Intracorporeal Gastroduodenostomy Research Articles

Textbook Outcome of Delta-Shaped Anastomosis in Minimally Invasive Distal Gastrectomy for Gastric Cancer in 4,505 Consecutive Patients.

Textbook outcome is a comprehensive measure used to assess surgical quality and is increasingly being recognized as a valuable evaluation tool. Delta-shaped anastomosis (DA), an intracorporeal gastroduodenostomy, is a viable option for minimally invasive distal gastrectomy in patients with gastric cancer. This study aims to evaluate the surgical outcomes and calculate the textbook outcome of DA. In this retrospective study, the records of 4,902 patients who underwent minimally invasive distal gastrectomy for DA between 2009 and 2020 were reviewed. The data were categorized into three phases to analyze the trends over time. Surgical outcomes, including the operation time, length of post-operative hospital stay, and complication rates, were assessed, and the textbook outcome was calculated. Among 4,505 patients, the textbook outcome is achieved in 3,736 (82.9%). Post-operative complications affect the textbook outcome the most significantly (91.9%). The highest textbook outcome is achieved in phase 2 (85.0%), which surpasses the rates of in phase 1 (81.7%) and phase 3 (82.3%). The post-operative complication rate within 30 d after surgery is 8.7%, and the rate of major complications exceeding the Clavien-Dindo classification grade 3 is 2.4%. Based on the outcomes of a large dataset, DA can be considered safe and feasible for gastric cancer.

Book-Binding Technique in Totally Laparoscopic Distal Gastrectomy with Billroth I Reconstruction: Clinical Results and Outcomes in 188 Patients with Gastric Cancer.

Laparoscopic gastrectomy is widely used as a curative treatment for gastric cancer. Although delta-shaped anastomosis is commonly used for Billroth I anastomosis after totally laparoscopic distal gastrectomy (TLDG), it has some drawbacks. The book-binding technique (BBT) was developed as an alternative, and this study aimed to examine its short-term results in 188 consecutive cases. This retrospective study included patients who underwent BBT reconstruction after TLDG for gastric malignancy between 2011 and 2020. BBT is a technique for intracorporeal gastroduodenostomy, which is a triangular anastomosis with a linear stapler that does not require additional dissection or rotation of the duodenum. The short-term outcomes of BBT reconstruction and postoperative endoscopic findings were analyzed. This study evaluated 188 patients who underwent TLDG and BBT reconstruction. Anastomotic stenosis and leakage occurred in 1.1% and 0.5% of the patients, respectively. The median time to the first diet was 3.1 days, and the median postoperative hospital stay was 11.9 days. BBT anastomoses were performed by 19 surgeons and took an average of 32.8 minutes to complete, with completion times decreasing as the surgical team became more proficient. On endoscopy performed 1 year postoperatively, 5.2% had reflux esophagitis (grade A or higher), 67.8% had gastritis (grade 1 or higher), 37.4% had residual food (grade 1 or higher), and 37.4% had bile reflux (grade 1). BBT is a safe and feasible method for intracorporeal gastroduodenostomy in TLDG for patients with gastric malignancy and demonstrates good surgical outcomes.

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.

Comparison of Converse Ω Anastomosis and Extracorporeal Anastomosis After Laparoscopic Distal Gastrectomy for Gastric Cancer.

Converse Ω anastomosis is a recently developed technique of delta-shaped anastomosis for intracorporeal gastroduodenostomy to simplify the anastomotic procedures and reduce their potential risks. This study aimed to evaluate the safety and effectiveness of converse Ω anastomosis, comparing it with conventional extracorporeal Billroth-I anastomosis after laparoscopic distal gastrectomy (LDG) for gastric cancer. Among 169 gastric cancer patients who underwent LDG with Billroth-I anastomosis anastomosis between April 2013 and March 2018, we selected 100 patients by propensity score matching (50 in the converse Ω anastomosis group and 50 in the extracorporeal anastomosis group). Patients' characteristics, intraoperative outcomes, postoperative complications, and survival time were compared between the 2 groups. Median anastomosis time was significantly longer in the converse Ω group than in the extracorporeal group (40.0 vs. 30.5 min, P=0.005). However, the total procedure time did not differ significantly between the groups. Intraoperative blood loss volume was significantly lower in the converse Ω group than in the extracorporeal anastomosis group (40 vs. 120 mL, P<0.001). There were no significant differences in the number of dissected lymph nodes, postoperative morbidity, mortality, or length of hospital stay. The postoperative body mass index and the prognostic nutritional index did not differ between the groups 1 year after surgery. There were no significant differences in overall survival and relapse-free survival between the 2 groups. Converse Ω anastomosis is feasible and safe. This novel technique can be adopted as a treatment option for reconstruction after LDG in patients with early-stage gastric cancer. Therefore, the risks and benefits of converse Ω anastomosis after LDG should be confirmed in larger cohorts.

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.

Systemic steroid application for treatment of edematous anastomotic stenosis following delta-shaped anastomosis in laparoscopic distal gastrectomy: a case report

BackgroundDelta-shaped anastomosis is a common method of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy. One common postoperative complication of this procedure is anastomotic stenosis, and endoscopic balloon dilatation is a major remedy for such complications. Other treatment strategies are necessary to manage unsuccessful endoscopic balloon dilatation.Case presentationWe present a case where systemic steroid treatment was applied in sustained anastomotic stenosis after endoscopic balloon dilatation. We performed delta-shaped anastomosis in laparoscopic distal gastrectomy to treat early-stage gastric cancer in a patient. The patient experienced abdominal pain post-surgery; subsequent investigation revealed edematous anastomotic stenosis. The stenosis sustained even after endoscopic balloon dilatation and local steroid injection. Consequently, we applied systemic steroid treatment.ConclusionSystemic steroid treatment improved the stenosis and no recurrence was observed. These results suggest that systemic steroid application could be useful to treat anastomotic stenosis.

Functional Outcomes of Delta-Shaped Anastomosis After Laparoscopic Distal Gastrectomy

BackgroundWe invented a simple and secure method of intracorporeal gastroduodenostomy, the delta-shaped anastomosis (DA), using endoscopic linear stapler only and standardized the DA procedure by resecting two-thirds of the stomach based on the anatomical landmarks. This study aimed to evaluate the feasibility of the standardized DA as the standard reconstruction procedure after a laparoscopic distal gastrectomy assessing functional outcomes including postoperative complications, body weight loss, nutritional status, and endoscopic findings. MethodsThe medical records of 349 patients with gastric cancer who underwent laparoscopic distal gastrectomy from April 2011 to December 2017 at our hospital were retrospectively reviewed. Functional outcomes were assessed according to nutritional status and endoscopic findings. ResultsThe operation time was shorter and complication rate was lower in the standardized DA than those in Billroth-II (BII) and Roux-en-Y (RY). The body weight loss in DA was 10% 1 year postoperatively and remained stable during the follow-up period, which showed no significant difference. The endoscopic findings showed the ratio of residual food in DA was lower than that in RY (DA:RY = 13.3%:13.6% and 8.4%:33.3% at 1 and 3 years postoperatively, respectively). Severe gastritis was extremely rare in DA (6.7% at 1 year and 15.6% at 3 years postoperatively). Bile reflux was more often found in DA than RY (DA:RY = 19.9%:4.8% and 26.6%:0% at 1 and 3 years postoperatively, respectively). Reflux esophagitis was found 10% of DA only. ConclusionsFunctional outcomes of the standardized DA were satisfactory and feasible. Our intracorporeal Billroth-I reconstruction, by resecting two-thirds of the stomach, can be one of the standard reconstruction methods after a laparoscopic distal gastrectomy.

Practicality and short-term outcomes of intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: A single-centre retrospective study.

Objective:Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis is feasible because of improved approaches to laparoscopic surgery and the availability of a variety of surgical instruments. This study was designed to evaluate the practicality, safety and short-term operative outcomes of intracorporeal gastroduodenostomy in TLDG for gastric cancer.Materials and Methods:Medical records of patients with primary distal gastric cancer undergoing Billroth I (B-I) (n = 37) or B-II anastomosis (n = 41) in TLDG from February 2010 to November 2015 were retrospectively analysed. Perioperative data including the extent of lymph node dissection, number of stapler cartridges used, time required to create the anastomosis, operative time, estimated blood loss, proximal and distal margin length, and number of lymph nodes harvested were collected. Short-term post-operative outcomes evaluated during the initial 30 days after surgery included time to first flatus and earliest liquid consumption, length of post-operative hospital stay and incidence of post-operative complications.Results:B-I anastomosis was mainly applied to patients with carcinoma in the lower third of the gastric body (B-I, 81.08% vs. B-II, 31.71%; P < 0.001). Mean operating (B-I, 153.57 ± 18.25 min vs. B-II, 120.17 ± 11.74 min; P = 0.004) and anastomosis (B-I, 31.92 ± 6.10 min vs. B-II, 25.29 ± 3.84 min; P = 0.01) times were significantly longer for B-I anastomosis compared to B-II anastomosis. There were no significant differences in the number of stapler cartridges used, estimated blood loss, time to first flatus and liquid consumption, length of hospital stay or incidence of complications between these groups.Conclusions:TLDG with B-I or B-II anastomosis is safe and feasible for gastric cancer. B-II anastomosis may require less time than B-I anastomosis.

The Learning Curve of Linear-Shaped Gastroduodenostomy Associated with Totally Laparoscopic Distal Gastrectomy

BackgroundLinear-shaped gastroduodenostomy (LSGD) is a new method of intracorporeal reconstruction that is simpler to perform and associated with a lower rate of bile reflux than delta-shaped anastomosis. Here, we analyzed the learning curve of LSGD in totally laparoscopic distal gastrectomy. MethodsThe cumulative sum method was used to retrospectively analyze consecutive gastric cancer patients undergoing intracorporeal gastroduodenostomy after distal gastrectomy between January 2009 and May 2016. The duration of surgery, postoperative complications, hospital stay, and endoscopic findings in the postoperative period and the first, third, and fifth year were evaluated according to the two phases of the learning curve (learning period versus mastery period). ResultsData from 222 patients were included in the analysis. The LSGD learning period was 29 cases. The surgical time in mastery period was significantly shorter than the learning period (124.9±34.5 versus 168.2±42.0 min, p < 0.001). The incidence of minor complications was significantly reduced after the learning period (p = 0.041), although there was no statistically significant difference in the rate of major complications. The long-term endoscopic findings showed that the presence of residual food decreased over the time (p = 0.022). ConclusionsLSGD can be mastered easily after a reasonable number of cases and was associated with safe and satisfactory short- and long-term outcomes before and after learning curve.

Billroth-I reconstruction using an overlap method in totally laparoscopic distal gastrectomy: propensity score matched cohort study of short- and long-term outcomes compared with Roux-en-Y reconstruction.

Delta-shaped anastomosis is an established procedure for intracorporeal Billroth-I reconstruction (B-I). However, this procedure has several technical and economic problems. The aim of the current study was to present the technique of B-I using an overlap method (overlap B-I), which is a side-to-side intracorporeal gastroduodenostomy in laparoscopic distal gastrectomy (LDG), and to evaluate the short- and long-term outcomes of this overlap B-I procedure. We retrospectively reviewed the medical records of 533 patients who underwent LDG with overlap B-I (n = 247) or Roux-en-Y reconstruction (R-Y) (n = 286). Patients with overlap B-I were propensity score matched to patients with R-Y in a 1:1 ratio. Short- and long-term outcomes of the two procedures were compared after matching. In the total cohort, anastomosis-related complications occurred in 2.4% of patients with overlap B-I, and 3.2% of those with R-Y (P = 0.794). Morbidity rate, including anastomosis-related complications, and postoperative course were comparable after overlap B-I performed by qualified versus general surgeons. Of 247 patients with overlap B-I, 169 could be matched. After matching, morbidity rate and postoperative course were comparable between the two procedures. Median operation time was significantly shorter for overlap B-I (205min) than R-Y (252min; P < 0.001). The incidence of readmission due to gastrointestinal complications was significantly lesser after overlap B-I (2.4%) compared with R-Y (21.9%; P < 0.001). The main causes of readmission after R-Y were bowel obstruction (7.3%) and gallstones (8.0%). Regarding the development of common bile duct (CBD) stones, 11 patients (3.8%) who underwent R-Y were readmitted due to CBD stones, whereas no patients who underwent B-I developed CBD stones. Overlap B-I is feasible and safe, even when performed by general surgeons. B-I was superior to R-Y concerning operation time and readmission due to gastrointestinal complications.

Feasibility of Linear-Shaped Gastroduodenostomy during the Performance of Totally Robotic Distal Gastrectomy.

PurposeAlthough linear-shaped gastroduodenostomy (LSGD) was reported to be a feasible and reliable method of Billroth I anastomosis in patients undergoing totally laparoscopic distal gastrectomy (TLDG), the feasibility of LSGD for patients undergoing totally robotic distal gastrectomy (TRDG) has not been determined. This study compared the feasibility of LSGD in patients undergoing TRDG and TLDG.Materials and Methods: All consecutive patients who underwent LSGD after distal gastrectomy for gastric cancer between January 2009 and December 2017 were analyzed retrospectively. Propensity score matching (PSM) analysis was performed to reduce the selection bias between TRDG and TLDG. Short-term outcomes, functional outcomes, learning curve, and risk factors for postoperative complications were analyzed.ResultsThis analysis included 414 patients, of whom 275 underwent laparoscopy and 139 underwent robotic surgery. PSM analysis showed that operation time was significantly longer (163.5 vs. 132.1 minutes, P<0.001) and postoperative hospital stay significantly shorter (6.2 vs. 7.5 days, P<0.003) in patients who underwent TRDG than in patients who underwent TLDG. Operation time was the independent risk factor for LSGD after intracorporeal gastroduodenostomy. Cumulative sum analysis showed no definitive turning point in the TRDG learning curve. Long-term endoscopic findings revealed similar results in the two groups, but bile reflux at 5 years showed significantly better improvement in the TLDG group than in the TRDG group (P=0.016).ConclusionsLSGD is feasible in TRDG, with short-term and long-term outcomes comparable to that in TLDG. LSGD may be a good option for intracorporeal Billroth I anastomosis in patients undergoing TRDG.

T-shaped Modified Delta Anastomosis as a Simple Intracorporeal Gastroduodenostomy

T-shaped Modified Delta Anastomosis as a Simple Intracorporeal Gastroduodenostomy

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.

Laparoscopic distal gastrectomy with D2 lymphadenectomy followed by intracorporeal gastroduodenostomy for advanced gastric cancer: technical guide and tips.

In 1994, Kitano and colleagues first reported laparoscopy-assisted Billroth I gastrectomy. Since then, laparoscopic gastrectomy (LG) has been associated with earlier patient recovery compared with open surgery, and has gained increasing international acceptance. Japan Society of Endoscopic Surgery biennial surveys confirm the increasing use of laparoscopic procedures for treatment of gastric cancer in Japan. Its thirteenth national survey indicates that of 31,264 patients treated at Japanese institutions in 2015, approximately 9,500 (30.3%) underwent LG, and laparoscopic distal gastrectomy (LDG) was the procedure most commonly performed. Despite evidence supporting the efficacy of LDG for gastric cancer in the short term, however, uncertainty remains concerning the efficacy of LG. Today, phase III randomized control trials on this procedure are ongoing in East Asian countries. Distal gastrectomy (DG) is the most commonly performed mode of resection, and as appropriate surgical techniques need to be acquired by gastric surgeons, here we describe a 'gold standard' method to perform total LDG.

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.

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.

Techniques of the Single-Port Totally Laparoscopic Distal Gastrectomy

Single-port laparoscopic surgery for patients with early gastric cancer has been rarely reported. Our aim was to introduce techniques of the single-port totally laparoscopic distal gastrectomy (TLDG) in patients with early gastric cancer. This procedure was performed using only one 3-3.5 cm skin incision on the umbilicus. One 12 mm and two 10 mm ports were used, and the flexible scope was used during the operation. Partial omentectomy with D1 + β or more lymph node dissection was performed. Bowel continuity was restored by intracorporeal gastroduodenostomy using two linear staplers. A total of 30 patients underwent single-port TLDG from June to August 2014. Median age of patients was 55 years (range 33-77) and median body mass index of patients was 21.2 kg/m(2) (range 15.7-26.1). Sixteen of 30 patients (53.3 %) were female. Operating times were 122.6 min, and blood losses during operations were 103.2 ml on average. The median length of postoperative hospital stay was 7 days, and the median number of dissected lymph nodes was 40 (range 16-67). No patients had dissected lymph nodes <15. The rate of complications was 20 % (6/30 patients), and no patients had an incisional hernia. Two patients experienced ileus (6.7 %), another two patients experienced delayed gastric emptying (6.7 %), and one patient suffered from small bowel obstruction. There were no postoperative mortalities. The single-port TLDG for patients with early gastric cancer is feasible in very selected patients and in specialized gastric cancer centers with experience in multi-trocar laparoscopy and single-port laparoscopic surgery.

Modified intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: early experience.

PurposeThis study presents findings on the clinical usefulness of an overlap method that is another modification for the currently well-known intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG).MethodsWe studied 42 patients diagnosed with gastric cancer who underwent TLDG between December 2011 and March 2013. Endoscopic linear staplers were used for intracorporeal anastomosis and patients were observed with endoscopic tracking six months after surgery. We retrospectively reviewed the outcome of the operation, the clinical pathological results, and the endoscopy results.ResultsThe mean duration of the operation for 42 patients was 228.3 ± 42.5 minutes and the mean time to complete the anastomosis was 12.18 ± 2.3 minutes. There were no mortalities and no cases of open conversion. Following the operation, 37 patients had stage IA, 5 in stage IB, and 3 in stage II gastric cancer. Abscesses were seen in 3 patients and 5 cases of stasis during the postoperative period. Duodenoscopy 6 months after the operation showed 11 cases of gastric stasis, 28 cases of bile reflux, and 1 new case of erosive gastritis. We did not observe contraction in any of the patients.ConclusionThe overlap method for intracorporeal gastroduodenostomy, using an endoscopic linear stapler, can be considered a feasible and safe technique for the treatment of stomach cancer. However, a long-term comparative study is required to sufficiently evaluate our findings.

Transumbilical single-incision laparoscopic subtotal gastrectomy and total intracorporeal reconstruction of the digestive tract in the treatment of benign peptic ulcers

BackgroundSingle-incision laparoscopic surgery is being applied increasingly in many surgical specialties. However, few reports are available regarding its use in the treatment of benign peptic ulcer disease. MethodsWe report here on nine patients with gastric or duodenal ulcers who underwent transumbilical single-incision laparoscopic subtotal gastrectomy (SILSG) between November 2010 and June 2013. All procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus. Total intracorporeal gastrojejunostomy or gastroduodenostomy was then performed for reconstruction of the digestive tract. ResultsOnly one case required conversion from single-incision to multiple-incision surgery. Among the eight patients who successfully underwent SILSG, total intracorporeal gastroduodenostomy was performed in two and gastrojejunostomy in six. The mean operation time was 290 ± 50 min (range 230–360 min), and blood loss was 200 ± 66 mL (range 100–300 mL). The patients recovered fully, and the single umbilical scars healed well. ConclusionsWe believe this is the first report of SILSG with total intracorporeal gastrojejunostomy or gastroduodenostomy in the treatment of benign peptic ulcers. On the basis of this initial experience, SILSG for this indication in the hands of experienced surgeons appears to be feasible and safe.

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.