proposed algorithms for the management of Stapfer Type 2 ERCP perforations, there is limited research on surgical treatment options specifically for this patient group. Our aim is not to propose a new algorithm for these patients but to describe our surgical approach and contribute to the literature with our surgical procedure applied in Stapfer Type 2 ERCP perforation cases. Between 2016 and 2023, a total of 12 patients with Stapfer Type 2 ERCP perforations underwent surgery at our hospital. Duodenal diverticulization is a commonly used method in complex duodenal perforation cases. We performed a procedure that involves the removal of the external biliary pathway, hepaticojejunostomy, and a wide Braun anastomosis in addition to the duodenal diverticulization procedure, which we have termed "modified duodenal diverticulization." Eleven out of the 12 patients were discharged successfully without any complications. One patient, who had a late diagnosis, underwent surgery 5 days after ERCP. This patient had ongoing sepsis before the operation, which continued postoperatively and eventually led to multiple organ failure and death. There are limited alternatives for the surgical treatment of Type 2 ERCP perforations, and the widely preferred triple ostomy method may not address the underlying pathology necessitating ERCP. The modified duodenal diverticulization method, offering a definitive treatment, can be considered a surgical option for Type 2 ERCP perforations.

The effectiveness of adding braun anastomosis to standard child reconstruction to reduce delayed gastric emptying after pancreatoduodenectomy: protocol for a multicenter randomized-controlled trial (REMBRANDT) by the Dutch Pancreatic Cancer Group

The effectiveness of adding braun anastomosis to standard child reconstruction to reduce delayed gastric emptying after pancreatoduodenectomy: protocol for a multicenter randomized-controlled trial (REMBRANDT) by the Dutch Pancreatic Cancer Group

Comparison of three different anastomotic methods of sleeve gastrectomy with transit bipartition using an obese rodent model

The long-term effects and safety of single-anastomosis sleeve ileal (SASI) bypass have not been confirmed. The one anastomosis procedure carries the risk of bile reflux, and Braun anastomosis has the capacity to reduce bile reflux. This study was designed to compare the influences of bile reflux and histological changes in the esogastric sections of rats. Obese Sprague–Dawley rats underwent sleeve gastrectomy with transit bipartition (RYTB) (n = 12), SASI (n = 12), SASI bypass with Braun anastomosis (BTB) (n = 12), esojejunostomy (EJ) (n = 12), and SHAM (n = 8) surgery. During the 12-week follow-up period, weight changes, glucose improvement, and changes in serum nutrition were evaluated. Histological expression and bile acid concentration in the rats in all groups were also evaluated. No significant differences in weight loss and glucose improvements were observed in the RYTB, SASI, and BTB groups. The RYTB and BTB groups had significantly lower bile acid concentration and albumin levels than the SASI group. In addition, mucosal height in the RYTB and BTB groups was significantly lower than in the SASI group. Braun anastomosis had a significant effect on anti-reflux. BTB may be a superior primary procedure due to its potential for parallel bariatric and metabolic improvements, effective anti-reflux effects, simplified operations, and avoidance of severe malnutrition. Further clinical studies are needed to confirm these findings.

Gastric adenocarcinoma in Situs inversus totalis: a case study and literature review.

Situs inversus totalis (SIT) is an uncommon disorder characterized by mirror-image anatomy, which can present unique challenges and potential vascular anomalies in surgical interventions, particularly in gastric cancer patients. We aim to delineate a rare case of gastric adenocarcinoma in a SIT patient and conduct a thorough review of the existing literature concerning surgical strategies, vascular anomalies, and outcomes observed across varied geographic locales and technological approaches. A thorough examination of a case involving a 39-year-old male SIT patient who underwent a successful distal gastrectomy with D2 lymph node dissection is presented alongside an expansive literature review. The review encompasses 47 articles, collating data on surgical approaches and vascular anomalies across 49 patients diagnosed with SIT and gastric cancer. The patient underwent curative distal gastrectomy and Billroth II with Braun anastomosis within 95 minutes, incurring minimal intraoperative blood loss (100ml). Postoperative pathology confirmed moderately to poorly differentiated gastric adenocarcinoma (pT3N0M0), with no signs of recurrence or metastasis after 6 months of S-1 adjuvant chemotherapy. The literature review revealed vascular anomalies in approximately 20% of reported cases, accentuating its surgical significance. Noteworthy variations in surgical strategies, operative times, blood loss, and complications across different surgical modalities were observed, providing a comprehensive view into the practical management of such cases. Despite the inherent challenges associated with SIT, various surgical techniques can be successfully applied with meticulous preoperative planning and understanding vascular anomalies. This compilation of diverse surgical experiences across numerous documented cases seeks to provide a consolidated resource for refining surgical strategies and enhancing postoperative outcomes for gastric cancer patients with SIT, underscoring the imperativeness of further research in this niche domain.

Total pancreatectomy with remnant stomach preservation in a patient with a history of proximal gastrectomy and interposed jejunal reconstruction with right gastroepiploic conduit preservation: a case report

BackgroundPancreatic head resection following proximal gastrectomy jeopardizes the blood flow of the remnant stomach owing to right gastroepiploic conduit sacrifice, thereby necessitating total gastrectomy. However, owing to its high invasiveness, concomitant remnant total gastrectomy with pancreatectomy should be avoided as much as possible. Herein, we describe our experience of total pancreatectomy with right gastroepiploic conduit preservation in a patient with a history of proximal gastrectomy and reconstruction by jejunum interposition.Case presentationA 78-year-old woman with a history of gastric cancer was followed up at our institute for multiple intraductal papillary mucinous neoplasm, and main pancreatic duct stricture in the pancreatic head was newly detected. The cystic lesion was extended to the pancreatic body. Proximal gastrectomy and reconstruction by jejunal interposition were previously performed, and the mesenteric stalk of the interposed jejunum was approached through the retrocolic route. We planned total pancreatectomy with right gastroepiploic conduit preservation. Following adhesiolysis, the interposed jejunum and its mesentery lying in front of the pancreas were isolated. The arterial arcade from the common hepatic artery to the right gastroepiploic artery was detached from the pancreas. Furthermore, the right gastroepiploic vein was isolated from the pancreas. The pancreatic body and tail were pulled up in front of the remnant stomach, and the splenic artery and vein were resected. The pancreatic body and tail were pulled out to the right side, and the pancreatic head was divided from the pancreatic nerve plexus to the portal vein. The jejunal limb for entero-biliary anastomosis was passed through the hole behind the superior mesenteric artery and vein, and gastrointestinal anastomosis using the antecolic route and Braun anastomosis were performed.ConclusionsTo avoid remnant total gastrectomy, right gastroepiploic conduit preservation is an optional procedure for pancreatic head resection in patients who have undergone proximal gastrectomy with reconstruction by jejunal interposition.

Intraoperative tumor localization using a titanium ring strip in totally laparoscopic distal gastrectomy for middle-third gastric cancer

Background: This study presents a novel technical tip for intraoperative tumor localization and determination of the proximal resection line using a titanium ring strip for totally laparoscopic distal gastrectomy in patients with middle-third gastric cancer and describes the short-term results of its application.Methods: In total, 42 patients with middle-third gastric cancer who underwent intraoperative tumor localization using a titanium ring strip and determination of the proximal resection line through intraoperative radiography between January 2020 and December 2021 were enrolled in this study. We retrospectively analyzed patients’ prospectively collected clinical, pathological, and surgical data.Results: Twenty-six men and 16 women with a mean age of 58.3±12.5 years were enrolled. The mean operation time and estimated blood loss were 212.6±43.0 minutes and 122.4±77.6 mL, respectively. The lengths of the proximal and distal resection margin were 2.0±0.4 cm (range, 0.8–3.7 cm) and 10.5±4.1 cm (range, 0.4–20.4 cm), respectively. Roux-en-Y anastomosis was performed in 30 patients, while Billroth II with Braun anastomosis was performed in 12 patients. There were no procedure-related complications, and the mean postoperative hospital stay was 7.2±1.9 days. For all patients, the negative proximal resection margin was confirmed by postoperative pathological examinations.Conclusions: Intraoperative tumor localization and determination of the proximal resection line using a titanium ring strip is a useful alternative method that can be easily and safely performed. This method is especially useful for patients with middle-third gastric cancer requiring an appropriate proximal resection margin.

Successful treatment of postoperative nonobstructive recurrent cholangitis by tract conversion surgery after total pancreatectomy: a case report

BackgroundPostoperative cholangitis is a complication of biliary reconstruction during hepatobiliary pancreatic surgery. Most cases are associated with anastomotic stenosis, but there are also cases of cholangitis without stenosis, and treatment can be difficult, especially in patients with recurrent symptoms. In this report, we describe a case of repeated nonobstructive cholangitis in a patient after total pancreatectomy, in which a good outcome was obtained after performing tract conversion surgery.Case presentationThe patient was a 75-year-old man. He underwent total pancreatectomy for stage IIA cancer of the pancreatic body, hepaticojejunostomy via the posterior colonic route, gastrojejunostomy and Braun anastomosis via the anterior colonic route using the Billroth II method. The patient had a good postoperative course and was receiving adjuvant chemotherapy on an outpatient basis, but he developed his first episode of cholangitis 4 months after surgery. Although conservative treatment with antimicrobial agents was successful, the patient continued to have recurrent biliary cholangitis and was repeatedly admitted and discharged from the hospital. Since stenosis at the anastomosis was suspected, endoscopic observation of the anastomosis was performed using small bowel endoscopy for close examination, but no apparent stenosis was observed. Small bowel imaging indicated a possible influx of contrast medium into the bile duct, and reflux due to food residue was suspected as the cause of cholangitis. Since conservative treatment alone did not suppress the flare-up of symptoms, the decision was made to perform tract conversion surgery for curative purposes. The afferent loop was cut midstream, and jejunojejunostomy was performed downstream. The postoperative course was good, and the patient was discharged on the 10th day after surgery. He is currently an outpatient and has been free of cholangitis symptoms for 4 years without cancer recurrence.ConclusionsAlthough the diagnosis of nonobstructive retrograde cholangitis can be difficult, surgical treatment should be considered in patients with recurrent symptoms and refractory treatment.

Application of endoscopic suturing instrument in laparoscopic gastrojejunostomy

Objective: To investigate the safety and feasibility of using an endoscopic suturing instrument in laparoscopic gastrojejunostomy. Methods: A descriptive case series study was conducted to retrospectively analyze the clinical data of 5 patients with gastric cancer who underwent laparoscopic distal gastrectomy (Billroth II + Braun anastomosis) at Tangdu Hospital, Air Force Medical University from October 2022 to January 2023. The common opening was closed using an endoscopic suturing instrument. The indications were as follows: (1) patients aged between 18 and 80 years; (2) patients with gastric adenocarcinoma; (3) cTNM between I-III; (4) lower-third gastric cancer and radical gastrectomy is recommended; (5) no history of upper abdominal surgery (except for laparoscopic cholecystectomy). The surgery was performed as follows: A side-to-side gastrojejunostomy was performed with endoscopic linear cutter stapler. Then the common opening was closed with endoscopic suturing instrument. During suturing and closing the common opening, a vertical mattress suture was used to completely invert and close the mucosa-to-mucosa and serosa-to-serosa of the gastric and jejunum walls. After the first layer of suture was completed, the seromuscular layer was sutured from top to bottom to embed the common opening of stomach and jejunum. Results: Laparoscopic closure of the common gastrojejunal opening with endoscopic suturing instrument was successfully completed in all 5 patients. The operative time was (308.6±22.6) minutes, while the time of gastrojejunostomy was (15.4±3.1) minutes. The operative blood loss was (34.0±10.8) ml. No intraoperative or postoperative complications occurred in any of the patients. The first passage of gas occurred at (2.6±0.9) days, and the postoperative hospital stay was (7.0±1.9) days. Conclusion: The application of endoscopic suturing instrument in laparoscopic gastrojejunostomy is safe and feasible.

Braun Anastomosis: A Technique for Bile Reflux Improvement After Single Anastomosis Sleeve Ileal (SASI) Bypass; a Pilot Study.

Background. Single anastomotic surgeries can increase the risk of reflux, marginal ulceration, and gastrointestinal complications. Braun anastomosis prevents bile reflux after gastric resection and gastrojejunal anastomosis surgeries. The present pilot study evaluated Braun's efficacy in a single anastomosis sleeve ileal (SASI) bypass surgery.Methods. 28 patients with a history of SASI bypass surgery from October 2017 to September 2021 were included in the study. Patients were divided into 2 groups based on having Braun anastomosis to this surgical procedure; group A: underwent SASI bypass without Braun anastomosis; group B: underwent SASI bypass with Braun anastomosis. The surgical complications in terms of bile reflux, marginal ulcer, reflux esophagitis, and gastritis were evaluated and compared between the groups. Results. Bile reflux and reflux esophagitis were seen more in group A than in group B (37.5% vs 8.3% and 18.8% vs 8.3%, respectively). In contrast, 2 patients (16.7%) in group B had marginal ulcers compared to 1 (6.3%) in group A. Also, gastritis was seen in 1 patient in each group (6.3% in group A vs 8.3% in group B). However, the differences were not statistically different. Conclusions. Braun anastomosis is probably an effective procedure to reduce bile reflux, a concern of SASI bypass. Besides, further studies with a larger study population are needed.

Left Hepatectomy (Réglée) for Cholangiocarcinoma Occurring 5 Years after Gastrectomy for Adenocarcinoma – Case Report

Background Intrahepatic cholangiocarcinoma is an aggressive primary cancer of the liver with limited systemic therapeutic options. Surgical resection may be the only feasible option. It has an overall low incidence among gastrointestinal tumours (3%), and is the second most common cancer of the liver after hepatocellular type. Most patients diagnosed are asymptomatic, however the most common complaint is abdominal pain and other less common non-specific symptoms such as weight loss. Case presentation Our patient is a 72 years old male with the following medical history and presentation: 5 years prior he is diagnosed with adenocarcinoma of the stomach, antro-pyloric region. A 4/5 gastric resection and gastro-entero anastomosis, Braun anastomosis with D2 lymphatic curage without splenectomy was performed. Examinations show a hepatic lesion of segments II – III. A fibrogastroscopy and colonoscopy result normal. By means of puncture-biopsy a diagnosis of cholangiocarcinoma is established. The patient undergoes a left hepatectomy (Réglée) after he receives a chemotherapy course. His post-operative course was uneventful and was discharged in good health. Discussion This specific case posed a diagnostic challenge, knowing his past history for adenocarcinoma of the stomach 5 years prior. Abdominal pain and weight loss lead to a cross sectional imaging detection of a hypovascular lesion of liver segments II – III. Careful evaluation with gastroscopy and colonoscopy, along with puncture biopsy was needed to determine whether it was a metastasis or a primary tumour. In contrast to other intrahepatic tumors like hepatocellular carcinoma, therapeutic methods for intrahepatic cholangiocarcinoma are still being developed due to its rarity. Hepatic resection does, however, have a most important place in the treatment of patients. Conclusion Intra-hepatic cholangiocarcinoma remains a difficult condition in terms of diagnosis, surgical decision-making and survivability. However multiple studies confirm the role of surgical resection R0 with lymphadenectomy. Lymphatic permeation, vascular invasion, and intrahepatic satellite lesions were acknowledged as predictors of poor survival. Other treatment options such as chemotherapy and tumor ablation or embolization are still controversial with respect to their survival benefit, but can provide a role in select cases. Keywords: General Surgery, Hepatobiliary Surgery, Cholangiocarcinoma, Adenocarcinoma, Hepatectomy. DOI: 10.7176/JEP/14-5-04 Publication date: February 28 th 2023

REMBRANDT trial:The effectiveness of adding Braun anastomosis to standard Child reconstruction to reduce delayed gastric emptying after pancreatoduodenectomy: a multicenter randomized-controlled trial

REMBRANDT trial:The effectiveness of adding Braun anastomosis to standard Child reconstruction to reduce delayed gastric emptying after pancreatoduodenectomy: a multicenter randomized-controlled trial