Delta-shaped Gastroduodenostomy Research Articles

Intracorporeal modified delta-shaped gastroduodenostomy during 2-port distal gastrectomy: technical aspects and short-term outcomes.

Surgeons have become increasingly interested in reduced-port gastrectomy to minimize trauma while maintaining oncologic safety. Although gastroduodenostomy has the benefits of better nutritional outcomes and fewer postoperative complications than other types of reconstruction, gastroduodenostomy is not a preferred option for reduced-port distal gastrectomy because of technical difficulties. In this study, we describe our intracorporeal modified delta-shaped gastroduodenostomy technique, which is easily applicable during 2-port distal gastrectomy. We retrospectively reviewed our database of 30 consecutive patients with gastric cancer who underwent 2-port distal gastrectomy with intracorporeal modified delta-shaped gastroduodenostomy from October 2016 to May 2021. In this reduced-port approach, we used a Tropian Single port (TROPIAN TECH) via a 25-mm transumbilical incision and a 12-mm port at the right flank. All anastomoses were performed using a 60-mm endolinear stapler. We used 3 additional sutures to provide proper traction and support for the anastomosis. Mean ± standard deviation of operation time was 148.9 ± 34.7 minutes; reconstruction time was 13.2 ± 4.6 minutes; estimated blood loss was 29.3 ± 44.4 mL; and length of hospital stay was 4.5 ± 1.2 postoperative days. A total of 11 patients (36.7%) had a Clavien-Dindo grade I or grade II complication, and there were no grade IIIa or higher complications. Intracorporeal modified delta-shaped gastroduodenostomy was safely performed via a 2-port approach, resulting in acceptable surgical outcomes and no major complications.

Application of Overlap Gastroduodenostomy in Billroth I Anastomosis after Totally Laparoscopic Distal Gastrectomy for Gastric Cancer.

Delta-shaped gastroduodenostomy (DSGD) and overlap gastroduodenostomy (OGD) are the two most widely used intracorporeal Billroth I anastomosis methods after distal gastrectomy. In this study, we compared the short-term outcomes of DSGD and OGD in total laparoscopic distal gastrectomy (TLDG). In a retrospective cohort study, we examined 92 gastric cancer patients who underwent TLDG performed by the same surgeon between January 2014 and June 2018. All patients underwent Billroth I reconstruction (OGD, n = 45; DSGD, n = 47) and D2 lymph node dissection. We retrospectively reviewed the surgical outcomes, clinical pathological results, and endoscopy results. Laparoscopic surgery was successfully performed in both groups without conversion to open surgery. The demographic and clinical characteristics were similar between the two groups (P > 0.05). There were no significant differences between the two groups in operation time (158.9 ± 13.6 min vs. 158.8 ± 14.8 min, P=0.955), anastomotic time (19.4 ± 3.0 min vs. 18.8 ± 2.9 min, P=0.354), intraoperative blood loss (88.9 ± 25.4 mL vs. 83.7 ± 24.3 mL, P=0.321), number of lymph node dissections (31.0 ± 7.1 vs. 29.2 ± 7.5, P=0.229), length of hospital stay (8.8 ± 2.7 days vs. 9.1 ± 3.0 days, P=0.636), fluid intake time (3.1 ± 0.7 days vs. 3.2 ± 0.7 days, P=0.914), and morbidity of postoperative complications (6.7% [3/45] vs. 10.6% [5/47], P=0.499). Endoscopy performed 6 months postoperatively showed that the residual food (P=0.033), gastritis (P=0.029), and bile (P=0.022) classification score significantly decreased in the OGD group, and there were no significant differences 12 months postoperatively. OGD is a safe and effective reconstruction technique with comparable postoperative surgical outcomes and endoscopy results when compared with those of DSGD.

The safety and feasibility of intra-corporeal gastroduodenostomy using a self-pulling and latter transected method (Delta SPLT) in totally laparoscopic distal gastrectomy.

In 2016, the self-pulling and latter transection method (named "Delta SPLT"), a modified delta-shaped gastroduodenostomy (DA) technique for totally laparoscopic distal gastrectomy, was described. Delta SPLT reduced the technical difficulty of the surgery and the quantity of cartridges required with a manageable initial safety profile. Here, the safety and feasibility of this technique are analyzed at 1 year's follow-up. The demographic and clinicopathologic profiles, perioperative details, and postoperative outcomes of 45 consecutive patients who underwent Delta SPLT from March 2016 to March 2019 were retrospectively analyzed. The Delta SPLT technique, which consisted of one endoscopic linear stapler and four cartridges each, was used for reconstruction in every case. The mean operative time was 127.1 ± 38.2 min, including a reconstruction duration of 22.6 ± 7.2 min. There were no surgical or anastomotic complications. The mean postoperative stay duration was 5.8 ± 1.2 days, and the morbidity rate was 2.2% with one case of postoperative pneumonia. The results at the one-year follow-up suggest that Delta SPLT is a safe and feasible procedure. Delta SPLT is characterized by fewer difficulties experienced during surgery, lower surgical costs, it is easy to practice, and it is beneficial for patients who are undergoing gastroduodenostomy.

Delta-shaped gastroduodenostomy using a robotic stapler in reduced-port totally robotic gastrectomy: its safety and efficiency compared with conventional anastomosis techniques

To investigate the safety and efficiency of using robotic staplers for intracorporeal gastroduodenostomy in reduced-port robotic gastrectomy for gastric adenocarcinoma. We retrospectively reviewed patients who underwent totally robotic and laparoscopic gastrectomy with intracorporeal gastroduodenostomy. Gastroduodenostomy using the ENDOWRIST robotic stapler (RR) was compared to that using an endolinear stapler during robotic gastrectomy (RE) and to that using an endolinear stapler during laparoscopic gastrectomy (LE). A total of 296 patients underwent gastroduodenostomy: 58, 28, and 210 patients with RR, RE, and LE, respectively. There were no conversions to other methods, and all robotic stapling procedures were performed on the console without receiving additional assistance from a bedside surgeon during RR. Comparing the operative outcomes of RR with those of RE and LE, respectively, we noted similar postoperative short-term outcomes. There were no major complications, including anastomosis-related complications, during the postoperative period after RR. The median reconstruction time during RR was 8 min and 45 s, which was similar to that during RE (8 min, 5 s [P > 0.9999]), but longer than that during LE (6 min, 30 s [P < 0.0001]). Intracorporeal gastroduodenostomy using the robotic stapler during robotic gastrectomy could be safely and feasibly performed on the console without the assistance of assistant, bedside surgeons.

Delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy for gastric cancer: comparative study of original and modified methods

Delta-shaped anastomosis (DA) has been widely accepted as a standard procedure for intracorporeal Billroth-I reconstruction after laparoscopic distal gastrectomy. We introduced DA in 2010 at our hospital and later developed a modified DA method in which a stapled corner of the duodenal stump was removed simultaneously with closure of an entry hole to reduce postoperative complications. The clinical data of 507 patients undergoing laparoscopic distal gastrectomy with DA from October 2010 through December 2018 were retrospectively collected from our in-house database. On the basis of the reviewed data, patients were divided into two groups: the original DA group (org-DA, n = 392) and the modified DA group (mod-DA, n = 115). Surgical outcomes, postoperative nutritional parameters, and endoscopic findings 1year after surgery were compared between the two groups. Baseline characteristics were similar between the two groups. Anastomotic stricture occurred in three patients (0.8%) in the org-DA group and one patient (0.9%) in the mod-DA group (P = 0.911). Anastomotic leakage was recorded in five patients (1.3%) in the org-DA group and none of the patients (0%) in the mod-DA group (P = 0.593). One year after surgery, the change in body weight in the org-DA group/mod-DA group was - 8.1%/- 7.0% (P = 0.285), and the change in hemoglobin level was - 5.0%/- 3.9% (P = 0.012). Endoscopic examination at the 1-year follow-up in the mod-DA group showed smaller amounts of food residue (P = 0.008) as well as less residual gastritis (P < 0.001) than in the org-DA group. The modified DA method can be performed safely with a complication rate comparable with the original DA method. Furthermore, better postoperative function is expected because of its more natural anatomy and physiology resulting from the modified method.

Modified delta-shaped gastroduodenostomy consisting of linear stapling and single-layer suturing with the operator positioned between the patient's legs: A technique preventing intraoperative duodenal injury and postoperative anastomotic stenosis.

BackgroundThe drawback of the delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG) is the presence of intraoperative duodenal injury and postoperative anastomotic stenosis, which can occur due to a relatively short duodenal bulb diameter.Materials and methodsFrom June 2013 to June 2019, 35 patients with gastric cancer underwent TLDG with a modified DSG consisting of linear stapling and single-layer hand suturing in our institution. All anastomotic procedures were performed by the right hand of the operator positioned between the patient’s legs. Linear stapling of the posterior walls of the remnant stomach and duodenum without creating a gap was performed using a 45-mm linear stapler, considering the prevention of intraoperative duodenal injury. The stapler entry hole was closed using a single-layer full-thickness hand suturing technique with knotted sutures and a knotless barbed suture. We described the clinical data and outcomes in the present retrospective patient series.ResultsNo intraoperative duodenal injury occurred in any of the 35 patients. The median staple length at linear stapling of the posterior walls of the remnant stomach and duodenum was 41.7 ± 4.2 (30–45) mm, and 2 patients (5.7%) had a staple length of 30 mm. There were no incidences of postoperative anastomotic stenosis.ConclusionsWe suggest that a modified DSG consisting of linear stapling and single-layer hand suturing performed by an operator positioned between the patient’s legs can be one option for B-Ⅰ reconstruction following TLDG because it can aid in preventing both intraoperative duodenal injury and postoperative anastomotic stenosis.

Modified Book Binding Technique (MBBT) for Intracorporeal Gastroduodenostomy in Totally Laparoscopic Distal Gastrectomy: Initial Experience

Totally laparoscopic distal gastrectomy (TLDG) frequently involves the use of delta shaped gastroduodenostomy (DSG) for intracorporeal anastomosis. However, DSG has some drawbacks, and the book binding technique (BBT) was developed as a new technique to overcome these drawbacks. Subsequently, this technique was further improved with the development of modified book binding technique (MBBT). This study evaluated the safety and feasibility of MBBT in patients undergoing TLDG. Thirty-three patients who underwent TLDG with MBBT were retrospectively evaluated. The mean operation time was 277.6±37.1 minutes, including 51.9±15.7 minutes for reconstruction. Two patients had anastomosis-related complications, one patient with stricture after leakage and 1 patient with stenosis. The former patient was treated with endoscopic balloon dilatation, and the latter was managed conservatively; neither required re-operation. MBBT is a safe and feasible technique, with acceptable surgical outcomes. It may be a good alternative option for the treatment of intracorporeal anastomosis in patients undergoing TLDG.

Intracorporeal delta-shaped gastroduodenostomy in reduced-port robotic distal subtotal gastrectomy: technical aspects and short-term outcomes.

Gastroduodenostomy is preferred as a method of reconstruction following distal subtotal gastrectomy. However, in initial reports on reduced-port gastrectomy, gastroduodenostomy has rarely been performed therein because of technical difficulties. The present study describes a novel intracorporeal gastroduodenostomy technique applicable during reduced-port robotic distal subtotal gastrectomy. Data were retrospectively reviewed for cases of reduced-port (three-port) robotic distal subtotal gastrectomy with intracorporeal delta-shaped gastroduodenostomy performed from February 2016 to December 2016. The reduced-port approach used a Single-Site™ port via a 25-mm infraumbilical incision and two additional ports. We performed intracorporeal gastroduodenostomy using a 45-mm robotic or laparoscopic endolinear stapler. All staplers were inserted via a port on the left lower abdomen. In our initial experience with intracorporeal gastroduodenostomy, 28 consecutive patients underwent successful surgery with the technique without needing to convert to open, laparoscopic, or conventional five-port robotic surgery. Mean operation time was 201.1min (110-282min), and no major complications, including anastomosis-related problems, were recorded. Intracorporeal delta-shaped gastroduodenostomy was safely and feasibly applied during reduced-port robotic gastrectomy with acceptable operative outcomes and no major complications. Intracorporeal gastroduodenostomy should be considered during reduced-port distal subtotal gastrectomy.

An option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-layer suturing technique for the stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures.

We report an option for delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. We detail a single-layer suturing technique for the endoscopic linear stapler entry hole using knotless barbed sutures combined with the application of additional knotted sutures. From June 2013 to February 2017, we performed TLDG with delta-shaped gastroduodenostomy in 20 patients with gastric cancer. The linear stapler was closed and fired to attach the posterior walls of the remnant stomach and the duodenum together. After creating a good view of the greater curvature side of the entry hole for the stapler by retracting the knotted suture on the lesser curvature side toward the ventral side, we performed single-layer entire-thickness continuous suturing of this hole using a 15-cm-long barbed suture running from the greater curvature side to the lesser curvature side. We placed the second and third stitches between the seromuscular layer of the remnant stomach and the entire-thickness layer of the duodenum while suturing the duodenal mucosa as minutely as possible. In addition, we routinely added one or two entire-thickness knotted sutures at the site near the greater curvature side. We placed similar additional knotted sutures at the site with a broad pitch. TLDG with this reconstruction technique was successfully performed in all patients with no occurrences of anastomotic leakage or intraabdominal abscess around the anastomosis. It is suggested that this method can be one option for delta-shaped gastroduodenostomy in TLDG due to its cost-effectiveness and feasibility.

A novel method of self-pulling and latter transected delta-shaped Billroth-I anastomosis in totally laparoscopic distal gastrectomy.

We developed a modified delta-shaped gastroduodenostomy technique in totally laparoscopic distal gastrectomy. This novel technique, which effectively reduces the required quantity of linear stapler [1-3], was named as self-pulling and latter transected delta-shaped anastomosis (Delta SPLT) [4]. Delta SPLT was performed on 15 patients with stage cT1-2 antral cancer. We ligated the duodenum with a rope instead of transecting it and used the ligature rope to pull the duodenum during the whole progress of gastroduodenostomy. When closing the entry hole, the duodenum was transected at the same time, which saved one linear stapler. Data of clinicopathologic characteristics, surgical and postoperative outcomes were collected and expressed as means±standard deviations. All the operations were successfully performed by using no more than four 60-mm linear staplers. The mean BMI of the patients is 23.0±2.5kg/m2 (range 17.0-26.0 kg/m2), and duration of the operation was 115.0±33.4min (range 75-215min), including 22.3±6.7min (range 15-35min) of reconstruction. Mean blood loss was 82.7±71.3mL (range 10-300mL), and mean times to first flatus was 2.3±1.1days (range 1-5days). A mean number of 27.5±5.4 (range 18-38) lymph nodes was retrieved. Overall postoperative morbidity rate was 6.7% (1/15). There was no anastomosis-related complication, but one case of pneumonia developed on postoperative day (POD) 2 which was successfully managed by conservative methods. Patients were discharged (POD mean 5.8±1.3, range 4-9) when their bowel movements recovered and no discomfort with soft diet was claimed. Delta SPLT is a safe and feasible technique and requires less clinical costs.

The technical outcomes of delta-shaped anastomosis in laparoscopic distal gastrectomy: a single-center safety and feasibility study

The indications for laparoscopic gastrectomy for early stomach cancer have spread worldwide, and the short-term outcomes have been favorable. Intraabdominal delta-shaped gastroduodenostomy using endoscopic linear staplers, a technique which was developed by Kanaya et al. is one of the feasible reconstructive procedures. Pure laparoscopic surgery is reported to be associated with several intraoperative and postoperative advantages in comparison with laparoscopy-assisted surgery. However, the clinical results remain uncertain. The present study aimed to evaluate both the technical feasibility and safety of delta-shaped anastomosis with LDG according to the short-term outcomes. The study group was composed of 229 patients who underwent delta-shaped anastomosis with LDG at Gifu University School of Medicine from December 2004 to December 2014. The median total operative blood loss and operative time were 20ml and 277min, respectively. Postoperative complications were detected in 20 (8.7%) patients. The complications included: anastomotic stenosis, n=3 (1.3%); anastomotic leakage, n=3 (1.3%); pancreatic injury, n=8 (3.5%); anastomotic ulcer, n=1 (0.4%); bowel obstruction, n=1 (0.4%); abdominal abscess, n=1 (0.4%); lymphorrhea, n=1 (0.4%); cardiac failure, n=1 (0.4%); and infection, n=1 (0.4%). The complications were classified as grade 2, n=4 (1.7%); grade 3a, n=12 (5.2%); grade 3b, n=4 (1.7%); and grade 4 and 5, n=0 (0%). The findings of the present study indicate the safety of Kanaya's procedure and that it should provide better outcomes in patients who undergo intracorporeal gastroduodenostomy after laparoscopic distal gastrectomy.

Totally laparoscopic versus laparoscopy-assisted Billroth-I anastomosis for gastric cancer: a case-control and case-matched study.

ObjectiveTo evaluate the safety, feasibility and clinical results of the modified delta-shaped gastroduodenostomy (MDSG) in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer (GC).MethodsWe performed a case–control and case-matched study enrolling 642 patients with GC undergoing laparoscopic distal gastrectomy with Billroth-I anastomosis from January 2011 to December 2014. TLDG with MDSG was performed in 158 patients (Group TL), and laparoscopy-assisted distal gastrectomy with circular anastomosis was performed in 484 patients (Group LA). One-to-one propensity score matching (PSM) was performed to compare the clinicopathological characteristics between the two groups.ResultsPatients with smaller tumors or stage I cancer were more likely to receive TLDG (P < 0.05). In the propensity-matched analysis of 143 pairs, there were no differences in demographic and pathologic characteristics between groups (all P < 0.05). All patients successfully underwent laparoscopic radical distal gastrectomy. Before PSM, Group TL had more dissected lymph nodes (LNs), a longer time to first fluid diet and a longer postoperative length of stay than Group LA (all P < 0.05). After PSM, except for the fact that more dissected LNs were obtained in Group LA (P < 0.05), no difference was found in the intraoperative and postoperative outcomes between the groups (all P > 0.05). The postoperative complications were similar in both groups (all P > 0.05). Stratification analysis performed after PSM showed that in early GC, no difference was observed in intraoperative and postoperative outcomes between the groups (all P > 0.05). However, in locally advanced GC, Group TL had more dissected LNs and a higher rate of postoperative complications (both P < 0.05). Univariate analysis carried out in locally advanced cases after PSM showed that the body mass index (BMI), the method of digestive tract reconstruction and Charlson’s score were significant factors that affected postoperative morbidity (all P < 0.05). Multivariate analysis indicated that BMI was an independent risk factor for postoperative morbidity (P < 0.05).ConclusionsThe MDSG in TLDG is safe and feasible for early GC; however, it should be chosen with caution in advanced GC, particularly in patients with a high BMI.

Linear-shaped gastroduodenostomy (LSGD): safe and feasible technique of intracorporeal Billroth I anastomosis.

Although delta-shaped gastroduodenostomy (DSGD) is used increasingly as an intracorporeal Billroth I anastomosis after distal gastrectomy, worries about anatomical distortion always exist in twisting stomach and making an oblique incision on duodenum. We developed a new method of intracorporeal gastroduodenostomy, the linear-shaped gastroduodenostomy (LSGD), in which anastomosis is done using endoscopic linear staplers only without any complicated rotation. In this report, we introduced LSGD and compared its short-term and long-term outcomes with DSGD. We analyzed 261 consecutive gastric cancer patients who underwent the intracorporeal gastroduodenostomy between January 2009 and May 2014 (LSGD: 190, DSGD: 71), retrospectively. All of them underwent a laparoscopic or robotic distal gastrectomy with regional lymph node dissection. Early surgical outcomes such as operation time, postoperative complications, days until soft diet began, length of hospital stay, and endoscopic findings in postoperative 6 and 12months were evaluated. Although the proportion of robotic approach and D2 lymphadenectomy were significantly higher in LSGD group, the rates for overall complications (13.2% [LSGD] vs. 9.9% [DSGD], p=0.470) and major complications (5.8 vs. 5.6%, p=1.0) were similar between two groups. There were no differences in anastomotic bleeding (1.1 vs. 1.4%, p=1.0), stenosis (3.2 vs. 2.8%, p=1.0), and leakage (0.5 vs. 0.0%, p=1.0). Endoscopy performed 6months postoperatively showed that residual food (p=0.022), gastritis (p=0.018), and bile reflux (42.0 vs. 63.2%, p=0.003) were significantly decreased in LSGD and there were no significant differences in postoperative 12months. LSGD is an innovative reconstruction technique with comparable short-term outcomes to DSGD. In addition, reduced residual food, gastritis, and bile reflux were seen in LSGD.

A modified intracorporeal billroth-I anastomosis after laparoscopic distal gastrectomy for gastric cancer: a safe and feasible technique.

The delta-shaped gastroduodenostomy, an intracorporeal Billroth-I anastomosis after laparoscopic distal gastrectomy and using only endoscopic linear staplers, has been increasingly adopted by gastrointestinal surgeons.1 (-) 5 We modified this technique to simplify operation procedures and reduce surgical trauma in patients with gastric cancer. After the stomach and duodenum were transected in predetermined positions, small incisions were made on the greater curvature of the remnant stomach and the posterior side of the duodenum. The forks of the stapler in each incision were closed and fired following approximation of the posterior walls of the gastric remnant and duodenum. The involution of the common stab incision was accomplished only by the instruments of the surgeon and assistant, and the duodenal cutting edge was completely resected when the common stab incision was closed with the stapler, thus decreasing the anastomotic weak point and avoiding poor blood supply to the duodenal stump. The above procedure was performed for 41 patients with stage cT1-4a disease. Mean operation time was 143.4 ± 23.4 min, mean anastomosis time was 13.9 ± 2.8 min, mean blood loss was 34.6 ± 20.8 ml, and mean times to first flatus, fluid diet, and soft diet were 3.5 ± 1.3, 5.1 ± 1.2, and 8.1 ± 4.3 days, respectively. No patient experienced any anastomosis-related complications, such as anastomotic leakage, anastomotic stricture, or anastomotic hemorrhage. At a median follow-up of 10 months, no patient had died or experienced recurrent or metastatic disease. The modified technique was technically safe and feasible, with acceptable surgical outcomes, in patients with gastric cancer.

Feasibility of delta-shaped gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer

To investigate the feasibility of delta-shaped (DS) gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. From July 2013 to November 2013, 22 gastric cancer patients underwent DS gastroduodenostomy using laparoscopic linear stapler. All the patients underwent TLDG with D2 lymphadenectomy. In addition, modified DS anastomosis (when closing the common entry hole, previous duodenal staple line was also removed) was used in selected patients. Clinical data of these 22 patients were retrospectively analyzed. All the patients underwent TLDG with D2 lymphadenectomy and DS gastroduodenostomy. Among them, 12 patients underwent modified DS anastomosis. The total operative time was (194.6±38.4) min, and the DS anastomosis time was (19.1±14.1) min. The number of linear stapler cartridges used per patient was 5.8±0.8. The intraoperative blood loss was (49.5±24.0) ml. The number of lymph nodes harvested per patient was 32.8±12.4. All the patients achieved microscopic cancer-free resection margin. The time to the first postoperative flatus, first water intake, and semi-liquid diet was (2.9±0.7) d, (4.8±1.1) d, and (6.6±1.2) d, respectively. The duration of postoperative hospital stay was (10.1±2.3) d. The postoperative complication rate was 9.1% (2/22). No patients developed anastomosis-related complications including anastomotic leakage, stenosis, or bleeding. Delta-shaped gastroduodenostomy is simple, easy, safe, and feasible. It will be an ideal choice for reconstruction after totally laparoscopic distal gastrectomy, and has great value in clinical practice.

Comparing the short-term outcomes of totally intracorporeal gastroduodenostomy with extracorporeal gastroduodenostomy after laparoscopic distal gastrectomy for gastric cancer: a single surgeon’s experience and a rapid systematic review with meta-analysis

Since delta-shaped gastroduodenostomy was introduced, many surgeons have utilized laparoscopic distal gastrectomy (LDG) with totally intracorporeal Billroth I (ICBI) for gastric cancer, because it is expected to have several advantages over laparoscopic-assisted distal gastrectomy with extracorporeal Billroth I (ECBI). In this study, we compared these two reconstruction options to evaluate their outcomes. The data of 166 gastric cancer patients who underwent LDG performed by a single surgeon between April 2009 and February 2012 were analyzed retrospectively. The subjects were divided into ECBI (n = 106) and ICBI (n = 60) groups, and then the clinical characteristics, surgical outcomes, symptoms, and change in BMI at 3 months after surgery were compared. Furthermore, a rapid systematic review and meta-analysis were conducted. The operative time was significantly shorter in the ICBI group (197.4 ± 45.5 vs. 157.1 ± 43.9 min), but blood loss was similar between the groups. Regarding surgical outcomes, there were no significant differences in the length of hospital stay, soft diet initiation, visual analogue scale, frequency of analgesics injection, and postoperative white blood cell counts and C-reactive protein levels between the groups. The surgical complication rates were 5.7 and 13.3% in the ECBI and ICBI groups, respectively, and one case of anastomosis leakage was observed in each group. At 3 months after surgery, reflux symptoms were more frequent in the ICBI group, but other gastrointestinal symptoms and the change of BMI were similar between the groups. The meta-analysis revealed no significant differences in the operative time, time to first flatus, length of hospital stay, frequency of analgesic usages, and rates of anastomosis complications between the groups. We could not demonstrate the clinical superiority of ICBI over ECBI based on our data and a rapid systematic review and meta-analysis. The anastomosis method may be selected according to patient conditions and the surgeon's preference.

Laparoscopic Technique and Initial Experience with Knotless, Unidirectional Barbed Suture Closure for Staple-Conserving, Delta-Shaped Gastroduodenostomy after Distal Gastrectomy

a a c h Since laparoscopy-assisted distal gastrectomy was first reported by Kitano and colleagues in 1994, laparoscopic gastrectomy (LG) for early gastric cancer (EGC) has been increasing rapidly and gaining popularity worldwide because it is associated with earlier patient recovery compared with open surgery. Improvements in instruments and aparoscopic technique have allowed for widespread accepance of LG, not only for various types of gastric resection ut also for totally laparoscopic procedures. In general, LG can be divided into laparoscopy-assisted and totally laparoscopic techniques. With laparoscopyassisted gastrectomy, although lymph node dissection is performed laparoscopically, transection of the stomach and the anastomosis are performed thorough an epigastric minilaparotomy. Performing the anastomosis in the narrow and restricted space is frequently difficult, especially for obese patients with thick abdominal walls or for patients with a small remnant stomach. Avoiding minilaparotomy also improves cosmesis, and performing all of the processes laparoscopically, including reconstruction of the digestive tract intracorporeally using laparoscopic linear stapling devices, offers the prospect of further improvements in quality of life. Recent results of retrospective studies have demonstrated the feasibility, safety, and efficiency of totally laparoscopic gastrectomy (TLG) when performed by high-volume laparoscopic surgeons, even with a relatively prolonged operating time. However, TLG as the disadvantages of technical difficulties in intracor-

An additional suture secures against pitfalls in delta-shaped gastroduodenostomy after laparoscopic distal gastrectomy

Laparoscopic gastrectomy is widely used as a minimally invasive surgery for gastric cancer. Laparoscopic distal gastrectomy must be followed by either a gastroduodenostomy or gastrojejunostomy to restore continuity of the alimentary tract. The intraabdominal delta-shaped gastroduodenostomy using endoscopic linear staplers, which was developed by Kanaya et al., is one of the feasible reconstructive procedures. However, the clinical results still remain uncertain. In 71 patients treated between February 2008 and February 2009, we found that anastomotic failure occurred in six patients and there was an intraabdominal abscess around the anastomosis in two patients, findings which might be associated with technical pitfalls in the procedure. After considering the mechanisms underlying these unfavorable complications, we developed a modification of the procedure to successfully overcome these complications by reinforcement of the anastomosis using simple suturing at the closed common channel on the greater curvature. This modified Kanaya's procedure will be safer and should provide a better intracorporeal gastroduodenostomy after laparoscopic distal gastrectomy.

Delta-Shaped Gastroduodenostomy after Totally Laparoscopic Distal Gastrectomy: A Comparison Analysis between Early and Late Experience

Purpose: We conducted this study to evaluate the feasibility and the safety of a delta-shaped gastroduodenostomy after totally laparoscopic distal gastrectomy (TLDG) and to know about the factors having influence on surgeons’ performance of anastomosis and technical details of this operation. Methods: The clinical characteristics and the surgical results of 57 consecutive patients with delta-shaped gastroduodenostomy after TLDG at Incheon St. Mary’s Hospital were reviewed. The patients were divided into 2 groups (before and after 20 cases) and their clinical characteristics and surgical results were compared. The factors which influenced the anastomotic time and the technical details of the operation were also investigated. Results: There was no difference in age, gender, body mass index, surgical results except for operation time, anastomotic time, and starting day of oral feeding between the 2 groups. The experience of the surgeon was the only factor that influenced the anastomotic time. Conclusion: Delta-shaped gastroduodenostomy is a feasible and safe procedure even in the early years of a surgeon’s career. It could feasibly be done in less than 20 minutes in relatively experienced hands. (J Korean Surg Soc 2010;79:110-115)