Totally Laparoscopic Distal Gastrectomy Research Articles

Functional Outcomes of Billroth I Gastroduodenostomy Using Linear Staplers in Totally Laparoscopic Distal Gastrectomy.

This study examined whether functional outcomes of linear-stapled Billroth I (LS-BI) in totally laparoscopic distal gastrectomy (TLDG) are comparable to those of circular-stapled Billroth I (CS-BI) in laparoscopy-assisted distal gastrectomy (LADG). This was a retrospective study of patients with gastric cancer undergoing TLDG with LS-BI (n=50) or LADG with CS-BI (n=50). Postoperative endoscopic findings of the remnant stomach and nutritional status were evaluated. The occurrence of grade 2 or more severe remnant gastritis in the LS-BI group (46.0%) was significantly higher than that in the CS-BI group (18.0%) (p=0.005), whereas there was no significant difference in the incidence of residual food and bile reflux between the two groups. Postoperative changes in body weight, and serum albumin and total protein levels were similar between the two groups. TLDG with LS-BI may be a good alternative to LADG with CS-BI because of its comparable nutritional outcomes, but with a higher occurrence of remnant gastritis.

Feasibility of No Prophylactic Antibiotics Use in Patients Undergoing Total Laparoscopic Distal Gastrectomy for Gastric Carcinoma: a Propensity Score-Matched Case-Control Study.

PurposeLaparoscopic surgery is associated with lower surgical site infection (SSI) rates due to minimal skin incision and non-exposure of visceral organs. Most previous studies have analyzed the efficacy of prophylactic antibiotic use in open surgery. Here, we investigated the feasibility of total laparoscopic distal gastrectomy (TLDG) for gastric carcinoma without prophylactic antibiotic use.Materials and MethodsSeventy-one patients who underwent TLDG without prophylactic antibiotic use were 1:1 propensity score matched with 393 patients who underwent TLDG with antibiotic prophylaxis. The short-term surgical outcomes, including SSI rates, were compared between the groups.ResultsAfter matching, 65 patients were selected in each group. The baseline clinicopathological characteristics were well balanced in the matched sample. In the matched group, there was no significant increase in postoperative morbidity in the non-prophylactic group compared with the prophylactic group (18.5% vs. 15.4%, P=0.640), and there were no grade 3≤ complications (1.4% vs. 0%, respectively; P=1.000). The SSI rates in the non-prophylactic and prophylactic groups were 3.1% and 1.5%, respectively (P=0.559). The time to gas passage, diet initiation, and mean hospital stay were not significantly different between the 2 groups. The SSI rate did not increase in the non-prophylactic group in the different subgroups based on different clinicopathological characteristics.ConclusionsPostoperative morbidity, including SSI rates, did not significantly increase in patients undergoing TLDG without prophylactic antibiotic use. A large prospective randomized trial is warranted to reappraise the efficacy of prophylactic antibiotic use in patients undergoing TLDG.

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.

Effectiveness and safety of total laparoscopic distal gastrectomy versus laparoscopy-assisted distal gastrectomy for gastric cancer: A retrospective cohort study

AimTo compare the results of total laparoscopic distal gastrectomy (TLDG) and laparoscopy-assisted distal gastrectomy (LADG) and explore the safety and feasibility of TLDG. MethodsData were collected and analyzed from patients underwent TLDG and LADG from January 2009 to December 2011 at our institution. Results127 LADG cases and 104 TLDG cases were included and balanced for age, sex, BMI, ASA scores, and CEA level in this study. A decrease in postoperative pain (P < 0.001), wound infection rate (P = 0.013), and hospitalization time after surgery (P < 0.001) was found in the TLDG group. Compared with the LADG group, there was no increase in operative time (P = 0.084), intraoperative blood loss (P = 0.061), or anastomotic fistula rate (P = 0.473). Statistical differences did not exist in recurrence and (or) metastasis (P = 0.204), 5-years disease-free survival (DFS) rate and overall survival (OS) (P = 0.570 and 0.560, respectively). ConclusionAs long as it follows the surgical principles of malignant tumor, TLDG can achieve the same therapeutic effect as LADG does. TLDG is safe and feasible for gastric cancer patients though further studies are needed.

Multimodal Enhanced Recovery After Surgery (ERAS) Program is the Optimal Perioperative Care in Patients Undergoing Totally Laparoscopic Distal Gastrectomy for Gastric Cancer: A Prospective, Randomized, Clinical Trial.

The application of ERAS protocol has widely gained acceptance after gastrointestinal surgery. Well-designed, randomized, control trials are needed to evaluate fully its safety and efficacy in the field of gastric cancer. This study aims to compare the enhanced recovery after surgery (ERAS) protocol and the conventional perioperative care program after totally laparoscopic distal gastrectomy (TLDG) in gastric cancer. Patients with gastric cancer indicated for TLDG were randomly assigned to either the ERAS group or the conventional group. The ERAS protocol included short fasting time, fluid restriction, early oral feeding, immediate mobilization, and use of epidural patient-controlled analgesia. Primary endpoint was recovery time, which was defined with the criteria of tolerable diet, safe ambulation, no requirement of additional analgesics, and afebrile state. Hospital stay, pain score, complications, and readmission rate were secondary endpoints. A total of 97 patients who underwent TLDG from October 2012 to August 2014 were enrolled (ERAS = 46, conventional = 51). The ERAS group had faster recovery time (111.6 ± 34.3 vs. 126.7 ± 30.7h; p = 0.026) and significantly less pain through postoperative days 1-4. Possible hospital stay also was faster in the ERAS group (5.0 ± 1.9 vs. 5.7 ± 1.6days, p = 0.038), but there was no difference in actual hospital stay. No difference was found in complication, and there was no mortality or readmission in both groups. ERAS is safe and enhances postoperative recovery after TLDG in gastric cancer. The trial was registered in ClinicalTrials.gov (NCT01938313).

Application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy

Objective To investigate the application value of different digestive tract reconstruction methods in laparoscopic distal gastrectomy (LDG). Methods The retrospective cohort study was conducted. The clinicopathological data of 164 with early gastric cancer (GC) who were admitted to the First Affiliated Hospital of Fujian Medical University between June 2010 and April 2015 were collected. Of 164 patients undergoing LDG, 45 receiving BillrothⅠ (BⅠ) anastomosis, 39 receiving Billroth Ⅱ (BⅡ) anastomosis, 44 receiving Roux-en-Y anastomosis and 36 receiving uncut Roux-en-Y anastomosis were allocated into the BⅠ group, BⅡgroup, RY group and uncut RY group, respectively. Observation indicators: (1) surgical and postoperative recovery situations; (2) postoperative short-term complications situations; (3) follow-up situations. Follow-up using outpatient examination and telephone interview was performed to detect postoperative nutriology and long-term complications up to May 2017. Measurement data with normal distribution were represented as ±s. Comparison among groups was analyzed using the ANOVA, and pairwise comparisons were done by the Tukey hsd test. Count data were described as the frequency and percentage, and comparisons among groups were analyzed the chi-square test or Fisher exact probability. Ordinal data were analyzed by the Kruskal Wallis test. Results (1) Surgical and postoperative recovery situations: patients in 4 groups underwent successfully LDG. Cases undergoing total LDG and assisted LDG and digestive tract reconstruction time in the BⅠ, BⅡ, RY and uncut RY groups were respectively 0, 29, 13, 15 and 45, 10, 31, 21 and (42±7)minutes, (55±8)minutes, (64±8)minutes, (51±6)minutes, with statistically significant differences among 4 groups (χ2=21.628, F=74.441, P 0.05). (3) Follow-up situations: all patients were followed up, and follow-up time in the BⅠ, BⅡ, RY and uncut RY groups were respectively (10.8±3.5)months, (10.9±3.4)months, (11.3±3.2)months and (11.2±2.2)months, with no statistically significant difference among 4 groups (F=0.200, P>0.05). ① Comparisons of postoperative 1-year nutritional indexes: rates of changes in body mass index (BMI), hemoglobin (Hb), total protein (TP) and albumin were respectively 93%±7%, 91%±7%, 90%±7%, 90%±9% and 94%±9%, 97%±11%, 95%±9%, 97%±9% and 101%±9%, 99%±7%, 98%±7%, 99%±7% and 101%±10%, 103%±7%, 100%±10%, 103%±9% in the BⅠ, BⅡ, RY and uncut RY groups, showing no statistically significant difference among 4 groups (F=1.182, 0.724, 1.050, 0.971, P>0.05). ② Of 164 patients within 1 year postoperatively, 47 were complicated with gastric retention (27, 12, 6 and 2 with severity in grade 1, 2 , 3 and 4), 87 with residual gastritis (53, 24, 10 and 0 with severity in grade 1, 2 , 3 and 4), and 38 with bile reflux (severity in grade 1). Of 38 patients with bile reflux, 33 were combined with residual gastritis, showing a correlation between residual gastritis and bile reflux (r=0.396, P<0.05). Cases with gastric retention, residual gastritis and bile reflux within 1 year postoperatively were respectively 16, 9, 21, 1 and 35, 30, 13, 9 and 16, 18, 3, 1 in the BⅠ, BⅡ, RY and uncut RY groups, showing statistically significant differences among 4 groups (χ2=21.261, 41.103, 30.469, P<0.05). There were statistically significant differences in gastric retention occurrence between uncut RY group and BⅠgroup or BⅡgroup or RY group (χ2=12.958, 6.675, 20.065, P<0.05), and in residual gastritis occurrence between RY group and BⅠgroup or BⅡgroup (χ2=20.831, 18.587, P<0.05) and between uncut RY group and BⅠgroup or BⅡgroup (χ2=22.452, 20.220, P<0.05). There were statistically significant differences in bile reflux occurrence between RY group and BⅠgroup or BⅡgroup (χ2=10.942, 16.926, P<0.05), and between uncut RY group and BⅠgroup or BⅡgroup (χ2=12.958, 18.620, P<0.05). Conclusion Roux-en-Y and uncut Roux-en-Y anastomoses are superior to BⅠand BⅡanastomoses in improving residual gastritis and bile reflux in the postoperative digestive tract reconstruction of LDG, and uncut Roux-en-Y anastomosis can effectively reduce occurrence of postoperative gastric retention. Key words: Gastric neoplasms; Distal gastrectomy; Uncut Roux-en-Y anastomosis; Reflux gastritis; Gastric retention; Laparoscopy

Case report about a successful full robotic radical gastric cancer surgery with intracorporeal robot-sewn anastomosis in a patient with situs inversus totalis and a two-and-a-half-year follow-up study

BackgroundDuring the last decade, total laparoscopic and laparoscopic-assisted distal gastrectomy for gastric cancer patients has been developed as alternatives to open resection. In recent years, this minimally invasive surgery has been extended using robotic-assisted surgery.Case presentationHere, we report a surgical intervention using a Da Vinci surgical robot in which a lower two-third stomach resection with subsequent Billroth II gastrojejunostomy was performed. The patient was a 53-year-old male with complete situs inversus gastric cancer who had received 2 cycles of neo-adjuvant oxaliplatin combined with S-1 medication. The operation took 3 h in total without complications. The amount of bleeding was about 50 mL, and on day 5 after the operation, the patient was discharged.ConclusionsThis is the first report of a successful robot-assisted gastric cancer resection of advanced gastric cancer in a patient with the anatomical abnormality of situs inversus totalis.

A comparative study of totally laparoscopic distal gastrectomy versus laparoscopic-assisted distal gastrectomy in gastric cancer patients: Short-term operative outcomes at a high-volume center.

ObjectiveLaparoscopic gastrectomy has been established as a standard treatment for early gastric cancer, and its use is increasing recently. Compared with the conventional laparoscopy-assisted distal gastrectomy (LADG), totally laparoscopic distal gastrectomy (TLDG) involves intracorporeal reconstruction, which can avoid the additional incision, resulting in pain reduction and early recovery. This study aimed to compare the short-term postoperative outcomes of TLDG vs. LADG in gastric cancer in a high-volume center. MethodsA retrospective cohort study was conducted on 1,322 patients who underwent laparoscopic distal gastrectomy from June 2012 to June 2017 at the National Cancer Center, Korea. LADG was performed in the early period before July 2015, and TLDG was applied in the later period. Postoperative short-term outcomes were compared in terms of complication and clinical course between the two groups. Pain score was measured by rating the pain intensity from 0 to 10 points on postoperative day (POD) 1 and 3.ResultsA total of 667 patients underwent LADG and 655 patients underwent TLDG. Clinicopathologic characteristics were not different in both groups. Intraoperative estimated blood loss (EBL) was significantly lower in the TLDG group (P<0.001). Postoperative pain scores were significantly lower in the TLDG group than in the LADG group on POD 1 (5.1±1.5vs. 4.8±1.4, P=0.015). First flatus passage after operation was significantly earlier in the TLDG group (3.4±0.8 d vs. 3.2±0.6 d, P<0.001). There were no differences in postoperative complications and hospital stay between the two groups. ConclusionsBased on the reported short-term postoperative outcomes, TLDG is safe and feasible as well as LADG. Moreover, compared with LADG, TLDG can reduce intraoperative EBL and postoperative pain and enhance the bowel motility in gastric cancer surgery.

Risk Factors for the Development of Incisional Hernia in Mini-laparotomy Wounds Following Laparoscopic Distal Gastrectomy in Patients with Gastric Cancer.

PurposeTo determine the incidence of incisional hernia (IH) in mini-laparotomy wounds and analyze the risk factors of IH following laparoscopic distal gastrectomy in patients with gastric cancer.Materials and MethodsA total of 565 patients who underwent laparoscopic distal gastrectomy for gastric cancer at Dong-A University Hospital, Busan, South Korea, between June 2010 and December 2015, were enrolled. IH was diagnosed through physical examination or computed tomography imaging. Incidence rate and risk factors of IH were evaluated through a long-term follow-up.ResultsOf those enrolled, 16 patients (2.8%) developed IH. The median duration of follow-up was 58 months (range, 25–90 months). Of the 16 patients with IH, 15 (93.7%) were diagnosed within 12 months postoperatively. Multivariate analysis showed that female sex (odds ratio [OR], 3.869; 95% confidence interval [CI], 1.325–11.296), higher body mass index (BMI; OR, 1.229; 95% CI, 1.048–1.422), and presence of comorbidity (OR, 3.806; 95% CI, 1.212–11.948) were significant risk factors of IH. The vast majority of IH cases (15/16 patients, 93.7%) developed in the totally laparoscopic distal gastrectomy (TLDG) group. However, the type of surgery (i.e., TLDG or laparoscopy-assisted distal gastrectomy) did not significantly affect the development of IH (P=0.060).ConclusionsA median follow-up of 58 months showed that the overall incidence of IH in mini-laparotomy wounds was 2.8%. Multivariate analysis showed that female sex, higher BMI, and presence of comorbidity were significant risk factors of IH. Thus, surgeons should monitor the closure of mini-laparotomy wounds in patients with risk factors of IH undergoing laparoscopic distal gastrectomy.

Application of delta-shaped anastomosis in totally laparoscopic distal gastrectomy digestive tract reconstruction of gastric cancer

Objective To investigate the feasibility and safety of delta-shaped anastomosis in totally laparoscopic distal gastrectomy digestive tract reconstruction of gastric cancer. Methods Clinical data of 26 patients with distal gastric cancer who received total laparoscopic distal gastrectomy with delta-shaped anastomosis from August 2013 to December 2014 were retrospectively analyzed. Results A total of 26 patients were successfully performed by laparoscopic distal gastrectomy with delta-shaped anastomosis. The operative time and delta-shaped anastomosis time was (186±28) min and (30±24) min respectively. The lengths of upper and lower segment of resection from gastric cancer were (4.9±1.2) cm and (3.5±1.5) cm respectively. Blood loss was (67±39) ml and the number of dissected lymph nodes was (27±11) for every patient. First time to ground activities, first flatus, time to fluid diet and hospital stay were respectively (1.7±0.8) d, (3.5±1.3) d, (4.2±1.6) d and (12±4) d. Pathological results showed upper and lower segment of resection cancers were not found. Only 1 patient had gastric small curved stump fistula and recovered after conservative treatment. There were no complications related to the anastomosis in all patients. Conclusion The delta-shaped anastomosis is safe and feasible for totally laparoscopic distal gastrectomy digestive tract reconstruction of gastric cancer with satisfactory short-term efficacy. Key words: Stomach neoplasms; Laparoscopes; Digestive tract reconstruction; Delta-shaped anastomosis

A propensity score matched case-control comparative study of totally laparoscopic distal gastrectomy and laparoscopic-assisted distal gastrectomy for early gastric cancer

Intracorporeal anastomosis remains a difficult procedure. This study was designed to clarify the advantage of totally laparoscopic distal gastrectomy (TLDG) compared with laparoscopic-assisted distal gastrectomy (LADG) regarding short-term surgical outcomes. We retrospectively identified 273 patients who were preoperatively diagnosed with early gastric cancer and underwent LADG or TLDG between March 2010 and May 2016. A propensity score matching analysis was used to create patient groups matched for sex, age, body mass index, previous abdominal surgery history, and American Society of Anesthesiologist score. The TLDG group showed statistically shorter operative time (250.9 ± 4.6 min vs. 281.8 ± 7.3 min, p = 0.000), lower estimated blood loss (77.6 ± 3.3 ml vs. 122.4 ± 6.2 ml, p = 0.000), and shorter time to first flatus after surgery (2.9 ± 0.1 days vs. 3.2 ± 0.1 days, p = 0.001) compared with the LADG group. However, there was no specific superiority in terms of the inflammatory profiles on postoperative days 1, 2, 4, and 7 between the two groups. Complication rates were also similar in the two groups (13.3% LADG vs. 6.1% TLDG). This study shows that TLDG for early gastric cancer is a safe surgical procedure and superior in cosmesis compared with LADG.

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.

Short-term surgical outcomes of laparoscopy-assisted versus totally laparoscopic Billroth-II gastrectomy for gastric cancer: a matched-cohort study

BackgroundTo evaluate feasibility and benefits of intracorporeal anastomosis, we compared short-term surgical outcomes between laparoscopy-assisted distal gastrectomy (LADG) and totally laparoscopic distal gastrectomy (TLDG) with Billroth-II (B-II) anastomosis for gastric cancer.MethodsSixty patients underwent attempted B-II TLDG from 2011 through 2013. Patients who underwent B-II LADG prior to 2011 were matched to TLDG cases for demographics, comorbidities, tumor characteristics, and TNM stage. Perioperative and short-term surgical outcomes were compared between the two groups.ResultsClinicopathological characteristics of both groups were comparable. The B-II TLDG group had a shorter hospital stay (9.4 vs. 12.0 days, P = 0.038) and average incision size was smaller (3.5 vs. 5.4 cm, P = 0.030) than in the B-II LADG group. Anastomotic leakage was not recorded in either group, and there were no differences in the rates of perioperative complications and in inflammatory parameters between the two groups.ConclusionsThis study suggests that B-II TLDG is feasible, compared to B-II LADG, and that it has several advantages over LADG, including a smaller incision, a shorter hospital stay, and more convenience during surgery. However, prospective randomized controlled studies are still needed to confirm that B-II TLDG can be used as a standard procedure for LDG.

A novel option for preoperative endoscopic marking with India ink in totally laparoscopic distal gastrectomy for gastric cancer: A useful technique considering the morphological characteristics of the stomach.

In totally laparoscopic distal gastrectomy (TLDG) for gastric cancer, accurately determining the proximal resection line may be difficult. This is because identifying the lesion intracorporeally is impossible, due to the lack of tactile sense, and, in addition, unlike the intestine, the most proximal site of the lesion is often different from the main site due to the distorted shape of the stomach. The aim of this study was to introduce a novel method of preoperative endoscopic marking with India ink, taking into consideration the morphological characteristics of the stomach. Between July, 2013 and April, 2016, 20 patients who underwent TLDG were enrolled in this study. Within the 3 days preceding the operation, after identifying the most proximal site of the lesion on the overlooking image of an endoscope, India ink was injected into the spot on the oral side of this site. The stomach was transected along the proximal border of the marked area. In all cases, the marked sites were localized and clearly identified during the operation, and the proximal resection margins were found to be negative on postoperative pathological examination. The mean length of the proximal margin was 46.0±14.0 mm. In conclusion, this preoperative endoscopic marking method may be useful in TLDG for gastric cancer.

A Promising Method for Tumor Localization during Total Laparoscopic Distal Gastrectomy: Preoperative Endoscopic Clipping based on Negative Biopsy and Selective Intraoperative Radiography Findings.

PurposePrecise localization of tumors and creation of sufficient proximal resection margins are complicated processes during total laparoscopic distal gastrectomy (TLDG) for clinical T1/T2 gastric cancers. Various solutions to this problem have also yielded many disadvantages. In this study, we reviewed a preoperative endoscopic clipping method based on the results of negative biopsy and selective intraoperative radiography.Materials and MethodsA retrospective review of 345 consecutive patients who underwent TLDG and preoperative endoscopic clipping for tumor localization was conducted. During preoperative endoscopy, the endoscopists performed negative biopsies just 1–2 cm selectively above the tumor's upper limit. After confirming the biopsy results, endoscopic metal clips were applied just proximal to the negative biopsy site the day before surgery. Selective intraoperative tumor localization using portable abdominal radiography was performed only when we could not ensure a precise resection line.ResultsNegative biopsy was performed in 244 patients. Larger tumor size (P=0.008) and more distally located tumors (P=0.052) were observed more frequently in the negative biopsy group than in the non-negative biopsy group. The non-negative biopsy group had significantly higher frequencies of differentiated tumor types than the negative biopsy group (P=0.003). Of the 244 patients who underwent negative biopsies, 6 had cancer cells in their biopsy specimens. We performed intraoperative radiography in 12 patients whose tumors had difficult-to-determine proximal margins. No tumors were found in the proximal resection margins of any patients.ConclusionsOur tumor localization method is a promising and accurate method for securing a sufficient resection margin during TLDG.

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.

B-II reconstruction with Braun’s anastomosis after totally laparoscopic distal gastrectomy with D2 lymph node dissection for advanced gastric cancer

Background: B-II reconstruction is a mature way in radical operation of gastric cancer. It can confirm the negative margin in advanced gastric cancer. And it makes the digestive juices flow more freely and prevents delayed gastric emptying with Braun’s anastomosis. Methods: We choose a 59-year-old man with moderately differentiated adenocarcinoma of gastric antrum who was diagnosed by gastroscopy and histological test and conform to the treatment standard of totally laparoscopic distal gastrectomy (TLDG) with D2 lymph node dissection and B-II reconstruction and Braun’s anastomosis. Results: The total length of operation was 190 min. The entire bleeding was 40 mL. The patient ate liquid diet on the 3rd day and discharged from hospital with the wound class-A healing on the 7th day. Conclusions: TLDG with B-II reconstruction and Braun’s anastomosis using laparoscopic linear staplers reduces gastrointestinal function disorder and minimals the surgical incision, is a safe and feasible surgical method.

Retrospective analysis of multi-center data on the application of uncut Roux-en-Y gastrojejunostomy in totally laparoscopic distal gastrectomy

To investigate the feasibility and safety of uncut Roux-en-Y gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG) for gastric cancer. Clinical data of 30 gastric cancer patients from 4 hospitals undergoing TLDG plus uncut Roux-en-Y gastroduodenostomy from February 2014 to January 2015 were analyzed retrospectively. Among 30 gastric cancer patients, 8 were in Guangdong General Hospital, 9 in The Second Hospital of Jilin University, 4 in Ruijin Hospital and 9 in Fujian Provincial Cancer Hospital, who were diagnosed as distal gastric cancer by pathology without distant metastasis. The clinical staging of these patients was stage I(A in 7 cases, stage I(B in 4, stage II(A in 6, stage II(B in 5, stage III(A in 5, stage III(B in 1, stage III(C in 2. All the main surgeons were experienced with more than 50 operations of totally laparoscopic distal gastrectomy for gastric cancer. All the 30 patients completed operations successfully. The incision length was (4.8±1.2) cm, total operation time and anastomosis time was (223.5±47.2) and (52.8±10.9) minutes, intra-operative blood loss was (53.0±30.7) ml and number of harvested lymph nodes was 36.9±0.9. No case was transferred to open operation. The detain time of gastric tube was (2.5±1.2) days, the first time to flatus was (2.9±0.9) days and the first time to liquid diet intake was (2.9±1.2) days. No perioperative death was found. Postoperative lymphatic leakage occurred in 1 case and peritoneal bleeding occurred in 1 case, which was cured by conservative treatment. No one developed anastomosis-related complication. Uncut Roux-en-Y gastroduodenostomy reconstruction is safe and feasible in totally laparoscopic distal gastrectomy for gastric cancer.

Gastric Resection Under Retroflexed Endoscopic Guidance: A Reliable Procedure for Totally Laparoscopic Subtotal Gastrectomy

Background/Aims: Totally laparoscopic distal gastrectomy (TLDG) has become a feasible and safe surgical option for early gastric cancer. However, determining the transection line of the stomach without palpation is still difficult. This study aimed to assess the efficacy of TLDG for gastric resection under retroflexed endoscopic guidance (GRREG) in patients with gastric cancer in the middle third of the stomach. Methods: Fifteen patients with gastric cancer underwent TLDG using GRREG. Preoperative tumor localization using endoscopic metal clips was performed in all cases. After lymphadenectomy, two-thirds of the estimated transection line was occluded by an endoscopic stapler, beginning at the lesser curvature. Under gastric occlusion, the gastroscope was passed via the narrow lumen along the greater curvature followed by retroflexion to reveal the occlusion line, marking clips, and tumor in the same field of view. This view verified the safe oncological transection line. Results: All patients had cancer-free margins and did not require additional surgery. The mean (±SD) proximal margin was 23.5 ± 10.4 mm. There were no procedure-related complications. Conclusions: GRREG was a safe and effective technique for TLDG. Ideal transection of the stomach was achieved using a combination of an endoscopic stapler and gastroscope retroflexion.

Efficacy of totally laparoscopic distal gastrectomy for gastric cancer in elderly patients.

Elderly patients are often considered as high-risk for major abdominal surgery due to reduced functional reserve and increased comorbidities. We herein evaluated the efficacy of totally laparoscopic distal gastrectomy (TLDG) in elderly patients with gastric cancer by measuring the postoperative systemic responses and postoperative analgesic consumption. A total of 102 patients with gastric cancer [57 who underwent TLDG and 45 who underwent laparoscopy-assisted distal gastrectomy (LADG)] were enrolled in this study. The patients were classified as elderly (aged ≥75 years) and non-elderly (aged <75 years) groups. The surgical outcome and postoperative analgesic consumption were evaluated. The elderly group exhibited a higher incidence of comorbidities and a longer postoperative hospital stay compared with those of younger patients, although there was no difference in the incidence of postoperative complications. In addition, the total consumption of additional analgesics until postoperative day 5 in patients who underwent TLDG was significantly lower compared with that in patients who underwent LADG in the elderly group; there was no such difference in the non-elderly group. The results suggested that TLDG was better for the management of postoperative pain in elderly patients with gastric cancer, who exhibit the highest mortality rates in the adult surgical population.