Braun Anastomosis Research Articles

Pancreaticoduodenectomy with malrotation following reoperation due to torsion of efferent loop: a case report

BackgroundMalrotation is a congenital anomaly during the development of the embryonic intestine. Although it is generally considered a pediatric surgical condition, it can have significant implications for adult surgery in terms of reconstruction.Case presentationThe patient was an 85-year-old man with pancreatic cancer and intestinal malrotation. He underwent pancreaticoduodenectomy with modified Child’s reconstruction. Because the ascending colon and efferent loop twisted easily, we fixed the ascending colon to the abdominal wall. Thereafter, right twist and stenosis of the efferent loop occurred. On the 22nd day after the initial surgery, detorsion and Braun anastomosis were performed for efferent loop fixation. Postoperative oral intake was good, and the patient was discharged from our hospital on the 24th day after the reoperation.ConclusionsThis is a rare case of pancreaticoduodenectomy with malrotation following reoperation due to a complication after Child’s reconstruction. In similar cases of intestinal malrotation, it is important to consider avoiding coaxial positioning of intestinal parts and an upper abdominal space while selecting a reconstruction method.

Reconstruction of the esophagus of patients with middle thoracic esophageal carcinoma using the remnant stomach following Billroth II gastrectomy.

It seems impossible to reconstruct the esophagus of patients with middle thoracic esophageal carcinoma with a history of distal gastrectomy using the remnant stomach. Although surgeons have made multiple efforts to reconstruct the esophagus using the remnant stomach, it can only be successfully used in cases of lower thoracic esophageal cancer. Additionally, the surgery is more complex than traditional esophagogastrostomy due to challenges including mobilization of the remnant stomach with the spleen and transposition of the pancreatic tail into the left hemithorax. Our operation proved that the remnant stomach, which we named as the completely mobilized remnant stomach after dissection of the feeding vessels, remained viable. We successfully integrated the completely mobilized remnant stomach in the reconstruction of the lower thoracic esophageal tract and then integrated it in Ivor Lewis esophagogastrostomy. We describe this new alternative surgical technique for the treatment of middle thoracic esophageal carcinoma in patients with a history of distal gastrectomy in this study. Clinical data of 23 patients from 2008 to 2019 were retrospectively analyzed. All patients underwent the Ivor Lewis procedure. All remaining vessels of the remnant stomach were dissected at their origins, and Roux-en-Y reconstruction or Braun anastomosis was performed. After esophagectomy during right thoracotomy, anastomosis of the remnant stomach and esophagus was performed. Two-field lymph node dissections were performed. There was no case of necrosis of the remnant stomach or of perioperative death. Serious complications included anastomotic leak in three cases, afferent-efferent loop syndrome in one, and anastomotic stricture in two. Application of the completely mobilized remnant stomach in Ivor Lewis esophagogastrostomy is feasible, and the surgical procedure is similar to that of normal esophagogastrostomy.

Total Laparoscopic Uncut Roux-en-Y for Radical Distal Gastrectomy: An Interim Analysis of a Randomized, Controlled, Clinical Trial.

The traditional Billroth II and Roux-en-Y anastomosis after laparoscopic distal gastrectomy for gastric cancer are associated with bile reflux gastritis and roux stasis syndrome, respectively. The uncut Roux-en-Y gastrojejunostomy can decrease the incidence of these complications by blocking the entry of bile and pancreatic juice into the residual stomach and retaining the impulses originating from the duodenum. The purpose of the present study was to compare the short-term outcomes of uncut Roux-en-Y (URY) and Billroth II combined Braun (BB) anastomosis. In this prospective, multi-center, two-arm randomized controlled trial, 124 patients with advanced distal gastric cancer were randomized into two groups: URY (n = 62) and BB (n = 62) groups. The mean gastric juice pH was significantly lower in the URY group compared with the BB group (3.94 ± 0.71 vs. 5.83 ± 0.91, P < 0.0001). The bile reflux gastritis at 3months (P < 0.0001) and 6months (P = 0.002) was significantly more frequent in the BB group. No recanalization occurred in the URY group, and no significant difference was found between the two groups in terms of mean operative time (P = 0.69), mean time to perform anastomosis (P = 0.86), mean estimated blood loss (P = 0.77), mean number of harvested lymph nodes (P = 0.90), time to first passage of flatus or defecation (P = 0.87), postoperative hospital stay (P = 0.83), and the incidence of postoperative complications (P = 0.70). URY anastomosis is associated with a significantly lower incidence of bile reflux gastritis and roux stasis syndrome compared with BB anastomosis.

Braun anastomosis may reduce the incidence of delayed gastric emptying following pancreaticoduodenectomy, but does not shorten the length of hospital stay

Introduction:: Delayed gastric emptying (DGE) is one of the most frequent complications following pancreaticoduodenectomy (PD). The preventive effect of Braun enteroenterostomy on DGE is still controversial. We examined the association between addition of a Braun anastomosis and the incidence and severity of DGE, the length of stay (LOS) and postoperative morbidity. Methods: A retrospective analysis of a prospectively collected database including all patients undergoing elective open PD by a single attending surgeon (January 2016 - June 2018). Reconstruction was based on a “classic” loop with an ante colic side to side gastroenterostomy. Braun was done in the second half of the cohort. The majority of patients were managed according to enhanced recovery protocol (ERAS). Using the ISGPS 2007 definition and classification of DGE, a univariate analysis was performed to evaluate the impact of adding a Braun enteroenterostomy, on the incidence of DGE, LOS and post-operative morbidity. Results: 82 patients were included (41 females and 41 males, mean age 65y, range 17-85), 35 with a Braun anastomosis vs. 47 without. Both groups are comparable with regard to demographic and clinical characteristics. Overall, 25 (30.5%) patients suffered from DGE, with 6 (7.3%) having grade C DGE. Only 1/35 (2.9%) of patients with Braun had grade C DGE, as opposed to 5/47 (10.6%) among the patients without a Braun. This difference did not reach statistical significance (p=0.36). The mean length of stay (LOS) was 17 days in both the Braun and non-Braun group, (range 8-53 and 6-95 respectively). 10/47 (21.2%) of patients in the non-Braun group suffered from at least one severe postoperative complication (Clavien Dindo ≥3) compared to 6/35 (17.1%) in the Braun group (p=0.62). Conclusion: Adding Braun anastomosis may reduce the incidence of delayed gastric emptying following pancreaticoduodenectomy, but does not shorten the length of hospital stay.

Prospective randomised study comparing Billroth II with Braun anastomosis versus Roux-en-Y reconstruction after radical distal gastrectomy for gastric cancer

Background: Enterogastric reflux of bile is a major cause of morbidity following distal gastrectomy. Various reconstructive methods were developed to overcome this.Methods: A prospective randomised study included all patients undergoing distal gastrectomy for gastric cancer was conducted during the period June 2012 and November 2016. After resection, they were randomized to undergo Billroth II with Braun anastomosis (BEE) (n = 28) or Roux-en-Y (RY) gastrojejunostomy (n = 26). Endoscopy and biliary scintigraphy were done at 3 months to assess the severity of gastritis and the presence of bile reflux in remnant stomach. Stomach was biopsied for histopathology. Quality of life (QOL) was assessed using gastric cancer-specific questionnaire.Results: Demographics and nutritional status was similar. Intraoperative variables, post-operative recovery and hospital stay were not statistically different. Remnant stomach in BEE group showed more severe and extensive gastritis than RY group. The incidence of bile reflux on endoscopy was statistically significantly high in BEE (P < 0.0001). The histological findings of endoscopic biopsies were similar. The incidence of bile reflux on scintigraphy was lower in RY group (10.7% vs. 46.2%; P = 0.03). The QOL symptom score was similar.Conclusions: The incidence of bile reflux and severity of gastritis is less in patients who underwent RY gastrojejunostomy when compared to Billroth II with Braun anastomosis without any significant difference in QOL.

Factors affecting ampullary access of ERCP after Billroth II gastrectomy

Objective To investigate factors affecting ampullary access of endoscopic retrograde cholangiopancreatography (ERCP) in patients undergoing Billroth Ⅱ gastrectomy. Methods A retrospective analysis was performed on data of 261 patients with Billroth Ⅱ gastrectomy who underwent ERCP at Changhai Hospital from January 2008 to December 2017. Multivariate logistic regression analysis was used to analyze the potential factors affecting successful ampullary access, and receiver operating characteristic (ROC) curve was used to assess the predictive ability of potential factors. Results A total of 345 ERCP sessions were collected. The successful ampullary access and cannulation rate were 82.3% (284/345) and 89.1% (253/284), respectively. The main reasons for ERCP procedural failure were unable to reach the duodenal blind end and find the papilla (66.3%, 61/92) and failure of selective cannulation (33.7%, 31/92). The ERCP-related complication rate was 14.2% (49/345), with post-ERCP pancreatitis rate was 3.2% (11/345). Multivariate logistic regression analysis indicated that the first ERCP attempt (OR=7.717, 95%CI: 2.581-23.068. P<0.001), with Braun anastomosis (OR=8.737, 95%CI: 2.479-30.797, P=0.001), and no cap-assisted forward-viewing gastroscope (OR=2.774, 95%CI: 1.283-5.997, P=0.009) were independent risk factors for failure of ampullary access. According to the B value of each risk factor in logistic regression analysis, that is, no cap-assisted as 1 point, the first ERCP attempt as 2 points, and Braun anastomosis as 2 points, the area under ROC curve was 0.773. When the cut-off point was 2.5, the sensitivity and specificity were 75.0% and 70.8%, respectively. Conclusion The first ERCP attempt, with Braun anastomosis, and no cap-assisted forward-viewing gastroscope are risk factors for failure of ampullary access of ERCP in Billroth Ⅱ gastrectomy patients. Early identification of high-risk patients may help to improve the success rate of ampullary access. Key words: Cholangiopancreatography, endoscopic retrograde; Gastrectomy, Billroth Ⅱ; Risk factors

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group.

Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions. From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years. Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%. Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Laparoscopic One Anastomosis Gastric Bypass Versus Laparoscopic One Anastomosis Gastric Bypass with Braun Anastomosis: What's Better?

Background and Aims: Although laparoscopic one anastomosis gastric bypass (LOAGB) is a promising bariatric procedure, a large number of surgeons have strong objections mainly because of risk of bile reflux, marginal ulceration, malnutrition, and long-term risk of gastric and esophageal cancer. Lateral enteroenterostomy placed distally to a gastrojejunal anastomosis shows efficacy in preventing bile reflux after gastric resection and gastrojejunal anastomosis, but at present its efficacy in a bariatric surgery context has not been evaluated. Patients and Methods: From January 2013 to December 2018, 100 patients have been admitted to our department to be treated by performing LOAGB. Patients have been divided into two groups on the basis of the indications to this surgical procedure; Group A: presence of de novo gastroesophageal reflux disease (GERD) or severe esophagitis after laparoscopic sleeve gastrectomy, with or without weight regain; Group B: LOAGB as primary procedure. Another group of 30 patients (Group C) underwent LOAGB with Braun anastomosis as primary bariatric surgical procedure for morbid obesity. We have conducted a retrospective analysis of the surgical outcomes in terms of perioperative mortality, short-, mid-, and long-term postoperative complications and weight loss. Results: Group A: 50 patients; incidence of postoperative GERD, esophagitis, or esophageal ulcers was 26% (13 cases). All these patients have been successfully treated by performing Braun anastomosis. Group B: 20 patients; incidence of de novo reflux was 25% (5 cases); Braun anastomosis was performed with complete resolution of signs and symptoms in all cases. Group C: 30 patients; no cases of de novo reflux, esophagitis, or anastomotic ulcers occurred. Conclusion: Braun anastomosis seems to be a useful surgical tool to prevent the onset of de novo reflux, esophagitis, and anastomotic ulcers.

Laparoscopic uncut Roux-en-Y for radical distal gastrectomy: the study protocol for a multirandomized controlled trial.

Gastric cancer is the third most common cause of cancer-related deaths and is the fifth highest incidence of cancer worldwide, especially in Eastern Asia, Central and Eastern Europe, and South America. Currently, surgery is the only curative treatment for gastric cancer; however, digestive tract reconstruction after distal gastrectomy for gastric cancer is controversial due to the postoperative complications such as reflux gastritis. There is an increasing trend toward laparoscopic uncut Roux-en-Y (URY) for radical gastrectomy. However, evidence on the feasibility of this procedure in patients undergoing laparoscopic radical distal gastrectomy is still absent. Thus, a prospective randomized trial is warranted. This is a prospective, multicenter, two-arm randomized controlled trial in which 210 patients will be randomly assigned to two groups: laparoscopic URY (n=105) and laparoscopic Billroth II plus Braun anastomosis (n=105). Each participant must be pathologically diagnosed with gastric cancer and undergo laparoscopic radical gastrectomy at Xijing Hospital and other four hospitals. The laparoscopic URY procedure is based on the Billroth II gastrojejunostomy plus Braun anastomosis, and then blocked the jejunum input loop at the stump–jejunal anastomosis. The patients’ demographic and pathological characteristics will be recorded. The total and oral nutritional intake, general data, total serum protein, serum albumin, blood glucose, and temperature will be recorded before surgery and at the time of hospitalization. Postoperative adverse events will also be recorded, as well as at follow-up appointments at three months and six months after surgery. The rate of reflux gastritis will represent the primary endpoint, and other secondary endpoints, which are all recorded.

Influence of body shape on the short-term therapeutic effects of laparoscopic distal gastrectomy: a multicentre retrospective study (A report of 506 cases)

Influence of body shape on the short-term therapeutic effects of laparoscopic distal gastrectomy: a multicentre retrospective study (A report of 506 cases)

Endoscopic retrograde cholangiopancreatography in Billroth II gastrectomy patients: Outcomes and potential factors affecting technical failure.

Background/Aims:Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II gastrectomy patients is technically demanding and factors affecting its technical difficulty have not yet been clarified. This study aimed to investigate the outcomes of ERCP in Billroth II gastrectomy patients and identify potential factors affecting its technical failure.Patients and Methods:A large retrospective study of 308 consecutive patients (391 procedures) with Billroth II gastrectomy—who underwent ERCP from January 2002 to December 2016—was conducted. The outcomes of ERCP and potential factors affecting its technical failure were analyzed.Results:The success rate of duodenal ampullary access, selective duct cannulation and the accomplishment of expected procedures was 81.3% (318/391), 86.5% (275/318) and 97.3% (256/263), respectively, and the technical success rate was 70.3% (275/391). The overall ERCP-related complication rate was 15.3% (60/391). The multivariate analysis indicated that first-time ERCP attempt [odds ratio (OR) 4.29, 95% confidence interval (CI) 2.34–7.85, P < 0.001], Braun anastomosis (OR 3.65, 95% CI 1.38–9.64, P < 0.009), and no cap-assisted gastroscope (OR 3.05, 95% CI 1.69–5.51, P < 0.001) were significantly associated with technical failure.Conclusions:ERCP is safe, effective and feasible for Billroth II gastrectomy patients. Previous ERCP history, absence of Braun anastomosis and the use of a cap-assisted gastroscope are the predictive factors for its technical success.

Bleeding Ulcer at Braun Anastomosis in Distal Gastrectomy Billroth II Reconstruction: A Case Report

症例は50歳代，男性。潰瘍性大腸炎の診断で近医通院中であり，プレドニゾロン11mgとアダリムマブ投与で寛解維持されていた。日中の仕事から帰宅後に吐血と血便を認めたため救急要請し当院へ搬送された。胃切除の既往があり，腸管再建に関する詳細な情報は不明であったが，造影CT検査からは，幽門側胃切除術Billroth Ⅱ法再建と考えられた。緊急上部消化管内視鏡検査を行なうと，Braun吻合部に露出血管を伴う潰瘍を認めたため，クリッピング止血を行なった。第4病日に再度吐血を認め，緊急上部消化管内視鏡検査を施行すると，Braun吻合部のクリップがすべて逸脱し，露出血管からの出血を認めたため，再びクリッピング止血した。その後は完全中心静脈栄養管理とし，2回目のクリッピングより14日後から経口摂取を再開。その後，再出血は認めず，第23病日に独歩退院した。幽門側胃切除術Billroth Ⅱ法再建後ではBraun吻合部が出血源となり得るため，緊急内視鏡検査時には同吻合の有無と，出血源となっていないかの評価が必要と考えられたので報告する。

Braun anastomosis reduces the problem of delayed gastric emptying that occurs after pancreaticoduodenectomy: a randomized controlled study

Braun anastomosis reduces the problem of delayed gastric emptying that occurs after pancreaticoduodenectomy: a randomized controlled study

Research advance in Billroth II with Braun anastomosis after distal gastrectomy

Methods of digestive tract reconstruction after distal gastrectomy include Billroth I, Billroth II and Roux-en-Y. Each of them has advantages and disadvantages respectively. Alkaline reflux gastritis (ARG) is one of the complications after distal gastrectomy, which is common after Billroth II. In the past 100 years, the ways of digestive tract reconstruction have been continuously improved and developed to prevent the occurrence of alkaline reflux gastritis, and Roux-en-Y is one of them. Still, there is a high incidence of Roux stasis syndrome resulting from Roux-en-Y, with impact on quality of life. Therefore, the appropriate reconstruction is needed urgently. Braun anastomosis was proposed in 1892 to lower the incidence of afferent syndrome. Because of its effect of diverting some alkaline digestive juice, it was applied to pancreaticoduodenectomy and distal gastrectomy. Some studies have proved its effect of diverting some alkaline digestive juice, but the diverted quantity was rarely shown. Besides, compared with Roux-en-Y, Billroth II with Braun anastomosis is safer and more convenient. Meantime it is likely to have benefits in aspect of preventing anemia and malnutrition. In order to provide evidence to clinical practice, this article summarizes the history and research advance of Billroth II with Braun anastomosis by reviewing previous reports.

Atypical anastomotic malignancies of small bowel after subtotal gastrectomy with Billorth II gastroenterostomy for peptic ulcer: Report of three cases and review of the literature.

AIMTo present patients who developed small-bowel malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy for ulcer, to review relevant literature, and to attempt to interpret the reasons those cancers developed to these postsurgical non-gastric sights.METHODSFor the current retrospective study and review of literature, the surgical and histopathological records dated from January 1, 1993 to December 31, 2017 of our department were examined, searching for patients who have undergone surgical treatment of small-bowel malignancy to identify those who have undergone subtotal gastrectomy for benign peptic ulcer. A systematic literature search was also conducted using PubMed, EMBASE, and Cochrane Library to identify similar cases.RESULTSWe identified three patients who had developed small-intestine malignancy at the level of the gastrointestinal anastomosis decades after a subtotal gastrectomy with Billroth II gastroenterostomy for benign peptic ulcer-two patients with adenocarcinoma originated in the Braun anastomosis and one patient with lymphoma of the efferent loop. All three patients were submitted to surgical resection of the tumor with Roux-en-Y reconstruction of the digestive tract. In the literature review, we only found one case of primary small-intestinal cancer that originated in the efferent loop after Billroth II gastrectomy because of duodenal ulcer but none reporting Braun anastomosis adenocarcinoma following partial gastrectomy for benign disease. We also did not find any case of efferent loop lymphoma following gastrectomy.CONCLUSIONAnastomotic gastric cancer following distal gastrectomy for peptic ulcer is a well-established clinical entity. However, malignancies of the afferent or efferent loop of the gastrointestinal anastomosis are extremely uncommon. The substantial diversion of the potent carcinogenic pancreaticobiliary secretions through the Braun anastomosis and the stomach hypochlorhydria, allowing the formation of carcinogenic factors from food, are the two most prominent pathogenetic mechanisms for those tumors.

Реконструкция пищеварительного тракта при распространённом раке желудка после гастрэктомии с формированием искусственного резервуара по Гофману

The article contains the results of the first clinical experience of application of original method of surgical treatment of stomach cancer by performing a gastrectomy and formation of artificial jejunum reservoir. The relevance of the study consists in the imposition of a submerged organ of the esophageal-jejunal anastomosis hanging down the lumen of the organ, anastomosing the stump of the pancreas with the jejunum by "end-to-side" type, with a mucosal mucosa seam with a sleeve-shaped anastomosis peritoneisation and a lean jejunum loop at the level of the choledochus stump - creating anti-reflux "end-to-side" choledochojejunoanastomosis, followed by the formation of Braun anastomosis with 20 cm reservoir, by Hoffman's stomach type, performing a function of the removed stomach. The method proposed by the authors of the present study is based on more than 15years of practice in the use of refluxing anastomoses in trans-abdominal surgery and 70-year-old practice of applying diaphragm crurotomy by A.G. Savinykh, as the only method of access to the esophagus. The treatment results were assessed using X-ray contrast techniques, endoscopic and ultrasound equipment, as well as traditional laboratory, radiographic and clinical tests. The results of treatment of 6 patients in terms from 6 months to 5years were estimated. Successful outcome of the surgery was achieved in all cases. The effectiveness of the intervention is confirmed throughout the range of clinical and instrumental criteria used. The authors conclude that the method shows a good clinical perspective.

Application value of Braun anastomosis in pancreaticoduodenectomy

Objective To investigate the application value of Braun anastomosis in pancreatico-duodenectomy. Methods The retrospective cohort study was conducted. The clinicopathological data of 389 patients who underwent pancreaticoduodenectomy in the Fudan University Shanghai Cancer Center from March 2012 to July 2014 were collected. Of 389 patients, 235 receiving Braun anastomosis and 154 receiving non-Braun anastomosis were respectively allocated into Braun anastomosis group and non-Braun anastomosis group. All the patients underwent pancreaticoduodenectomy with digestive tract reconstruction using Child method. Patients in the Braun anastomosis group received 5-10 cm Braun anastomosis between input and output end of jejunum, and patients in the non-Braun anastomosis group didn′t receive jejunum-jejunum Braun anastomosis after gastrojejunostomy. Observation indicators included: (1) intraoperative situations; (2) postoperative recovery; (3) follow-up. Patients were followed up using outpatient examination and telephone interview up to May 2015. Follow-up included monthly routine blood retest, hepatorenal function retest and urine and stool routine retest, and enhanced CT scan in the epigastric region for every three months to detect recovery of digestive tract function. Measurement data with normal distribution were represented as ±s. Comparison between groups was analyzed using t test, and count data were analyzed using chi-square test. Results (1) Intraoperative situations: 389 patients underwent successful pancreaticoduodenectomy. Standard pancreaticoduodenectomy and pyloric-preserving pancreaticoduodenectomy were respectively applied to 205 and 30 patients in the Braun anastomosis group and 137 and 17 patients in the non-Braun anastomosis group, with no statistically significant difference (χ2=0.259, P>0.05). Anastomosis and reconstruction of pancreatic stump: anastomosis of main pancreatic duct and jejunal mucosa, embedded anastomosis of papillary main pancreatic duct and pancreas-stomach anastomosis were detected in 138, 89, 8 patients in the Braun anastomosis group and 85, 60, 9 patients in the non-Braun anastomosis group, respectively, with no statistically significant difference (χ2=1.535, P>0.05). Total operation time, pancreas-jejunum anastomosis time and volume of intraoperative blood loss were (398.9±61.9)minutes, (20.6±3.5)minutes, (401±59)mL in the Braun anastomosis group and (401.3±59.2)minutes, (20.7±2.1)minutes, (407±159)mL in the non-Braun anastomosis group, respectively, with no statistically significant difference (t=-0.380, -0.562, -0.319, P>0.05). (2) Postoperative recovery: time to initial anal exsufflation, time for fluid diet intake and time of drainage tube removal were (103±28)hours, (77±25)hours, (12±5)days in the Braun anastomosis group and (102±31)hours, (79±30)hours, (13±6)days in the non-Braun anastomosis group, respectively, with no statistically significant difference (t=0.330, -0.712, -1.783, P>0.05). Delayed gastric emptying, gastrointestinal hemorrhage, obstruction of afferent loop and pancreatic fistula were detected in 25, 3, 0, 30 patients in the Braun anastomosis group and 27, 4, 2, 23 patients in the non-Braun anastomosis group, respectively, with no statistically significant difference (χ2=3.818, 0.918, 3.068, 0.695, P>0.05). Seventeen patients were combined with delayed gastric emptying and pancreatic fistula, including 8 in the Braun anastomosis group and 9 in the non-Braun anastomosis group, with no statistically significant difference between the 2 groups (χ2=1.363, P>0.05). Patients with postoperative complications were improved by symptomatic and supporting treatment. Duration of hospital stay and treatment expenses were (14±7)days, (73 205±4 538)yuan in the Braun anastomosis group and (22±11)days, (83 219±5 738)yuan in the non-Braun anastomosis group, with statistically significant differences between the 2 groups (t=-8.767, -19.139, P<0.05). (3) Follow-up: 389 patients were followed up for 6 months, without death. Six and 9 patients in the Braun anastomosis group and non-Braun anastomosis group had regurgitation cholangitis. There was no readmission due to gastrointestinal hemorrhage and digestive tract obstruction, and no signs of hyperglycaemia and intractable diarrhea occurred. Conclusion Braun anastomosis can reduce duration of postoperative hospital stay and treatment expenses. Key words: Pancreaticoduodenectomy; Braun anastomosis; Delayed gastric emptying; Pancreatic fistula

Does Braun Anastomosis Have an Impact on the Incidence of Delayed Gastric Emptying and the Extent of Intragastric Bile Reflux Following Pancreatoduodenectomy? - A Randomized Controlled Study

Background/Aims: This study investigated the impact of Braun anastomosis on the incidence of delayed gastric emptying (DGE) and on the intragastric bile reflux after pancreatoduodenectomy with Child reconstruction. Methods: Sixty-eight patients who underwent subtotal stomach-preserving pancreatoduodenectomy were included. Patients were randomly assigned to a group with or without Braun anastomosis intraoperatively. Twenty-four-hour intragastric bilirubin monitoring was performed to investigate the extent of intragastric bile reflux after surgery. The incidence of DGE and other complications was also monitored. Results: There were no differences between the non-Braun and Braun groups in terms of patient characteristics. The incidence rate of DGE was 29.4% (n = 10/34) in the non-Braun group and 20.6% (n = 7/34) in the Braun group (p = 0.401). Forty-six of the 68 patients consented to intragastric bilirubin monitoring. The fraction time of intragastric bilirubin reflux was comparable between the 2 groups. Although the fraction time of intragastric bilirubin reflux had no impact on the incidence of DGE, the incidence of pancreatic fistula was significantly higher in patients with DGE than those without DGE (47.1 vs. 21.6%, p = 0.043). Conclusion: The addition of Braun anastomosis after pancreatoduodenectomy did not effectively reduce the intragastric bile reflux and had minor impact in reducing the incidence of DGE.

Billroth II with Braun Enteroenterostomy Is a Good Alternative Reconstruction to Roux-en-Y Gastrojejunostomy in Laparoscopic Distal Gastrectomy.

Background. Although Billroth II (BII) reconstruction is simpler and faster than Billroth I or Roux-en-Y (RY) reconstruction in patients undergoing totally laparoscopic distal gastrectomy (TLDG), BII reconstruction is associated with several complications, including more severe bile reflux. BII Braun anastomosis may be a better alternative to RY reconstruction. Methods. This retrospective study included 56 consecutive patients who underwent TLDG for gastric cancer, followed by BII Braun or RY reconstruction, between January 2013 and December 2015. Surgical outcomes, including length of operation, quantity of blood lost, and postoperative complications, were compared in the two groups. Results. Clinicopathological characteristics did not differ between the BII Braun and RY groups. Mean length of operation was significantly longer in the RY than the BII Braun group (157.3 min versus 134.6 min, p < 0.010), but length of hospital stay, blood loss, and complication rate did not differ between the two groups. Ileus occurred in three patients (10.0%) in the RY group. Endoscopic findings 6 months after surgery showed bile reflux in seven (28%) patients in the BII Braun group and five (17.2%) in the RY group (p = 0.343), but no significant differences in rate of gastric residue or degree of gastritis in the remnant stomach in the two groups. Conclusions. B-II Braun anastomosis is a good alternative to RY reconstruction, reducing length of operation and ileus after TLDG.

Tips and tricks of double-balloon endoscopic retrograde cholangiopancreatography (with video).

Although endoscopic retrograde cholangiopancreatography (ERCP) is technically difficult in patients with altered gastrointestinal tract, double-balloon endoscopy (DBE) allows endoscopic access to pancreato-biliary system in such patients. Balloon dilation of biliary stricture and extraction of bile duct stones, placement of biliary stent in patients with Roux-en-Y or Billroth-II reconstruction, using DBE have been reported. However, two major technical parts are required for double-balloon ERCP (DB-ERCP). One is insertion of DBE and the other is an ERCP-related procedure. The important point of DBE insertion is a sure approach to the afferent limb with Roux-en-Y reconstruction or Braun anastomosis. Short type DBE with working length 152 cm is beneficial for DB-ERCP because it is short enough for most biliary accessory devices. In this paper, we introduce our tips and tricks for successful DB-ERCP.