Optimal choice of stapler and digestive tract reconstruction method after distal gastrectomy for gastric cancer:A prospective case–control study

BACKGROUND Gastric cancer is the most common cause of cancer-related deaths,and is classified according to its location in the proximal,middle,or distal stomach.Surgical resection is the primary approach for treating gastric cancer.This prospective study aimed to determine the best reconstruction method after distal gastrectomy for gastric cancer.AIM To explore the efficacy of different staplers and digestive tract reconstruction(DTR)methods after radical gastrectomy and their influence on prognosis.METHODS Eighty-seven patients who underwent radical gastrectomy for distal gastric cancer at our institution between April 2017 and April 2020 were included in this study,with a follow-up period of 12-26 mo.The patients were assigned to four groups based on the stapler and DTR plan as follows:BillrothⅠ(B-I)reconstruction+linear stapler group(group A,22 cases),B-I reconstruction+circular stapler group(group B,22 cases),Billroth II(B-II)reconstruction+linear stapler group(group C,22 cases),and B-II reconstruction+circular stapler group(group D,21 cases).The pathological parameters,postoperative gastrointestinal function recovery,postoperative complications,and quality of life(QOL)were compared among the four groups.RESULTS No significant differences in the maximum diameter of the gastric tumors,total number of lymph nodes dissected,drainage tube removal time,QLQ(QOL questionnaire)-C30 and QLQ-STO22 scores at 1 year postoperatively,and incidence of complications were observed among the four groups(P>0.05).However,groups A and C(linear stapler)had significantly lower intraoperative blood loss and significantly shorter anastomosis time,operation time,first fluid diet intake time,first exhaust time,and length of postoperative hospital stay(P<0.05)than groups B and D(circular stapler).CONCLUSION Linear staplers offer several advantages for postoperative recovery.B-I and B-II reconstruction methods had similar effects on QOL.The optimal solution can be selected according to individual conditions and postoperative convenience.

Digestive tract reconstruction options after laparoscopic gastrectomy for gastric cancer

In addition to the popularity of laparoscopic gastrectomy(LG),many reconstructive procedures after LG have been reported.Surgical resection and lymphatic dissection determine long-term survival;however,the election of a reconstruction procedure determines the postoperative quality of life for patients with gastric cancer(GC).Presently,no consensus exists regarding the optimal reconstructive procedure.In this review,the current state of digestive tract reconstruction after LG is reviewed.According to the determining influence of the tumor site on the procedures of surgical resection and reconstruction,we divide these reconstruction procedures into three categories consistent with the resection procedures.We focus on the technical tips of every reconstruction procedure and examine the surgical outcomes(length of surgery and blood loss)and postoperative complications(anastomotic leakage and stricture)to facilitate gastrointestinal surgeons to understand the merits and demerits of every reconstruction procedure.

Effects on the pouch of different digestive tract reconstruction modes assessed by radionuclide scintigraphy

AIM: To determine the effect of three digestive tract reconstruction procedures on pouch function, after radical surgery undertaken because of gastric cancer, as assessed by radionuclide dynamic imaging. METHODS: As a measure of the reservoir function, with a designed diet containing technetium-99m (99mTc), the emptying time of the gastric substitute was evaluated using a 99mTc-labeled solid test meal. Immediately after the meal, the patient was placed in front of a γ camera in a supine position and the radioactivity was measured over the whole abdomen every minute. A frame image was obtained. The emptying sequences were recorded by the microprocessor and then stored on a computer disk. According to a computer processing system, the half-emptying actual curve and the fitting curve of food containing isotope in the detected region were depicted, and the half-emptying actual curves of the three reconstruction procedures were directly compared. RESULTS: Of the three reconstruction procedures, the half-emptying time of food containing isotope in the Dual Braun type esophagojejunal anastomosis procedure (51.86±6.43 min) was far closer to normal, signif icantly better than that of the proximal gastrectomy orthotopic reconstruction (30.07±15.77 min, P=0.002) and P type esophagojejunal anastomosis (27.88±6.07 min, P=0.001) methods. The half-emptying actual curve and f itting curves for the Dual Braun type esophagojejunal anastomosis were fairly similar while those of the proximal gastrectomy orthotopic reconstruction and P type esophagojejunal anastomosis were obviously separated, which indicated bad food conservation in the reconstructed pouches. CONCLUSION: Dual Braun type esophagojejunal anastomosis is the most useful of the three procedures for improving food accommodation in patients with a pouch and can retard evacuation of solid food from the reconstructed pouch.

Pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction for benign pancreatic diseases

Surgery such as digestive tract reconstruction is usually required for pancreatic trauma and severe pancreatitis as well as malignant pancreatic lesions. The most common digestive tract reconstruction techniques (e.g., Child&#x02019;s type reconstruction) for neoplastic diseases of the pancreatic head often encompass pancreaticojejunostomy, choledochojejunostomy and then gastrojejunostomy with pancreaticoduodenectomy, whereas these techniques may not be applicable in benign pancreatic diseases due to an integrated stomach and duodenum in these patients. In benign pancreatic diseases, the aforementioned reconstruction will not only increase the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the risks of traction, twisting and angularity of the jejunal loop. In addition, postoperative complications such as mixed fistula are refractory and life-threatening after common reconstruction procedures. We here introduce a novel pancreaticojejunostomy, hepaticojejunostomy and double Roux-en-Y digestive tract reconstruction in two cases of benign pancreatic disease, thus decreasing not only the distance between the pancreaticojejunostomy and choledochojejunostomy, but also the possibility of postoperative complications compared to common reconstruction methods. Postoperatively, the recovery of these patients was uneventful and complications such as bile leakage, pancreatic leakage and digestive tract obstruction were not observed during the follow-up period.

Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China: a national questionnaire survey

Background Pancreaticoduodenectomy(PD)has been widely applied in general hospitals in China;however,there is still a lack of unified standards for each surgical technique and procedure.This survey is intended to investigate the current status of digestive tract reconstruction after PD in university hospitals in China.Method A cross-sectional survey was conducted among the members of the Young Elite Pancreatic Surgery Club of China by using the Questionnaire for Digestive Tract Reconstruction after Pancreaticoduodenectomy.The questionnaire was disseminated and collected by point-to-point communication via WeChat public platforms.Results A total of 73 valid questionnaires were returned from 65 university hospitals in 28 provincial divisions of China's Mainland.The respondents who performed PD surgery with an annual volume of over 100 cases accounted for 63%.Generally,laparoscopic PD was performed less often than open PD.Child and Whipple reconstructions accounted for 70%and 26%,respectively.The sequence of pancreatoenteric,biliary-enteric,and gastrointestinal reconstruction accounted for 84%of cases.In pancreatoenteric anastomosis,double-layer anastomosis is the most commonly employed type,accounting for approximately 67%,while single-layer anastomosis accounts for 30%.Of the double-layer anastomoses,duct-to-mucosa/dunking(94%/4%)PJ was performed with duct-mucosa using the Blumgart method(39%)and Cattel-Warren(29%),with continuous/interrupted sutures in the inner layer(69%/31%)and continuous/interrupted sutures in the outer layer(53%/23%).In single-layer anastomosis,continuous/interrupted sutures accounted for 41%/45%.In hepatojejunostomy,single-layer/double-layer suture accounted for 79%/4%,and continuous/interrupted suture accounted for 75%/9%.Forty-six percent of the responding units had not applied double-layer biliary-intestinal anastomosis in the last 3 years,75%of the responding surgeons chose the anastomosis method according to bile duct diameter,with absorbable/non-absorbable suture accounting for 86%/12%.PD/pylorus-preserving PD accounted for 79%/11%of GJ cases,the distance between GJ and HJ<30 cm,30-50 cm and>50 cm were 11%,75%,and 14%,respectively.Antecolic/retrocolic GJ accounted for 71%/23%of cases.Twenty-two percent of GJ cases employed Braun anastomosis,while 55%and 19%of GJ cases used linear cutting staplers/tube-type staplers,respectively;60%/14%were reinforced/not reinforced via manual suturing after stapler anastomosis.Manual anastomosis in GJ surgery employed absorbable/non-absorbable sutures(91%/9%).Significant differences in reconstruction techniques were detected between different volumes of PD procedures(<100/year and>100/year),regions with different economic development levels,and between north and south China.Conclusion Digestive tract reconstruction following PD exists heterogeneity in Chinese university hospitals.Corresponding prospective clinical studies are needed to determine the consensus on pancreatic surgery that meets the clinical reality in China.

Digestive tract reconstruction in pancreaticoduodenectomy in University Hospitals of China:a national questionnaire survey

Background:Pancreaticoduodenectomy(PD)has been widely applied in general hospitals in China;however,there is still a lack of unified standards for each surgical technique and procedure.This survey is intended to investigate the current status of digestive tract reconstruction after PD in university hospitals in China.Method:A cross-sectional survey was conducted among the members of the Young Elite Pancreatic Surgery Club of China by using the Questionnaire for Digestive Tract Reconstruction after Pancreaticoduodenectomy.The questionnaire was disseminated and collected by point-to-point communication via WeChat public platforms.Results:A total of 73 valid questionnaires were returned from 65 university hospitals in 28 provincial divisions of China's Mainland.The respondents who performed PD surgery with an annual volume of over 100 cases accounted for 63%.Generally,laparoscopic PD was performed less often than open PD.Child and Whipple reconstructions accounted for 70%and 26%,respectively.The sequence of pancreatoenteric,biliary-enteric,and gastrointestinal reconstruction accounted for 84%of cases.In pancreatoenteric anastomosis,double-layer anastomosis is the most commonly employed type,accounting for approximately 67%,while single-layer anastomosis accounts for 30%.Of the double-layer anastomoses,duct-to-mucosa/dunking(94%/4%)pancreatojejunostomy was performed with duct-mucosa using the Blumgart method(39%)and Cattel-Warren(29%),with continuous/interrupted sutures in the inner layer(69%/31%)and continuous/interrupted sutures in the outer layer(53%/23%).In single-layer anastomosis,continuous/interrupted sutures accounted for 41%/45%.In hepatojejunostomy,single-layer/double-layer suture accounted for 79%/4%,and continuous/interrupted suture accounted for 75%/9%.Forty-six percent of the responding units had not applied double-layer biliary-intestinal anastomosis in the last 3 years,75%of the responding surgeons chose the anastomosis method according to bile duct diameter,with absorbable/non-absorbable suture accounting for 86%/12%.PD/pylorus-preserving PD accounted for 79%/11%of gastrojejunostomy(GJ)cases,the distance between GJ and hepaticojejunostomy<30,30-50,and>50 cm were 11%,75%,and 14%,respectively.Antecolic/retrocolic GJ accounted for 71%/23%of cases.Twenty-two percent of GJ cases employed Braun anastomosis,while 55%and 19%of GJ cases used linear cutting staplers/tube-type staplers,respectively;60%/14%were reinforced/not reinforced via manual suturing after stapler anastomosis.Manual anastomosis in GJ surgery employed absorbable/non-absorbable sutures(91%/9%).Significant differences in reconstruction techniques were detected between different volumes of PD procedures(<100/year and>100/year),regions with different economic development levels,and between north and south China.Conclusion:Digestive tract reconstruction following PD exists heterogeneity in Chinese university hospitals.Corresponding prospective clinical studies are needed to determine the consensus on pancreatic surgery that meets the clinical reality in China.

Clinical efficacy and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in gastrectomy

BACKGROUND With the continuous progress of surgical technology and improvements in medical standards,the treatment of gastric cancer surgery is also evolving.Proximal gastrectomy is a common treatment,but double-channel anastomosis and tubular gastroesophageal anastomosis have attracted much attention in terms of surgical options.Each of these two surgical methods has advantages and disadvantages,so it is particularly important to compare and analyze their clinical efficacy and safety.AIM To compare the surgical safety,clinical efficacy,and safety of double-channel anastomosis and tubular gastroesophageal anastomosis in proximal gastrectomy.METHODS The clinical and follow-up data of 99 patients with proximal gastric cancer who underwent proximal gastrectomy and were admitted to our hospital between January 2018 and September 2023 were included in this retrospective cohort study.According to the different anastomosis methods used,the patients were divided into a double-channel anastomosis group(50 patients)and a tubular gastroesophageal anastomosis group(49 patients).In the double-channel anastomosis,Roux-en-Y anastomosis of the esophagus and jejunum was performed after proximal gastric dissection,and then side-to-side anastomosis was performed between the residual stomach and jejunum to establish an antireflux barrier and reduce postoperative gastroesophageal reflux.In the tubular gastroesophageal anastomosis group,after the proximal end of the stomach was cut,tubular gastroplasty was performed on the distal stump of the stomach and a linear stapler was used to anastomose the posterior wall of the esophagus and the anterior wall of the stomach tube.The main outcome measure was quality of life 1 year after surgery in both groups,and the evaluation criteria were based on the postgastrectomy syndrome assessment scale.The greater the changes in body mass,food intake per meal,meal quality subscale score,and total measures of physical and mental health score,the better the condition;the greater the other indicators,the worse the condition.The secondary outcome measures were intraoperative and postoperative conditions,the incidence of postoperative long-term complications,and changes in nutritional status at 1,3,6,and 12 months after surgery.RESULTS In the double-channel anastomosis cohort,there were 35 males(70%)and 15 females(30%),33(66.0%)were under 65 years of age,and 37(74.0%)had a body mass index ranging from 18 to 25 kg/m2.In the group undergoing tubular gastroesophageal anastomosis,there were eight females(16.3%),21(42.9%)individuals were under the age of 65 years,and 34(69.4%)had a body mass index ranging from 18 to 25 kg/m2.The baseline data did not significantly differ between the two groups(P>0.05 for all),with the exception of age(P=0.021).The duration of hospitalization,number of lymph nodes dissected,intraoperative blood loss,and perioperative complication rate did not differ significantly between the two groups(P>0.05 for all).Patients in the dual-channel anastomosis group scored better on quality of life measures than did those in the tubular gastroesophageal anastomosis group.Specifically,they had lower scores for esophageal reflux[2.8(2.3,4.0)vs 4.8(3.8,5.0),Z=3.489,P<0.001],eating discomfort[2.7(1.7,3.0)vs 3.3(2.7,4.0),Z=3.393,P=0.001],total symptoms[2.3(1.7,2.7)vs 2.5(2.2,2.9),Z=2.243,P=0.025],and other aspects of quality of life.The postoperative symptoms[2.0(1.0,3.0)vs 2.0(2.0,3.0),Z=2.127,P=0.033],meals[2.0(1.0,2.0)vs 2.0(2.0,3.0),Z=3.976,P<0.001],work[1.0(1.0,2.0)vs 2.0(1.0,2.0),Z=2.279,P=0.023],and daily life[1.7(1.3,2.0)vs 2.0(2.0,2.3),Z=3.950,P<0.001]were all better than those of the tubular gastroesophageal anastomosis group.The group that underwent tubular gastroesophageal anastomosis had a superior anal exhaust score[3.0(2.0,4.0)vs 3.5(2.0,5.0),Z=2.345,P=0.019]compared to the dual-channel anastomosis group.Hemoglobin,serum albumin,total serum protein,and the rate at which body mass decreased one year following surgery did not differ significantly between the two groups(P>0.05 for all).CONCLUSION The safety of double-channel anastomosis in proximal gastric cancer surgery is equivalent to that of tubular gastric surgery.Compared with tubular gastric surgery,double-channel anastomosis is a preferred surgical technique for proximal gastric cancer.It offers advantages such as less esophageal reflux and improved quality of life.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy

BACKGROUND Reflux esophagitis is a common postoperative complication of proximal gastrectomy.There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy.We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis(EGAA)can prevent postoperative reflux in a safe and feasible manner.To observe a novel method of EGAA to prevent postoperative reflux.METHODS Initially,we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis.This was done in order to better understand the anti-reflux function and mechanism.Next,we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy.Post-surgery,we monitored the structure and function of the reconstruction through imaging exams and gastroscopy.Finally,the patients were followed up to assess the efficacy of the anti-reflux effects.RESULTS Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma,providing a means to prevent the reverse flow of gastric fluids.Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy,with a mean operation time of 304.2±44.3 min.After the operation,the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux,three had mild reflux,and two had obvious reflux.The abdominal computed tomography examination showed a valve-like structure at the anastomosis.During followup,gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients.Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy.CONCLUSION EGAA is a feasible and safe surgical method,with an excellent anti-reflux effect after proximal gastrectomy.

Comparision of modified and conventional delta-shaped gastroduodenostomy in totally laparoscopic surgery

AIM: To evaluate the safety and feasibility of a modified delta-shaped gastroduodenostomy (DSG) in totally laparoscopic distal gastrectomy (TLDG).

Comparison of long-term quality of life between Billroth-I and Roux-en-Y anastomosis after distal gastrectomy for gastric cancer: a randomized controlled trial

Background:The results of studies comparing Billroth-I(B-I)with Roux-en-Y(R-Y)reconstruction on the quality of life(QoL)are still inconsistent.The aim of this trial was to compare the long-term QoL of B-I with R-Y anastomosis after curative distal gastrectomy for gastric cancer.Methods:A total of 140 patients undergoing curative distal gastrectomy with D2 lymphadenectomy in West China Hospital,Sichuan University from May 2011 to May 2014 were randomly assigned to the B-I group(N=70)and R-Y group(N=70).The follow-up time points were 1,3,6,9,12,24,36,48,and 60 months after the operation.The final follow-up time was May 2019.The clinicopathological features,operative safety,postoperative recovery,long-term survival as well as QoL were compared,among which QoL score was the primary outcome.An intention-to-treat analysis was applied.Results:The baseline characteristics were comparable between the two groups.There were no statistically significant differences in terms of postoperative morbidity and mortality rates,and postoperative recovery between the two groups.Less estimated blood loss and shorter surgical duration were found in the B-I group.There were no statistically significant differences in 5-year overall survival(79%[55/70]of the B-I group vs.80%[56/70]of the R-Y group,P=0.966)and recurrence-free survival rates(79%[55/70]of the B-I group vs.78%[55/70]of the R-Y group,P=0.979)between the two groups.The scores of the global health status of the R-Y group were higher than those of the B-I group with statistically significant differences(postoperative 1 year:85.4±13.1 vs.88.8±16.1,P=0.033;postoperative 3 year:87.3±15.2 vs.92.8±11.3,P=0.028;postoperative 5 year:90.9±13.7 vs.96.4±5.6,P=0.010),and the reflux(postoperative 3 year:8.8±12.9 vs.2.8±5.3,P=0.001;postoperative 5 year:5.1±9.8 vs.1.8±4.7,P=0.033)and epigastric pain(postoperative 1 year:11.8±12.7 vs.6.1±8.8,P=0.008;postoperative 3 year:9.4±10.6 vs.4.6±7.9,P=0.006;postoperative 5 year:6.0±8.9 vs.2.7±4.6,P=0.022)were milder in the R-Y group than those of the B-I group at the postoperative 1,3,and 5-year time points.Conclusions:Compared with B-I group,R-Y reconstruction was associated with better long-term QoL by reducing reflux and epigastric pain,without changing survival outcomes.Trial Registration:ChiCTR.org.cn,ChiCTR-TRC-10001434.