Comparison of postoperative mid-term and long-term quality of life between Billroth-I gastroduodenostomy and Billroth-II gastrojejunostomy after radical distal gastrectomy in patients with gastric cancer: a cohort study based on a case registry database / 中华胃肠外科杂志

Objective: The pattern of digestive tract reconstruction in radical gastrectomy for gastric cancer is still inconclusive. This study aims to compare mid-term and long-term quality of life after radical gastrectomy for distal gastric cancer between Billroth-I (B-I) and Billroth-II (B-II) reconstruction. Methods: A retrospective cohort study was conducted.Clinicopathological and follow-up data of 859 gastric cancer patients were colected cellected from the surgical case registry database of Gastrointestinal Surgery Center of Sichuan University West China Hospital, who underwent radical distal gastric cancer resection between January 2016 and December 2020. Inclusion criteria: (1) gastric cancer confirmed by preoperative gastroscopy and biopsy; (2) elective radical distal major gastrectomy performed according to the Japanese Society for Gastric Cancer treatment guidelines for gastric cancer; (3) TNM staging referenced to the American Cancer Society 8th edition criteria and exclusion of patients with stage IV by postoperative pathology; (4) combined organ resection only involving the gallbladder or appendix; (5) gastrointestinal tract reconstruction modality of B-I or B-II; (6) complete clinicopathological data; (7) survivor during the last follow-up period from December 15, 2021 to January 15, 2022. Exclusion criteria: (1) poor compliance to follow-up; (2) incomplete information on questionnaire evaluation; (3) survivors with tumors; (4) concurrent malignancies in other systems; (5) concurrent psychiatric and neurological disorders that seriously affected the objectivity of the questionnaire or interfered with patient's cognition. Telephone follow-up was conducted by a single investigator from December 2021 to January 2022, and the standardized questionnaire EORTC QLQ-C30 scale (symptom domains, functional domains and general health status) and EORTC QLQ-STO22 scale (5 symptoms of dysphagia, pain, reflux, restricted eating, anxiety; 4 single items of dry mouth, taste, body image, hair loss) were applied to evaluate postoperative quality of life. In 859 patients, 271 were females and 588 were males; the median age was 57.0 (49.5, 66.0) years. The included cases were divided into the postoperative follow-up first year group (202 cases), the second year group (236 cases), the third year group (148 cases), the fourth year group (129 cases) and the fifth year group (144 cases) according to the number of years of postoperative follow-up. Each group was then divided into B-I reconstruction group and B-II reconstruction group according to procedure of digestive tract reconstruction. Except for T-stage in the fourth year group, and age, tumor T-stage and tumor TNM-stage in the fifth year group, whose differences were statistically significant between the B-I and B-II reconstruction groups (all P<0.05), the differences between the B-I and B-II reconstruction groups in terms of demographics, body mass index (BMI), tumor TNM-stage and tumor pathological grading in postoperative follow-up each year group were not statistically significant (all P>0.05), suggesting that the baseline information between B-I reconstruction group and the B-II reconstruction group in postoperative each year group was comparable. Evaluation indicators of quality of life (EORTC QLQ-C30 and EORTC QLQ-STO22 scales) and nutrition-related laboratory tests (serum hemoglobin, albumin, total protein, triglycerides) between the B-I reconstruction group and B-II reconstruction group in each year group were compared. Non-normally distributed continuous variables were presented as median (Q(1),Q(3)), and compared by using the Wilcoxon rank sum test (paired=False). The χ(2) test or Fisher's exact test was used for comparison of categorical variables between groups. Results: There were no statistically significant differences in all indexes EORTC QLQ-30 scale between the B-I reconstruction group and the B-II reconstruction group among all postoperative follow-up year groups (all P>0.05). The EORTC QLQ-STO22 scale showed that significant differences in pain and eating scores between the B-I reconstruction group and the B-II reconstruction group were found in the second year group, and significant differences in eating, body and hair loss scores between the B-I reconstruction group and the B-II reconstruction group were found in the third year group (all P<0.05), while no significant differences of other item scores between the B-I reconstruction group and the B-II reconstruction group were found in postoperative follow-up of all year groups (P>0.05). Triglyceride level was higher in the B-II reconstruction group than that in the B-I reconstruction group (W=2 060.5, P=0.038), and the proportion of patients with hyperlipidemia (triglycerides >1.85 mmol/L) was also higher in the B-II reconstruction group (19/168, 11.3%) than that in the B-I reconstruction group (0/34) (χ(2)=0.047, P=0.030) in the first year group with significant difference. Albumin level was lower in the B-II reconstruction group than that in the B-I reconstruction group (W=482.5, P=0.036), and the proportion of patients with hypoproteinemia (albumin <40 g/L) was also higher in the B-II reconstruction group (19/125, 15.2%) than that in the B-I reconstruction group (0/19) in the fifth year group, but the difference was not statistically significant (χ(2)=0.341, P=0.164). Other nutrition-related clinical laboratory tests were not statistically different between the B-I reconstruction and the B-II reconstruction in each year group (all P>0.05). Conclusions: The effects of both B-I and B-II reconstruction methods on postoperative mid-term and long-term quality of life are comparable. The choice of reconstruction method after radical resection of distal gastric cancer can be based on a combination of patients' condition, sugenos' eoperience and operational convenience.

Comparison of clinical efficacy and quality of life between uncut Roux-en-Y and Billroth II with Braun anastomosis in laparoscopic distal gastrectomy for gastric cancer / 中华胃肠外科杂志

Objective: To compare the clinical efficacy and quality of life between uncut Roux-en-Y and Billroth II with Braun anastomosis in laparoscopic distal gastrectomy for gastric cancer patients. Methods: A retrospective cohort study was performed. Inclusion criteria: (1) 18 to 75 years old; (2) gastric cancer proved by preoperative gastroscopy, CT and pathological results and tumor was suitable for D2 radical distal gastrectomy; (3) postoperative pathological diagnosis stage was T1-4aN0-3M0 (according to the AJCC-7th TNM tumor stage), and the margin was negative; (4) Eastern Cooperative Oncology Group (ECOG) physical status score <2 points, and American Association of Anesthesiologists (ASA) grade 1 to 3; (5) no mental illness; (6) able to answer questionnaires independently; (7) patients agreed to undergo laparoscopic distal gastrectomy and signed an informed consent. Exclusion criteria: (1) patients with severe chronic diseases and American Association of Anesthesiologists (ASA) grade >3; (2) patients with other malignant tumors; (3) patients suffered from serious mental diseases; (4) patients received neoadjuvant chemotherapy or immunotherapy. According to the above criteria, clinical data of 200 patients who underwent laparoscopic distal gastrectomy at the Department of General Surgery of the First Affiliated Hospital of Army Medical University from January 2016 to December 2019 were collected. Of the 200 patients, 108 underwent uncut Roux-en-Y anastomosis and 92 underwent Billroth II with Braun anastomosis. The general data, intraoperative and postoperative conditions, complications, and endoscopic evaluation 1 year after the surgery were compared. Besides, the quality of life of two groups was also compared using the Chinese version of the European Organization For Research and Treatment of Cancer (EORTC) quality of life questionnaire-Core 30 (QLQ-C30) and quality of life questionnaire-stomach 22 (QLQ-STO22). Results: There were no significant differences in baseline data between the two groups (all P>0.05). All the 200 patients successfully underwent laparoscopic distal gastrectomy without intraoperative complications, conversion to open surgery or perioperative death. There were no significant differences between two groups in operative time, intraoperative blood loss, postoperative complications, time to flatus, time to removal of gastric tube, time to liquid diet, time to removal of drainage tube or length of postoperative hospital stay (all P>0.05). Endoscopic evaluation was conducted 1 year after surgery. Compared to Billroth II with Braun group, the uncut Roux-en-Y group had a significantly lower incidences of gastric stasis [19.8% (17/86) vs. 37.0% (27/73), χ(2)=11.199, P=0.024], gastritis [11.6% (10/86) vs. 34.2% (25/73), χ(2)=20.892, P<0.001] and bile reflux [1.2% (1/86) vs. 28.8% (21/73), χ(2)=25.237, P<0.001], and the differences were statistically significant. The EORTC questionnaire was performed 1 year after surgery, there were no significant differences in the scores of QLQ-C30 scale between the two groups (all P>0.05), while the scores of QLQ-STO22 showed that, compared to the Billroth II with Braun group, the uncut Roux-en-Y group had a lower pain score (median: 8.3 vs. 16.7, Z=-2.342, P=0.019) and reflux score (median: 0 vs 5.6, Z=-2.284, P=0.022), and the differences were statistically significant (all P<0.05), indicating milder symptoms. Conclusion: The uncut Roux-en-Y anastomosis is safe and reliable in laparoscopic distal gastrectomy, which can reduce the incidences of gastric stasis, gastritis and bile reflux, and improve the quality of life of patients after surgery.

Endoscopic Retrograde Cholangiopancreatography in Post Gastrectomy Patients

Endoscopic retrograde cholangiopancreatography (ERCP) in post-gastrectomy patients with Billroth II (BII) reconstruction and Roux-en-Y (RY) reconstruction presents a challenge to therapeutic endoscopists. Major difficulties, including intubation to the ampulla of Vater, selective cannulation, and ampullary intervention, must be overcome in these patients. Recent data have shown that device-assisted ERCP allows for high success rates in these patients because various devices are useful for overcoming major difficulties. Therefore, good knowledge of postoperative anatomy and various devices is mandatory before performing ERCP procedures for post-gastrectomy patients.

Efficacy and Safety of Endoscopic Papillary Balloon Dilation Using Cap-Fitted Forward-Viewing Endoscope in Patients Who Underwent Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic exploration of the common bile duct (CBD) is difficult and dangerous in patients with Billroth II gastrectomy (B-II). Endoscopic papillary balloon dilation (EPBD) via a cap-fitted forward-viewing endoscope has been reported to be an effective and safe procedure. We analyzed the technical success and complications of EPBD in patients who underwent B-II. METHODS: Thirty-six consecutive patients with B-II were enrolled from among 2,378 patients who had undergone endoscopic retrograde cholangiopancreatography in a single institute in the last 4 years. The EPBD procedure was carried out using a cap-fitted forward-viewing endoscope with 8-mm balloon catheters for 60 seconds. We analyzed the rates of CBD exploration, technical success, and complications. RESULTS: Afferent loop intubation was performed in all patients and selective cannulation of the bile duct was performed in 32 patients (88.9%). Complications such as transient hypoxia were observed in two patients (5.6%) and perforation, in three patients (9.7%). The perforation sites were ductal injury in two patients and one patient showed retroperitoneal air alone without symptoms. Three patients manifested different clinical courses of severe acute pancreatitis and peritonitis, transient abdominal pain, and retroperitoneal air alone. The condition of one patient improved with surgery and that of the other two patients, with conservative management. CONCLUSIONS: Patients with perforation during EPBD in B-II showed different clinical courses. Tailored treatment strategies are necessary for improving the clinical outcomes.

Feasibility of Cap-Assisted Endoscopic Retrograde Cholangiopancreatography in Patients with Altered Gastrointestinal Anatomy

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is technically challenging in patients with altered gastrointestinal (GI) anatomy. We evaluated the feasibility of cap-assisted ERCP in patients with altered GI anatomy. METHODS: The outcome of ERCP procedures (n=136) was analyzed in 78 patients with Billroth II (B-II) gastrectomy (n=72), Roux-en-Y total gastrectomy (n=4), and hepaticoduodenostomy (n=2). The intubation rate for reaching the papilla of Vater (POV), deep biliary cannulation rate, therapeutic interventions and procedure-related complications were analyzed. All of the procedures were conducted using a cap-fitted forward-viewing endoscope. RESULTS: The rate of access to the POV was 97.1% (132/136). In cases with successful access, selective biliary cannulation was achieved in 98.5% (130/132) of the patients. The successful biliary cannulation rates were 100% (125/125) for B-II gastrectomy, 50% (2/4) for Roux-en-Y gastrectomy and 100% (3/3) for hepaticoduodenostomy. After selective biliary cannulation, therapeutic interventions, including stone extraction (n=57), sphincterotomy (n=54), stent placement (n=37), nasobiliary drainage (n=20), endoscopic papillary balloon dilatation (n=7) and mechanical lithotripsy (n=15), were performed successfully. The procedure-related complication rate was 8.8% (12/136), including immediate bleeding (5.9%, 8/136), pancreatitis (2.2%, 3/136), and perforation (0.7%, 1/136). There were no procedure-related deaths. CONCLUSIONS: Cap-assisted ERCP is efficient and safe in patients with altered GI anatomy.

Afferent loop obstruction following laparoscopic distal gastrectomy with Billroth-II gastrojejunostomy / 대한외과학회지

PURPOSE: Afferent loop (A-loop) obstruction is an uncommon postgastrectomy complication following Billroth-II (B-II) or Roux-en-Y reconstruction. Moreover, its development after laparoscopic gastrectomy has not been reported. Here we report 4 cases of A-loop obstructions after laparoscopic distal gastrectomy (LDG) with B-II reconstruction. METHODS: Among the 396 patients who underwent LDG with a B-II anastomosis between April 2004 and December 2011, 4 patients had A-loop obstruction. Their data were obtained from a prospectively maintained institutional database and analyzed for outcomes. RESULTS: Four patients (1.01%) developed A-loop obstruction. All were male, and their median age was 52 years (range, 30 to 73 years). The interval between the initial gastrectomies and the operation for A-loop obstruction ranged from 4 to 540 days (median, 33 days). All 4 patients had symptoms of vomiting and abdominal pain and were diagnosed by abdominal computed tomographic (CT) scan. The causes of the A-loop obstructions were adhesions (2 cases) and internal herniations (2 cases) that were treated with Braun anastomoses and reduction of the herniated small bowels, respectively. All patients recovered following the emergency operations. CONCLUSION: A-loop obstruction is a rare but serious complication following laparoscopic and open gastrectomy. It should be considered when a patient complains of continuous abdominal pain and/or vomiting after LDG with B-II reconstruction. Prompt CT scan may play an important role in diagnosis and treatment.

Comparison of Intracorporeal Reconstruction after Laparoscopic Distal Gastrectomy with Extracorporeal Reconstruction in the View of Learning Curve

PURPOSE: The intracorporeal reconstruction after laparoscopic gastrectomy can minimize postoperative pain, and give better cosmetic effect, while it may have technical difficulties and require the learning curve. This study aimed to analyze the surgical outcome of intracorporeal reconstruction according to the surgeon's experience comparing with extracorporeal procedure. MATERIALS AND METHODS: From January 2009 to September 2011, intracorporeal reconstruction in laparoscopic surgery for gastric cancer was performed for 71 patients (Intra group). During same period, 231 patients underwent laparoscopy-assisted gastrectomy (Extra group). These patients were classified into initial (1st to 20th case of intra group), intermediate (21th to 46th case), and experienced (after 47th case) phases. RESULTS: Intracorporeal procedures included 35 cases of Billroth-I, 30 Billroth-II and 6 Roux en Y reconstructions. In the initial phase, operation time (P=0.022) were significantly longer for the patients of intra group than them of extra group. Although the difference was not significant, the length of hospital stay was longer and complication rate was higher in the intra group. In intermediate and experienced phases, there was no difference between two groups in operation time and hospital stay. In these phases, complication rate was lower in the intra group than the extra group (3.9% versus 9.7%). The pain scale was significantly lower post operation day 5 in the intra group. CONCLUSIONS: Intracorporeal reconstruction after laparoscopic distal gastrectomy was feasible and safe, and the technique was stabilized after 20th case if the surgeon has sufficient experiences when we compared it with extracorporeal reconstruction.

Usefulness of Forward-Viewing Endoscope for Endoscopic Retrograde Cholangiopancreatography in Patients with Billroth II Gastrectomy

BACKGROUND/AIMS: Patients undergoing Billroth II (B II) gastrectomy are at higher risk of perforation during endoscopic retrograde cholangiopancreatography (ERCP). We assessed the success rate and safety of forward-viewing endoscopic biliary intervention in patients with B II gastrectomy. METHODS: A total of 2,280 ERCP procedures were performed in our institution between October 2008 and June 2011. Of these, forward-viewing endoscopic biliary intervention was performed in 46 patients (38 men and 8 women with B II gastrectomy). Wire-guided selective cannulations of the common bile duct using a standard catheter and guide wire were performed in all patients. RESULTS: The success rate of afferent loop entrance was 42 out of 46 patients (91.3%) and of biliary cannulation after the approach of the papilla was 42 out of 42 patients (100%). No serious complications were encountered, except for one case of small perforation due to endoscopic sphincterotomy site injury. CONCLUSIONS: When a biliary endoscopist has less experience and patient volume is low, ERCP with a forward-viewing endoscope is preferred because of its ease and safety in all patients with prior B II gastrectomies. Also, forward-viewing endoscope can be used to improve the success rate of biliary intervention in B II patients.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy. METHODS: Between March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications. RESULTS: Successful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred. CONCLUSIONS: Without preceding sphincterotomy, one-step EPBD (> or =10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (> or =10 mm) with CBD dilatation in Billroth II gastrectomy.

Comparative Study of Hand-Sutured versus Circular Stapled Anastomosis for Gastrojejunostomy in Laparoscopy Assisted Distal Gastrectomy

PURPOSE: Mechanical stapler is regarded as a good alternative to the hand sewing technique, when used in gastric reconstruction. The circular stapling method has been widely applied to gastrectomy (open orlaparoscopic), for gastric cancer. We illustrated and compared the hand-sutured method to the circular stapling method, for Billroth-II, in patients who underwent laparoscopy assisted distal gastrectomy for gastric cancer. MATERIALS AND METHODS: Between April 2009 and May 2011, 60 patients who underwent laparoscopy assisted distal gastrectomy, with Billroth-II, were enrolled. Hand-sutured Billroth-II was performed in 40 patients (manual group) and circular stapler Billroth-II was performed in 20 patients (stapler group). Clinicopathological features and post-operative outcomes were evaluated and compared between the two groups. RESULTS: Nosignificant differences were observed in clinicopathologic parameters and post-operative outcomes, except in the operation times. Operation times and anastomosis times were significantly shorter in the stapler group (P=0.004 and P<0.001). CONCLUSIONS: Compared to the hand-sutured method, the circular stapling method can be applied safely and more efficiently, when performing Billroth-II anastomosis, after laparoscopy assisted distal gastrectomy in patients with gastric cancer.

Comparison of laparoscopy-assisted and totally laparoscopic Billroth-II distal gastrectomy for gastric cancer / 대한외과학회지

PURPOSE: In laparoscopic distal gastrectomy for gastric cancer, most surgeons prefer extra-corporeal anastomosis because of technical challenges and unfamiliarity with intra-corporeal anastomosis. Herein, we report the feasibility and safety of intra-corporeal Billroth-II anastomosis in gastric cancer. METHODS: From April 2004 to March 2011, 130 underwent totally laparoscopic distal gastrectomy with intra-corporeal Billroth-II reconstruction, and 269 patients underwent laparoscopy-assisted distal gastrectomy with extra-corporeal Billroth-II reconstruction. Surgical efficacies and outcomes between two groups were compared. RESULTS: There were no differences in demographics and clinicopathological characteristics. The mean operation and reconstruction times of totally laparoscopic distal gastrectomy were statistically shorter than laparoscopy-assisted distal gastrectomy (P = 0.019; P < 0.001). Anastomosis-related complications were observed in 11 (8.5%) totally laparoscopic distal gastrectomy and 21 (7.8%) laparoscopy-assisted distal gastrectomy patients, and the incidence of these events was not significantly different. Post-operative hospital stays for totally laparoscopic distal gastrectomy were shorter than laparoscopy-assisted distal gastrectomy patients (8.3 +/- 3.2 days vs. 9.9 +/- 5.3 days, respectively; P = 0.016), and the number of times parenteral analgesic administration was required in laparoscopy-assisted distal gastrectomy patients was more frequent after surgery. CONCLUSION: Intra-corporeal Billroth-II anastomosis is a feasible procedure and can be safely performed with the proper experience for laparoscopic distal gastrectomy. This method may be less time consuming and may produce a more cosmetic result.

Endoscopic Papillary Large Balloon Dilation Combined with Guidewire-Assisted Precut Papillotomy for the Treatment of Choledocholithiasis in Patients with Billroth II Gastrectomy

BACKGROUND/AIMS: Endoscopic extraction of bile duct stones is difficult and often complicated in patients with a Billroth II gastrectomy. We evaluated a simpler technique to achieve an adequate ampullary opening for the removal of choledocholithiasis using endoscopic papillary large balloon dilation (EPLBD) combined with a guidewire-assisted needle-knife papillotomy. METHODS: Sixteen patients who had a Billroth II gastrectomy were included in this study. Following placement of the guidewire in the bile duct, a precut incision was made over the guidewire with a needle knife sphincterotome inserted alongside the guidewire. Balloon dilation of the ampullary orifice was gradually performed. RESULTS: Needle knife papillotomy over the guidewire with subsequent EPLBD was successful in all patients. Complete stone removal was achieved in 15 (93.7%) patients in 1 session. However, 1 (6.3%) patient required mechanical lithotripsy with an additional procedure for complete ductal clearance, and there was 1 case of minor bleeding following the EPLBD. There were no cases of pancreatitis or perforation. CONCLUSIONS: EPLBD followed by guidewire-assisted needle-knife papillotomy appears to be a useful method with few technical difficulties and a low risk of complications for the removal of bile duct stones in patients with prior Billroth II gastrectomy.

Using Multidetector-Row CT for the Diagnosis of Afferent Loop Syndrome Following Gastroenterostomy Reconstruction

PURPOSE: To assess the clinical manifestations and multidetector-row computed tomography (MDCT) findings of afferent loop syndrome (ALS) and to determine the role of MDCT on treatment decisions. MATERIALS AND METHODS: From January 2004 to December 2008, 1,100 patients had undergone gastroenterostomy reconstruction in our institution. Of these, 22 (2%) patients were diagnosed as ALS after surgery that included Roux-en-Y gastroenterotomy (n=9), Billroth-II gastrojejunostomy (n=7), and Whipple's operation (n=6). Clinical manifestations and MDCT features of these patients were recorded and statistically analyzed. The presumed etiologies of obstruction shown on the MDCT were correlated with clinical information and confirmed by surgery or endoscopic biopsy. RESULTS: The most common clinical symptom was acute abdominal pain, presenting in 18 patients (82%). We found that a fluid-filled C-shaped afferent loop in combination with valvulae conniventes projecting into the lumen was the most common MDCT features of ALS. Malignant causes of ALS, such as local recurrence and carcinomatosis, are the most common etiologies of obstruction. These etiologies and associated complications can be predicted 100% by MDCT. CONCLUSION: Our results suggest that MDCT is a reliable modality for assessing the etiologies of ALS and guiding treatment decisions.

Intracorporeal Anastomosis Using Linear Stapler in Laparoscopic Distal Gastrectomy: Comparison between Gastroduodenostomy and Gastrojejunostomy

PURPOSE: Intracorporeal anastomosis during laparoscopic gastrectomy is becoming increasingly prevalent. However, selection of the anastomosis method after laparoscopic distal gastrectomy is equivocal because of a lack of technical feasibility and safety. We compared intracorporeal gastroduodenostomy with gastrojejunostomy using linear staplers to evaluate the technical feasibility and safety of intracorporeal anastomoses as well as its' minimally invasiveness. MATERIALS AND METHODS: Retrospective analyses of a prospectively collected database for gastric cancer revealed 47 gastric cancer patients who underwent laparoscopic distal gastrectomy with either intracorporeal gastroduodenostomy or gastrojejunostomy from March 2011 to June 2011. Perioperative outcomes such as operation time, postoperative complication, and hospital stay were compared according to the type of anastomosis. Postoperative inflammatory response was also compared between the two groups using white blood cell count and high sensitivity C-reactive protein. RESULTS: Among the 47 patients, 26 patients received gastroduodenostomy, whereas 21 patients received gastrojejunostomy without open conversion or additional mini-laparotomy incision. There was no difference in mean operation time, blood loss, and length of postoperative hospital stays. There was no statistically significant difference in postoperative complication or mortality between two groups. However, significantly more staplers were used for gastroduodenostomy than for gastrojejunostomy (n=6) than for gastroduodenostomy and (n=5). CONCLUSIONS: Intracorporeal anastomosis during laparoscopic gastrectomy using linear stapler, either gastroduodenostomy or gastrojejunostomy, shows comparable and acceptable early postoperative outcomes and are safe and feasible. Therefore, surgeons may choose either anastomosis method as long as oncological safety is guaranteed.

Cap-assisted ERCP in Surgically Altered Anatomy / 대한소화기내시경학회지

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) is a difficult procedure to perform on patients who have undergone a Billroth II gastrectomy, Whipple's operation or Roux-en-Y gastrobypass surgery. Our study was designed to evaluate the clinical usefulness of cap-assisted ERCP for beginner endoscopists in cases of surgically altered anatomy. METHODS: From April 2008 to March 2010, 16 patients with biliary diseases and who had previously undergone abdominal surgery such as Billroth II gastrectomy or Roux-en-Y operation were analyzed. A single endoscopist performed all the procedures using a cap-assisted gastroscope, after ERCP training. RESULTS: Cap-assisted ERCP was attempted in 24 sessions of 16 patients. Afferent loop intubation and selective bile duct cannulation was successfully achieved in 19 sessions (79.1%). Among the patients who had undergone a Billroth II gastrectomy, 19 out of 20 sessions were successfully conducted. Only 4 patients who had undergone a previous Roux-en-Y operation failed afferent loop intubation. Duodenal free wall perforation developed in one case. There were no cases of mortality. CONCLUSIONS: Therapeutic cap-assisted ERCP was useful in patients who had previously undergone a Billroth II gastrectomy and this may be helpful for inexperienced endoscopists.

Fistulopapilotomia por sobre balão transpapilar em pacientes com Billroth II: uma nova técnica / Fistulotomy over transpapillary balloon in patientes with Billroth II: a new technique

Introdução: A CPRE diagnóstica e terapêutica, em pacientes com gastrectomia à Billroth 11, é mais difícil devido às alterações anatômicas. Acessórios e técnicas têm sido desenvolvidos para minimizar estas adversidades. Objetivo: Nova técnica de acesso biliar em pacientes gastrectomizados à Billroth 11. Pacientes: No período de fevereiro de 2003 a agosto de 2007, foram realizadas 157 CPRE em pacientes gastrectomizados à Billroth 11, por coledocolitíase. Em 37 desses pacientes, não foi possível cateterização pela técnica convencional, sendo submetidos a nova técnica. Métodos: Após fistulopapilotomia para acessar via biliar principal, passava-se fio-guia de 0,035mm, seguido por balão dilatador de 8mm, que se mantinha transpapilar. Pelo canal de trabalho, passava-se o estilete; ao posicionar em frente à papila, procedia-se secção do esfíncter por sobre balão insuflado com contraste até desaparecimento da cintura na radioscopia. Resultados: Dos 37 pacientes submetidos ao novo procedimento, seis foram excluídos. Dezesseis pacientes (51,6%) eram do sexo feminino e quinze (48,4%) do masculino. A idade variou de 29 a 89 anos, com média de 62,3 anos. Todos tinham icterícia clínica e laboratorial. O tempo do procedimento variou de 18 a 48 minutos (30 minutos). O diâmetro da via biliar foi de 4,5 a 12,8mm (7,7mm), apresentando de um a quatro cálculos. Ocorreram seis (19,3%) complicações relacionadas ao procedimento, sendo três (9,7%) pancreatites, duas (6,4%) hemorragias e uma (3,2%) perfuração. Não houve óbitos relacionados ao procedimento. Conclusão: O sucesso desta técnica foi de 83,8% (31 dos 37 casos), sendo 88,6% (31 de 35 casos) se considerarmos apenas a canulação da via biliar, portanto método seguro e eficaz em pacientes com Billroth 11 e papila duodenal difícil.

Evaluation of Different Methods of Gastroenterostomy after Distal Gastrectomy for Gastric Carcinoma

PURPOSE: Billroth II gastroenterostomy is a typical reconstruction method after distal gastrectomy for gastric carcinoma, but it has problems, especially frequent reflux esophagitis. Various methods have been tried to address this problem. Among them are Braun enteroenterostomy and Roux-en-Y gastroenterostomy, which are performed separately according to the size of the gastric remnant. The aim of our study was to determine whether these applications are compatible. MATERIALS AND METHODS: Between September 2003 and April 2007, we performed Roux-en-Y gastroenterostomy operations (14 patients) when the size of the gastric remnant was <10%, Braun enteroenterostomy (17 patients) when the size was between 10 and 20%, and Billroth II gastroenterostomy (14 patients) when the size was between 20 and 40% after subtotal gastrectomy for gastric cancer by a single surgeon at our hospital. We analyzed the results of each treatment. We evaluated the symptoms and endoscopic findings using questionnaires and hospital records. To evaluate nutritional states, we reviewed albumin and hemoglobin levels and body weight changes. RESULTS: All operations were performed safely mortality was 0% and postoperative complications were 8.9%. On endoscopy, reflux gastritis was observed to occur in 7.63%, 18.65% and 40.0%, respectively, of patients who had undergone Roux-en-Y, Braun and Billroth II operations (P=0.13). Reflux esophagitis was observed in 1 patient in the Roux-en-Y group and 1 patient in the Braun group. Endoscopic gastrostasis was observed in 2 patients in the Roux-en-Y group, one of which was thought to cause reflux esophagitis. Patients in the Roux-en-Y group and Braun groups ingested a lower volume of food than did those in the Billroth II group (respectively, 7.1%, 0.0% and 28.7%) and complained less of postprandial discomforts (respectively, 14.3%, 23.5% and 57.1%) and reflux symptoms (respectively 0.0%, 11.8% and 42.9%). CONCLUSION: The application of Braun enteroenterostomy and Roux-en-Y gastroenterostomy to the small gastric remnant may be effective for reducing reflux symptoms and abdominal discomfort after distal gastric resection. We recommend Roux-en-Y gastroenterostomy when the size of the gastric remnant is <10%, and Braun anastomosis in the others. It will need to be determined which reconstructive procedure is better for many different conditions.

A Case of Afferent Loop Syndrome Treated by Endoscopic Drainage Procedure using Nasogastric Tube / 대한소화기학회지

Afferent loop syndrome is an uncommon complication which occurs in patients with Billroth II partial gastrectomy. Clinically, the diagnosis of afferent loop syndrome may be difficult to establish and thus, depends on the finding of computed tomography, abdominal ultrasound, barium studies and hepatobiliary scan. When the diagnosis is made, most of the cases are treated by surgical operation. We present a case of 67-year-old male patient with afferent loop syndrome associated with acute pancreatitis which was treated by endoscopic drainage procedure using a nasogastric tube.

Comparison of the Results in Gastric Carcinoma Patients undergoing Billroth I and Billroth II Gastrectomiesy

PURPOSE: The proper reconstruction technique to use after a distal subtotal gastrectomy for a gastric carcinoma, there has been a subject for debated what is the proper reconstruction technique. The aim of this study was to compare the gastric- emptying time and the quality of life following both B-I and B-II reconstructions after a distal gastrectomy for a gastric adenocarcinoma. MATERIALS AND METHODS: We studied 122 patients who had undergone a distal gastrectomy for a gastric adenocarcinoma between June 1999 and July 2002 at our hospital. 51 patients underwent B-I group, and 71 patients underwent B-II group. To evaluate the gastric-emptying time, we analyzed the T1/2 time by means of radionuclide scintigraphy using a gamma camera after ingestion of an (99m)Tc-tin-colloid steamed egg. The nutritional status was measured by the weight change. Postgastrectomy syndrome was evaluated using an abdominal symptoms survey. Dumping syndrome was measured using the Sigstad dumping score. RESULTS: The gastric-emptying time was somewhat delayed in the B-I group after a 6 month period, but there was no difference after 12 months between the two groups. There was less weight loss in the B-I group than in the B-II group (P=0.023). Fewer abdominal symptoms were occurred in the B-I group than in the B-II group. Dumping syndrome occurred less frequently in the B-I group than in the B-II group (P=0.013). CONCLUSION: In our study, the Billroth I reconstruction led to less weight loss, a better nutritional status, and a better quality of life than the Billroth II reconstruction. We concluded that after a distal subtotal gastrectomy, the Billroth I reconstruction would be considered when the procedure is oncologically suitable.

Endoscopic Papillary Large Balloon Dilatation for Large Biliary Stones in a Hemodialysis Patient: A Case Report / 대한소화기내시경학회지

In retrieving bile duct stones, full-endoscopic sphincterotomy (EST) with endoscopic mechanical lithotripsy (EML) is considered as a traditional method, and balloon dilation of the papillary sphincter has also been used. Recent studies have reported that mid-EST and endoscopic papillary large balloon dilatation (EPLBD) was as useful as full-EST with EML, without serious complications. In patients with coagulopathy, such as end-stage renal disease, even a small incision of the sphincter could cause profuse bleeding. In such patients, balloon dilation of the sphincter is a preferred technique over EST. A prior Billroth-II operation renders EST more difficult and increases the risk of a complication. In these patients, the use of EPBD is also preferred as well. We report a case of successfully retrieving large bile duct stones by EPLBD without EST, in a patient who had a prior Billroth-II operation, and is undergoing hemodialysis. The patient is free of complications, such as bleeding or acute pancreatitis.