Yonsei Med J.  2014 Jan;55(1):162-169. 10.3349/ymj.2014.55.1.162.

Totally Laparoscopic Roux-en-Y Gastrojejunostomy after Laparoscopic Distal Gastrectomy: Analysis of Initial 50 Consecutive Cases of Single Surgeon in Comparison with Totally Laparoscopic Billroth I Reconstruction

• An JY
• Cho I
• Choi YY
• Kim YM
• Noh SH

• KMID: 1779901
• DOI: http://doi.org/10.3349/ymj.2014.55.1.162

Abstract

PURPOSE
Roux-en-Y reconstruction (RY) in laparoscopic distal gastrectomy for gastric cancer is a more complicated procedure than Billroth-I (BI) or Billroth-II. Here, we offer a totally laparoscopic simple RY using linear staplers.
MATERIALS AND METHODS
Each 50 consecutive patients with totally laparoscopic distal gastrectomy with RY and BI were enrolled in this study. Technical safety and surgical outcomes of RY were evaluated in comparison with BI.
RESULTS
In all patients, RY gastrectomy using linear staplers was safely performed without any events during surgery. The mean operation time and anastomosis time were 177.0+/-37.6 min and 14.4+/-5.6 min for RY, respectively, which were significantly longer than those for BI (150.4+/-34.0 min and 5.9+/-2.2 min, respectively). There were no differences in amount of blood loss, time to flatus passage, diet start, length of hospital stay, and postoperative inflammatory response between the two groups. Although there was no significant difference in surgical complications between RY and BI (6.0% and 14.0%), the RY group showed no anastomosis site-related complications.
CONCLUSION
The double stapling method using linear staplers in totally laparoscopic RY reconstruction is a simple and safe procedure.

Keyword

Intracorporeal Roux-en-Y gastrojejunostomy; totally laparoscopic distal gastrectomy; intracorporeal Billroth-I reconstruction; technical safety; surgical outcome

MeSH Terms

Aged
Female
Gastrectomy/*methods
Gastric Bypass/*methods
Humans
Laparoscopy/*methods
Male
Middle Aged
Stomach Neoplasms/surgery

Figure

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  Fig. 1 Placement of trocars in a laparoscopic distal gastrectomy.

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  Fig. 2 Surgical techniques for gastrojejunostomy. (A) Side-to-side anastomosis between the greater curvature of the stomach and the jejunum with a linear stapler. (B) Closure of the common entry hole using a linear stapler. (C) Completion of the gastrojejunostomy.

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  Fig. 3 Surgical techniques for jejeunojejunostomy. (A) Side-to-side jejunojejunostomy using a linear stapler. (B and C) Closure of the common entry hole using a linear stapler. (D) Completion of the jejunojejunostomy.

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  Fig. 4 Operation time. Changes of operation time by case number accumulation for RY and BI. BI, Billroth-I; RY, Roux-en-Y reconstruction.

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  Fig. 5 Anastomosis time. Changes in anastomosis time by case number accumulation for RY and BI. BI, Billroth-I; RY, Roux-en-Y reconstruction.

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  Fig. 6 Changes of preoperative and postoperative laboratory data. (A) White blood cell count (WBC) (×103/µL), neutrophil (×103/µL), total protein (g/dL), albumin (mg/dL) level. (B) Serum high sensitive C-reactive protein level (mg/L). BI, Billroth-I; RY, Roux-en-Y reconstruction; POD, postoperative day.

Reference

1. The Information Committee of the Korean Gastric Cancer Association. 2004 Nationwide Gastric Cancer Report in Korea. J Korean Gastric Cancer Assoc. 2007; 7:47–54.

2. Kang KC, Cho GS, Han SU, Kim W, Kim HH, Kim MC, et al. Comparison of Billroth I and Billroth II reconstructions after laparoscopy-assisted distal gastrectomy: a retrospective analysis of large-scale multicenter results from Korea. Surg Endosc. 2011; 25:1953–1961.

3. Kim MG, Kawada H, Kim BS, Kim TH, Kim KC, Yook JH, et al. A totally laparoscopic distal gastrectomy with gastroduodenostomy (TLDG) for improvement of the early surgical outcomes in high BMI patients. Surg Endosc. 2011; 25:1076–1082.

4. Kim BS, Yook JH, Choi YB, Kim KC, Kim MG, Kim TH, et al. Comparison of early outcomes of intracorporeal and extracorporeal gastroduodenostomy after laparoscopic distal gastrectomy for gastric cancer. J Laparoendosc Adv Surg Tech A. 2011; 21:387–391.

5. Takaori K, Nomura E, Mabuchi H, Lee SW, Agui T, Miyamoto Y, et al. A secure technique of intracorporeal Roux-Y reconstruction after laparoscopic distal gastrectomy. Am J Surg. 2005; 189:178–183.

6. Bouras G, Lee SW, Nomura E, Tokuhara T, Nitta T, Yoshinaka R, et al. Surgical outcomes from laparoscopic distal gastrectomy and Roux-en-Y reconstruction: evolution in a totally intracorporeal technique. Surg Laparosc Endosc Percutan Tech. 2011; 21:37–41.

7. Kim DH, Kim HY, Kim DH, Jeon TY, Hwang SH, Kim GH. Double stapling Roux-en-Y reconstruction in a laparoscopy-assisted distal gastrectomy. Surg Today. 2010; 40:943–948.

8. Kojima K, Yamada H, Inokuchi M, Kawano T, Sugihara K. A comparison of Roux-en-Y and Billroth-I reconstruction after laparoscopy-assisted distal gastrectomy. Ann Surg. 2008; 247:962–967.

9. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009; 250:187–196.

10. Edge SB, Byrd DR, Compton CC, Fritz AG, Greene FL, Trotti A. AJCC Cancer Staging Handbook. 7th ed. Springer;2010.

11. Nunobe S, Okaro A, Sasako M, Saka M, Fukagawa T, Katai H, et al. Billroth 1 versus Roux-en-Y reconstructions: a quality-of-life survey at 5 years. Int J Clin Oncol. 2007; 12:433–439.

12. Fukuhara K, Osugi H, Takada N, Takemura M, Higashino M, Kinoshita H. Reconstructive procedure after distal gastrectomy for gastric cancer that best prevents duodenogastroesophageal reflux. World J Surg. 2002; 26:1452–1457.

13. Hoya Y, Mitsumori N, Yanaga K. The advantages and disadvantages of a Roux-en-Y reconstruction after a distal gastrectomy for gastric cancer. Surg Today. 2009; 39:647–651.

14. Noshiro H, Ohuchida K, Kawamoto M, Ishikawa M, Uchiyama A, Shimizu S, et al. Intraabdominal Roux-en-Y reconstruction with a novel stapling technique after laparoscopic distal gastrectomy. Gastric Cancer. 2009; 12:164–169.

15. Kanaya S, Gomi T, Momoi H, Tamaki N, Isobe H, Katayama T, et al. Delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy: new technique of intraabdominal gastroduodenostomy. J Am Coll Surg. 2002; 195:284–287.

16. Lee HW, Kim HI, An JY, Cheong JH, Lee KY, Hyung WJ, et al. Intracorporeal Anastomosis Using Linear Stapler in Laparoscopic Distal Gastrectomy: Comparison between Gastroduodenostomy and Gastrojejunostomy. J Gastric Cancer. 2011; 11:212–218.

17. Kanaya S, Kawamura Y, Kawada H, Iwasaki H, Gomi T, Satoh S, et al. The delta-shaped anastomosis in laparoscopic distal gastrectomy: analysis of the initial 100 consecutive procedures of intracorporeal gastroduodenostomy. Gastric Cancer. 2011; 14:365–371.

18. Noshiro H, Iwasaki H, Miyasaka Y, Kobayashi K, Masatsugu T, Akashi M, et al. An additional suture secures against pitfalls in delta-shaped gastroduodenostomy after laparoscopic distal gastrectomy. Gastric Cancer. 2011; 14:385–389.

19. Fujita T, Katai H, Morita S, Saka M, Fukagawa T, Sano T. Short-term outcomes of Roux-en-Y stapled anastomosis after distal gastrectomy for gastric adenocarcinoma. J Gastrointest Surg. 2010; 14:289–294.